Laparoscopic Partial Nephrectomy For Tumors Research Articles

Laparoscopic partial nephrectomy for tumors 7cm and above. Perioperative outcomes.

ABSTRACTPurpose:To assess and report the outcomes of laparoscopic partial nephrectomy) LPN) for T2 renal masses.Materials and Methods:Retrospective review of patients undergoing LPN for clinically localized renal masses ≥7cm between the years 2005-2016. Descriptive analyses were generated for demographics, lesion characteristics, perioperative variables (operative time, warm ischemia time (WIT), estimated blood loss (EBL), intra-operative and postoperative complications (IOC and POC) and pathologic variables (pathology, subtype and Fuhrman grade).Results:A total of 27 patients underwent LPN for a T2 renal mass at our institution between 2005 and early 2016 of which 19 were males. The mean age was 66 (52-72). All procedures were transperitoneal with 16 on the right and 11 on the left. Median operative time was 200 minutes (IQR 181-236) and median WIT 19 minutes (IQR 16-23). EBL was 125mL (IQR 75-175). One case was converted to laparoscopic radical nephrectomy due to suspected tumor thrombus in the renal vein. Surgical margins were positive in one renal tumor in a patient with multiple tumors. There was a total of 2 IOC (7.4%) and 3 POC (11%) classified as Clavien grade 3.Conclusions:To our knowledge, this series is the first to describe the outcomes of LPN for cT2 renal masses. In our series, LPN for larger renal masses appears feasible with favorable perioperative outcomes. Additional data are needed to further explore the benefits of minimally invasive surgical approaches to larger renal masses.

Robotic versus laparoscopic partial nephrectomy for tumor in a solitary kidney: A single institution comparative analysis

To compare the outcomes of robot-assisted laparoscopic partial nephrectomy and laparoscopic partial nephrectomy for renal tumor in patients with a solitary kidney. We retrospectively reviewed data of patients with solitary kidney who underwent laparoscopic (n = 52) and robot-assisted (n = 15) partial nephrectomy for renal tumor at Cleveland Clinic, Cleveland, Ohio, USA, between June 2000 and April 2012. Patient demographic data, perioperative parameters and follow-up data were compared. The two groups were similar in terms of patients and tumor characteristics, including preoperative renal function and etiology of solitary kidney. The median operative time (225 vs 171 min, P = 0.02), warm ischemia time (19 vs 15 min, P = 0.04) and hospital stay (4 vs 3 days, P = 0.03) were significantly shorter in the robotic group. No significant differences were found in terms of estimated blood loss, transfusion, complications, pathological results and margin status. The median percentage change of renal function was not significantly different between two groups. Long-term hemodialysis was required for three patients in the laparoscopic group (6%) and none of the patients in the robotic group. Median follow up was 15.6 and 5.9 months in the laparoscopic and robotic group, respectively. Robot-assisted partial nephrectomy represents a safe and effective minimally-invasive treatment option for renal masses in patients with a solitary kidney. Early comparative outcomes suggest that it offers a significant benefit over the laparoscopic approach in terms of operative time, warm ischemia time and hospital stay. Further studies with a longer follow up are required to confirm the likelihood of better long-term functional and oncological outcomes.

Editorial Comment to Robotic versus laparoscopic partial nephrectomy for tumor in a solitary kidney: A single institution comparative analysis

Editorial Comment to <scp>R</scp>obotic versus laparoscopic partial nephrectomy for tumor in a solitary kidney: A single institution comparative analysis

Off‐clamp versus complete hilar control laparoscopic partial nephrectomy: comparison by clinical stage

Study Type--Therapy (case series). Level of Evidence 4. What's known on the subject? And what does the study add? Minimizing renal ischemia and reperfusion injury is an area of active investigation and is particularly significant in cases of laparoscopic renal surgery where the kidney experiences warm ischemia. Reports of partial clamping, early unclamping, and off-clamp laparoscopic partial nephrectomy have demonstrated potential technical modifications that can offer a protective role in preserving renal function. We investigated off-clamp laparoscopic partial nephrectomy for tumours with varying clinical stage to determine feasibility, perioperative outcomes, and renal functional changes when compared to a contemporary cohort of standard laparoscopic partial nephrectomy with complete hilar clamping performed by a single surgeon. • To compare the operative outcomes and oncological efficacy of off-clamp (OC) laparoscopic partial nephrectomy (LPN) vs complete hilar control (HC) LPN for stage T1a-T2 renal cell carcinoma. • Retrospective review of all LPNs between June 2006 and March 2010 was performed, stratifying 390 patients by clinical T stage (cT1a = 313, cT1b = 62, cT2 = 15). • Perioperative and postoperative parameters were analysed comparing patients who underwent OC LPN (n= 126) with those who had HC LPN (n= 264) collectively and within each clinical stage cohort. • There was no significant difference in the proportion of OC LPN for cT1a tumours compared with cT1b and cT2, P= 0.21. • OC vs HC LPN patients had a greater estimated blood loss (EBL) but with no significant difference in perioperative blood transfusion rates. • When compared by clinical stage, EBL was greater only for clinical stage T1a disease (P= 0.02) but not cT1b (P= 0.91) or cT2 (P= 0.42) tumours. • There was no difference in the operative time or length of hospitalization between OC and HC LPN by stage: cT1a (P= 0.77 and P= 0.17), cT1b (P= 0.77 and P= 0.07) and cT2 (P= 0.42 and P= 0.66), respectively. • In our series, one case (0.3%) of HC LPN had a positive margin on final pathology, one case was converted to open partial nephrectomy (0.3%), and two cases of OC LPN (1.6%) were intraoperatively converted to HC LPN. • OC LPN is a feasible surgical option for patients with cT1-T2 renal cell carcinoma that completely avoids renal ischaemic injury with the benefits of minimally invasive surgery. • LPN can be performed OC in patients with larger, more complex renal tumours without compromising the operative time, blood loss requiring transfusions, length of hospitalization, complication rates, or positive surgical margin rates compared with HC LPN.

Laparoscopic partial nephrectomy for tumours &gt;4 cm compared with smaller tumours: perioperative results

The use of laparoscopic partial nephrectomy (LPN) in patients with tumours >4 cm remains to be further evaluated. We report our experience with LPN in tumours >4 cm compared with tumours ≤4 cm. This is a retrospective study of data from all LPN patients operated from 2003 to 2008. Inclusion criteria were a single organ confined contrast enhancing mass/Bosniac III-IV cyst. Hospital admission records were used to extract operative and follow-up data. Patients were grouped into group A: ≤4 cm (32 patients, 53% of total), and group B: >4 cm (28 patients, 47% of total). A total of 60 patients (mean ± SD age, 47.4 ± 13.4 years; M/F, 36/24) were included. Mean ± SD tumour size was 31.5 ± 7.3 mm and 51.6 ± 10.9 mm in groups A and B, respectively. (P < 0.001) Malignant pathology was present in 22 (69%) and 16 patients (57%) in groups A and B, respectively. (P > 0.05) There was no statistically significant difference in age, gender, pre-operative creatinine, estimated glomerular filtration rate (eGFR), and other investigated pre-operative characteristics between study groups. (all P > 0.05) Nor any difference was observed regarding operative and pathologic (warm ischaemia time, operation duration, transfusion, positive margins, and malignant histology) as well as post-operative variables (re-hospitalization, post-operative complications, hospital stay, or eGFR changes). The results of this study supports the feasibility and comparability of operative and post-operative early complications for LPN when applied to tumours >4 cm in selected patients compared with tumours ≤4 cm.

910 ROBOT ASSISTED LAPAROSCOPIC PARTIAL NEPHRECTOMY FOR TUMORS GREATER THAN 4 CM: FEASIBILITY AND EARLY FUNCTIONAL OUTCOMES

You have accessJournal of UrologyTechnology & Instruments: Robotics/Laparoscopy/Ureteroscopy II1 Apr 2010910 ROBOT ASSISTED LAPAROSCOPIC PARTIAL NEPHRECTOMY FOR TUMORS GREATER THAN 4 CM: FEASIBILITY AND EARLY FUNCTIONAL OUTCOMES Paul H. Chung, Gopal Gupta, Ronald S. Boris, W. Marston Linehan, Peter A. Pinto, and Gennady Bratslavsky Paul H. ChungPaul H. Chung More articles by this author , Gopal GuptaGopal Gupta More articles by this author , Ronald S. BorisRonald S. Boris More articles by this author , W. Marston LinehanW. Marston Linehan More articles by this author , Peter A. PintoPeter A. Pinto More articles by this author , and Gennady BratslavskyGennady Bratslavsky More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1666AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The oncologic efficacy and preservation of renal function has been well established for nephron sparing surgery (NSS) with T1b tumors. Robot assisted laparoscopic partial nephrectomy (RALPN) has emerged offering benefits of earlier convalescence similar to traditional laparoscopy. Initially introduced to excise small exophytic tumors, RALPN has recently evolved to allow treatment of more complex renal masses. We report on the technical feasibility and early functional outcomes of RALPN for tumors greater than 4 cm. METHODS Between 2007 and 2009, we identified 19 RALPN in 17 patients (10 with and 7 without known hereditary syndromes) treated at our institution for solid tumors greater than 4 cm. Demographic, operative, and pathologic data were collected. Renal function was assessed by serum creatinine levels, estimated glomerular filtration rate (GFR) and nuclear renal scans assessed at baseline and 3 months post-operatively. All tumors were assigned a R.E.N.A.L. nephrometry score (www.nephrometry.com). RESULTS Patient, tumor and intraoperative data are listed in Table 1.x Three of 19 cases (16%) required intraoperative conversion. No renal units were lost. Average R.E.N.A.L. nephrometry score for the largest tumor from each kidney was 8.9 (range 6-11), while the average size was 6.1 cm (range 4.1 to 15). One patient developed ureteropelvic junction obstruction requiring subsequent stenting. There were no statistically significant differences between preoperative and postoperative creatinine (0.9 mg/dL vs. 1.0 mg/dL, p=0.12) or eGFR (87.6 mg/dL vs. 88.7 mg/dL, p= 0.81). However, there was a statistically significant decline of ipsilateral renal scan function (49.9% vs. 44.5%, p=0.002) at three months. No patients had evidence of recurrent disease or metastatic disease at a mean follow up of 10 months (range 1-25). Patient Data Operation # / Patient # 19/17 Age, yrs (range) 46(26to71) Mean BMI (range) 28.5(19.8to40.4) Male (%) 9(53) Surgery on the right, # (%) 11(58) Hereditary Disease, # (%) 10(59) Tumor Data Mean Tumor per patient, # (range) 1.6(1to4) Tumor Histology, # (%) Clear Cell 11(58) Papillary Type 1 4(21) Chromophobe 2(11) Oncocytoma 1(5) Angiomyolipoma 1(5) Operative Data Operative Time, min (range) 317(220to496) Warm Ischemia Time, min (range) 35.6(11to61) Estimated Blood Loss, mL (range) 659.4(100to1600) CONCLUSIONS RALPN is feasible for renal tumors greater than 4 cm and higher nephrometry scores. Although there was a modest decline in renal function of the operated unit, RALPN affords the ability to resect challenging tumors that require complex renal reconstruction. Longer follow up will be needed to further assess functional and oncologic outcomes. Bethesda, MD© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e355 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Paul H. Chung More articles by this author Gopal Gupta More articles by this author Ronald S. Boris More articles by this author W. Marston Linehan More articles by this author Peter A. Pinto More articles by this author Gennady Bratslavsky More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Laparoscopic partial nephrectomy for large renal masses: results of a European survey

To evaluate the perioperative effectiveness of laparoscopic partial nephrectomy (LPN) for large (4-7 cm) renal masses, with a review of the experience of six European advanced laparoscopic centres. A survey was planned; data were extracted from each institutional data base to obtain information about patients who had undergone LPN for renal masses larger than 4 cm. Demographic, radiological growth patterns of the tumours and intraoperative data were collected. Post-operative complications and pathological data were also recorded. All data were processed through statistical software. Data on 63 patients were collected. Radiological tumour size was 4.7 cm (4.1-7), growth pattern was cortical in 33 cases and cortico-medullar in 30 cases. Warm ischemia time (WIT) was 25.7 min in 7.3% cases bleeding occurred intra-operatively, post-operative surgical complications occurred in 14.6% cases. Pathological analyses revealed malignant lesion in 73% and positive margins in 6.5%. Complications and positive margins are more frequent for cortico-medullar lesions. This survey confirms that LPN for tumours 4-7 cm in size is feasible in experienced hands. WIT and overall complication rate remain questionable points.

Renal Artery Pseudoaneurysm: Complication of Minimally Invasive Kidney Surgery

We retrospectively reviewed the charts of patients with renal artery pseudoaneurysms (RAPs) to document their clinical presentation, surgical background, and outcome. In all, 7 of the 1965 patients who underwent percutaneous stone surgery and 3 of the 25 patients who underwent laparoscopic nephron-sparing surgery had a diagnosis of RAP and were treated accordingly. The most common symptom was hematuria, which was classified as early or delayed according to the time of presentation, as mild, moderate, or severe according to the hemodynamics of the patient. In addition, angiographic images were reviewed, and the correlation between the clinical presentation of RAP and its location was investigated. In the percutaneous stone surgery group, four patients experienced early mild to moderate hematuria and three experienced late moderate hematuria. All of the RAPs were located on the interlobar and arcuate arteries. In the laparoscopic nephron-sparing surgery group, one patient was asymptomatic, with diagnosis of renal-cell cancer recurrence at the 3-month follow-up, and had radical nephrectomy. Two patients presented with delayed moderate hematuria with lesions that were located on the interlobar, arcuate, and segmentary arteries. Two sessions of embolization were sufficient to stop bleeding in one patient with a segmentary artery aneurysm that had unfortunately lost kidney function during follow-up. There is no predictive factor for patients undergoing percutaneous nephrolithotomy procedure yet, but laparoscopic partial nephrectomy for tumors localized in the central portion of kidney may end up with RAP especially if no adjuvant sealing agents are used. The outcome of RAPs depends primarily on early recognition and a high index of suspicion, which facilitates correct diagnosis and appropriate management. Selective angiography and embolization together is the gold standard, both for diagnosis and treatment.

800 Laparoscopic Partial Nephrectomies: A Single Surgeon Series

We hypothesized that from 1999 to 2008 patient and tumor selection criteria, perioperative outcomes, complications and renal function outcomes may have evolved significantly in 800 laparoscopic partial nephrectomies. We retrospectively divided 800 patients who underwent laparoscopic partial nephrectomy for tumor, as done by 1 surgeon, into 3 chronologic eras, including era 1-276 from September 1999 to December 2003, era 2-289 from January 2004 to December 2006 and era 3-235 from January 2007 through November 2008. We evaluated prospectively collected data on tumor characteristics, perioperative outcomes and renal function outcomes. When comparing eras 1 to 3, tumors in the most recent era were larger, more commonly 4 cm or greater, and central, and less often peripheral and less than 4 cm (each p value significant). Despite increasing tumor complexity warm ischemia time was shorter (31.9, 31.6 and 14.4 minutes, respectively, p <0.0001), and the overall rates of postoperative and urological complications were significantly lower in the most recent era. The rate of parenchymal margins positive for cancer was 1%, 1% and 0.6%, respectively. Renal function outcomes were superior in era 3, as reflected by a lesser decrease in the estimated glomerular filtration rate (18%, 20% and 11%, respectively). In the 744 patients with pathologically confirmed malignancy 5-year overall, cancer specific and recurrence-free survival was 90%, 99% and 97%, respectively. During our 9-year experience with 800 consecutive laparoscopic partial nephrectomies tumor characteristics and surgical outcomes evolved. Despite increasing tumor complexity in contemporary practice 3 key outcomes of laparoscopic partial nephrectomy improved significantly, including ischemia time, complications and renal function. We now routinely offer laparoscopic partial nephrectomy for most tumors hitherto reserved for open nephron sparing surgery.

Augmented Reality During Robot-assisted Laparoscopic Partial Nephrectomy: Toward Real-Time 3D-CT to Stereoscopic Video Registration

To investigate a markerless tracking system for real-time stereo-endoscopic visualization of preoperative computed tomographic imaging as an augmented display during robot-assisted laparoscopic partial nephrectomy. Stereoscopic video segments of a patient undergoing robot-assisted laparoscopic partial nephrectomy for tumor and another for a partial staghorn renal calculus were processed to evaluate the performance of a three-dimensional (3D)-to-3D registration algorithm. After both cases, we registered a segment of the video recording to the corresponding preoperative 3D-computed tomography image. After calibrating the camera and overlay, 3D-to-3D registration was created between the model and the surgical recording using a modified iterative closest point technique. Image-based tracking technology tracked selected fixed points on the kidney surface to augment the image-to-model registration. Our investigation has demonstrated that we can identify and track the kidney surface in real time when applied to intraoperative video recordings and overlay the 3D models of the kidney, tumor (or stone), and collecting system semitransparently. Using a basic computer research platform, we achieved an update rate of 10 Hz and an overlay latency of 4 frames. The accuracy of the 3D registration was 1 mm. Augmented reality overlay of reconstructed 3D-computed tomography images onto real-time stereo video footage is possible using iterative closest point and image-based surface tracking technology that does not use external navigation tracking systems or preplaced surface markers. Additional studies are needed to assess the precision and to achieve fully automated registration and display for intraoperative use.

Comparison of Laparoscopic and Open Partial Nephrectomy for Tumor in a Solitary Kidney

We compared the postoperative and renal functional outcomes of patients undergoing open or laparoscopic partial nephrectomy for tumor in a solitary functioning kidney. Between 1999 and 2006, 169 open and 30 laparoscopic partial nephrectomies were performed for 7 cm or smaller tumors in a solitary functioning kidney. Data were collected in an institutional review board approved registry and median followup was 2.0 years. Preoperative and postoperative glomerular filtration rates were estimated with the abbreviated Modification of Diet in Renal Disease equation. By 3 months after open or laparoscopic partial nephrectomy, the glomerular filtration rate decreased by 21% or 28%, respectively (p = 0.24). Postoperative dialysis was required acutely after 1 open partial nephrectomy (0.6%) and 3 laparoscopic partial nephrectomies (10%, p = 0.01), and dialysis dependent end stage renal failure within 1 year occurred after 1 open partial nephrectomy (0.6%) and 2 laparoscopic partial nephrectomies (6.6%, p = 0.06). In multivariate analysis warm ischemia time was 9 minutes longer (p <0.0001) and the chance of postoperative complications was 2.54-fold higher (p <0.05) with laparoscopic partial nephrectomy. Longer warm ischemia time (more than 20 minutes) and preoperative glomerular filtration rate were associated with poorer postoperative glomerular filtration rate in multivariate analysis. Notwithstanding the association with warm ischemia time, the surgical approach itself was not an independent predictor of postoperative glomerular filtration rate (p = 0.77). While laparoscopic partial nephrectomy is technically feasible for tumor in a solitary kidney, warm ischemia time was longer and complication rates higher compared with open partial nephrectomy. In addition, although average loss of renal function at 3 months is equivalent (after accounting for warm ischemia time), a greater proportion of patients required dialysis temporarily or permanently after laparoscopic partial nephrectomy in this initial series. Therefore, open partial nephrectomy may be the preferred nephron sparing approach at this time for these patients at high risk for chronic kidney disease.