Feasibility Of Laparoscopic Partial Nephrectomy Research Articles

Clinicoradiological parameters predicting operative difficulty in laparoscopic partial nephrectomy for renal tumors.

The number of renal tumors amenable to laparoscopic surgery is rising, both, due early detection by improved imaging techniques and due to progressive improvements in minimal access surgery. Conversion to open surgery, which is a significant event, can be minimized by proper case selection. We assessed the pre-operative factors that can predict the operative difficulty and can help in case selection, thus avoiding complications and reducing the chances of conversion to open. One hundred and sixteen patients (73 males and 43 females) with the mean age of 50.78 ± 14.2 years, meeting the inclusion criteria underwent transperitoneal laparoscopic partial nephrectomy (LPN). Various clinical, anthropometric, radiological, and pathological parameters were recorded. Intraoperative difficulty was assessed and graded on a scale of 1 (easiest) to 4 (most difficult or open conversion) by an independent observer to calculate the difficulty score, which along with the other parameters of operative difficulty, was used to calculate the difficulty scale. Significant parameters on the univariate analysis, were subjected to a multivariate analysis, to find parameters that can predict the operative difficulty. The mean age was 52 ± 14.29 years, mean size was 4 ± 1.04 cm, male:female ratio was 1.6:1, most of the tumors were exophytic (60%) and anteriorly located (62%) and had a mean perinephric fat surface density (PnFSD) of 6446.026 ± 2244 surface density pixel units (SDPU). On the univariate analysis, age >60 years, Eastern Cooperative Oncology Group performance score >1, presence of perinephric fat stranding, increased PnFSD (>10,000 SDPU), large tumor size (>4 cm), hilar/posterior location, endophytic tumors and higher clinical stage were significantly associated with intraoperative difficulty. However, on the multivariate analysis, no single factor could independently predict intraoperative difficulty in LPN for Renal tumors. It is difficult to predict the intra-operative difficulty during LPN. Feasibility of LPN should be based on multiple factors rather than a single factor.

Feasibility of laparoscopic partial nephrectomy in the obese patient and assessment of predictors of perioperative outcomes.

Introduction:Partial nephrectomy is the gold standard for treatment of small renal masses. Our study compares outcomes for obese (body mass index [BMI] ≥30) and healthy (BMI <30) patients undergoing laparoscopic partial nephrectomy (LPN) with the intention of defining preoperative risk factors for complications and renal insufficiency in the obese.Materials and Methods:We conducted a retrospective review of 187 consecutive patients who underwent LPN. We examined the association between BMI and postoperative complication, estimated blood loss (EBL), hospital length of stay, warm ischemic time (WIT), and postoperative renal function. We did similar analyses using the RENAL nephrometry score and the comorbidity status of the patients.Results:We found no statistically significant increase in complications in obese (BMI ≥30) individuals relative to healthy (BMI <30) patients. The obese experienced approximately 100 cc more EBL (P = 0.0111). Patients experienced more complications if they had a Charlson comorbidity score ≥3 (P = 0.0065), an American Association of Anesthesiologists score ≥3 (P = 0.0042), or a history of diabetes mellitus (P = 0.0196). There was no association between RENAL nephrometry score and complication. However, patients with a score ≥8 experienced higher WIT (P = 0.0022), a greater decline in estimated glomerular filtration rate postoperatively (P = 0.0488), and an increased risk of developing chronic kidney disease ≥3 (P = 0.0065).Conclusions:Obese patients undergoing LPN are not at significantly increased risk of complication relative to nonobese patients. Comorbidity status and RENAL nephrometry score, independent of BMI, should be the main considerations of a patient's suitability for LPN.

Retroperitoneal Laparoscopic Partial Nephrectomy with Segmental Renal Artery Clamping

Abstract Introduction: Laparoscopic partial nephrectomy (LPN) is an option in the treatment of T1a kidney tumor. We study the feasibility of LPN with segmental renal artery clamping for T1a-T1b kid...

Visual Enhancement of Laparoscopic Partial Nephrectomy With 3-Charge Coupled Device Camera: Assessing Intraoperative Tissue Perfusion and Vascular Anatomy by Visible Hemoglobin Spectral Response

We report the novel use of 3-charge coupled device camera technology to infer tissue oxygenation. The technique can aid surgeons to reliably differentiate vascular structures and noninvasively assess laparoscopic intraoperative changes in renal tissue perfusion during and after warm ischemia. We analyzed select digital video images from 10 laparoscopic partial nephrectomies for their individual 3-charge coupled device response. We enhanced surgical images by subtracting the red charge coupled device response from the blue response and overlaying the calculated image on the original image. Mean intensity values for regions of interest were compared and used to differentiate arterial and venous vasculature, and ischemic and nonischemic renal parenchyma. The 3-charge coupled device enhanced images clearly delineated the vessels in all cases. Arteries were indicated by an intense red color while veins were shown in blue. Differences in mean region of interest intensity values for arteries and veins were statistically significant (p >0.0001). Three-charge coupled device analysis of pre-clamp and post-clamp renal images revealed visible, dramatic color enhancement for ischemic vs nonischemic kidneys. Differences in the mean region of interest intensity values were also significant (p <0.05). We present a simple use of conventional 3-charge coupled device camera technology in a way that may provide urological surgeons with the ability to reliably distinguish vascular structures during hilar dissection, and detect and monitor changes in renal tissue perfusion during and after warm ischemia.

Editorial Comment

Incidental detection of the small renal mass (SRM) is increasingly common in the elderly population. 1 Hock L.M. Lynch J. Balaji K.C. Increasing incidence of all stages of kidney cancer in the last 2 decades in the United States: an analysis of surveillance, epidemiology and end results program data. J Urol. 2002; 167: 57-60 Abstract Full Text Full Text PDF PubMed Scopus (339) Google Scholar Although most of these lesions are clinical stage I renal cell carcinomas (RCC), a growing body of published data exists demonstrating that the natural history of untreated localized SRMs is rather indolent in the short to intermediate term. 2 Jewett M.A. Zuniga A. Renal tumor natural history: the rationale and role for active surveillance. Urol Clin North Am. 2008; 35: 627-634 Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar Multiple observational series note that the rate of progression to metastatic disease is 1%-2% during a median time of 30 months. 3 Chawla S. Crispen P. Hanlon A. et al. The natural history of enhancing renal masses: a meta-analysis and review of the world literature. J Urol. 2006; 175: 425-431 Abstract Full Text Full Text PDF PubMed Scopus (592) Google Scholar Moreover, of those lesions under active surveillance reported in the published data that do metastasize, the average time from diagnosis to metastatic RCC (mRCC) was in excess of 65 months. 4 Kunkle D.A. Chen D.Y.T. Greenberg R.E. et al. Metastatic progression of enhancing renal masses under active surveillance is associated with rapid interval growth of the primary tumor. J Urol. 2008; 179: S375 Abstract Full Text PDF Google Scholar The possibility of overtreatment of the SRM in the elderly patients poses a clinical dilemma, namely whether excision, ablation, or observation is best in this population. 5 Kunkle D.A. Egleston B.L. Uzzo R.G. Excise, ablate or observe: the small renal mass dilemma—a meta-analysis and review. J Urol. 2008; 179 (discussion:1233-1234): 1227-1233 Abstract Full Text Full Text PDF PubMed Scopus (416) Google Scholar Laparoscopic Partial Nephrectomy in OctogenariansUrologyVol. 74Issue 5PreviewTo assess the safety and technical feasibility of laparoscopic partial nephrectomy in patients aged ≥80 years at our institution to determine whether this treatment modality may be justifiable in select octogenarians. As the US population ages, an increasing number of elderly patients with renal masses are considered for partial nephrectomy. We present our experience with laparoscopic partial nephrectomy in octogenarians to determine the safety and technical feasibility of this procedure in an elderly population. Full-Text PDF Editorial CommentUrologyVol. 74Issue 5PreviewThe current manuscript demonstrates that laparoscopic partial nephrectomy can be performed safely in octogenarians. However, it must be noted that the authors represent extremely talented and experienced laparoscopic surgeons and are considered pioneers in the field of laparoscopic renal surgery. Although it is doubtful that these findings can be generalized to all practicing Urologists, the manuscript details several critical concepts in the contemporary management of renal tumors, including proper patient selection, preservation of renal function, and limiting treatment-associated morbidity. Full-Text PDF ReplyUrologyVol. 74Issue 5PreviewAlthough fundamental, the question, “Should we excise SRMs in the elderly?” is not the topic of our retrospective review. We agree whole-heartedly that in the elderly and the infirm population, the risk of competing comorbidities must be weighed against the admittedly limited oncological risk of the small renal mass (SRM).1 The goal of our manuscript is less lofty; namely, to evaluate the technical feasibility, safety, and outcomes of LPN surgery in an elderly subgroup. All patients underwent LPN for an “enhancing” SRM, on the basis of CT imaging performed at our institution. Full-Text PDF ReplyUrologyVol. 74Issue 5PreviewAlthough fundamental, the question, ‘Should we excise SRMs in the elderly?’ is not the topic of our retrospective review. We agree whole-heartedly that, in the elderly and the infirm, the risk of competing comorbidities must be weighed against the admittedly limited oncological risk of the small renal mass (SRM).1 The goal of our manuscript is less lofty, namely, to evaluate the technical feasibility, safety, and outcomes of LPN surgery in the elderly. All patients underwent LPN for an “enhancing” SRM, based on CT imaging performed at our institution. Full-Text PDF

Editorial Comment

The current manuscript demonstrates that laparoscopic partial nephrectomy can be performed safely in octogenarians. However, it must be noted that the authors represent extremely talented and experienced laparoscopic surgeons and are considered pioneers in the field of laparoscopic renal surgery. Although it is doubtful that these findings can be generalized to all practicing Urologists, the manuscript details several critical concepts in the contemporary management of renal tumors, including proper patient selection, preservation of renal function, and limiting treatment-associated morbidity. Laparoscopic Partial Nephrectomy in OctogenariansUrologyVol. 74Issue 5PreviewTo assess the safety and technical feasibility of laparoscopic partial nephrectomy in patients aged ≥80 years at our institution to determine whether this treatment modality may be justifiable in select octogenarians. As the US population ages, an increasing number of elderly patients with renal masses are considered for partial nephrectomy. We present our experience with laparoscopic partial nephrectomy in octogenarians to determine the safety and technical feasibility of this procedure in an elderly population. Full-Text PDF ReplyUrologyVol. 74Issue 5PreviewAlthough fundamental, the question, “Should we excise SRMs in the elderly?” is not the topic of our retrospective review. We agree whole-heartedly that in the elderly and the infirm population, the risk of competing comorbidities must be weighed against the admittedly limited oncological risk of the small renal mass (SRM).1 The goal of our manuscript is less lofty; namely, to evaluate the technical feasibility, safety, and outcomes of LPN surgery in an elderly subgroup. All patients underwent LPN for an “enhancing” SRM, on the basis of CT imaging performed at our institution. Full-Text PDF Editorial CommentUrologyVol. 74Issue 5PreviewIncidental detection of the small renal mass (SRM) is increasingly common in the elderly population.1 Although most of these lesions are clinical stage I renal cell carcinomas (RCC), a growing body of published data exists demonstrating that the natural history of untreated localized SRMs is rather indolent in the short to intermediate term.2 Multiple observational series note that the rate of progression to metastatic disease is 1%-2% during a median time of 30 months.3 Moreover, of those lesions under active surveillance reported in the published data that do metastasize, the average time from diagnosis to metastatic RCC (mRCC) was in excess of 65 months. Full-Text PDF ReplyUrologyVol. 74Issue 5PreviewAlthough fundamental, the question, ‘Should we excise SRMs in the elderly?’ is not the topic of our retrospective review. We agree whole-heartedly that, in the elderly and the infirm, the risk of competing comorbidities must be weighed against the admittedly limited oncological risk of the small renal mass (SRM).1 The goal of our manuscript is less lofty, namely, to evaluate the technical feasibility, safety, and outcomes of LPN surgery in the elderly. All patients underwent LPN for an “enhancing” SRM, based on CT imaging performed at our institution. Full-Text PDF

Reply

Although fundamental, the question, ‘Should we excise SRMs in the elderly?’ is not the topic of our retrospective review. We agree whole-heartedly that, in the elderly and the infirm, the risk of competing comorbidities must be weighed against the admittedly limited oncological risk of the small renal mass (SRM). 1 Lane B.R. Abouassaly R. Gao T. et al. Active treatment of localized renal tumors may not impact overall survival in patients 75 years of age or older with medical comorbidity. 2009 Google Scholar The goal of our manuscript is less lofty, namely, to evaluate the technical feasibility, safety, and outcomes of LPN surgery in the elderly. All patients underwent LPN for an “enhancing” SRM, based on CT imaging performed at our institution. The nearly 40% benign rate on final pathology reflects the inherent issues with radiologic imaging. Although an overall 32% complication rate was seen in our elderly cohort, this included minor nonurological complications (atelectasis, ileus) and was not significantly different from the younger cohort. Furthermore, none of the elderly patients studied required postoperative dialysis. Laparoscopic Partial Nephrectomy in OctogenariansUrologyVol. 74Issue 5PreviewTo assess the safety and technical feasibility of laparoscopic partial nephrectomy in patients aged ≥80 years at our institution to determine whether this treatment modality may be justifiable in select octogenarians. As the US population ages, an increasing number of elderly patients with renal masses are considered for partial nephrectomy. We present our experience with laparoscopic partial nephrectomy in octogenarians to determine the safety and technical feasibility of this procedure in an elderly population. Full-Text PDF Editorial CommentUrologyVol. 74Issue 5PreviewThe current manuscript demonstrates that laparoscopic partial nephrectomy can be performed safely in octogenarians. However, it must be noted that the authors represent extremely talented and experienced laparoscopic surgeons and are considered pioneers in the field of laparoscopic renal surgery. Although it is doubtful that these findings can be generalized to all practicing Urologists, the manuscript details several critical concepts in the contemporary management of renal tumors, including proper patient selection, preservation of renal function, and limiting treatment-associated morbidity. Full-Text PDF ReplyUrologyVol. 74Issue 5PreviewAlthough fundamental, the question, “Should we excise SRMs in the elderly?” is not the topic of our retrospective review. We agree whole-heartedly that in the elderly and the infirm population, the risk of competing comorbidities must be weighed against the admittedly limited oncological risk of the small renal mass (SRM).1 The goal of our manuscript is less lofty; namely, to evaluate the technical feasibility, safety, and outcomes of LPN surgery in an elderly subgroup. All patients underwent LPN for an “enhancing” SRM, on the basis of CT imaging performed at our institution. Full-Text PDF Editorial CommentUrologyVol. 74Issue 5PreviewIncidental detection of the small renal mass (SRM) is increasingly common in the elderly population.1 Although most of these lesions are clinical stage I renal cell carcinomas (RCC), a growing body of published data exists demonstrating that the natural history of untreated localized SRMs is rather indolent in the short to intermediate term.2 Multiple observational series note that the rate of progression to metastatic disease is 1%-2% during a median time of 30 months.3 Moreover, of those lesions under active surveillance reported in the published data that do metastasize, the average time from diagnosis to metastatic RCC (mRCC) was in excess of 65 months. Full-Text PDF

Laparoscopic Partial Nephrectomy in Octogenarians

To assess the safety and technical feasibility of laparoscopic partial nephrectomy in patients aged >or=80 years at our institution to determine whether this treatment modality may be justifiable in select octogenarians. As the US population ages, an increasing number of elderly patients with renal masses are considered for partial nephrectomy. We present our experience with laparoscopic partial nephrectomy in octogenarians to determine the safety and technical feasibility of this procedure in an elderly population. Between 1999 and 2007, we reviewed 832 patients who underwent laparoscopic partial nephrectomy for renal tumors at our institution. Demographics, perioperative data, and renal function of patients aged >or=80 years were compared with younger patients. A total of 791 patients aged <80 years (median 59, range 17-79) and 41 patients aged >or=80 years (median 82, range 80-88) underwent laparoscopic partial nephrectomy. In comparison with patients aged <80 years, octogenarians had higher overall American Society of Anesthesiology (P = .002) and Charlson Comorbidity Scores (P = .006) with an increased incidence of chronic kidney disease (P = .008); however, intraoperative and postoperative complications were similar between the groups (P = .3, P = .5). Despite a lower preoperative glomerular filtration rate in the octogenarian group (median 68 vs 82, P <.0001), the overall decline in glomerular filtration rate between age groups was not significantly different (P = .7). Laparoscopic partial nephrectomy can be performed safely in appropriately selected patients aged >or=80 years, with rates of perioperative morbidity similar to those observed in younger patients. On the basis of our data, age alone should not be a contraindication to laparoscopic partial nephrectomy.

Commentary on Feasibility of laparoscopic partial nephrectomy after previous ipsilateral renal procedures

Previous renal surgery has been considered a relative contraindication to laparoscopic partial nephrectomy (LPN) because of perirenal surgical adhesions. We present our experience with LPN in patients with previous ipsilateral renal surgery. Of 679 patients undergoing LPN for a renal mass from September 1999 to November 2006, 25 (3.7%) had undergone previous ipsilateral open or percutaneous renal procedures. The LPN technique included hilar clamping, cold tumor excision, and sutured renal reconstruction. The perioperative outcomes were retrospectively analyzed from a prospectively maintained database. Previous renal surgery included open surgery in 12 patients (nephro/pyelolithotomy in 8, pyeloplasty in 2, and partial nephrectomy in 2) and percutaneous surgery in 13 (percutaneous nephrolithotomy in 9 and renal biopsy in 4). The mean interval from previous surgery was 6.6 years (range 0.3–34). LPN (16 transperitoneal and 9 retroperitoneal) was successful in all patients. The mean tumor size was 2.5 cm (range 1–5.6), the warm ischemia time was 35.8 minutes (range 22–57), and the estimated blood loss was 215 ml (range 25–600). The mean operative time was 3 hours (range 1.5–4.5), and the hospital stay was 3.1 days (range 1–7.6). Histopathologic examination confirmed renal cell carcinoma in 19 patients (76%). No open conversions were needed, and no kidneys were lost. No intraoperative complications and 3 postoperative complications (12%) developed, including blood transfusion in 1, nausea and epistaxis in 1, and compartment syndrome requiring fasciotomy in 1 patient. The results of our study have shown that in select patients LPN is feasible after previous ipsilateral renal surgery. However, it can be technically challenging, and adequate previous experience with LPN is necessary.

Laparoscopic Partial Nephrectomy without Renal Arterial Clamping

Purpose: Renal vascular clamping during a laparoscopic partial nephrectomy is a time-consuming procedure with a risk of renal ischemia. To study the feasibility of laparoscopic partial nephrectomy without renal arterial clamping, we compared the procedure with laparoscopic partial nephrectomy with vascular clamping. Materials and Methods: Seventeen patients underwent laparoscopic partial nephrectomy without renal arterial clamping (group 1) from February 2004 to June 2008. The operative results were reviewed retrospectively and compared with those of 16 patients who underwent laparoscopic partial nephrectomy with arterial clamping (group 2). Patient characteristics did not differ significantly between the 2 groups. However, exophytic tumors were detected in 13 patients in group 1 and 3 patients in group 2 (p=0.001). Scores on the preoperative aspects and dimensions used for an anatomical (PADUA) classification were 6.9 in group 1 and 7.7 in group 2 (p=0.037). All surgeries by the transperitoneal approach were performed by a single surgeon. Results: The mean operative times were 103 and 130 minutes in groups 1 and 2, respectively (p=0.312). The mean renal arterial clamping time of group 2 was 27.6 minutes (range, 20-42 minutes). The mean estimated blood loss was 327 ml in group 1 and 315 ml in group 2 (p=0.971). The mean postoperative change in the glomerular filtration rate was 20.11 ml/min/1.73 m in group 1 and 18.95 ml/min/1.73 m in group 2 (p=0.748). The mean times to postoperative initiation of ambulation and of oral intake were 1.6 and 1.7 days (p=0.486) and 1.3 and 1.6 days (p=0.811) in groups 1 and 2, respectively. The mean length of hospital stay was 7.4 and 7.9 days in groups 1 and 2, respectively (p=0.9). The mean tumor size was 2.1 cm (range, 1-7 cm) in group 1 and 3.3 cm (range, 1.5-9 cm) in group 2. Conclusions: Laparoscopic partial nephrectomy without renal arterial clamping is feasible for a localized renal tumor. However, patients should be selected carefully, such as those with an exophytic tumor. (Korean J Urol 2009;50:1208-1212) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏

Feasibility of Laparoscopic Partial Nephrectomy After Previous Ipsilateral Renal Procedures

Previous renal surgery has been considered a relative contraindication to laparoscopic partial nephrectomy (LPN) because of perirenal surgical adhesions. We present our experience with LPN in patients with previous ipsilateral renal surgery. Of 679 patients undergoing LPN for a renal mass from September 1999 to November 2006, 25 (3.7%) had undergone previous ipsilateral open or percutaneous renal procedures. The LPN technique included hilar clamping, cold tumor excision, and sutured renal reconstruction. The perioperative outcomes were retrospectively analyzed from a prospectively maintained database. Previous renal surgery included open surgery in 12 patients (nephro/pyelolithotomy in 8, pyeloplasty in 2, and partial nephrectomy in 2) and percutaneous surgery in 13 (percutaneous nephrolithotomy in 9 and renal biopsy in 4). The mean interval from previous surgery was 6.6 years (range 0.3-34). LPN (16 transperitoneal and 9 retroperitoneal) was successful in all patients. The mean tumor size was 2.5 cm (range 1-5.6), the warm ischemia time was 35.8 minutes (range 22-57), and the estimated blood loss was 215 mL (range 25-600). The mean operative time was 3 hours (range 1.5-4.5), and the hospital stay was 3.1 days (range 1-7.6). Histopathologic examination confirmed renal cell carcinoma in 19 patients (76%). No open conversions were needed, and no kidneys were lost. No intraoperative complications and 3 postoperative complications (12%) developed, including blood transfusion in 1, nausea and epistaxis in 1, and compartment syndrome requiring fasciotomy in 1 patient. The results of our study have shown that, in select patients, LPN is feasible after previous ipsilateral renal surgery. However, it can be technically challenging, and adequate previous experience with LPN is necessary.

Néphrectomie partielle laparoscopique : courbe d’apprentissage d’un interne en urologie sur un modèle porcin

Several teams have recently confirmed the technical feasibility of laparoscopic partial nephrectomy (LPN). However, this procedure is not widely performed because it is technically difficult and associated with a high rate of bleeding complications, even for experienced teams. The authors studied the LPN learning curve for urology residents using a porcine model based on analysis of the following criteria: operating time, warm ischaemia time and intraoperative and postoperative bleeding. Forty LPN were performed by the same operator. All operations were performed after arterial clamping and heparinisation of the animal. The renal section was always the same, removing 40% of the kidney and always comprised the excretory tract. A continuous running suture on the excretory tract and interrupted sutures on the parenchyma were performed. Operating time and warm ischaemia time were recorded. Animals were monitored for ten days. Intraoperative and postoperative bleeding via drains was recorded and retrograde urography was performed on the 10th day to confirm the absence of excretory tract leaks. Linear regression statistical tests investigated a correlation between these various criteria and the number of cases performed. The mean total operating time, warm ischaemia time and total bleeding (intraoperative and postoperative) were 108 minutes (70-140 minutes), 38 minutes (22-50 minutes) and 95 ml (10-300 ml), respectively. Linear regression analysis revealed a direct correlation between the number of cases performed and intraoperative bleeding (p<0.001) and warm ischaemia time (p<0.001). These parameters became stable after the 10th operated case. Two cases of urine leaks were observed on D10 out of a series of 40 operations, with no correlation with the number of cases performed. The operating time and warm ischaemia time are directly correlated with the number of cases performed. Training on a porcine model appears to be a good way to reduce the learning curve in man. Ten operations are necessary to acquire the various steps of the procedure.

621: Feasibility of Laparoscopic Partial Nephrectomy after Previous Ipsilateral Renal Surgery

You have accessJournal of UrologyPodium 22, Sunday, May 20, 2007, 3:30 - 5:30 pm1 Apr 2007621: Feasibility of Laparoscopic Partial Nephrectomy after Previous Ipsilateral Renal Surgery Burak Tuma, Rodrigo Frota, Yi-Chia Lin, and Inderbir S. Gill Burak TumaBurak Tuma More articles by this author , Rodrigo FrotaRodrigo Frota More articles by this author , Yi-Chia LinYi-Chia Lin More articles by this author , and Inderbir S. GillInderbir S. Gill More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(18)30861-9AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "621: Feasibility of Laparoscopic Partial Nephrectomy after Previous Ipsilateral Renal Surgery." The Journal of Urology, 177(4S), p. 208 © 2016 by American Urological AssociationFiguresReferencesRelatedDetails Volume 177Issue 4SApril 2007Page: 208 Advertisement Copyright & Permissions© 2016 by American Urological AssociationMetricsAuthor Information Burak Tuma More articles by this author Rodrigo Frota More articles by this author Yi-Chia Lin More articles by this author Inderbir S. Gill More articles by this author Expand All Advertisement Loading ...

Early Experience of Laparoscopic Partial Nephrectomy for Renal Tumor

Purpose: To evaluate the feasibility of laparoscopic partial nephrectomy for patients with renal tumors from our early experiences. Materials and Methods: Between February 2004 and February 2006, 20 patients with renal tumors underwent a laparoscopic partial nephrectomy, and of these, 15 were enrolled in our study. The mean age and body mass index of 6 male and 9 female were 55.2 years and 23.9, respectively. The mean tumor size was 4.2 cm. The operation was performed with a 4 trocar system through a transperitoneal approach. Bleeding from the renal parenchyme was controlled using sutures, argon beam coagulation, fibrin glue and cellulose meshes. Results: The laparoscopic partial nephrectomies were successfully performed in all patients. The mean operative time and transfusion rate were 180.7 minutes and 60%, respectively. In 6 patients, vascular bulldog clamps were used to remove the tumor mass, with a mean warm ischemic time of 32.5 minutes. The initiation of the postoperative oral intake and ambulation were 1.6 and 2.7 days, respectively, with a mean hospital stay of 8.8 days. Complications were detected in 2 patients, one case each of urinary leakage and an incisional hernia. Pathological examinations revealed renal cell carcinomas with negative surgical margins in 9 patients and angiomyolipomas in a further 6. There was no recurrence during the mean follow-up of 11.4 months. Conclusions: A laparoscopic partial nephrectomy for a renal tumor can be safely performed. Although excellent perioperative outcomes were observed, long-term follow-up is still necessary to confirm theist effect on cancer control. (Korean J Urol 2007;48:1-5) ꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏ

APPLICATION OF NOVEL HEMOSTATIC AGENT DURING LAPAROSCOPIC PARTIAL NEPHRECTOMY

We determined if QuikClot, a novel hemostatic agent made of a granulated mineral substance, could be used to control renal parenchymal bleeding and collecting system leakage during open and laparoscopic partial nephrectomy. After obtaining renal hilar vascular control 2 domestic female pigs underwent bilateral open and 4 underwent unilateral laparoscopic partial nephrectomy. After excision of the lower pole without cautery the hemostatic agent was applied to the cut surface of the kidney and hilar vascular control was released. Additional QuikClot was added until complete hemostasis was achieved. One week postoperatively the animals were sacrificed and the operated kidneys were harvested for ex vivo retrograde pyelograms and histopathological analysis. All partial nephrectomies were performed without complication. Mean operative and warm ischemia times were 62 and 16 minutes, respectively. An average of 23% of renal mass by weight was resected with a mean blood loss of 73 ml per procedure. No cautery, additional hemostatic agents or techniques were used. No animal had clinical or radiographic evidence of urinoma or delayed hemorrhage. Histopathological analysis showed preservation of the renal parenchyma immediately beneath the QuikClot layer. In the porcine model QuikClot allowed the resection of large renal segments, while providing reliable hemostasis and closure of the renal collecting system. No deleterious effect on underlying renal parenchyma or surrounding tissues was observed.

Robotic-assisted laparoscopic partial nephrectomy: Technique and initial clinical experience with daVinci robotic system

ObjectivesTo develop and assess the feasibility of laparoscopic partial nephrectomy performed using the daVinci robotic system. MethodsBetween November 2002 and August 2003, 13 patients with solid or suspicious cystic renal masses underwent robotic-assisted laparoscopic partial nephrectomy. In 8 cases, an intra-arterial catheter was inserted for renal cooling before occlusion of the renal artery. The remaining 5 patients underwent partial nephrectomy after the renal hilum had been clamped. Tumor excision and intracorporeal suturing were performed entirely with telerobotics. The perioperative data and pathologic results were retrospectively reviewed. ResultsThe mean lesion diameter was 3.5 cm (range 2.0 to 6.0). The mean operative time was 215 minutes (range 130 to 262), and the mean blood loss was 170 mL (range 50 to 300). The mean warm ischemia was 22 minutes (range 15 to 29), and the mean cold ischemia time was 33 minutes (range 18 to 43). The length of hospital stay averaged 4.3 days (range 2 to 7). The resected lesions included renal cell carcinoma in 10, oncocytoma in 2, and a complex renal cyst in 1. In 1 case, a positive margin occurred despite negative frozen sections; laparoscopic nephrectomy was performed and showed no residual tumor. One patient experienced postoperative ileus. At 2 to 11 months of follow-up, no recurrence had been observed. ConclusionsRobotic-assisted partial nephrectomy is feasible. Robotic partial nephrectomy can be safely performed using a transperitoneal or retroperitoneal approach. A second scrubbed assistant is mandatory to provide assistance using conventional laparoscopic instruments with this technique.

PIG KIDNEY: ANATOMICAL RELATIONSHIPS BETWEEN THE INTRARENAL ARTERIES AND THE KIDNEY COLLECTING SYSTEM. APPLIED STUDY FOR UROLOGICAL RESEARCH AND SURGICAL TRAINING

We present a systematic study of the anatomical relationships between intrarenal arteries and the kidney collecting system in pigs. The intrarenal anatomy (collecting system and arteries) was studied in 91, 3-dimensional endocasts of the kidney collecting system together with the intrarenal arteries. Some anatomical details that have importance to help research and surgical training in urology when using the pig as an animal model were observed and described. It was found that there was only 1 artery per kidney. This artery divided into cranial and caudal branches in 85 cases (93.4%). In 6 cases (6.6%) the primary division of the renal artery was in a dorsal and in a ventral branch. In all cases 2 arteries (1 ventral and 1 dorsal) involved the cranial caliceal group. In the dorsal mid zone a dorsal artery originated from the cranial division of the renal artery, which was obliquely positioned in 47.25% of cases. The arterial supply related to the ventral mid zone of the kidney consisted of branches that coursed horizontally in the ventral surface of the renal pelvis in 81.32% of cases. The caudal division of the renal artery supplied the ventral and dorsal surfaces of the caudal caliceal group in 84.62% of cases, while in 15.38% a dorsal artery supplied its dorsal surface. Although the results of renal and intrarenal anatomy in pigs could not be completely transposed to humans, many similarities in the pig and human intrarenal arteries support its use as the best animal model for urological procedures.

Feasibility of laparoscopic partial nephrectomy using pledgeted compression sutures for hemostasis.

To develop a technique for laparoscopic partial nephrectomy (LPN) without the use of hilar occlusion that allows large renal resection and excellent hemostasis. Five female domestic pigs underwent right laparoscopic transperitoneal lower-pole partial nephrectomy after placement of pledgeted parenchymal compression sutures tied intracorporeally to induce regional renal hypoperfusion. Postoperatively, serial serum creatinine measurements were obtained to monitor renal function. The pigs were allowed to recover and 2 weeks later underwent an identical procedure on the left side. The animals were sacrificed after the second procedure, and both renal units were removed for ex vivo retrograde urograms and histologic analysis. The median operative time was 154.5 minutes (range 110-305 minutes), and the median blood loss was 137.5 mL (range 100-300 mL). On average, 35% (range 31%-36.8%) of the kidney was resected. All cases required use of adjunctive hemostatic clips to control bleeding from central vessels. All animals survived 2 weeks and had no evidence of urinary extravasation clinically or on ex vivo retrograde urograms. In the porcine model, LPN with placement of pledgeted sutures allows resection of large renal segments, although technical refinements are required to improve hemostasis. Currently, the need for adjunctive hemostatic measures limits the initial clinical application of this technique to small, exophytic tumors.

Hemostatic laparoscopic partial nephrectomy assisted by a water-cooled, high-density, monopolar device without renal vascular control

Objectives To evaluate the feasibility of laparoscopic partial nephrectomy assisted by a water-cooled, high-density, monopolar device (TissueLink Floating Ball). Methods Transperitoneal laparoscopic partial nephrectomy was performed without vascular control for four renal tumors in 3 patients. A flexible ultrasound probe was used to confirm tumor location and depth. Gerota’s fascia was opened distant from the tumor site. Renal fat was dissected from the renal parenchyma except for the fat overlying the tumor. The tumor resection area was marked 1 cm outside the boundaries of the tumor. After application of the TissueLink Floating Ball at the planned surgical margin, the tumor was resected with cold laparoscopic scissors. Bleeding from the vessels of the divided renal parenchyma was controlled with the Floating Ball if necessary. The specimen was sent for frozen section to confirm margin status. Results Mean estimated blood loss per tumor was 275 mL. The dissection extended to the collecting system in 2 of 4 cases. In 1 patient, a minor postoperative urine leak resolved spontaneously. Conclusions Use of the TissueLink Floating Ball facilitated resection of small renal tumors without renal vascular control. Although further study is necessary, water-cooled, high-density monopolar energy may have a role in laparoscopic partial nephrectomy.