Technique Of Nephrectomy Research Articles

Risk factors for acute renal failure in nephrectomized patients treated in a university hospital.

BackgroundNew surgical techniques for nephrectomy mainly related to early diagnosis made possible by advances in imaging studies have been developed in recent decades. However, postoperative renal dysfunction is a constant concern because of the major problems faced by healthcare services and by the patients themselves. To assess risk factors for developing acute renal failure (ARF) in patients submitted to nephrectomy in a university hospital.MethodsSeventy-seven patients submitted to nephrectomy for benign and malignant diseases in a university hospital were evaluated in respect to preoperative and postoperative creatinine clearance. Demographic (gender, age), clinical (cancer, diabetes, high blood pressure, chronic kidney disease) and surgical (anesthesia time, open or laparoscopic surgery) variables were also analyzed.ResultsOf the 77 patients, 72 met the inclusion criteria. Of these, ten (13.8%) had a diagnosis of chronic renal failure (CRF), 30 (48%) had stage I ARF and one (16.1%) had stage II ARF. The anesthesia time, type of surgery (open or laparoscopy), total or partial nephrectomy, the side of the procedure, hypertension, diabetes, CRF, renal cancer, preoperative and postoperative creatinine concentrations were analyzed. Only the difference between preoperative and postoperative creatinine clearance was clinically significant (P<0.001).ConclusionsAn altered preoperative renal function is a risk factor for the development of ARF in nephrectomized patients.

Preventive hemostatic suture during open kidney resection as an option to preserve the renal function

Introduction . Renal cancer is one of the leading urological cancers due to annually increasing morbidity and mortality rates. Objective: to prove the efficiency of preventive hemostatic sutures during partial nephrectomy for maximal preservation of functional renal parenchyma in patients with renal cell carcinoma. Materials and methods. We developed and implemented a new technique of partial nephrectomy with preventive hemostatic suture, that allows not to clamp the renal pedicle, even in case of central tumor location. Main benefit of this technique is minimization of kidney function loss after the operation, which is the major aim of nephron sparing surgery. Study included 150 patients with pT1a–pT2bN0M0 kidney cancers. Central tumor location was in 64 patients, 45 patients had upper segment tumors and 41 lower segment tumors. 74 patients had T1a tumor stage, T1b and T2a stage observed in 53 and 4 patients respectively. Nineteen patients were diagnosed with cystic carcinoma. To evaluate renal function, dynamic nephroscintigraphy was carried out and volume indices were calculated by computed tomography data. Results. All patients underwent nephron sparing surgery using preventive hemostatic sutures. Mean operative time was 180 ± 40 minutes, mean anesthesia time was 190.5 ± 15.0 minutes. Mean blood loss was 250 ± 70 ml. We didn’t used arteria clamping and warm ischemia and there was no conversions to nephrectomy during all partial nephrectomies. Perfusion index of the kidney before the surgery was 54.13 ± 2.00 %, after the surgery 46.23 ± 3.00 %, renal index was 53.24 ± 4.00 % and 46.82 ± 2.39 %, respectfully. In our opinion decreasing of renal indexes in early postoperative period is associated with loss of kidney parenchyma due to the surgery. Mean kidney volume was 140 ± 30 cm3 with 120 ± 20 см3 functional parenchyma volume and mean tumor volume 40 ± 20 сm3. Functional parenchyma volume after surgery insignificantly decreased to 115 ± 20 сm3. Conclusion. Preventive hemostatic sutures during partial nephrectomy allows to remove the tumor in almost any part of the kidney. Rejection of renal hilum clamping minimizes ischemical damages of renal parenchyma.

The results of organ-preserving treatment of patients with localized renal cell carcinoma according to the original methodology

The article presents results of treatment of patients with localized renal cell carcinoma using the original technique of open partial nephrectomy. This technique involves the use of intraoperative ultrasonoscopy to define and mark the boundaries of the tumor and the method of creating a zone of local ischemia to resection the tumor without the use of total renal ischemia. The developed methodology in the comparative analysis of the immediate and remote results significantly (p &gt; 0.05) reduces the amount of intraoperative blood loss without increasing the duration of the operation, reduces the risk of development of acute disorders of renal function in the early postoperative period, without compromising kidney function in the late postoperative period. This technique is comparable to the classical open radical resection of the kidney, does not affect the overall, oncospecific and relapse-free survival.

Optimising renal cancer patients for nephron-sparing surgery: a review of pre-operative considerations and peri-operative techniques for partial nephrectomy.

Nonmodifiable factors including pre-operative renal function and amount of healthy renal tissue preserved are the most important predictive factors that determine renal function after partial nephrectomy. Ischaemia time is an important modifiable risk factor and cold ischaemia time should be used if longer ischaemia time is anticipated. New techniques may have a role in maximising postoperative kidney function, but more robust studies are required to understand their potential benefits and risks.

Use of Nonmuscle Cutting Lumbotomy Incision for Single Site Laparoscopic Retroperitoneal Donor Nephrectomy: A Novel Approach

Introduction: Laparoscopic donor nephrectomy has become the standard method of retrieval of donor kidneys from living donors. However, it has the disadvantage of breaching the peritoneal cavity with attendant risks of injury to intraperitoneal organs as well as long-term risk of adhesive intestinal obstruction. Retroperitoneal laparoscopic donor nephrectomy (RPLDN) is not popular, as it requires a muscle cutting incision for retrieval of donor kidney, thereby minimizing the benefits of laparoscopy. However, a single port RPLDN performed through lumbotomy can provide a nearly ideal approach to donor kidneys.1 This study provides the first experience in the literature of performing a single port RPLDN through lumbotomy incision. Methods: Between November 2014 and December 2015, 231 patients underwent laparoscopic donor nephrectomy at our institute. Of the 231 patients, 50 voluntary kidney donors were offered translumbar RPLDN. And 12 of the 50 patients consented for single port translumbar RPLDN. Mean donor age was 39.6±7.7, M:F 3:9, left: right 10:2, and mean body mass index was 21.86±2.64. Technique of nephrectomy—Kidney was approached through 6 cm curved lumbotomy incision nearly parallel to sacrospinalis muscle with donor in lateral position. Alexis® port with rubber glove was used as a single port with two 10 mm and two 5 mm ports placed in the finger of gloves.2 Renal vessels and ureter were ligated with double Hemolok® clips as a standard policy for all donors at our institute. Kidney was taken out through the Alexis retractor after removing the glove. Visual analogue score (VAS) was used to evaluate severity of pain in the postop period. Results: RPLDN was effectively carried out in all patients. No patient required conversion to open or transperitoneal approach. An additional port for retraction was required in the two of the first three cases. No special angulated instruments were required. Only one patient had double renal artery (8.3%) and all patients had single renal vein and ureter. No intra/perioperative complications were encountered. Mean operating time was 200.7+65 minutes (range 130–322). There was significant reduction in operative time after the initial experience. Mean warm ischemia time was 5+1.28 minutes (range 3–8 minutes). Average blood loss during surgery was 55.4+18 mL (range 30–100 mL). Mean graft kidney weight was 129.5+25 g (range 85–168 g). Mean analgesic requirement (tramadol) in postoperative period was 281.8+189.4 mg (range 100–800 mg). Mean VAS on postop day (POD) 0 and POD 1 was 5.6+1.5 and 3.9+0.9, respectively. Mean hospital stay was 2.5 days (range 2–3 days). All recipients had good initial renal function and the mean creatinine at discharge was 1.34+0.4 mg/dL. Conclusions: Single site translumbar RPLDN is a feasible alternative approach to donor surgery and can avoid inherent risks associated with the transperitoneal technique. A larger comparative study is required to know the potential benefits of this route over the transperitoneal approach. No competing financial interests exist. Runtime of video: 9 mins 58 secs

Zero ischaemia partial nephrectomy: a call for standardized nomenclature and functional outcomes.

Nephron-sparing surgery for the removal of small renal masses delivers equivalent oncological outcomes and better functional outcomes compared with those associated with radical nephrectomy. All contemporary partial nephrectomy techniques including open, laparoscopic and robotic approaches involve the use of hilar clamping in order to facilitate haemostasis, and to enable accurate tumour excision and parenchymal reconstruction. Zero ischaemia was subsequently introduced as a technique to eliminate the renal ischaemia induced by hilar clamping. Following the introduction of zero ischaemia techniques, researchers have arbitrarily applied this term to techniques ranging from no use of clamping to selective clamping of renal arteries and/or veins, or their branches. Substantial variations exist in the way that zero ischaemia and other renal preservation techniques are described in the literature. Similarly, further diversity exists in the measurement and reporting of functional outcomes after surgery. The introduction of standard and reproducible classifications or guidelines will ensure consistency and uniformity. Establishing consensus on the terminology used to describe techniques and functional outcomes will not only facilitate improved communication and surgical practice, but will also enable critical appraisal of surgical techniques.

“Zero-Ischemia” Laparoscopic-assisted Partial Nephrectomy for the Management of Selected Children With Wilms Tumor Following Neoadjuvant Chemotherapy

To describe the experience and technique of zero-ischemia laparoscopic-assisted partial nephrectomy at The Hospital for Sick Children, as an alternative to the traditional open approach for nephron-sparing surgery (NSS) in selected children with Wilms tumor (WT). Patients with diagnosis of WT treated with neoadjuvant chemotherapy and who underwent laparoscopic-assisted NSS at the Hospital for Sick Children from 2012 to 2016 were identified and their charts were reviewed retrospectively. Patients underwent laparoscopic exploration, lymph node sampling, kidney mobilization, vascular control, and adrenal sparing. This was followed by open NSS through a small flank incision; no clamping of the hilum or major renal branches was performed. Six patients were identified; all patients underwent successful resection. One patient required radical nephrectomy due to inability to safely define negative margins. Tumors ranged in size from 0.9 to 5.6 cm in diameter. Mean operating time was 293 ± 50.2 minutes, with an average duration of pneumoperitoneum of 216 ± 27 minutes. Intraoperative blood loss was negligible. No tumor spillages occurred. Postoperative pathology revealed negative margins in all resected specimens. One case of urine leak occurred postoperatively, which resolved spontaneously. Renal function was preserved in all children. At a mean follow up of 11.5 months, all patients have been recurrence free. The herein presented strategy allows for safe nephron-sparing resection of selected WT with acceptable morbidity, good short-term disease-free survival, and potentially better cosmesis and recovery than traditional open surgery. This preliminary experience suggests that minimally invasive options for NSS in children merit further evaluation.

The Authors' Reply.

We are grateful to Prof. Wadström for commenting on our recent manuscript on the long-term outcomes with 3 different laparoscopic donor nephrectomy (LDN) techniques at the University of Minnesota. It is evident that the group at Karolinska University Hospital has advanced our knowledge of the retroperitoneoscopic LDN (RP-LDN). As Prof. Wadström indicates, our incidence of postoperative ileus and incisional hernia was 3% to 4% and 1% to 4%, respectively. By contrast, in one of the largest series in the literature with RP-LDN, Wadström et al1 did not observe a single case of postoperative ileus and a 0.4% hernia rate in 413 patients. Of interest, this was a multi-institutional study that included 4 different centers and significant differences were noted in the learning curve of the technique between centers. Conceptually, there are theoretical advantages of RP-LDN, namely, direct hilar access, avoidance of intraabdominal organ mobilization, and ease of access in a hostile abdomen. We acknowledge that RP-LDN has the potential to reduce postoperative ileus and intraabdominal adhesions as a result of the avoidance of intraperitoneal (IP) entry. However, despite these advantages, RP-LDN has not been adopted widely. Two recent review articles comparing techniques in LDN concluded that RP-LDN appears to be associated with fewer postoperative complications.2,3 Both articles acknowledge the poor quality and considerable heterogeneity of the included studies. For instance, in their meta-analysis He et al3 reviewed 55 articles on the IP LDN and compared them with only 6 articles on the RP-LDN. Thus, the Karolinska University Hospital experience has not been consistently reproduced by other groups. In our limited and anecdotal experience, we found RP-LDN to be a useful adjunct; however, one that was not easily replicated in the setting of a transplant surgery training program. In our article, we emphasized our diverse experience with LDN as a component of an abdominal transplant surgery fellowship where fellows play an integral role in the kidney program. We speculate that part of our initial reservations with RP-LDN were due to the ease with which fellows could adopt the IP LDN technique. Also, considering that in the current general surgery training paradigm, surgery residents are exposed to extensive IP laparoscopy and are therefore familiar with the logistics of the technique, it is not surprising why RP-LDN was not embraced. These observations are corroborated by a recent study from China, where Ma et al4 explored the learning curve of RP-LDN. They report a 23% complication rate in their first 40 cases. By contrast, we recently presented our experience with teaching transplant surgery fellows the hand-assisted LDN and found that fellows learn the procedure by approximately 36 cases with an estimated complication rate of 3.2%.5 In summary, we acknowledge that RP-LDN is a useful technique in the LDN armamentarium. In certain clinical situations, namely, those in which IP access raises the risks of the procedure, RP-LDN may prove especially valuable. However, we caution that widespread experience with this procedure is limited, and the theoretical advantages have not been reproducibly documented.

Laparoscopic retroperitoneal partial nephrectomy using an ergonomic chair: demonstration of technique and matched-pair analysis.

To present the technique and long-term results of retroperitoneal laparoscopic partial nephrectomy (LPN), focusing on the impact of an ergonomic platform. Between January 2000 and May 2016, 287 patients (193 men, 94 women) underwent LPN performed by four surgeons. The median (range) patient age was 59 (19-85) years, tumour size 3.1 (1-9) cm and PADUA score 7.3 (6-12). Access was retroperitoneal in 235 cases (82%). Since October 2010, we have used the ETHOS™ chair (ETHOS™ , Seattle, WA, USA) during excision of the tumour in 130 patients (45.3%). A total of 51 tumours (17.7%) were excised without ischaemia and 226 (78.7%) under warm ischaemia, with clamping of the renal artery using an enucleo-resection technique. We suture the resection bed and perform renorrhaphy using a barbed-suture pre-loaded with absorbable LAPRA-TY™ clips (Ethicon, Somerville, NJ, USA). The impact of the ETHOS chair was examined using a matched-pair analysis (66 with ETHOS chair vs 67 without ETHOS chair). The median (range) operating time was 146 (60-325) min, the median (range) estimated blood loss was 99 (10-3 000) mL and the mean (range) warm ischaemia time (WIT) was 17.1 (7-47) min. Histology showed 240 (83.6%) renal cell carcinomas (RCCs) and 46 (15.9%) benign tumours. The cumulative overall disease-free survival rate after a median (range) follow-up of 84 (3-155) months was 100% for 203 pT1 RCCs and local recurrence was observed in one patient (0.4%), who was managed by radical nephrectomy. There were two conversions (0.7%) to open surgery, both to hand-assisted laparoscopy. Perirenal haematoma was observed in 13 patients (4.5%). A total of 20 patients (6.9%) required transfusions (2-11 units). We observed five urine leaks (1.7%) requiring prolonged drainage. The median (range) length of hospital stay was 5 (3-24) days. Three patients developed arteriovenous fistulas, which were successfully occluded by superselective embolization (1.0%). Use of the ETHOS chair resulted in shorter operating time (134.7 vs 168.5 min; P = 0.04), including WIT (13.1 vs 15.9 min; P = 0.01), and a lower complication rate (15 vs 29.8%; P = 0.02). Laparoscopic partial nephrectomy is technically difficult but oncologically effective. Standardization and simplification of endoscopic suturing using the ETHOS chair significantly improved the outcomes of the surgical procedure.

Robotic-assisted laparoscopic radical nephrectomy using the Da Vinci Si system: how to improve surgeon autonomy. Our step-by-step technique.

Herein, we describe several steps to improve surgeon autonomy during a Left Robotic-Assisted Laparoscopic Radical Nephrectomy (RALRN), using the Da Vinci Si system. Our kidney cancer program is based on 2 community hospitals. We use the Da Vinci Si system. Access is obtained with the following trocars: Two 8mm robotic, one 8mm robotic, bariatric length (arm 3), 15mm for the assistant and 12mm for the camera. We use curved monopolar scissors in robotic arm 1, Bipolar Maryland in arm 2, Prograsp Forceps in arm 3, and we alternate throughout the surgery with EndoWrist clip appliers and the vessel sealer. Here, we described three steps and the use of 3 robotic instruments to improve surgeon autonomy. Step 1: the lower pole of the kidney was dissected and this was retracted upwards and laterally. This maneuver was performed using the 3rd robotic arm with the Prograsp Forceps. Step 2: the monopolar scissors was replaced (robotic arm 1) with the robotic EndoWrist clip applier, 10mm Hem-o-Lok. The renal artery and vein were controlled and transected by the main surgeon. Step 3: the superior, posterolateral dissection and all bleeders were carefully coagulated by the surgeon with the EndoWrist one vessel sealer. We have now performed 15 RALRN following these steps. Our results were: blood loss 300cc, console time 140min, operating room time 200min, anesthesia time 180min, hospital stay 2.5days, 1 incisional hernia, pathology: (13) RCC clear cell, (1) chromophobe and (1) papillary type 1. Tumor Stage: (5) T1b, (8) T2a, (2) T2b. We provide a concise, step-by-step technique for radical nephrectomy (RN) using the Da Vinci Si robotic system that may provide more autonomy to the surgeon, while maintaining surgical outcome equivalent to standard laparoscopic RN.

MP41-08 COMPARISON OF PERIOPERATIVE OUTCOMES WITH OR WITHOUT RENORRHAPHY IN OPEN PARTIAL NEPHRECTOMY: A PROPENSITY SCORE-MATCHED STUDY

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy I1 Apr 2016MP41-08 COMPARISON OF PERIOPERATIVE OUTCOMES WITH OR WITHOUT RENORRHAPHY IN OPEN PARTIAL NEPHRECTOMY: A PROPENSITY SCORE-MATCHED STUDY Hidekazu Tachibana, Toshio Takagi, Junpei Iizuka, Tsunenori Kondo, and Kazunari Tanabe Hidekazu TachibanaHidekazu Tachibana More articles by this author , Toshio TakagiToshio Takagi More articles by this author , Junpei IizukaJunpei Iizuka More articles by this author , Tsunenori KondoTsunenori Kondo More articles by this author , and Kazunari TanabeKazunari Tanabe More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.175AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To preserve renal function after partial nephrectomy, various renorrhaphy techniques have been presented. However, any renorrhaphy technique may damage intraparenchymal vessels and compress the renal parenchyma, which may lead to renal artery pseudoaneurysm or vascularized parenchymal volume reduction. We therefore adopted a non-renorrhaphy technique in 2012 to avoid these issues. Using propensity score matching, we compared surgical outcomes of the non-renorrhaphy and renorrhaphy techniques for open partial nephrectomy for T1a renal tumors. METHODS We retrospectively analyzed data from 159 patients with normal contralateral kidneys who underwent open partial nephrectomy for T1a renal tumors and pre- and postoperative enhanced computed tomography between 2012 and 2015. Patient variables, including age, sex, body mass index, presence of hypertension and/or diabetes mellitus, performance status, tumor size, RENAL nephrometry score, and preoperative estimated glomerular filtration rate (eGFR), were adjusted using 1:1 propensity score matching between the renorrhaphy and non-renorrhaphy groups. For the renorrhaphy technique, we coagulated the surface of the resected renal parenchyma with monopolar soft coagulation after pressing a TachoSil tissue-sealing sheet on the resected bed for 10 minutes. RESULTS We matched 43 patients per group. Operative time, estimated blood loss, cold ischemic time, and postoperative hospital stay were not significantly different between the groups. Urine leakage occurred in 9 non-renorrhaphy cases and 1 renorrhaphy case (2.3% vs. 20%, P = 0.02). Renal artery pseudoaneurysm (RAP) occurred in 6 renorrhaphy cases but in 0 non-renorrhaphy cases (13% vs. 0%, P = 0.02). Postoperative eGFR decreased significantly less in the non-renorrhaphy group than in the renorrhaphy group (-11% vs. -1.5%, P = 0.04). CONCLUSIONS Despite the risk of urine leakage, the non-renorrhaphy technique compared to the renorrhaphy technique resulted in a lower risk of RAP and better preservation of eGFR for T1a renal tumors. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e562-e563 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Hidekazu Tachibana More articles by this author Toshio Takagi More articles by this author Junpei Iizuka More articles by this author Tsunenori Kondo More articles by this author Kazunari Tanabe More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

V9-11 ROBOTIC PARTIAL NEPHRECTOMY FOR COMPLETELY ENDOPHYTIC RENAL MASSES: VARIATIONS IN SURGICAL TECHNIQUE

You have accessJournal of UrologyRobotics - Renal1 Apr 2016V9-11 ROBOTIC PARTIAL NEPHRECTOMY FOR COMPLETELY ENDOPHYTIC RENAL MASSES: VARIATIONS IN SURGICAL TECHNIQUE Daniel Ramirez, Matthew J. Maurice, Peter A. Caputo, Ryan J. Nelson, Ercan Malkoc, Onder Kara, and Jihad H. Kaouk Daniel RamirezDaniel Ramirez More articles by this author , Matthew J. MauriceMatthew J. Maurice More articles by this author , Peter A. CaputoPeter A. Caputo More articles by this author , Ryan J. NelsonRyan J. Nelson More articles by this author , Ercan MalkocErcan Malkoc More articles by this author , Onder KaraOnder Kara More articles by this author , and Jihad H. KaoukJihad H. Kaouk More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1202AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Robotic partial nephrectomy (RPN) for completely endophytic renal masses is feasible with increased robotic surgical experience. In this video we demonstrate our surgical technique for robotic partial nephrectomy, focusing on the technical variations for RPN for completely endophytic tumors. METHODS Between June 2006 and August 2015, our institution performed 1,123 partial nephrectomies. 130 were performed for completely endophytic renal tumors. We present 2 patients with completely endophytic, central renal masses who underwent RPN, one in the left kidney and one in the right. Our approach to surgical removal of completely endophytic renal tumors includes the use of intraoperative ultrasound to delineate the margins of the mass, initial shallow angle of resection to improve visualization of the parenchymal margin and tumor base, and correction of excision trajectory at the renal sinus. This technique is described in detail in our video presentation. RESULTS Of the 1,123 RPN performed at our institution over the last 10 years, 11.6% were performed for completely endophytic renal masses. Mean operative time, warm ischemia and estimated blood loss in this cohort were 180 minutes, 24.5 minutes, and 197 cc, respectively. Minor complicate rate in this group was 13.9%, while major complication rate was 13.9%. 7 patients in this group had positive margins (5.4%). Successfully surgical extirpation of completely endophytic renal masses is optimized by an initially shallow incision in order to obtain a clear view of the parenchymal edge and base of tumor. Once the sinus fat and collecting system are exposed, the trajectory of the excision is corrected and the sides and back of the tumor are excised in a step-wise, circumferential fashion. CONCLUSIONS RPN for completely endophytic renal tumors is feasible and necessitates technical variations in excision in order to optimize outcomes. Excision of the tumor should be performed in a step-wise systematic fashion with a shallow initial incision to improve visualization into the renal defect and to avoid cutting into the tumor. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e863 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Daniel Ramirez More articles by this author Matthew J. Maurice More articles by this author Peter A. Caputo More articles by this author Ryan J. Nelson More articles by this author Ercan Malkoc More articles by this author Onder Kara More articles by this author Jihad H. Kaouk More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Robotic Level III IVC Tumor Thrombectomy: Duplicating the Open Approach

To describe our surgical technique for robotic radical nephrectomy and thrombectomy for renal cell carcinoma and associated level III inferior vena cava (IVC) thrombus with retroperitoneal lymph node dissection. The patient is a 75-year-old Caucasian man with a 10-cm right renal neoplasm and associated level III tumor thrombus. After preoperative imaging was reviewed, a robotic approach was planned. Real-time intraoperative transesophageal ultrasonography was performed to assess the cranial extent of tumor thrombus. The major steps of our technique include early inter-aortocaval control of the right renal artery, circumferential mobilization of the IVC, contralateral renal vein control, cavotomy, thrombectomy, and reconstruction of the IVC. Operative time was 5 hours and 53 minutes (353 minutes) with 150 mL estimated blood loss. The patient was allowed to have a clear liquid diet immediately after surgery and was discharged home on postoperative day 3. Final pathology demonstrated a 9.8-cm clear cell renal cell carcinoma, nuclear grade 3 with a pT3bN1 stage. With adequate team experience and preparation, robotic radical nephrectomy and IVC tumor thrombectomy for level III tumor thrombus is challenging but feasible in select patients. Herein we describe our robotic technique which duplicates the open approach. This minimally invasive approach may offer lower estimated blood loss, improved pain control, and expedited recovery.

Role of Robotic Partial Nephrectomy in the Treatment of Eenal Cell Carcinoma

Abstract This article lays an emphasis on the Role of Robotic Partial Nephrectomy in the treatment of renal cell carcinoma. The increasing radiological detection of histological low-grade low-stage renal masses has presented a challenging task to the practising urologist. Nephron sparing surgery (NSS) not only preserves the kidney but also allows safe removal of tumour of unknown malignant potential without removing the kidney. Advent of robotic technology and evolution of surgical technique together have offered to serve patients with these tumours, yet a large number of which are asymptomatic at the time of diagnosis. Centres which have the facility for robotic surgery have been offering partial nephrectomy to patients with more and more challenging nephrometric scores. On the other hand, radical nephrectomy is being offered to a large proportion of patients with tumours otherwise suitable for NSS. Advances in technology like firefly and intra operative real time ultrasound have further refined the technique of Robotic Partial Nephrectomy.

Training techniques in laparoscopic donor nephrectomy: a systematic review.

The learning curve to achieve competency in laparoscopic donor nephrectomy (LDN) is poorly outlined. Online databases were searched for training in LDN. Abstracts and manuscripts were excluded if they did not address introduction of a laparoscopic technique for donor nephrectomy. Relevant manuscripts were reviewed for surgical technique, use of animal models, co-surgeons, surgeon specialty and training, institution type/volume, and assessment of training method. Forty-four met inclusion criteria, with 75% describing the evolution from open to LDN. Eighty-two percent were from academic centers, and 36% were from centers performing <25 donor nephrectomies each year. The learner was an attending surgeon 80% of the time, mostly urologists with prior laparoscopy or open nephrectomy experience. The learning curve, defined by decreased operating time, averaged 35 cases. Improved intra-operative, patient, and recipient outcomes were observed for centers performing ≥50 LDNs annually. The United Network of Organ Sharing requires 15 cases as surgeon or assistant to be certified as the primary LDN surgeon. This falls below the described learning curve for LDN. The assessment of training and competency for LDN is heterogeneous, and objective learner-based metrics could help surgeons and institutions reach a quality standard for performing this operation.

Laparoscopic Partial Nephrectomy with Precise Segmental Renal Artery Clamping for Clinical T1b Tumors.

To assess the technique and short-term outcomes of laparoscopic partial nephrectomy (LPN) with precise segmental renal artery clamping for clinical T1b (cT1b) tumors and to analyze the possible factors affecting the glomerular filtration rate (GFR) reduction. This retrospective study investigated the outcomes of 72 patients with cT1b tumors who received LPN from June 2008 to May 2014. Based on three-dimensional dynamic renal vascular models built before surgery, target arteries were precisely clamped and tumors were removed under regional parenchymal ischemia. Perioperative and follow-up outcomes were analyzed. All the LPN procedures were effectively performed using the novel technique, without converting to main renal artery clamping or open surgery. The mean operative time was 86 min, with a mean warm ischemic time of 25 min. The median estimated blood loss was 200 mL (range: 80-800). The postoperative mean GFR was 64% of the preoperative baseline, and the total complication rate was 19.4%. In multivariable analyses, the two independent factors affecting postoperative GFR were the RENAL nephrometry score (RNS) and number of intraoperative clamped segmental arteries. The median follow-up was 24 months (range: 6-72). The overall, recurrence-free, and cancer-specific survival rates were 100%, 95.8%, and 100%, respectively. For patients with cT1b tumor, LPN with precise segmental renal artery clamping is safe and feasible for removing tumors and preserving the blood supply and normal renal parenchyma. Short-term oncologic and functional outcomes were satisfactory. Postoperative GFR was related to the preoperative RNS and number of intraoperative clamped segmental arteries.

Laparoscopic partial nephrectomy without intracorporeal suturing.

Partial nephrectomy has gained wider acceptance as a surgical technique in treating small renal tumors. Laparoscopic partial nephrectomy (LPN) still remains a technically demanding surgery to this day. We present our technique of laparoscopic partial nephrectomy, one that is performed without intracorporeal suturing. We performed LPN on 31 patients with localized renal parenchymal tumor (stage T1). The procedures were done from September 2009 to March 2015 at the Kaohsiung Medical University Hospital and the Kaohsiung Municipal Ta-Tung Hospital. Our technique involves the covering of renal defect layer by layer with FloSeal, Tisseel and a fat pad after monopolar coagulation. Thirty-one patients were included in this study. Mean patient age was 53 years old (range 39-70). Mean tumor size was 2.9 cm (range 1.8-6.3). Mean RENAL nephrometry score was 5.3 (range 4-7). The average operation time was 188 min (range 120-290), and the average warm ischemic time was 19.0 min (range 9-26). Mean estimated blood loss was 171 ml (range 10-650), with no postoperative bleeding among the total 31 patients. No recurrent tumors were identified at a mean follow-up of 29 months postoperatively. The mean change in eGFR was 6.5 (ml/min/m2). Laparoscopic partial nephrectomy is a feasible surgical method for most patients with stage 1 tumor. Our technique has shown to reduce warm ischemic time significantly and provide patients with excellent functional outcomes without affecting oncological results. With this technique, surgeons can perform LPN with more efficiency and with fewer complications.

Robotic Unclamped “Minimal-margin” Partial Nephrectomy: Ongoing Refinement of the Anatomic Zero-ischemia Concept

BackgroundAnatomic partial nephrectomy (PN) techniques aim to decrease or eliminate global renal ischemia. ObjectiveTo report the technical feasibility of completely unclamped “minimal-margin” robotic PN. We also illustrate the stepwise evolution of anatomic PN surgery with related outcomes data. Design, setting, and participantsThis study was a retrospective analysis of 179 contemporary patients undergoing anatomic PN at a tertiary academic institution between October 2009 and February 2013. Consecutive consented patients were grouped into three cohorts: group 1, with superselective clamping and developmental-curve experience (n = 70); group 2, with superselective clamping and mature experience (n = 60); and group 3, which had completely unclamped, minimal-margin PN (n = 49). Surgical procedurePatients in groups 1 and 2 underwent superselective tumor-specific devascularization, whereas patients in group 3 underwent completely unclamped minimal-margin PN adjacent to the tumor edge, a technique that takes advantage of the radially oriented intrarenal architecture and anatomy. Outcome measurements and statistical analysisPrimary outcomes assessed the technical feasibility of robotic, completely unclamped, minimal-margin PN; short-term changes in estimated glomerular filtration rate (eGFR); and development of new-onset chronic kidney disease (CKD) stage >3. Secondary outcome measures included perioperative variables, 30-d complications, and histopathologic outcomes. Results and limitationsDemographic data were similar among groups. For similarly sized tumors (p = 0.13), percentage of kidney preserved was greater (p = 0.047) and margin width was narrower (p = 0.0004) in group 3. In addition, group 3 had less blood loss (200, 225, and 150ml; p = 0.04), lower transfusion rates (21%, 23%, and 4%; p = 0.008), and shorter hospital stay (p = 0.006), whereas operative time and 30-d complication rates were similar. At 1-mo postoperatively, median percentage reduction in eGFR was similar (7.6%, 0%, and 3.0%; p = 0.53); however, new-onset CKD stage >3 occurred less frequently in group 3 (23%, 10%, and 2%; p = 0.003). Study limitations included retrospective analysis, small sample size, and short follow-up. ConclusionsWe developed an anatomically based technique of robotic, unclamped, minimal-margin PN. This evolution from selective clamped to unclamped PN may further optimize functional outcomes but requires external validation and longer follow-up. Patient summaryThe technical evolution of partial nephrectomy surgery is aimed at eliminating global renal damage from the cessation of blood flow. An unclamped minimal-margin technique is described and may offer renal functional advantage but requires long-term follow-up and validation at other institutions.

Effect of Donor Nephrectomy Technique on Recipient Lymphatic Drainage

AimWe sought to evaluate the postoperative recipient lymphatic drainage depending on open donor nephrectomy (ODN) or laparoscopic (LDN) techniques. MethodBetween March 2012 and August 2014, 58 patients underwent renal transplantation from living-related donors. Thirty donors underwent ODN (group 1), and 28 LDN (group 2). Operations were performed by the same surgeons. Both cranial and caudal drainage catheters for lymphatic leakage were placed preoperatively and all the recipients received tacrolimus, mycophenolate mofetil, and steroid as immunosuppressive regimen. None of the patients had coagulation abnormalities. ResultsAll grafts were functioning during the early postoperative period and diuresis was ensured. No difference was observed on early postoperative period regarding to acute rejection (P = .329) or infection (P = .546). No difference was seen concerning mycophenolate mofetil and mycophenolate sodium regimens among the 2 groups (P = .227). In groups 1 and 2, the cranial drainage catheters were not taken out until postoperative days 5.5 ± 2.5 (range, 0–11) and 6.4 ± 3.8 (range, 0–14) and the caudal catheters stayed in place until days 8.8 ± 3.5 (range, 1–16) and 9.9 ± 5.9 (range, 3–22), respectively. No difference was found when comparing the cranial (P = .308) and caudal (P = .426) drainage periods. However, during clinical acute rejection episodes the cranial drainage period was longer in group 1 (P = .003). Three patients developed lymphoceles, 1 requiring drainage, in group 2. ConclusionsThere seems to be no difference in recipient lymphatic drainage by donor nephrectomy technique. A laparoscopic procedure may be advantageous owing to shorter lymphatic drainage during clinical acute rejection episodes.

Robotic Partial and Radical Nephrectomy in Renal Allograft: Demonstration of Technique

Introduction: Renal tumors in allografts are rare but a serious condition. It presents a challenging clinical scenario where proper radiologic evaluation is commonly hindered by the suboptimal renal function. When surgical intervention is indicated, nephron sparing approaches are confronted with a risk of metastasis in an immunocompromised host, whereas graft nephrectomy results in significant postoperative morbidity and mortality as dialysis is reinitiated. Regardless of the surgical plan, graft surgery can be associated with significant vascular morbidities secondary to the dense desmoplastic reaction surrounding the anastomotic areas. Robotic surgery allows meticulous anastomotic dissection due to benefits of magnification, three-dimensional vision, and enhanced seven degrees of freedom of the robotic instruments. This may increase the chances of graft preservation. Moreover, it offers the benefits of minimally invasive surgery with less pain, shorter hospitalization, and less blood loss if total graft nephrectomy is desired. Methods: In this video, we are describing our technique of both robotic partial and total graft nephrectomy in a patient who was found to have a 1.4 cm allograft mass. The patient is a recipient of an extended criteria cadaveric kidney transplant 3 years before presentation. Evaluation was triggered by the fact that the recipient of the contralateral cadaveric kidney developed donor-derived squamous cell carcinoma originating from the allograft. Results: In this video, we demonstrated the key steps in the procedure, which included early control of the external iliac artery, release of the desmoplastic reaction around the transplanted vessels, vascular pedicle control, lysis of adhesions between the kidney and anterior abdominal wall, ultrasound-guided tumor excision, and renorrhaphy. Finally, the frozen section of the partial nephrectomy specimen revealed squamous cell cancer with negative margin. However, we felt that a radical nephrectomy was clinically indicated. Final pathology revealed T3 squamous cell carcinoma. Conclusion: Robotic approach may play a role in partial and the more commonly performed graft nephrectomy. It may provide an opportunity for better vascular dissection and offer the patient a minimally invasive approach to this challenging procedure. No competing financial interests exist. Runtime of video: 8 mins