Parenchymal Sutures Research Articles

Autologous mesenchymal stromal cells embedded with Tissucol Duo® for prevention of air leak after anatomical lung resection: results of a prospective phase I/II clinical trial with long-term follow-up

BackgroundProlonged air leak (PAL) is the most frequent complication after pulmonary resection. Several measures have been described to prevent the occurrence of PAL in high-risk patients, however, the potential role of mesenchymal stem cells (MSCs) applied in the parenchymal suture line to prevent postoperative air leak in this setting has not been fully addressed. ObjectiveTo analyse the feasibility, safety and potential clinical efficacy of the implantation of autologous MSCs embedded in Tissucol Duo® as a prophylactic alternative to prevent postoperative prolonged air leak after pulmonary resection in high-risk patients.Study designPhase I/II single-arm prospective clinical trial.MethodsSix patients with high risk of PAL undergoing elective pulmonary resection were included. Autologous bone marrow-derived MSCs were expanded at our Good Manufacturing Practice (GMP) Facility and implanted (embedded in a Tissucol Duo® carrier) in the parenchymal suture line during pulmonary resection surgery. Patients were monitored in the early postoperative period and evaluated for possible complications or adverse reactions. In addition, all patients were followed-up to 5 years for clinical outcomes.ResultsThe median age of patients included was 66 years (range: 55–70 years), and male/female ratio was 5/1. Autologous MSCs were expanded in five cases, in one case MSCs expansion was insufficient. There were no adverse effects related to cell implantation. Regarding efficacy, median air leak duration was 0 days (range: 0–2 days). The incidence of PAL was nil. Radiologically, only one patient presented pneumothorax in the chest X-ray at discharge. No adverse effects related to the procedure were recorded during the follow-up.ConclusionsThe use of autologous MSCs for prevention of PAL in patients with high risk of PAL is feasible, safe and potentially effective.Trial registration No. EudraCT: 2013-000535-27. Clinicaltrials.gov idenfier: NCT02045745.

PD40-12 FUNCTIONAL OUTCOMES PREDICTION AFTER ROBOTIC PARTIAL NEPHRECTOMY USING PADUA SCORE ASSESSED WITH 3D VIRTUAL MODELS: PRELIMINARY RESULTS OF A COLLABORATIVE ERUS STUDY

PD40-12 FUNCTIONAL OUTCOMES PREDICTION AFTER ROBOTIC PARTIAL NEPHRECTOMY USING PADUA SCORE ASSESSED WITH 3D VIRTUAL MODELS: PRELIMINARY RESULTS OF A COLLABORATIVE ERUS STUDY

Preservation of Split Renal Function After Laparoscopic and Robot-assisted Partial Nephrectomy.

To analyze the effects of laparoscopic partial nephrectomy (LPN) and robot-assisted partial nephrectomy (RAPN) for the treatment of renal cell carcinoma (RCC) on subsequent split renal function using renal scintigraphy. We retrospectively analyzed data from 174 patients who underwent LPN or RAPN by a single surgeon, and assessed their total and split renal function before and 6 months after each procedure. Split renal function was analyzed using 99mTc-2,3 dimercaptosuccinic acid renal imaging and calculated as the total estimated glomerular filtration rate (eGFR) × uptake ratio on the surgical side/uptake ratio on the contralateral side. LPN or RAPN were performed in 51 (29.3%) and 123 (70.7%) participants, respectively. Their median eGFRs before and after surgery were 32.76 and 27.74 ml/min/1.73 m2, respectively, and 70 of them (40.2%) showed a preservation of split eGFR of >90%, which was used to define a successful procedure. Participants who underwent a successful procedure had significantly lower RENAL nephrometry scoring system (RNS) scores and fewer of them had external tumors. Successful procedures were associated with shorter warm ischemia time, were more likely to be RAPN, and less likely to involve parenchymal suturing. Multivariate analysis showed that a low RNS score and parenchymal suturing were significant independent predictors of split renal function following partial nephrectomy (PN). Preoperative RNS score and the use of parenchymal suturing are significantly associated with a preservation of split renal function of >90% in patients who undergo PN for the treatment of RCC.

Parenchymal Suture-Assisted Inner Suture Method: Tips to Achieve a Reliable Inner Suture in Partial Nephrectomy

Parenchymal Suture-Assisted Inner Suture Method: Tips to Achieve a Reliable Inner Suture in Partial Nephrectomy

A Modified Superior Pedicle Mastopexy Technique With an Inferolateral-Based Auto Augmentation Flap.

Current mastopexy techniques have evolved to decrease scar length and maintain a more consistent upper pole fullness, improving the breast shape. Many different approaches have tried to suspend breast tissues to achieve a more attractive upper pole. Most of the auto-augmentation mastopexy techniques use inferior-based breast parenchymal tissues to fill the upper part. This paper presents a modified approach to fill the breast's upper pole, with an inferolateral-based breast flap. The advantages of changing the inferior-based auto-augmentation technique to the inferolateral comprise improving blood supply and increasing repositioned breast flap's mobility. In our technique, the breast tissue used to auto-augment the upper pole receives its blood supply from pectoral perforators and lateral breast tissue. When surgeons need more flap mobility, they can raise the medial edge of this flap from the pectoral fascia to mobilize this flap higher on the chest wall, depending on the lateral blood supply. One other advantage is that when the inferolateral-based breast tissue is pulled in a superomedial direction to fill the upper part, the lateral ptotic breast tissues come closer to the breast meridian to meet with medial breast parenchyma easily. The tension on the vertical parenchymal suture line is reduced with this approach. Our technique can be used in most mastopexy operations and for all types of ptosis except for cases with insufficient breast volume. It brings safety to the auto-augmentation procedure and is also time-saving. The stability of breast shape and upper pole fullness lasts as long as other auto-augmentation procedures; therefore, it can be an excellent alternative to other techniques. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

FORECASTING THE BURDENED COURSE OF SURGERIES AND EARLY POSTOPERATIVE PERIOD IN PATIENTS WITH PULMONARY TUBERCULOSIS ON THE BASIS OF DENSITOMETRIC ANALYSIS OF PREOPERATIVE COMPUTER TOMOGRAPHY OF CHEST ORGANS

Topicality – the success of the use of densitotometry in computed tomography of the lungs to assess the condition of the lungs prompted to determine the possibility of predicting the course of the disease in the surgical treatment of patients with pulmonary tuberculosis. The aim – to determine densitometric criteria for prognosis of burdened intra- and postoperative course in patients operated on for pulmonary tuberculosis. Methods – the analysis of preoperative densitometry indices in CT of the lungs in the upper and lower pulmonary fields on the side of the operation in 40 patients operated on for chemoresistant pulmonary tuberculosis with a burdened intra- and postoperative period and the effect of densitometric abnormalities on intra-operative period. Results – in all examined patients the deviation of values of densitometry from conditional norm was revealed. In most patients with high parenchymal density there was obliteration of the pleural cavity and between the lobular fissures, fibrous changes in the root of the lung, with low density in most cases there was bleeding and insufficient tightness of the parenchymal suture, which together aggravates the early postoperative period. Conclusions – the relationship between deviations in the density of the lung parenchyma before surgery and the possibility of aggravating factors in the process of surgical treatment of patients with pulmonary tuberculosis was discovered; it was determined that predicting the occurrence of certain aggravating factors in the process of surgical treatment of patients with pulmonary tuberculosis can help prevent complications of the operation or significantly reduce their manifestations.

Is fixation suture necessary in undescended testicle surgery?

Aim: It is still controversial whether or not testicular fixation is required for undescended testes surgery. In this study, we aimed to compare the results of the patients with undescended testis in a single center, who underwent orchiopexy with or without transfixation suture. Material and Methods: The medical records of the patients with undescended testes who were operated at our tertiary pediatric surgery department were retrospectively analyzed between July 2015 and November 2018. Patients were divided into two groups as fixation performed (Group 1) and not performed (Group 2). Group 1 included n=30 patients (40 testes) and Group 2 included n=41 patients (49 testes). The age of the patients, type of undescended testis, surgical technique and complication rates were determined Results: The mean age of the patients was 37.2 (12-104) months in Group 1 and 41.2 (12-110) months in Group 2. In both groups, complications such as recurrence, testicular atrophy, testis torsion, and hernia or hydrocele formation were not observed. One patient in Group 2 developed wound infection, which was recovered with antibiotic treatment. Conclusion: As a result of the short-term follow-up of our study, there was no clinically significant difference between the two groups. Therefore, we recommend the use of other techniques that do not include parenchymal suture fixation during orchiopexy, and avoiding the routine use of testicular parenchymal sutures if possible.

Non-ischemic laparoscopic partial nephrectomy using 1318-nm diode laser for small exophytic renal tumors

PurposeWarm ischemia (WI) and bleeding constitute the main challenges for surgeons during laparoscopic partial nephrectomy (LPN). Current literature on the use of lasers for cutting and coagulation remains scarce and with small cohorts. We present the largest case series to date of non-ischemic LPN using a diode laser for small exophytic renal tumors.MethodsWe retrospectively evaluated 29 patients with clinically localized exophytic renal tumors who underwent non-ischemic laser–assisted LPN with a 1318-nm wavelength diode laser. We started applying the laser 5 mm beyond the visible tumor margin, 5 mm away from the tissue in a non-contact fashion for coagulation and in direct contact with the parenchymal tissue for cutting. ResultsThe renal vessels were not clamped, resulting in a WIT (warm ischaemic time) of 0 min, except for one case that required warm ischemia for 12 min and parenchymal sutures. No transfusion was needed, with a mean Hemoglobin drop of 1,4 mg/dl and no postoperative complications. The eGFR did not significantly change by 6 months. Histologically, the majority of lesions (n = 22/29) were renal-cell carcinoma stage pT1a. The majority of malignant lesions (n = 13/22) had a negative margin. However, margin interpretation was difficult in 9 cases due to charring of the tumor base. A mean follow-up of 1.8 years revealed no tumor recurrence. The mean tumor diameter was 19.4 mm.ConclusionThe 1318-nm diode laser has the advantages of excellent cutting and sealing properties when applied to small vessels in the renal parenchyma, reducing the need for parenchymal sutures. However, excessive smoke, charring of the surgical margin, and inability to seal large blood vessels are encountered with this technique.

Robotic Double Purse-String Telescoped Pancreaticogastrostomy: How I Do It.

Some articles have recently shown that robotic pancreaticoduodenectomy (PD) is feasible and can be a safe method. On the other hand, pancreatic fistulas (PF) remain the most dreaded complication after PD, and a secured pancreaticoenteric reconstruction may be essential in this regard. Previous articles have highlighted the usefulness of telescoped pancreaticogastrostomy (PG) in open PD to reduce the risk of postoperative PF. Additionally, in 2016, Addeo et al. described a double purse-string telescoped PG (DPS-PG), simplified from previous techniques, with favorable short-term results. The attached video reports our standardized technique for robotic DPS-PG, which is based on Addeo's approach. The main characteristic of this technique is an easy placement of two seromuscular purse-string sutures without the need for gastric wall dissection or deep pancreatic parenchymal sutures. We modified and developed Addeo's technique to suit the robotic PD. In our robotic DPS-PG, there is no need to perform the opening of the distal gastric stump, the anterior gastrostomy, or the suture fixation of the pancreatic parenchyma to the stomach, as it could lead to a rupture of the pancreas, particularly when the parenchyma is soft. We consider that our technique of robotic DPS-PG might be feasible and can be safely performed, just as a previously described technique in open surgery. Further evaluation with clinical trials is required to validate its real benefits.

Modified Nephrometry Score With Body Mass Index More Accurately Predicts Ischemic Time in Transabdominal Laparoscopic Partial Nephrectomy for Small Renal Masses

ObjectiveTo accurately predict the ischemic time (IT) and select candidates for transabdominal laparoscopic partial nephrectomy (LPN). MethodsTransabdominal LPN was performed for 135 Japanese patients with renal masses <7 cm in diameter between 2009 and 2016 by a single surgeon in a single institute. The renal parenchymal sutures were done with a combination of felt, Hem-o-lok and Lapra-Ty. The original R.E.N.A.L. nephreometry score (NS) was modified as follows. In terms of the tumor size (R), 1, 2, and 3 points were given for ≤2.5, 2.5-4, and >4 cm, respectively. For tumor location (A), 1, 2, and 3 points were given for anterior, on the coronal plane, and posterior, respectively. ResultsThe median IT was 24.6 minutes. Using the original NS, 64, 65, and 6 patients were categorized into low (4-6), moderate (7-9), and high (10-12) complexity, respectively. With the modified NS, 42, 75, and 18 patients were categorized into low (5-7), moderate (8-11), and high (12-15) complexity, respectively. Pearson's correlation coefficient (R) between the original NS and IT was 0.297, whereas the R was improved to 0.388 when the modified NS was employed. If the modified NS was low complexity, 95.2% achieved IT <30 minutes. Of them, none showed IT ≥30 minutes if the body mass index was <25 kg/m2. ConclusionThe modified NS had a better correlation to the IT than the original NS for patients with tumor sizes <7 cm who underwent transabdominal LPN. The modified NS with body mass index is a practical tool to select candidates for transabdominal LPN.

PD07-05 THE OUTCOME OF GASLESS LAPAROSCOPIC SINGLE-PORT CLAMPLESS SUTURELESS PARTIAL NEPHRECTOMY USING THREE-DIMENSIONAL HEAD-MOUNTED DISPLAY

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy I1 Apr 2018PD07-05 THE OUTCOME OF GASLESS LAPAROSCOPIC SINGLE-PORT CLAMPLESS SUTURELESS PARTIAL NEPHRECTOMY USING THREE-DIMENSIONAL HEAD-MOUNTED DISPLAY Yosuke Yasuda, Kazutaka Saito, Takahiko Soma, Toshiki Kijima, Soichiro Yoshida, Minato Yokoyama, Junichiro Ishioka, Yoh Matsuoka, Kazunori Kihara, and Yasuhisa Fujii Yosuke YasudaYosuke Yasuda More articles by this author , Kazutaka SaitoKazutaka Saito More articles by this author , Takahiko SomaTakahiko Soma More articles by this author , Toshiki KijimaToshiki Kijima More articles by this author , Soichiro YoshidaSoichiro Yoshida More articles by this author , Minato YokoyamaMinato Yokoyama More articles by this author , Junichiro IshiokaJunichiro Ishioka More articles by this author , Yoh MatsuokaYoh Matsuoka More articles by this author , Kazunori KiharaKazunori Kihara More articles by this author , and Yasuhisa FujiiYasuhisa Fujii More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.438AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Partial nephrectomy (PN) is now the standard treatment for clinically localized renal cancers. Vascular clamping during the tumor resection might induce renal ischemia and reperfusion injury. Renal renorrhaphy could be associated with postoperative pseudoaneurysm. We have performed gasless laparoscopic single-port clampless sutureless PN using a three-dimensional head-mounted display (3D-HMD) system which combines a high-definition 3-D organic electroluminescent HMD with a high-definition 3D endoscope (Kihara K, Int. J. Urol 2015). The tumor is resected in a three-step procedure called the mushroom technique; the three steps are as follows 1) coagulating the resection margin and creating a groove around the tumor, 2) tapering the bottom of the groove to create a “mushroom stalk” shape in the tumor base, and 3) transecting the mushroom stalk. The surgical, oncological and functional outcomes of this surgery are presented. METHODS Between November 2011 and April 2017, consecutive 328 patients with suspected renal cell carcinoma (RCC) underwent gasless laparoscopic single-port PN using 3D-HMD by 21 surgeons. Six patients with metastatic RCC and 11 patients with bilateral RCC were excluded. RESULTS Of the 311 patients, 301 patients (97%) were treated by PN without vascular clamping and parenchymal suture. Median tumor size was 2.5 cm (range 0.9-9.8 cm). The median PADUA score was 8 (range 6-12), and 89 patients (29%) were complex cases (PADUA score = 10). Ninety-three patients (30%) had central tumors and 32 patients (10%) had hilar tumors. Median operative time and blood loss were 225 min and 300ml, respectively. Eight patients (3%) received allogeneic blood transfusions. Twenty-two major complications (7%, all grade 3 urinary leakage) were observed. No patients developed postoperative pseudoaneurysms. Of the 282 RCC patients, eight patients (3%) had positive surgical margins. During the follow-up period (median, 31 months), one patient (0.4%) and four patients (1%) developed bone metastasis and local recurrences, respectively. No patients died of RCC. The median percent decrease in estimated glomerular filtration rate three months after PN was 5.3%. CONCLUSIONS Gasless laparoscopic single-port clampless sutureless PN can be accomplished in almost all cases. This surgery is technically feasible and safe, yielding favorable oncological and functional outcomes. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e158 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Yosuke Yasuda More articles by this author Kazutaka Saito More articles by this author Takahiko Soma More articles by this author Toshiki Kijima More articles by this author Soichiro Yoshida More articles by this author Minato Yokoyama More articles by this author Junichiro Ishioka More articles by this author Yoh Matsuoka More articles by this author Kazunori Kihara More articles by this author Yasuhisa Fujii More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Breast Reduction: Decreasing Complications and Improving Long-Term Aesthetic Results with Parenchymal Sutures.

The inverted T/keyhole pattern is commonly used for large breast reductions. This technique relies on the breast skin to retain the shape. With the passage of time "fallout" (pseudoptosis) occurs impairing the cosmetic result. A technique is described that uses parenchymal sutures and inframammary fold (IMF) reinforcement sutures to maintain the intraoperative shape. A retrospective study of 25 consecutive patients (50 breasts) where the IMF was reinforced and parenchymal sutures were inserted. The patients were followed up and the nipple to notch and nipple to IMF distance was measured and compared with that marked preoperatively and set intraoperatively. Complications, especially T junction breakdown, were also recorded. The mean age was 38 years (range, 16-62 years) with a mean follow-up of 12 months. The mean body mass index was 31 (range, 22-41). The mean mass of tissue excised was 925 g (range, 340-1,800 g) per side. The distance from the suprasternal notch to the nipple remained unchanged. The distance from the nipple to the IMF remained the same as that marked preoperatively except in 3 patients who developed pseudoptosis. Only 3 patients had wound dehiscence. Parenchymal and superficial fascial system sutures combined with IMF reinforcement contributes to maintaining the aesthetic result and decreasing complications, in weight stable patients.

V11-10 ROBOT ASSISTED PARTIAL ADRENALECTOMY FOR FUNCTIONING ADRENAL MASSES

You have accessJournal of UrologyAdrenal/Single Port Surgery/LESS/NOTES1 Apr 2016V11-10 ROBOT ASSISTED PARTIAL ADRENALECTOMY FOR FUNCTIONING ADRENAL MASSES Giuseppe Simone, Gabriele Tuderti, Antonio Stigliano, Rocco Papalia, Mariaconsiglia Ferriero, Riccardo Mastroianni, Francesco Minisola, Leonardo Misuraca, Salvatore Guaglianone, and Michele Gallucci Giuseppe SimoneGiuseppe Simone More articles by this author , Gabriele TudertiGabriele Tuderti More articles by this author , Antonio StiglianoAntonio Stigliano More articles by this author , Rocco PapaliaRocco Papalia More articles by this author , Mariaconsiglia FerrieroMariaconsiglia Ferriero More articles by this author , Riccardo MastroianniRiccardo Mastroianni More articles by this author , Francesco MinisolaFrancesco Minisola More articles by this author , Leonardo MisuracaLeonardo Misuraca More articles by this author , Salvatore GuaglianoneSalvatore Guaglianone More articles by this author , and Michele GallucciMichele Gallucci More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1827AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES We present two cases of robotic partial adrenalectomy performed in a 54yr-old female with a 3 cm left adrenal mass and increased levels of urinary metanephrines and in a 40 yr-old female with a 2 cm left adrenal mass and increased levels of serum aldosterone, respectively. METHODS In the first case, with the patient in a flank position, a four trocar access was performed; Gerota' s fascia was incised at the level of the upper pole and the adrenal gland identified; the medial aspect of the gland was bluntly dissected and some minor vessels feeding the mass were selectively clip legated and divided; the mass was progressively mobilised starting from the medial aspect and an enucleation was performed in order to maximize the adrenal parenchyma spared; the specimen was macroscopically inspected to ensure the absence of any margin violation and it was placed into an endobag for extraction. The second case shows the same surgical access. Enucleation was performed as previously described, and a sliding clip suture was performed to approximate the margins of the adrenal gland; pathological evaluation showed the presence of an intact 1,5 mm capsule all around the adenoma, with a small rim of adrenal cortex parenchyma. RESULTS Intraoperative blood loss was negligible, postoperative course was uneventful in both cases and patients were discharged on second postoperative day. Both patients bacame normotensive immediately after surgery. Both the patients were referred to endocrinological consultation after discharge. Aldosterone and potassium levels for the first patient, as well as urinary metanephrines for the second patient were in the normal range. CONCLUSIONS Robotic partial adrenalectomy is a safe, feasible and minimally technique; robotic platform facilitates either tumor enucleation or parenchymal suture. An increasing adoption of adrenal sparing surgery is likely to be anticipated. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e1006 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Giuseppe Simone More articles by this author Gabriele Tuderti More articles by this author Antonio Stigliano More articles by this author Rocco Papalia More articles by this author Mariaconsiglia Ferriero More articles by this author Riccardo Mastroianni More articles by this author Francesco Minisola More articles by this author Leonardo Misuraca More articles by this author Salvatore Guaglianone More articles by this author Michele Gallucci More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Margin Distance Does Not Influence Recurrence and Survival After Wedge Resection for Lung Cancer

The relationship between the free margin distance and the recurrence rate and overall survival after R0 wedge resection for non-small cell lung cancer (NSCLC) is still not clear. We retrospectively evaluated the long-term oncologic outcome of patients who had undergone wedge resection for NSCLC to assess the prognostic effect of margin distance in this setting. Between 2003 and 2013, 243 consecutive patients with a functional contraindication to major lung resection underwent wedge resection with systematic lymph node dissection for clinical stage I NSCLC. The study enrolled 182 patients with pathologic stage I and R0 resection and divided them into three subgroups according to margin distance of less than 1 cm (n = 30), 1 to 2 cm (n = 80), and more than 2 cm (n = 72). The histologic assessment was adenocarcinoma in 112 patients, squamous cell in 30, and other in 40. Postoperative morbidity was 18.7%, and postoperative mortality was 1.1%. The median follow-up was 31 months (range, 2 to 133 months). The locoregional (lung parenchyma, hilum, mediastinum) recurrence rate was 26.4% (n = 48). The distant recurrence rate was 11% (n = 20). Overall 5-year survival was 70.4%. Disease-free 5-year survival was 51.7%. There was no statistical difference in locoregional (p = 0.9) and distant (p = 0.3) recurrence rate and no difference in overall survival (p = 0.07) when the three groups were compared. Wedge resection is a viable option for the surgical treatment of stage I NSCLC when lobectomy is contraindicated. The distance between the tumor and the parenchymal suture margin does not influence recurrence or the survival rate when an R0 resection is achieved.

Patellar Fractures: An Innovative Surgical Technique With Transosseous Suture to Avoid Implant Removal.

To describe a new surgical procedure and its outcomes: osteosynthesis with high-resistance sutures, avoiding metallic implants. Open sky osteosynthesis with Kirschner and cerclage wiring is the current gold standard for patella fractures. Favorable functional outcomes have been observed, although implant removal is required in many cases due to the prominent wires under the skin. New implants have been sought after to minimize the need for second surgeries. Eight patients, aged between 25 and 61 years, with a minimum follow-up of 24 months, were included in the present study. The surgical procedure consists of open reduction followed by internal fixation performing 3 longitudinal tunnels crossing double high-resistance sutures within these tunnels and suturing among them. Next, an anterior cerclage with parenchymal suture was performed. During follow-up, no secondary fracture displacement was observed. No patient required or requested implant removal. Functional outcomes were equitable to other surgical techniques. Despite the relatively small number of patients, osteosynthesis with high-resistance suture presents as an acceptable alternative within patella fracture treatment, being safe and with similar functional outcomes when compared with other techniques. Furthermore, no second surgeries for implant removal were required during the present study.

Effects of testicular transfixation on seminiferous tubule morphology and sperm parameters of prepubertal, pubertal, and adult rats

Orchiopexy is performed as part of cryptorchidism and testicular torsion treatment. The inflammation caused by the needle and suture penetration has been suggested to be one of the possible causes of subfertility after parenchymal transfixation of the testicles. The purpose of the present study was to investigate testicular alterations after parenchymal transfixation sutures at different ages in rats. Prepubertal, pubertal, and adult rats were submitted to parenchymal suturing (without tying the knots, thus avoiding local ischemic injury) of the right testicle, which was maintained for 4 hours. All animals were subjected to euthanasia on completion of 14 weeks of life. The right testicles were studied as the sutured testicles, whereas the left organs were studied as contralateral. One age-matched control group of rats that was not submitted to any procedure was used for comparison. During euthanasia, sperm were collected from the tail of the epididymal and evaluated for concentration, motility, and viability. Samples from testicular tissue were collected for morphologic analysis. Sperm analysis indicated that only the adult operated animals presented reductions in motility (38.2% of adult vs. 54.1% of control; P = 0.02) and viability (16.6% of adult vs. 24.6% of control; P = 0.003). Several morphologic alterations were noted both in sutured and in contralateral testes at all ages. For instance, the seminiferous epithelium volumetric density of right testicles was reduced from 50.4% in controls to 32.3% in prepubertal operated animals, 45.3% in pubertal operated animals, and 39.4% in adult operated animals (P < 0.05). The seminiferous epithelium volumetric density was also reduced to 39.9% and 39.0% in contralateral testicles of animals operated before and after puberty, respectively (P < 0.05). The animals operated on before puberty and in adulthood showed more testicular morphologic alterations, as seminiferous tubule volumetric density, seminiferous tubule length, and tubular diameter were reduced only in prepubertal and/or adult operated animals. Testicular transfixation in rats led to important morphologic modifications in the ipsilateral and contralateral organs. These alterations were observed regardless of the age when surgery was performed, but they were milder in animals operated on during puberty. Orchiopexy techniques that do not involve the application of testicular transfixation sutures should be recommended.

Gasless laparoendoscopic single-port clampless sutureless partial nephrectomy for peripheral renal tumors: perioperative outcomes.

To describe the technical aspects of gasless laparoendoscopic single-port clampless sutureless partial nephrectomy for peripheral renal tumors, and to evaluate its outcomes, including surgical, pathological, and short-term oncological and functional outcomes. Between January 2010 and June 2013, 103 patients with peripheral renal tumors suggestive of renal cell carcinoma underwent gasless laparoendoscopic single-port partial nephrectomy. In all cases, an attempt was made to accomplish partial nephrectomy without vascular clamping using ultrasonic coagulating and bipolar sealing devices. Hemostasis was achieved by coagulation and hemostatic agents without reconstructing the renal parenchyma. Of the 103 patients, gasless laparoendoscopic single-port partial nephrectomy was accomplished without vascular clamping and parenchymal suture in all but two patients (98%). Median operative time and blood loss were 191 min and 244 mL, respectively. One patient (1%) received allogeneic blood transfusion. The median postoperative time to full recovery was 3 days. Three major complications (3%, all grade 3 urinary leakage) were observed. Of 92 renal cell carcinoma patients, four (4%) had positive surgical margins, most of which underwent thermal degeneration histologically. In 91 non-metastatic renal cell carcinoma patients, 3-year local recurrence-free, progression-free, cancer-specific and overall survival rates were 100%, 99%, 100%, and 100%, respectively (mean follow-up period, 21 months). In the 103 patients, the median percent decrease in estimated glomerular filtration rate 3 months after partial nephrectomy was 2.4%. Gasless laparoendoscopic single-port clampless sutureless partial nephrectomy can be accomplished in almost all cases of peripheral renal tumors. This surgery is technically feasible and safe, yielding acceptable short-term oncological outcomes and maximal preservation of renal function.

Initial experiences with the Hemopatch® as a hemostatic agent in zero-ischemia partial nephrectomy.

Nephron-sparing surgery (NSS) is the gold standard treatment for resectable renal tumors. In the last decade, laparoscopic partial nephrectomy (LPN) has evolved in technical, surgical and oncological aspects and is an accepted treatment option for local-stage renal tumors. Improvements in not only surgical techniques, but also potent hemostats have encouraged this evolution. Here, we report our initial experiences with a new hemostatic agent, Hemopatch(®) (polyethylene glycol-coated collagen patch, Baxter), in zero-ischemia LPN. Seven patients with confirmed renal masses were enrolled and subjected to zero-ischemia LPN. In all cases, Hemopatch(®) was applied to the tumor resection site after suturing of the renal parenchyma. The following clinical data were captured for analysis: staging information, PADUA and RENAL nephrometry scores, operation time, blood loss, complications, pathology and hospitalization length. The median tumor size was 30.0 mm (range 9.5-72). The median PADUA and RENAL nephrometry scores were 6 (range 6-7) and 4 (range 4-6), respectively. All LPNs were performed with the zero-ischemia technique. In six of the seven patients, parenchymal suturing of the resection site was performed. No uncontrolled bleeding was observed. The median operation duration was 139 min (range 103-194), the median blood loss was 325 cc (range 50-700) and the median hospitalization length was 6 days (range 4-7). Hemopatch(®) provided sufficient hemostasis in all cases. No postoperative complications were observed. Although this study is limited to a small set of initial experiences with Hemopatch(®) in LPN, it proves the feasibility and reliability of this new hemostat. Following further evaluation in prospective randomized comparative studies, Hemopatch(®) might represent a promising tool in NSS.

Laparoscopic partial nephrectomy: a challenging operation with a steep learning curve

In this issue of CUAJ, Tse and colleagues1 present an interesting study on the Regina experience with laparoscopic partial nephrectomy (LPN) for T1 renal tumours. The authors describe a single-institution experience of 47 cases of LPN with the introduction of an LPN utilization rate parameter, from a centre with a high volume of laparoscopic urological cases. Of this experience, 31 lesions resected were nonhilar tumours and 16 tumours were in hilar locations. Twenty-five percent of tumours resected were T1b tumours, with a maximum tumour size of 7.2 cm. Eighty percent of renal lesions resected were malignant tumours. The mean tumour size was 3.8 cm, and the mean operating time was 2.8 hours. The average hospital stay was 5 days, which seems somewhat higher than expected for laparoscopic procedures. Operative hilar clamping in this experience was with en bloc clamping. This is in contrast to many centres, such as St. Joseph’s Hospital, which preferentially clamps the renal artery only. This may decrease the intraoperative blood loss, and allows some renal perfusion. En bloc hilar clamping has the advantage that the individual renal artery and vein do not need to be dissected out, and may decrease the risk of injury to the major vessels during the procedure. It has become fairly standard that LPN requires some clamping of the renal hilum (either en bloc or renal artery only) to minimize intraoperative blood loss. This can be done with laparoscopic locking Satinsky clamps (Teleflex), locking DeBakey clamps or detachable laparoscopic bulldog clamps. The authors discuss their experience with complications from LPN, which are not insignificant. The reported blood transfusion rate is 13% (6 patients), 1 patient required emergent postoperative nephrectomy for bleeding, 1 patient developed prolonged urinary leakage and 1 patient developed late calyceal stricture. Two patients had positive surgical margins (which likely will not compromise cancer control in the long term). These complications attest to the steep learning curve of this operation. Of almost 200 cases of LPN at St. Joseph’s Hospital, the blood transfusion rate is not insignificant at 6%, with 4 cases of postoperative pseudoaneurysm requiring radiological embolization. These postoperative issues are echoed by other high-volume centres. Meticulous suturing of transected blood vessels and collecting system reconstruction with parenchymal repair is required, all within an optimal warm ischemic clamp time of 30 minutes. In our experience, use of the absorbable Lapra-Ty (Ethicon) suture allows quick suturing to minimize ischemic time. Some centres use the permanent Hem-O-Lok (Pilling Weck) for parenchymal suturing to minimize ischemic time. Use of either Tisseel (Baxter) or Floseal (Baxter) may improve intraoperative hemostasis after parenchymal repair. Is LPN a procedure that all urologists should be doing, or is this a procedure that should be done only in high-volume centres? The learning curve for this operation is steep, with the optimal number of cases likely in the 10–20 range. Urologists should select patients with nonhilar T1a lesions for their initial experiences with LPN. Overall, LPN is a difficult procedure to master, and the Regina experience is useful to disseminate to Canadian urologists.

Alternative techniques to reduce warm ischemia time in laparoscopic partial nephrectomy

Demonstrate two alternatives that permit a warm ischemia time reduction during laparoscopic partial nephrectomy. In this video, two cases of intermediate complexity renal tumors according to the RENAL nephrometry renal scoring system illustrating the techniques and our preliminary experience: a 65 year old man with a 4 cm right, posterior renal tumor. This patient underwent an early unclamping and parenchymal suturing using a greek bar continuous suture with hem-o-lock clips attached to the respective extremities of the suture; The second patient is a 49 year old man with a 3 cm renal tumor. The technique utilized was no clamping resection following the ABC Medical School technique: dissection of renal hilum for eventual clamping if necessary, a frontal 360 degrees visualization of tumor limits, pneumoperitoneum pressure elevated to 25mmHg during tumor resection, spiral excavation of normal parenchyma around the tumor and resection with negative margins. We previously performed 15 cases utilizing the early unclamping technique. The mean clamp time was 15 minutes with a mean blood loss of 285 mL. Only 1 patient had focal positive surgical margins, without recurrence demonstrated at 30 months. Fifteen partial nephrectomies were previously performed with on demand clamping. In 3 cases, clamping was necessary with a mean ischemia time of 11 minutes. The mean blood loss was 390 mL and 2 cases required a perioperative blood transfusion. One case presented with a positive focal margin without recurrence demonstrated at 24 months of follow-up. Renal function was preserved in all cases regardless of the technique applied. Warm ischemia time can be reduced and kidney function can be preserved during laparoscopic nephrectomy if either early unclamping or on demand clamping are selectively applied.