Partial Nephrectomy For Hilar Tumors Research Articles

Vascular injury during laparoscopic partial nephrectomy in a solitary kidney: management, outcome and audit

BackgroundVascular injury during laparoscopic partial nephrectomy is a dreadful complication. Though it is a commonly discussed complication, the literature on the circumstances leading to vascular injury, methods of managing the complication and reporting of final outcomes in those cases are limited. We report a case of vascular injury during laparoscopic partial nephrectomy for a hilar tumor in a solitary kidney. We highlight the management of the complication, present the outcome and review the surgical technique.Case presentationA 62-year-old male with solitary kidney presented with left renal hilar mass of size 4.4 × 3.8x3.6 cm. The renal nephrometry score was 10ph. The serum creatinine at the time of presentation to the hospital was 1.4 mg/dl. Laparoscopic partial nephrectomy was performed. The patient had severe intraoperative bleeding due to a segmental renal artery injury. The bleeding presented after hilar unclamping and was managed by intracorporeal vascular repair. The blood loss was around 500 ml. The postoperative period was uneventful without the need for hemodialysis. The histopathology report was suggestive of clear cell renal cell carcinoma with negative surgical margin. The follow-up magnetic resonance urogram did not show evidence of any arterial pseudoaneurysm or residual/recurrent tumor. At 18-month follow-up, the serum creatinine was 1.9 mg/dl and the patient did not have any complaints.ConclusionsComplication of vascular injury while performing laparoscopic partial nephrectomy for complex hilar tumors should be anticipated beforehand. Contingency plans to tackle this complication must be in place before attempting the surgery. Intracorporeal repair of vascular injury during laparoscopic partial nephrectomy is feasible when expertise is available. Low threshold for using endoscopic ultrasound, employing cold ischemia techniques, careful usage of hot cut during tumor resection and complete defatting of the kidney can all be considered ‘safe surgical practices’ during laparoscopic partial nephrectomy for complex hilar tumors. Following aforementioned ‘safe surgical practices’ helps in improving the outcomes and reducing the possibility of complication of vascular injury and helps in managing the complication effectively if it happens despite the precautions.

V004 - Robot assisted partial nephrectomy for hilar tumors: Technique, perioperative, oncologic and functional outcomes from a single center series

V004 - Robot assisted partial nephrectomy for hilar tumors: Technique, perioperative, oncologic and functional outcomes from a single center series

Vessel and Tension-Free Reconstruction During Robot-Assisted Partial Nephrectomy for Hilar Tumors: "Garland" Technique and Midterm Outcomes.

Purpose: Robot-assisted partial nephrectomy (RAPN) is increasingly applied to renal hilar tumors. The present study aims to introduce our vessel and tension-free reconstruction technique and discuss the perioperative, functional, and midterm oncologic outcomes of RAPN for hilar tumors in a large cohort. Materials and Methods: We retrospectively reviewed clinical data of 286 consecutive patients with hilar tumors who underwent RAPN from June 2013 to December 2016 in our center. Our anatomy-based "Garland" technique specialized in protecting the large hilar vessels and minimizing the tension of suturing the defect via trans/retroperitoneal approaches for anterior/posterior lip hilar tumors, respectively. Results: "Garland" technique was effectively applied in 286 patients, and the warm ischemia time was 18.2 ± 4.1 minutes. Median estimated blood loss for RAPN was 100 mL (interquartile range [IQR]: 50-200 mL). Median operative time was 120 minutes (IQR: 90-150 minutes). No patient was converted to open surgery. Postoperative stay was 4.0 days (IQR: 4.0-5.0 days). Three patients (1.1%) had positive surgical margin. Two patients (0.7%) received blood transfusion. Complications occurred in 20 patients (7.0%), in which 18 patients were Clavien 1 and 2. Three patients (1.1%) had local recurrence. All patients were alive at a 48-month median follow-up (range: 24-66 months). Conclusions: "Garland" technique is safe and feasible for hilar tumor resection and kidney reconstruction. The trans/retroperitoneal approaches are options for anterior/posterior hilar tumors. Longer follow-up involving more patients is required.

Robot-Assisted Laparoscopic Partial Nephrectomy of Hilar Renal Tumor

Introduction: This video illustrates the surgical techniques in robot-assisted laparoscopic partial nephrectomy (RALPN) of a 5.3 cm hilar tumor. CT images delineated the exact location of the tumor related to the renal hilar vasculature and collecting system. The renal nephrometry score was 2 + 2 + 3+A+3. Materials and Methods: Partial nephrectomy for hilar tumors can be challenging because of the closely related hilar vasculature and collecting system. A high-quality triphasic CT is required for surgical planning. Intraoperative ultrasonography is essential for real-time confirmation of tumor margins and plane of resection. Enucleation, instead of resection with a margin, is often required especially where the tumor abuts the renal vessels, and the usual parenchymal margin is nonexistent. An open-ended ureteral catheter for methylene blue injection can facilitate the identification of the collecting system during renorrhaphy. The technique and configuration of renorrhaphy must be individualized depending upon the tumor size and relationship with other structures. A single layer renorrhaphy may be optimal in some patients. Results: Our video comes from a single surgeon series (C.P.S.) in an academic center. We reviewed the clinical outcomes of robotic partial nephrectomy for hilar tumors at our institution and compared them against the outcomes for nonhilar tumors. The data for 236 patients were analyzed, with 34 having hilar tumors and 202 having nonhilar tumors. For baseline demographics, the hilar vs nonhilar groups were similar in age (59.9 years vs 60.0 years; p = 0.96), gender (male 61.8% vs 63.9%; female 38.2% vs 36.1%; chi square p = 0.814), body mass index (31.2 vs 30.9; p = 0.78) and preoperative creatinine (1.1 mg/dL vs 1.0 mg/dL; p = 0.11), but were different in tumor size (42.3 mm vs 33.5 mm; p = 0.004). For outcomes, the hilar and nonhilar groups were similar in estimated blood loss (188.2 mL vs 242.8 mL; p = 0.17), postoperative creatinine at 1 month (1.19 vs 1.13; p = 0.47), and postoperative creatinine at 6 months (1.26 vs 1.14; p = 0.18), but were different in warm ischemic time (22.7 minutes vs 17.4 minutes; p = 0.002). The patient depicted in the video had no complications at 1 month after surgery; his renal function at 1 month returned to baseline, with a creatinine of 1.08 mg/dL and eGFR >60 mL/minute/1.73 m2. Conclusions: This video shows that RALPN can be safely performed on hilar tumors. The authors have received and archived patient consent for video recording/publication in advance of video recording of the procedure. No competing financial interests exist. Runtime of video: 9 mins 57 secs

V9-06 ROBOTIC PARTIAL NEPHRECTOMY FOR HILAR TUMORS: ZERO ISCHEMIA OR EARLY UNCLAMPING?

You have accessJournal of UrologyRobotics – Renal1 Apr 2015V9-06 ROBOTIC PARTIAL NEPHRECTOMY FOR HILAR TUMORS: ZERO ISCHEMIA OR EARLY UNCLAMPING? Benoit Peyronnet, Quentin Alimi, Tarek Fardoun, Romain Mathieu, Gregory Verhoest, and Karim Bensalah Benoit PeyronnetBenoit Peyronnet More articles by this author , Quentin AlimiQuentin Alimi More articles by this author , Tarek FardounTarek Fardoun More articles by this author , Romain MathieuRomain Mathieu More articles by this author , Gregory VerhoestGregory Verhoest More articles by this author , and Karim BensalahKarim Bensalah More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2281AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES An arterial clamping is usually performed during partial nephrectomy in order to decrease blood loss and improve vision during tumorectomy. However, it causes warm ischemia which is potentially harmful for the kidney. The concept of “zero ischemia” robotic partially nephrectomy appeared in the early 2010's. Its aim is to avoid warm ischemia time by omitting to clamp the main renal artery. The aim of this video was to compare two managements of the renal pedicle during robotic partial nephrectomy for hilar tumors: early unclamping vs. zero ischemia. METHODS We present 2 cases of robotic partial nephrectomy for complex (RENAL NEPHROMETRY score ≥ 7) and hilar tumors. In the first case, a 6 cm tumor of the left kidney has been diagnosed in a 57 year-old male. RENAL NEPHROMETRY score was 10-ph. The main renal artery was clamped with an early unclamping (unclamping after one or two running suture in the tumor bed but before parenchymal repair). In the second case, a 4 cm totally endophytic tumor of the left kidney arised in a 66 year-old male. RENAL NEPHROMETRY score was 9-h. An off-clamp technique was chosen. RESULTS In the first case, warm ischemia time was 24 minutes and estimated blood loss was 500 mL. There were no transfusions or postoperative complications. The patient was discharged on postoperative day 5. Surgical margins were negative. At 1 month postoperatively, 88% of renal function was preserved. In the second case, an important bleeding occurred during tumorectomy. First, the surgeon switched to a selective arterial clamping. The bleeding continued and the surgeon had to clamp the main renal artery. Warm ischemia time was 8 minutes and estimated blood loss was 1200 mL. There were no transfusions or postoperative complications. The patient was discharged on postoperative day 4. Surgical margins were negative. At 1 mont postoperatively, 86% of renal function was preserved. CONCLUSIONS Hilar tumors are good candidates for the “zero ischemia” techniques during robotic partial nephrectomy. However, they could lead to important bleeding that could increase the surgical morbidity and the risk of positive margins. As recent data suggest that a limited warm ischemia time (< 30 minutes) could have no impact on renal function, the early unclamping technique, which appear safer, could be the preferred option in these patients. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e776-e777 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Benoit Peyronnet More articles by this author Quentin Alimi More articles by this author Tarek Fardoun More articles by this author Romain Mathieu More articles by this author Gregory Verhoest More articles by this author Karim Bensalah More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Off-Clamp Laparoscopic Partial Nephrectomy for Hilar Tumors: Oncologic and Renal Functional Outcomes

To present our experience demonstrating the feasibility of off-clamp laparoscopic partial nephrectomy (LPN) for hilar tumors and evaluate intermediate oncologic and renal functional outcomes. A retrospective review of LPN cases in nine patients was performed. Hilar lesions were defined as renal cortical tumors in direct physical contact with the renal artery, vein, or both as identified on preoperative imaging and confirmed intraoperatively. Although the renal hilum vasculature was isolated for possible clamping if needed, tumor extirpation was performed off-clamp, eliminating warm ischemia time (WIT). The clinicopathologic parameters, perioperative course, complications, and long-term oncologic and renal functional outcomes were analyzed. Nine patients underwent off-clamp LPN for complex hilar tumors. The mean age was 60.5 years, mean American Society of Anesthesiologists physical classification (ASA) score was 2, and mean BMI was 27.7 kg/m(2). The mean tumor size and volume were 3.2 cm and 35.8 cm(3), respectively. A greater proportion of the tumors (55.6%) were endophytic and mostly of clear cell histology (78%). The mean operative time was 131 minutes, estimated blood loss 250 cc, need for transfusion 0%, and complication rates 22%. No positive margins were present intraoperatively or on final pathology. After a median follow-up of 42.8 months, there was no evidence of clinical or radiographic recurrence in any patient. There was no change in the mean estimated glomerular filtration rate preoperatively and at a median follow-up of 32 months (97.2 mL/minute vs 81.3 mL/minute; p=0.052). Complex renal hilar tumors can be successfully managed with laparoscopic nephron-sparing surgery with elimination of WIT with preservation of perioperative, renal functional, and oncologic outcomes.

Laparoscopic Partial Nephrectomy for Hilar Tumors: Oncologic and Renal Functional Outcomes

To present our experience with laparoscopic partial nephrectomy (LPN) for hilar tumors and evaluate intermediate oncologic and renal functional outcomes. A retrospective review of LPN cases performed in 488 patients was performed. Hilar lesions were defined as renal cortical tumors in direct physical contact with the renal artery, vein, or both, as identified on preoperative imaging and confirmed intraoperatively. The clinicopathologic parameters, perioperative course, complications, and oncologic and 6-month renal functional outcomes were analyzed. A total of 488 patients underwent LPN, of which 43 were hilar. The mean tumor size for hilar and nonhilar tumors was 3.6 cm and 3.1 cm, respectively. The mean operative time was shorter for hilar as compared with nonhilar tumors (129.1 minutes vs 141.8 minutes). Mean estimated blood loss was greater in LPN for hilar tumors (311.65 mL vs 298.4 mL). There were no statistically significant differences noted in any of the perioperative parameters investigated despite a higher nephrometry complexity score in the hilar group. Change in estimated glomerular filtration rate at 6 months showed a decrease of 10.9 mL/min and 8.8 mL/min for hilar and nonhilar tumors, respectively (P= NS). There was 1 recurrence detected in the hilar group, with a median follow-up of 41.6 months. In the hands of an experienced laparoscopist, LPN can safely be performed for hilar tumors, withpreservation of perioperative outcomes and durable renal functional and oncologic outcomes.

Editorial Comment

The authors describe their evolving experience with robot-assisted partial nephrectomy. Their results with relatively complex renal tumors reflect their experience and continuing refinements of their technique. They demonstrate that resection of “hilar” tumors using robot-assisted laparoscopy, in this retrospective series, is feasible and can be done with acceptable patient-related morbidity. Robot-assisted Partial Nephrectomy for Hilar Tumors: Perioperative OutcomesUrologyVol. 81Issue 6PreviewTo compare perioperative outcomes of robot-assisted partial nephrectomy (RAPN) for hilar vs nonhilar tumors. Full-Text PDF

Robot-assisted Partial Nephrectomy for Hilar Tumors: Perioperative Outcomes

To compare perioperative outcomes of robot-assisted partial nephrectomy (RAPN) for hilar vs nonhilar tumors. The study retrospectively reviewed 364 patients with available computed tomography scans undergoing RAPN. Demographic data and perioperative outcomes results were compared between the hilar (group 1, n= 70) and nonhilar tumors (group 2, n= 294). Multivariate analysis was used to identify predictors of warm ischemia time (WIT), estimated blood loss (EBL), major perioperative complications, and postoperative renal function. There were no differences with respect to demographic variables. Hilar tumors had higher RENAL (radius, exophytic/endophytic properties of the tumor, nearness of tumor deepest portion to the collecting system or sinus, anterior/posterior descriptor and the location relative to polar lines) scores (P<.001) and were larger (3.9 vs 2.6 cm, P<.001). Surgeries for hilar tumors were associated with greater operative time (210 vs 180 minutes, P<.001), longer WIT (27 vs 17minutes, P<.001), and increased EBL (250 vs 200 mL, P= .04). No differences were noted in transfusion rate, length of stay, complications (overall and major) and positive margins. Postoperative estimated glomerular filtration rate showed no significant difference between hilar vs nonhilar patients on postoperative day 3 (70.12 vs 74.71 mL/min/1.73 m(2), P= .31) or at last follow-up (72.62 vs 75.78 mL/min/1.73 m(2), P= .40), respectively. Multivariate analysis found hilar location was independently associated with increased WIT without significant changes in EBL, major complications, or postoperative renal function. RAPN represents a safe and effective procedure for hilar tumors. Hilar location for patients undergoing RAPN in a high-volume institution seems not be associated with an increased risk of transfusions, major complications, or decline of early postoperative renal function.

256 Robot assisted partial nephrectomy for hilar tumors: Perioperative outcomes

256 Robot assisted partial nephrectomy for hilar tumors: Perioperative outcomes

Laparoscopic Partial Nephrectomy for Completely Intraparenchymal Tumors

Management for intraparenchymal renal tumors represents a technical challenge during laparoscopic partial nephrectomy since, unlike exophytic tumors, there are no external visual cues on the renal surface to guide tumor localization or excision. Also, hemostatic renorrhaphy and pelvicalyceal suture repair in these completely intrarenal tumors create additional challenges. We examined the safety and technical feasibility of this procedure in this cohort. Of 800 patients who underwent laparoscopic partial nephrectomy 55 (6.9%) had completely intraparenchymal tumors. Technical steps included intraoperative ultrasound guidance of tumor resection, en bloc hilar clamping, cold excision of tumor and sutured renal reconstruction. Mean tumor size was 2.3 cm (range 1.0 to 4.5), mean blood loss was 236 cc (range 25 to 1,000) and mean warm ischemia time was 29.9 minutes (range 7 to 57). There were no positive margins. When we compared laparoscopic partial nephrectomy for intraparenchymal tumors to the same procedure in another 3 tumor groups, including completely exophytic tumors, tumors infiltrating up to sinus fat and tumors infiltrating but not up to sinus fat, there were no statistically significant differences among the groups in complications, positive margin rate, blood loss, or tumor excision or warm ischemia time. Laparoscopic partial nephrectomy for completely intrarenal tumors is a technically advanced but effective, safe procedure. Facility and experience with the technique, effective use of intracorporeal laparoscopic ultrasound and adherence to sound surgical principles are the keys to success. Most recently we have performed laparoscopic and robotic partial nephrectomy for such completely intrarenal tumors using a zero ischemia technique.

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.

The R.E.N.A.L. Nephrometry Score: A Comprehensive Standardized System for Quantitating Renal Tumor Size, Location and Depth

Treatment decisions for renal malignancies depend largely on qualitative data, including a description of tumor anatomy and the experience of the treating surgeon. Currently characterization of renal tumor anatomical elements is descriptive and lacks standardization. Surgical decision making and data set comparisons would be significantly enhanced by a consistent, reproducible system that quantitates the pertinent characteristics of localized renal lesions. We have developed and propose a standardized nephrometry scoring system (R.E.N.A.L. Nephrometry Score) to quantify the anatomical characteristics of renal masses on computerized tomography/magnetic resonance imaging. The nephrometry score is based on 5 critical and reproducible anatomical features of solid renal masses. Of the 5 components 4 are scored on a 1, 2 or 3-point scale with the 5th indicating the anterior or posterior location of the mass relative to the coronal plane of the kidney. We applied the R.E.N.A.L. Nephrometry Score to 50 consecutive masses resected at Fox Chase Cancer Center. The R.E.N.A.L. Nephrometry Score consists of (R)adius (tumor size as maximal diameter), (E)xophytic/endophytic properties of the tumor, (N)earness of tumor deepest portion to the collecting system or sinus, (A)nterior (a)/posterior (p) descriptor and the (L)ocation relative to the polar line. The suffix h (hilar) is assigned to tumors that abut the main renal artery or vein. The nephrometry scoring system accurately classified the complexity of 50 consecutive tumors undergoing excision at our institution. Standardized reporting of renal tumor size, location and depth is essential for decision making and effective comparisons. The R.E.N.A.L. Nephrometry Score is a reproducible standardized classification system that quantitates the salient anatomy of renal masses. This novel approach for the systematic characterization of renal tumors provides a tool for meaningful comparisons of renal masses in clinical practice and in the urological literature.

Laparoscopic Partial Nephrectomy for Hilar Tumors: Technique and Results

BackgroundLaparoscopic partial nephrectomy for hilar tumors is a cutting edge procedure for which little data is available in the current literature. ObjectiveTo describe our technique and results of laparoscopic partial nephrectomy for renal hilar tumors. Design, Setting, and ParticipantsBetween April 2000 and September 2006, 94 partial laparoscopic nephrectomies were performed at our institution. A total of 18 (19.1%) patients had hilar tumors. A hilar tumor was defined as a lesion suspicious for renal cell carcinoma in contact with a major renal vessel on preoperative cross-sectional imaging. In 3 (16.7%) of the patients, the indication for nephron-sparing surgery was imperative. Mean tumor size was 3cm (range, 2–4.5). Eight (44.4%) surgeries were performed with renal artery perfusion for cold ischemia; the remaining surgeries were performed under warm ischemia. Intervention(s)After occluding the renal artery and controlling the renal vein by using separate rubber band tourniquets, we excised the tumor mass including delicate mobilization away from the blood vessels. Although we used to insert a ureteral stent at the beginning of our experience with laparoscopic partial nephrectomies, we no longer do so. All surgeries were performed by a single urologist (G.J.). MeasurementsOperative time, ischemia time, blood loss, renal function using the Cockroft formula as well as renal scans, operative and post-operative complications, pathology parameters. Results and LimitationsAll surgeries were completed laparoscopically. Mean surgical time was 238min (range, 150–420). Mean ischemia times were 42.5min (range, 27–63) and 34.1min (range, 24–56) for the cold and warm ischemia groups, respectively. Estimated intraoperative blood loss was 165ml (range, 50–500). There were two (11%) entries into major vessels during tumor excision, namely a segmental renal artery in one patient and a segmental renal vein in another. Both of these occurrences were managed laparoscopically. One patient necessitated laparoscopic reexploration for urine extravasation in the immediate postoperative period. All postoperative nuclear scans (available in 12 of 18 patients) showed functional kidney moiety. Mean split renal function was 38.6% (range, 24–50) on the operated side. Histopathological examination confirmed renal cell carcinoma in 14 (77.8%) of the patients. One (7.1%) patient had a positive surgical margin on the surface that was adjacent to the renal artery. In a median follow-up of 26 mo (range, 1–59), no local recurrence or systemic progression occurred. ConclusionLaparoscopic partial nephrectomy for hilar tumors is a feasible and safe procedure in the hands of experienced laparoscopic surgeons. Oncological results seem excellent, but further follow-up is needed for accurate long-term assessment of this surgical approach.

Laparoscopic Partial Nephrectomy for Hilar Tumors: Evaluation of Short-Term Oncologic Outcome

To present our experience performing laparoscopic partial nephrectomy (LPN) for hilar renal tumors and demonstrate the feasibility and short-term oncologic efficacy. The patients who had undergone LPN for excision of a hilar tumor, defined as a renal tumor that came in direct contact with the renal artery and/or vein, were identified. The clinicopathologic parameters, perioperative course, complications, and oncologic outcomes were analyzed. A total of 18 patients with a hilar renal mass (4.4%) underwent elective LPN. The mean tumor size was 3.24 cm (range 1.3 to 8), and the mean preoperative creatinine was 1.04 mg/dL (range 0.6 to 1.8). The mean operating room and warm ischemia time was 173 minutes (range 93 to 337) and 29.4 minutes (range 17 to 50), respectively. The pelvicaliceal system was entered and repaired in 10 patients (55.6%), and the median estimated blood loss was 394.4 mL (range 100 to 1500). The mean hospital stay was 3 days (range 2 to 5). Histopathologic examination confirmed renal cell carcinoma in 13 patients (72.2%). The surgical margins and frozen sections of the tumor base were negative in all cases. The tumor stage was pT1 in 11 patients (85%), pT2 in 1 patient (7.7%), and pT4 in 1 patient (7.7%). The mean postoperative creatinine was 1.2 mg/dL (range 0.6 to 2.3). Postoperative transfusion was required in 4 patients (22.2%), including 1 patient who required intraoperative transfusion (5.5%) and 1 who required angioembolization (5.5%). During a mean follow-up of 12.3 months (range 0.2 to 66), no patient had evidence of local recurrence or metastatic disease. Experienced laparoscopic surgeons can safely perform LPN for hilar renal tumors. The short-term oncologic results have been promising; however, long-term follow-up is necessary.

Temporary Renal Ischemia During Nephron Sparing Surgery is Associated With Short-Term but Not Long-Term Impairment in Renal Function

The emergence of laparoscopic nephron sparing surgery has rekindled interest in the impact of warm renal ischemia on renal function. To provide data with which warm renal ischemia can be compared we analyzed short-term and long-term changes in the glomerular filtration rate after temporary cold renal ischemia. In patients undergoing open nephron sparing surgery the estimated glomerular filtration rate was assessed preoperatively, early in the postoperative hospital stay, and 1 and 12 months after surgery using the abbreviated Modification of Diet in Renal Disease Study equation. We separately analyzed 70 patients with a solitary kidney and 592 with 2 functioning kidneys. The end point was the percent change from the baseline glomerular filtration rate. A linear regression model was used to test the association between the glomerular filtration rate change, and ischemia time, patient age, tumor size, estimated blood loss and intraoperative fluid administration. Median cold ischemia time was 31 minutes in patients with a solitary kidney and 35 minutes in those with 2 kidneys. Compared to patients with 2 kidneys those with a solitary kidney had a significantly lower preoperative estimated glomerular filtration rate (p < 0.001), which decreased a median of 30% during the early postoperative period, and 15% and 32% 1 and 12 months after surgery, respectively. In patients with 2 kidneys the corresponding glomerular filtration rate decreases were 16%, 13% and 14%, respectively. On multivariate analyses in each group cold ischemia duration and intraoperative blood loss were significantly associated with early glomerular filtration rate changes. However, 12 months after surgery age was the only independent predictor of a glomerular filtration rate decrease in patients with 2 kidneys. Cold renal ischemia during nephron sparing surgery is a significant determinant of the short-term postoperative glomerular filtration rate. Longer clamping time is particularly detrimental in patients with a solitary kidney but it does not appear to influence long-term renal function. Patients of advanced age may be less likely to recover from acute ischemic renal injury.

Laparoscopic Partial Nephrectomy in Solitary Kidney

We report our experience with LPN for tumor in a solitary kidney. Of 430 patients undergoing LPN since February 1999 at our institution 22 (5%) underwent LPN for tumor in a solitary kidney, as performed by a single surgeon. The laparoscopic technique that we used duplicated open principles, including hilar clamping, cold cut tumor excision and sutured renal reconstruction. Mean tumor size was 3.6 cm (range 1.4 to 8.3, median 3 cm), median blood loss was 200 cc (range 50 to 500), warm ischemia time was 29 minutes (range 14 to 55), total operative time was 3.3 hours (range 2.2 to 4.5) and hospital stay was 2.8 days (range 1.3 to 12). Two cases (9%) were electively converted to open surgery. Pathological findings confirmed renal cell carcinoma in 16 patients (73%) with negative surgical margins in all those with LPN. Major complications occurred in 3 patients (15%) and minor complications developed in 7 (32%). Median preoperative and postoperative serum creatinine (1.2 and 1.5 mg/dl) and estimated glomerular filtration rate (67.5 and 50 ml per minute per 1.73 m2) reflected a change of 33% and 27%, respectively, which appeared proportionate to the median amount of kidney parenchyma excised (23%). One patient (4.5%) required temporary hemodialysis. At a median followup of 2.5 years (range 0.5 to 4.5) cancer specific and overall survival was 100% and 91%, respectively. No patient with LPN had local or port site recurrence, or metastatic disease. LPN can be performed efficaciously and safely in select patients with tumor in a solitary kidney. To our knowledge we present the largest series in the literature. Advanced laparoscopic experience and expertise are necessary in this high risk population.

LAPAROSCOPIC PARTIAL NEPHRECTOMY FOR HILAR TUMORS

Partial nephrectomy for hilar tumors represents a technical challenge not only for laparoscopic, but also for open surgeons. We report the technical feasibility and perioperative outcomes of laparoscopic partial nephrectomy (LPN) for hilar tumors. Between January 2001 and September 2004, 25 of 362 patients (6.9%) undergoing LPN for tumor, as performed by a single surgeon, had a hilar tumor. We defined hilar tumor as a tumor located in the renal hilum that was demonstrated to be in actual physical contact with the renal artery and/or renal vein on preoperative 3-dimensional computerized tomography. En bloc hilar clamping with cold excision of the tumor, including its delicate mobilization from the renal vessels, followed by sutured renal reconstruction was performed routinely. Laparoscopic surgery was successful in all cases without any open conversions or operative re-interventions. Mean tumor size was 3.7 cm (range 1 to 10.3), 4 patients (16%) had a solitary kidney and the indication for LPN was imperative in 10 patients (40%). Pelvicaliceal repair was performed in 22 patients (88%), mean warm ischemia time was 36.4 minutes (range 27 to 48), mean blood loss was 231 cc (range 50 to 900), mean total operative time was 3.6 hours (range 2 to 5) and mean hospital stay was 3.5 days (range 1.5 to 6.7). Histopathology confirmed renal cell carcinoma in 17 patients (68%), of whom all had negative margins. In 2002 or earlier hemorrhagic complications occurred in 3 patients (12%). No kidney was lost for technical reasons. LPN can be performed in select patients with a hilar tumor. The technical feasibility reported further extends the scope of LPN. To our knowledge the initial experience in the literature is reported.