Anatomic landmarks and time management during retroperitoneoscopic radical nephrectomy

BACKGROUND AND PURPOSE: Retroperitoneoscopy has not been widely considered the preferred approach to laparoscopic radical nephrectomy for cancer, in part because the retroperitoneal anatomic landmarks have not been well defined. The aim of this study is to provide prospective, objective data on retroperitoneoscopic radical nephrectomy with regard to anatomic landmarks and time management of the sequential operative steps. MATERIALS AND METHODS: A uniform database was devised to record predetermined intraoperative parameters prospectively in 18 consecutive retroperitoneoscopic radical nephrectomies. RESULTS: A three- or four-port technique was employed to perform 10 left and 8 right retroperitoneoscopic radical nephrectomies. Initial balloon dilation was routinely performed outside of and posterior to Gerota's fascia. The anatomic landmarks visible immediately on initial insertion of the laparoscope were: psoas muscle in 18 cases (100%), Gerota's fascia in 18 (100%), peritoneal reflection in 15 (83%), ureter and/or gonadal vein in 11 (61%), and renal artery pulsations in 10 (56%). Aortic pulsations were seen in 9 of 10 left (90%) and the inferior vena cava in 2 of 8 right (25%) radical nephrectomies. The mean surgical time was 203 +/- 52.9 minutes (range 105-290 minutes). The sequential operative steps and their individual time breakdowns were: port placement 12 +/- 3.9 minutes, hilar dissection 63 +/- 29.1 minutes, adrenal mobilization 49 +/- 12.1 minutes, specimen mobilization 19 +/- 20.8 minutes, and specimen entrapment and exit 23 +/- 18.2 minutes. When the initial balloon dilation resulted in visibility of four or more anatomic landmarks, the hilar dissection time was significantly shorter (P < 0.001). CONCLUSIONS: Proper development of the retroperitoneal space and identification of adequate anatomic landmarks is important during retroperitoneoscopy. This timed analysis of the sequential operative steps of retroperitoneoscopic radical nephrectomy has served as an important self-assessment tool for us in improving our surgical technique. As a result, our surgical time for retroperitoneoscopic radical nephrectomy has decreased from the earlier 4- to 5-hour range to the current 2- to 3-hour range.     

Retroperitoneal laparoscopic radical nephrectomy: the Cleveland clinic experience

PURPOSE: Laparoscopic radical nephrectomy is usually performed by the transperitoneal approach. At our institution the retroperitoneoscopic approach is preferred. We confirm the technical feasibility of retroperitoneoscopic radical nephrectomy, even for large specimens, and compare its results with open surgery in a contemporary cohort. MATERIALS AND METHODS: A total of 47 patients underwent 53 retroperitoneoscopic radical nephrectomies. Data from the most recent 34 laparoscopic cases were retrospectively compared with 34 contemporary cases treated with open radical nephrectomy. RESULTS: For the 53 retroperitoneoscopic radical nephrectomies mean tumor size was 4.6 cm. (range 2 to 12), surgical time was 2.9 hours (range 1.2 to 4.5) and blood loss was 128 cc. Mean specimen weight was 484 gm. (range 52 to 1,328), and concomitant adrenalectomy was performed in 72% of patients. Mean analgesic requirement was 31 mg. morphine sulfate equivalent. Average hospital stay was 1.6 days, with 68% of patients discharged from the hospital within 23 hours of the procedure. Minor complications occurred in 8 patients (17%) and major complications occurred in 2 (4%) who required conversion to open surgery. Various parameters, including patient age, body mass index, American Society of Anesthesiologists status, tumor size (5 versus 6.1 cm.), specimen weight (605 versus 638 gm.) and surgical time (3.1 versus 3.1 hours), were comparable between patients undergoing laparoscopic (34) and open (34) radical nephrectomy. However, laparoscopy resulted in decreased blood loss (p <0.001), hospital stay (p <0.001), analgesic requirements (p <0.001) and convalescence (p = 0.005). Complications occurred in 13% of patients in the laparoscopic group and 24% in the open group. CONCLUSIONS: Retroperitoneoscopy is a reliable, effective and, in our hands, the preferred technique of laparoscopic radical nephrectomy. At our institution retroperitoneoscopy has emerged as an attractive alternative to open radical nephrectomy in patients with T1-T2N0M0 renal tumors.     

Prospective, case matched comparison of hand assisted laparoscopic and open surgical live donor nephrectomy

PURPOSE: The technical difficulty of standard laparoscopic live donor nephrectomy has limited its application. Hand assistance, which takes advantage of the incision necessary for organ removal, facilitates laparoscopy without significant impact on patient recovery. We prospectively compared open surgical and hand assisted laparoscopic donor nephrectomy. MATERIALS AND METHODS: Our first 10 laparoscopic live donor nephrectomies were matched with 40 open donor nephrectomies by gender, age and body mass index. Data were obtained by pain scales, SF-12 survey instruments, questionnaires and chart abstraction. RESULTS: Operative time was longer for the laparoscopic approach (mean 95 versus 215 minutes). However, laparoscopic group patients had a shorter hospital stay compared to those undergoing open surgery (mean 2.9 versus 1.8 days), returned sooner to nonstrenuous activity (mean 19.0 versus 9.9 days) and reported less pain 6 weeks postoperatively (mean 2.3 versus 0.6) (p 相似文献   

Retroperitoneoscopic radical and partial nephrectomy in the patient with cirrhosis

PURPOSE: In patients with cirrhosis and a renal mass options may be limited by medical disease and the surgical difficulties associated with portal hypertension. We describe a retrospective review of patients with cirrhosis with renal masses who underwent radical or partial nephrectomy through a retroperitoneoscopic approach. MATERIALS AND METHODS: Ten consecutive patients, including 4 men and 6 women, with cirrhosis, of whom 2 had undergone liver transplantation, underwent radical (7) or partial (3) nephrectomy for a total of 5 right and 5 left renal neoplasms via the retroperitoneoscopic approach at our institution from March 2002 to February 2004. Recovery data were prospectively obtained and other information was gathered retrospectively from the medical record. RESULTS: Average patient age was 58 years and average American Society of Anesthesiology score was 2.8. Average renal tumor size for radical and partial nephrectomy was 4.6 (range 2.9 to 7) and 1.8 cm (range 1.3 to 2.3), respectively. Operative time was 140 to 315 minutes (median 172) and estimated blood loss was 100 to 5,000 ml (median 225). One patient required open conversion due to hemorrhage from left portosystemic venous communications. Mean postoperative hospitalization was 1.5 days (range 1 to 6). CONCLUSIONS: Although retroperitoneoscopic surgery avoids many surgical dangers associated with portal hypertension and it is our preferred approach to renal surgery in patients with cirrhosis, significant portosystemic venous communications exist in the retroperitoneum, especially on the left side, and they still lead to substantial blood loss in some patients.     

Laparoscopic radical adrenalectomy for malignancy in 31 patients

PURPOSE: Laparoscopic adrenalectomy for malignancy is controversial. We analyzed our experience with laparoscopic radical adrenalectomy for cancer with an emphasis on predictors of surgical outcome and oncological followup data. MATERIALS AND METHODS: Since July 1997, 31 patients have undergone a total of 33 laparoscopic adrenalectomies for malignancy. Mean adrenal tumor size was 5 cm (range 1.8 to 9). The laparoscopic approach was transperitoneal in 17 cases, retroperitoneal in 15 and transthoracic in 1. Data were obtained from patient charts, radiographic reports and direct telephone calls to patient families. RESULTS: Associated organ resection (radical nephrectomy) was performed in 3 patients. One case was electively converted to open surgery. There was no operative mortality. The pathological diagnoses were metastatic cancer in 26 cases and primary adrenal malignancy in 7. Current median followup, available on 30 patients, was 26 months (range 1 to 69). Overall 15 patients (48%) died and 16 (52%) were alive, of whom 13 (42%) showed no evidence of disease. Cancer specific survival at a median followup of 42 months was 53% and 5-year actuarial survival was 40%. Local recurrence was noted in 7 patients (23%). There were no port site metastases. Survival was similar in patients with tumors less than 5 cm vs 5 cm or greater. Survival was not associated with patient age, tumor size, operative time or surgical approach. Survival was compromised in patients with local recurrence (p = 0.016). CONCLUSIONS: Laparoscopic radical adrenalectomy can be performed with acceptable outcomes in the carefully selected patient with a small, organ confined, solitary adrenal metastasis or primary adrenal carcinoma. To our knowledge the largest series in the literature to date is presented.     

Laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous testicular carcinoma: long-term outcome

PURPOSE: We report the long-term oncological efficacy and morbidity of laparoscopic retroperitoneal lymph node dissection for testicular carcinoma. MATERIALS AND METHODS: From August 1992 to September 1999, 73 consecutive patients underwent laparoscopic retroperitoneal lymph node dissection with modified unilateral template dissection. All lumbar vessels within the template were routinely transected in the initial 29 cases only. Patients with positive lymph nodes received 2 cycles of chemotherapy. RESULTS: Operative time ranged from 150 to 630 minutes (mean 221) in our most recent 28 cases. All but 2 operations were completed as planned for a conversion rate of 2.7%. Minor intraoperative complications developed in only 6.8% of cases. In our last 44 patients there was no major and only 1 minor (2.3%) postoperative complication. Mean postoperative hospitalization was 3.3 days. Ejaculation was preserved in all patients. Lymph nodes were positive in 19 cases (26%). Mean followup in 47 patients with pathological stage I disease was 43.3 months (range 7 to 84). We noted 1 retroperitoneal recurrence due to false-negative histological findings but there were no other relapses. At a mean followup of 42.7 months (range 6 to 86) 17 patients with pathological stage II carcinoma treated with 2 cycles of adjuvant chemotherapy were also free of disease. CONCLUSIONS: In our hands laparoscopic retroperitoneal lymph node dissection has not only proved its surgical efficiency, but also its oncological efficacy. Patient satisfaction is high. During long-term followup of more than 3 years not a single recurrence developed due to surgical failure.     

Laparoscopic retroperitoneal live donor right nephrectomy for purposes of allotransplantation and autotransplantation

PURPOSE: We report the technique of and initial experience with retroperitoneal laparoscopic live donor right nephrectomy for purposes of renal allotransplantation and autotransplantation. MATERIALS AND METHODS: A total of 5 patients underwent retroperitoneoscopic live donor nephrectomy of the right kidney for autotransplantation in 4 and living related renal donation in 1. Indications for autotransplantation included a large proximal ureteral tumor, a long distal ureteral stricture and 2 cases of the loin pain hematuria syndrome. In all cases a 3-port retroperitoneal laparoscopic approach and a pelvic muscle splitting Gibson incision for kidney extraction were used. In patients undergoing autotransplantation the same incision was used for subsequent transplantation. RESULTS: All procedures were successfully accomplished without technical or surgical complications. Total mean operating time was 5.8 hours and average laparoscopic donor nephrectomy time was 3.1 hours. Mean renal warm ischemia time, including endoscopic cross clamping of the renal artery to ex vivo cold perfusion, was 4 minutes. Average blood loss for the entire procedure was 400 cc. Radionuclide scan on postoperative day 1 confirmed good blood flow and function in all transplanted kidneys. Mean analgesic requirement was 58 mg. fentanyl. Mean hospital stay was 4 days (range 2 to 8), and convalescence was completed in 3 to 4 weeks. CONCLUSIONS: In the occasional patient requiring renal autotransplantation live donor nephrectomy can be performed laparoscopically with renal extraction and subsequent transplantation through a single standard extraperitoneal Gibson incision, thus, minimizing the overall operative morbidity. Furthermore, these data demonstrate that live donor nephrectomy of the right kidney can be performed safely using a retroperitoneal approach with an adequate length of the right renal vein obtained for allotransplantation or autotransplantation.     

Hydro-jet assisted laparoscopic partial nephrectomy: initial experience in a porcine model

PURPOSE: Hemostasis represents a challenge when performing laparoscopic partial nephrectomy. Hydro-Jet cutting is an advanced technology that has been used to create an ultra-coherent water force that functions like a sharp knife. In the surgical field, it has mainly been used for liver surgery and initial clinical experience with laparoscopic cholecystectomies has been favorable. This technique allowed selective parenchymal cutting with preservation of vessels and bile ducts. We describe a novel Hydro-Jet assisted dissection technique for laparoscopic partial nephrectomy in a porcine model. MATERIALS AND METHODS: Ten partial nephrectomies were performed in 5 pigs using a Muritz 1000 (Euromed Medizintechnik, A. Pein, Schwerin, Germany) Hydro-Jet generator. A thin stream of ultra coherent fluid is forced at a high velocity through a small nozzle. A modified probe allows both blunt dissection concomitantly with high-pressure water application. Coagulation can be applied via a bipolar thermoapplicator as needed. RESULTS: Laparoscopic partial nephrectomy was successful in all animals. Water-jet cutting through the parenchyma was virtually bloodless and preserved the vasculature and the collecting system. The vessels were then ligated or coagulated under direct vision. The continuous water flow established a bloodless operating field and a clear view for the surgeon. The mean dissection time and warm ischemia time were 45+/-9 and 17+/-3 minutes, respectively. CONCLUSIONS: This preliminary study supports the suitability of this technique for laparoscopic partial nephrectomy to improve hemostasis. The improved anatomical dissection and hemostasis may further decrease morbidity and operative time. Further studies are underway to compare this technique with laser coagulation for laparoscopic partial nephrectomy.     

Laparoscopic Doppler Technology in Laparoscopic Renal Surgery

Background and Objectives:

Laparoscopic Doppler technology has previously been reported to help identify vasculature during laparoscopy. Recently, we published our initial experience with this technology during laparoscopic radical nephrectomy, laparoscopic nephroureterectomy, laparoscopic partial nephrectomy, and robotic-assisted laparoscopic pyeloplasty. We now present a prospective, pilot evaluation of the Doppler probe for these procedures.

Methods:

A laparoscopic Doppler probe was used in the above laparoscopic renal surgeries in 50 patients. Anatomic findings, Doppler survey time, dissection time, operative time, estimated blood loss, changes in management, subjective time saved/utility, technical difficulties, clinical complications, and ease of use were prospectively recorded.

Results:

Mean Doppler survey time was 1.77 minutes. Mean hilar dissection time was 9.25 minutes. Eight accessory vessels were not seen on preoperative imaging in 7 patients (17%). In 3 cases of RALP, Doppler rectified preoperative imaging in detecting a crossing vessel. The probe altered management in 16% of patients, subjectively saved time in 78% of patients, and had 100% concordance with dissection. There were no complications but 2 technical failures.

Conclusion:

The probe is quick, safe, easy to use, and has perfect concordance with surgical dissection. Randomized comparison with and without Doppler assistance is necessary to confirm the utility of this technology.     

Retroperitoneal laparoscopic live-donor nephrectomy: introduction of simple hand-assisted technique (without hand port)

Objective

Compared with the transperitoneal approach, retroperitoneal laparoscopic live-donor nephrectomy offers a substantial advantage. However, retroperitoneal access is more difficult because of the limited working space. The objective of this study was to report our experience with hand-assisted retroperitoneal laparoscopic live-donor nephrectomy without a hand port.

Materials and Methods

Intraoperative and immediate postoperative surgical outcomes were reviewed for 23 modified retroperitoneal laparoscopic live-donor nephrectomies performed from May 2009 to January 2010. All kidneys were from living related donors. No prisoners or organs from prisoners were used in this study.

Results

Retroperitoneal laparoscopic live-donor nephrectomy was successfully completed in all patients, without conversion to open surgery. Mean (range) operative was 114 (98-130) minutes; warm ischemia time was 1.6 (1.3-2.1) minutes; estimated blood loss was 20 (10-50) mL; and postoperative hospital stay was 6.9 (5-10) days. No serious complications such as massive bleeding or bowel injury occurred. In 1 patient, a hematoma of renal fossa developed, which was successfully treated at repeat operation. All kidneys demonstrated good primary function except 1 that exhibited delayed graft function.

Conclusions

Retroperitoneal laparoscopic live-donor nephrectomy combines the benefits of both hand assistance and the retroperitoneal approach, to minimize the risk of short- and long-term complications associated with the transabdominal approach. The technique could be a cost-effective procedure suitable for use in developing countries.     

Laparoscopic renal surgery after spontaneous retroperitoneal hemorrhage

PURPOSE: We assessed the role of laparoscopic management in patients following spontaneous retroperitoneal hemorrhage from a renal tumor. MATERIALS AND METHODS: A retrospective chart review revealed 4 patients with spontaneous retroperitoneal hemorrhage treated at our institution in the last 2 years. After conservative management elsewhere patients were referred for definitive therapy. Patient characteristics and tumor size were examined and correlated with ease of surgical dissection and surgical outcome. No patient had any history of trauma. Computerized tomography was used to identify the initial extent of hemorrhage in all patients. RESULTS: All patients underwent successful laparoscopic exploration without the need for open conversion. Three patients underwent radical nephrectomy and 1 underwent laparoscopic partial nephrectomy. Renal hemorrhage extending outside of the renal capsule was associated with significantly more adhesions than renal hemorrhage confined to the renal capsule. Mean patient age was 56 years (range 36 to 70). Mean retroperitoneal tumor size was 5.3 cm (range 2.5 to 10). Three renal hematomas were extracapsular and 1 was subcapsular. Mean operative time was 182.3 minutes (range 59 to 235). Average estimated blood loss was 800 cc (range 150 to 2,100). CONCLUSIONS: Nontraumatic retroperitoneal hemorrhage of renal origin may be managed using traditional laparoscopic techniques with results similar to those achieved with open renal exploration. These cases may prove technically challenging due to fibrosis and associated tissue plane loss.     

Hand assisted laparoscopic radical nephrectomy for renal carcinoma using a new abdominal wall sealing device

PURPOSE: We report our initial experience with a hand assisted laparoscopic radical nephrectomy for patients with renal carcinoma, and compare our results to those of conventional open radical nephrectomy. MATERIALS AND METHODS: The clinical data on 6 consecutive patients who underwent hand assisted laparoscopic radical nephrectomy for stage T1N0M0 renal cell carcinoma were reviewed. We performed hand assisted laparoscopic surgery using the new LAP DISC* abdominal wall sealing device. We compared the results of this procedure with those of conventional open radical nephrectomy in 12 patients with stage T1N0M0 renal cell carcinoma. RESULTS: The hand assisted laparoscopic radical nephrectomy for renal carcinoma was successfully performed without any major or minor complications in all 6 patients. Mean operation time for the laparoscopic group was significantly longer than that for the open surgery group (303 minutes versus 224 minutes, p = 0.0042). However, no significant difference was observed in mean estimated blood loss for the 2 groups (264 ml. in the laparoscopic group versus 341 ml. in the open surgery group). The frequency of parenteral analgesia postoperatively in the laparoscopic group was significantly lower than that in the open surgery group (16.7% versus 75.0%, p = 0.043). In addition, the laparoscopic group seemed to recover more rapidly than the open surgery group. The abdominal wall sealing device was easy to attach to the abdominal wall, and allowed rapid hand removal and reinsertion. CONCLUSIONS: Our preliminary results indicate that a hand assisted laparoscopic radical nephrectomy with the abdominal wall sealing device is an effective and safe surgical procedure, and is less invasive than open radical nephrectomy.     

Retroperitoneoscopy: A laparoscopic approach for adrenal and renal surgery

Objectives

Retroperitoneoscopy has gained acceptance for urologic surgery. We assessed the safety and efficacy of this procedure for renal and adrenal surgery.

Methods

Since December 1994, 20 patients (18 to 75 years old) have undergone laparoscopic adrenalectomy and nephrectomy, including simple nephrectomy in 8, partial nephrectomy in 1, radical nephrectomy in 2, tumorectomy with cyst excision in 1, and adrenalectomy in 8. The retroperitoneal space was created by blunt dissection with the index finger, completed by insufflation, without balloon dissection.

Results

Average kidney size was 65 mm (range 50 to 108), and average adrenal tumor size was 31 mm (range 20 to 40). The average operating time was 127 minutes (range 60 to 180) for nephrectomy and 84 minutes (range 45 to 140) for adrenalectomy. The average hospital stay was 3 days (range 1 to 7) for nephrectomy and 2.4 days (range 1 to 4) for adrenalectomy. Average blood loss was 65 mL for both nephrectomy and adrenalectomy. Conversion from the laparoscopic procedure to open surgery was never required. Peritoneal effraction and ureteral injury occurred in only 4 patients and 1 patient, respectively.

Conclusions

The laparoscopic retroperitoneal approach is safe and effective for simple renal nephrectomy and for excision of small adrenal tumors. Perioperative morbidity and hospital stay are reduced.     

经腹腔与腹膜后行腹腔镜肾癌根治术的比较

目的:比较经腹腔和腹膜后方式行腹腔镜肾癌根治术的优缺点。方法:随机将60例肾癌患者分别经腹腔或腹膜后方式行腹腔镜下肾癌根治术,比较两组术中、术后的情况。结果:与经腹腔方式比较,腹膜后方式处理肾动脉平均时间、处理肾静脉平均时间、总的手术平均时间较短。但经腹膜和腹膜后方式在估计出血量、术后住院时间、术中并发症和术后并发症发生率上无明显差异。结论:腹腔镜下经腹腔或腹膜后方式行肾癌根治术均有效,但后者在处理肾门和总的手术时间方面更快。     

Retroperitoneoscopic living donor nephrectomy: initial experience with a unique hand‐assisted approach

Capolicchio J‐P, Feifer A, Plante MK, Tchervenkov J. Retroperitoneoscopic living donor nephrectomy: initial experience with a unique hand‐assisted approach.
Clin Transplant 2011: 25: 352–359. © 2010 John Wiley & Sons A/S. Abstract: The retroperitoneoscopic (RP) approach to live donor nephrectomy (LDN) may be advantageous for the donor because it avoids mobilization of peritoneal organs and provides direct access to the renal vessels. Notwithstanding, this approach is not popular, likely because of the steeper learning curve. We feel that hand‐assistance (HA) can reduce the learning curve and in this study, we present our experience with a novel hand‐assist approach to retroperitoneoscopic live donor nephrectomy (HARP‐LDN). Over a one‐yr period, 10 consecutive patients underwent left HARP‐LDN with a mean body mass index of 29 and three with prior left abdomen surgery. The surgical technique utilizes a 7 cm, muscle‐sparing incision for the hand‐port with two endoscopic ports. Operative time was an average of 155 min., with no open conversions. Mean blood loss was 68 mL, and warm ischemia time was 2.5 min. Hospital stay averaged 2.7 d with postoperative complications limited to one urinary retention. Our modified HARP approach to left LDN is safe, effective and can be performed expeditiously. Our promising initial results require a larger patient cohort to confirm the advantages of the hand‐assisted retroperitoneal technique.     

Safe retroperitoneoscopic radical nephrectomy with small incision for renal cell carcinoma

PURPOSE: Retroperitoneoscopic radical nephrectomy (RRN) has been performed at Yokohama City University Medical Center since May 2002. Three surgeons have become skilled in performing RRN without major complications. We investigated the outcomes of the surgery and attempt to clarify whether the technique we adopted is suitable to perform this procedure safely. PATIENTS AND METHODS: Between May 2002 and June 2003, 14 patients suspected of renal cell carcinoma underwent retroperitoneoscopic radical nephrectomy at Yokohama City University Medical Center. The surgical procedure is shown below. In a lateral position, a lumbar oblique incision 6 cm long is made to approach the retroperitoneal space. Under direct vision, the ureter is dissected and Gerota's fascia is dissected from the peritoneum and the psoas muscle to signalize the subsequent dissection line. After the dissection, hand port device was attached to the skin and three 12 mm trocars were placed. The subsequent procedures are performed by retroperitoneoscopic surgery with carbon dioxide insufflation. The isolated kidney was removed through the incision that was made initially. We investigated the outcomes of this procedure. RESULTS: The mean surgical duration was 244.4 minutes and mean blood loss was 217.9 ml. Conversion to open surgery was required in one case due to bleeding and in one case due to incomplete management of a small artery. Blood transfusion was not required in any case. There were no major complications during the perioperative period. CONCLUSIONS: The three operators have become skilled in performing RRN safely with this technique.     

Retroperitoneoscopic nephron-sparing surgery of renal tumor using a microwave tissue coagulator without renal ischemia: comparison with open procedure

PURPOSE: It is ideal to use not a transperitoneal but a retroperitoneal approach for both open and endoscopic partial nephrectomy. We compared the results of retroperitoneoscopic nephron-sparing surgery for small renal tumors using a microwave tissue coagulator without renal pedicle clamping with those of a retroperitoneal open procedure. PATIENTS AND METHODS: Between 1996 and 2002, eight patients with small renal tumors underwent retroperitoneoscopic partial nephrectomy without renal ischemia, and nine patients with small renal tumors underwent open partial nephrectomy via a retroperitoneal approach. Both groups were operated on using a microwave tissue coagulator. RESULTS: Retroperitoneoscopic partial nephrectomy without renal ischemia was performed without any major or minor complications in any patient. The mean operation time for retroperitoneoscopic surgery was significantly longer than that for open partial nephrectomy (221.9 minutes v 145.9 minutes; P = 0.0004). However, the mean estimated blood loss for retroperitoneoscopic surgery was less than that for open partial nephrectomy (137.5 mL v 334.8 mL; P = 0.012). In addition, the retroperitoneoscopic group seemed to recover more rapidly than the open surgery group. CONCLUSIONS: Retroperitoneoscopic nephron-sparing surgery of small renal tumors using a microwave tissue coagulator without renal ischemia is feasible as minimally invasive procedure. It results in saving renal function, minimal blood loss, and rapid recovery.     

Comparison of laparoscopic versus open nephrectomy in the pediatric population

PURPOSE: Laparoscopic renal surgery has become an accepted approach for benign disease in adults. We compare our experience with laparoscopic and open nephrectomy in a pediatric population. MATERIALS AND METHODS: A total of 10 pediatric patients underwent laparoscopic nephrectomy or nephroureterectomy and an additional 10 consecutive children underwent similar open procedures. All patients had benign disease and were treated at a single institution. Medical records were reviewed retrospectively for relevant clinical data. RESULTS: Planned surgery was completed in all cases. There were no conversions to open surgery in the laparoscopic group. Mean operative time was 175.6 versus 120.2 minutes (p = 0.01) and mean hospital stay was 22.5 versus 41.3 hours (p = 0.03) in the laparoscopic and open nephrectomy groups, respectively. Blood loss was not statistically different. Analgesic use was qualitatively less in the laparoscopic nephrectomy group. CONCLUSIONS: Laparoscopic nephrectomy and nephroureterectomy may be performed safely in children. While operative time was somewhat longer in our initial laparoscopic series, postoperative hospital stay was significantly shorter than for open surgery. Further experience with this technique is warranted.     

Strategic Hand Assistance for Effective and Safe Retroperitoneoscopic Live Donor Nephrectomy

Hand-assisted laparoscopic live donor nephrectomy has been widely applied, because it enables safe dissection of the renal vessels, reducing warm ischemia time (WIT) during rapid extraction of the kidney. In the method described in the current series, the hand-port device was placed after the kidney was mostly mobilized using a pure retroperitoneoscopic procedure. After placement of the hand port, the ureter was completely dissected by an open procedure. Finally, the renal vessels were dissected and transected under the hand-assisted retroperitoneoscopic procedure, and the kidney removed through the hand port. We performed 66 retroperitoneoscopic live donor nephrectomies, including 14 right-sided and 52 left-sided procedures, with this original method of hand assistance. The mean operative time, WIT, blood loss, and renal vein length were 246 ± 43 minutes, 209 ± 124 seconds, 202 ± 180 mL, and 17.4 ± 6.4 mm, respectively. Comparison of the operative data between the initial 30 cases and the recent 36 cases using the established method showed significant differences in blood loss and WIT that approached statistical significance. No delayed graft function was observed in the current series. The technical and functional outcomes were acceptable. The site and timing of hand assistance minimize the disadvantage of a small working space during the retroperitoneoscopic procedure, making surgery easier and safer.     

TRANSPERITONEAL AND RETROPERITONEAL LAPAROSCOPIC NEPHRECTOMY FOR GIANT HYDRONEPHROSIS

PURPOSE: We evaluate laparoscopic nephrectomy for giant hydronephrosis with an emphasis on the operative technique of retroperitoneoscopic surgery. MATERIALS AND METHODS: During the last 2 years 13 men and 5 women underwent laparoscopic nephrectomy for giant hydronephrosis via a transperitoneal (6) or retroperitoneal (12) approach. The etiology was congenital ureteropelvic junction obstruction in 17 patients and hydronephrosis caused by stone disease in 1. Three patients had a contralateral obstructed kidney. Renal parameters were normal in all patients. RESULTS: All procedures were successfully completed without the need for conversion to open surgery. Mean operating time was 113.8 minutes (range 70 to 165) and average blood loss was 260 ml. (range 40 to 600). No patient required a blood transfusion. Postoperative recovery was uneventful with an average postoperative hospital stay of only 3.2 days (range 2 to 5). CONCLUSIONS: Laparoscopic nephrectomy is a good alternative to open surgery for giant hydronephrosis and significantly reduced the morbidity of surgery. A retroperitoneal approach is feasible, despite the large amount of retroperitoneal space occupied by these hugely dilated kidneys. Modifications of our technique have been invaluable to the successful outcome in this series.