Robotic Laparoendoscopic Single-Site Radical Prostatectomy: Technique and Early Outcomes

Background

Laparoendoscopic single-site (LESS) surgery is challenging. To help overcome current technical and ergonomic limitations, the da Vinci robotic platform can be applied to LESS.

Objectives

Our aim was to describe the surgical technique and to report the early outcomes of robotic LESS (R-LESS) radical prostatectomy (RP).

Design, setting, and participants

A retrospective review of prospectively captured R-LESS RP data was performed between May 2008 and May 2010. A total of 20 procedures were scheduled (12 with and 8 without pelvic lymph node dissection).

Surgical procedure

R-LESS prostatectomy was performed using the methods outlined in the paper and in the supplemental video material.

Interventions

All patients underwent R-LESS RP by one high-volume surgeon. Single-port access was achieved via a commercially available multichannel port. The da Vinci S and da Vinci Si surgical platform was used with pediatric and standard instruments.

Measurements

Preoperative, perioperative, pathologic, and functional outcomes data were analyzed.

Results and limitations

The mean age was 60.4 yr; body mass index was 25.4 kg/m². The mean operative time was 189.5 min; estimated blood loss was 142.0 ml. The average length of stay was 2.7 d, and the visual analog pain score at discharge was 1.4 of 10. Four focal positive margins were encountered, with two occurring during the first three cases. Pathology revealed a Gleason score of 3 + 3 in 3 patients, 3 + 4 in 11 patients, 4 + 3 in 4 patients, and 4 + 4 in 2 patients. There were a total of four complications according to the Clavien system including one grade 1, two grade 2, and one grade 4. The median follow-up has been 4 mo (range: 1–24 mo). Study limitations include the small sample size, the short follow-up, and the lack of comparative cohort.

Conclusions

The R-LESS RP is technically feasible and reduces some of the difficulties encountered with conventional LESS RP.     

R-LESS Partial Nephrectomy Trifecta Outcome Is Inferior to Multiport Robotic Partial Nephrectomy: Comparative Analysis

Background

Trifecta achievement in partial nephrectomy (PN) is defined as the combination of warm ischemia time ≤20 min, negative surgical margins, and no surgical complications.

Objective

To compare trifecta achievement between robotic, laparoendoscopic, single-site (R-LESS) PN and multiport robotic PN (RPN).

Design, setting, and participants

Data from 167 patients who underwent RPN from 2006 to 2012 were retrospectively analyzed.

Outcome measurements and statistical analysis

Primary outcome measurement was trifecta achievement; secondary outcome was the perioperative and postoperative comparison between groups. The measurements were estimated and analyzed with SPSS v.18 using univariable, multivariable, and subgroup analyses.

Results and limitations

Eighty-nine patients were treated with RPN and 78 were treated with R-LESS PN. Baseline characteristics of both groups were similar. Trifecta was achieved in 38 patients (42.7%) in the multiport RPN group and 20 patients (25.6%) in the R-LESS PN group (p = 0.021). Patients in the R-LESS PN group had longer mean operative time, warm ischemia time, and increased estimated glomerular filtration rate (eGFR) percentage change. No significant differences were found between the two groups in days of hospitalization, blood loss, postoperative eGFR, positive surgical margins, and surgical complications. Patients with increased PADUA and RENAL scores, infiltration of the collecting system, and renal sinus involvement had an increased probability of not achieving the trifecta. In regression analysis, the type of procedure and the tumor size could predict trifecta accomplishment (p = 0.019 and 0.043, respectively). The retrospective study, the low number of series, and the controversial definition of trifecta were the main limitations.

Conclusions

The trifecta was achieved in significantly more patients who underwent multiport RPN than those who underwent R-LESS PN. R-LESS PN could be an alternative option for patients with decreased tumor size, low PADUA and RENAL scores, and without renal sinus or collecting system involvement.

Patient summary

In this study, we looked at the outcomes of patients who had undergone robotic partial nephrectomy. We found that conventional robotic partial nephrectomy is superior to R-LESS partial nephrectomy with regard to the accomplishment of negative margins, reduced warm ischemia time, and minimal surgical complications.     

Laparoendoscopic Single-site Nephrectomy Compared with Conventional Laparoscopic Nephrectomy: A 5-year,Single-surgeon Experience

Background

Conventional laparoscopic nephrectomy (LN) is the gold standard approach for nephrectomy. An advance in minimally invasive nephrectomy is laparoendoscopic single-site nephrectomy (LESS-N).

Objective

To compare 5-yr experience and outcomes of LESS-N to LN.

Design, setting, and participants

Retrospective, case-control, single-surgeon series of 47 LESS-N cases matched in a 1:2 fashion by age, indication, and tumor size to 94 LN controls. LESS-N procedures were performed between August 2007 and February 2012 and LN procedures between December 1999 and 2009.

Intervention

LESS-N or LN.

Outcome measurements and statistical analysis

Categorical variables were compared by χ² analysis, and continuous variables were compared using the Mann-Whitney test.

Results and limitations

There were significantly more female patients (66% vs 46%; p = 0.023) and a significantly lower median body mass index (24 kg/m² vs 28 kg/m²; p < 0.001) in the LESS-N group compared with the LN group. Surgical indication was benign in 69 patients (23 LESS-N and 46 LN) and malignant in 72 patients (24 LESS-N and 48 LN). There were no significant differences for the LESS-N and LN groups, respectively, in mean operative time (149 min vs 150 min; p = 0.9), change in hematocrit (5.6% vs 4.8%; p = 0.661), change in creatinine (0.18 mg/dl vs 0.49 mg/dl; p = 0.18), analgesic use (morphine equivalents) (18.4 vs 17.5; p = 0.81), or intraoperative complication rates (6.4% vs 2.1%; p = 0.20). Length of stay was shorter (49 h vs 70 h; p = 0.017) and estimated blood loss was lower (56 ml vs 137 ml; p = 0.002) for the LESS-N group. Over a mean follow-up of 3 yr, postoperative complications (12.8% vs 7.4%; p = 0.30), disease-free survival (95.8% vs 87.5%; p = 0.384), and overall survival (91.7% vs 95.8%; p = 0.123) were not significantly different. The most significant limitation of this study is the retrospective design.

Conclusions

This series demonstrates that LESS-N is safe and durable in properly selected patients; however, multi-institutional randomized trials are required to confirm benefits.     

Technique and Outcomes of Robot-assisted Retroperitoneoscopic Partial Nephrectomy: A Multicenter Study

Background

Robot-assisted retroperitoneoscopic partial nephrectomy (RARPN) may be used for posterior renal masses or with prior abdominal surgery; however, there is relatively less familiarity with RARPN.

Objective

To demonstrate RARPN technique and outcomes.

Design, setting, and participants

A retrospective multicenter study of 227 consecutive RARPNs was performed at the Swedish Medical Center, the University of Michigan, and the University of California, Los Angeles, from 2006 to 2013.

Surgical procedure

RARPN.

Outcome measurements and statistical analysis

We assessed positive margins and cancer recurrence. Stepwise regression was used to examine factors associated with complications, estimated blood loss (EBL), warm ischemia time (WIT), operative time (OT), and length of stay (LOS).

Results and limitations

The median age was 60 yr (interquartile range [IQR]: 52–66), and the median body mass index (BMI) was 28.2 kg/m² (IQR: 25.6–32.6). Median maximum tumor diameter was 2.3 cm (IQR: 1.7–3.1). Median OT and WIT were 165 min (IQR: 134–200) and 19 min (IQR: 16–24), respectively; median EBL was 75 ml (IQR: 50–150), and median LOS was 2 d (IQR: 1–3). Twenty-eight subjects (12.3%) experienced complications, three (1.3%) had urine leaks, and three (1.3%) had pseudoaneurysms that required reintervention. There was one conversion to radical nephrectomy and three transfusions. Overall, 143 clear cell carcinomas (62.6%) composed most of the histology with eight positive margins (3.5%) and two recurrences (0.9%) with a median follow-up of 2.7 yr. In adjusted analyses, intersurgeon variation was associated with complications (odds ratio [OR]: 3.66; 95% confidence interval, 1.31–10.27; p = 0.014) and WIT (parameter estimate [PE; plus or minus standard error]: 4.84 ± 2.14; p = 0.025). Higher surgeon volume was associated with shorter WIT (PE: −0.06 ± 0.02; p = 0.002). Higher BMI was associated with longer OT (PE: 2.09 ± 0.56; p < 0.001). Longer OT was associated with longer LOS (PE: 0.01 ± 0.01; p = 0.002). Finally, there was a trend for intersurgeon variation in OT (PE: 18.5 ± 10.3; p = 0.075).

Conclusions

RARPN has acceptable morbidity and oncologic outcomes, despite intersurgeon variation in WIT and complications. Greater experience is associated with shorter WIT.

Patient summary

Robot-assisted retroperitoneoscopic partial nephrectomy has acceptable morbidity and oncologic outcomes, and there is intersurgeon variation in warm ischemia time and complications.     

Laparo-Endoscopic Single Site (LESS) versus Standard Laparoscopic Left Donor Nephrectomy: Matched-pair Comparison

Background

Laparo-Endoscopic Single Site (LESS) surgery is a recent development in minimally invasive surgery. Presented herein is the initial comparison of LESS donor nephrectomy (LESS-DN) and standard laparoscopic living donor nephrectomy (LLDN).

Objective

To determine whether LESS-DN provides any measurable benefit over LLDN during the perioperative period and subsequent convalescence.

Design, setting, and participants

Between November 2007 and November 2008, 18 consecutive patients underwent LESS-DN (17 left DN, 1 right DN). A contemporary matched-pair cohort of 17 patients undergoing standard LLDN was selected for retrospective comparison.

Interventions

LESS-DN was performed through an intraumbilical novel multichannel port. The kidney was extracted through a slightly extended umbilical incision.

Measurements

All data were prospectively accrued in an institutional review board–approved database. Convalescence data included visual analog pain scores and questionnaires containing patient-reported time to recovery end points.

Results and limitations

One right-sided donor was converted to standard laparoscopy and excluded from analysis. Baseline demographics, operating time, blood loss, and hospital stay were comparable between groups. Compared to LLDN, patients undergoing LESS-DN had similar in-hospital analgesic requirements and mean visual analog scores at discharge. After discharge, patient-reported convalescence was faster in the LESS-DN group, including days on oral pain medication (20 vs 6; p = 0.01), days off work (46 vs 18; p = 0.0009), and days to 100% physical recovery (83 vs 29; p = 0.03). Mean warm ischemia time was longer in the LESS-DN group (3 vs 6.1 min; p < 0.0001); however, allograft function was immediate and comparable between groups. One allograft in the LESS-DN group thrombosed postoperatively. Regardless of laparoscopic approach, patients’ global satisfaction with kidney donation and willingness to recommend their procedure to others were favorable and equivalent between groups.

Conclusions

This retrospective matched-pair comparison between LESS-DN and LLDN suggests that the single-port approach may be associated with quicker convalescence. In this initial series, LESS-DN had longer ischemia time, yet early allograft outcomes were comparable.     

Laparoendoscopic Single-site Partial Nephrectomy Without Ischemia for Very Small,Exophytic Renal Masses: Surgical Details and Functional Outcomes

Background

Laparoendoscopic single-site surgery (LESS) has emerged as a natural progression from standard laparoscopy aiming to further minimize the morbidity of urologic procedures.

Objective

To describe our technique and report the surgical and functional outcomes of unclamped LESS partial nephrectomy (PN) in the treatment of small renal masses (SRMs).

Design, setting, and participants

Prospective evaluation of pre- and postoperative variables of patients undergoing the LESS-PN without ischemia between 2009 and 2012. The indications were single exophytic SRMs.

Surgical procedure

Unclamped LESS-PN was performed through a transperitoneal approach. A pararectal Hasson access technique was preferred. Single-port access was achieved via different single-port devices. A combination of straight and articulating laparoscopic instruments was used. The tumor was excised using bipolar scissors during normal renal perfusion. Hemostasis was achieved by bipolar electrocautery, parenchymal stitches, and hemostatic agents.

Outcome measurements and statistical analysis

Demographic, operative, postoperative, and pathologic outcomes data were recorded and analyzed.

Results and limitations

A total of 21 LESS-PN were performed (operative time: 111 ± 41 min; blood loss: 196 ± 195 ml: tumor size: 2.0 ± 0.3 cm). Neither conversion to open surgery nor transfusions occurred. Three patients required conversion to standard laparoscopy. Postoperatively, three complications (Clavien grades 2, 3a, and 4) were recorded. Pathologic examination revealed 14 clear cell carcinomas, four renal cysts, two oncocytomas, and one angiomyolipoma. Hospital stay was 4.4 ± 1.9 d. At the last follow-up (mean: 17 ± 11.5 mo), no port-site, local, or distant recurrences were detected. No significant variation in serum creatinine and estimated glomerular filtration rate was observed. Subjective scar evaluation indicated 66% of patients were very satisfied/enthusiastic. Study limitations include the small sample size, the lack of a control group, the short follow-up period, and the arbitrary measure of patient's scar perception.

Conclusions

Unclamped LESS-PN for selected SRMs is a safe and feasible procedure providing favorable postoperative outcomes and ensuring high levels of subjective, cosmetic satisfaction.     

Feasibility of Transvaginal NOTES-Assisted Laparoscopic Nephrectomy

Background

Recently, the feasibility of a transvaginal hybrid natural orifice transluminal endoscopic surgery (NOTES) nephrectomy was demonstrated in a 23-yr-old woman with a nonfunctional atrophic kidney.

Objective

To evaluate the feasibility and reproducibility of transvaginal NOTES-assisted laparoscopic nephrectomy in female patients with and without renal cancer.

Design, setting, and participants

Between March 2008 and June 2009, 14 female patients were submitted to transvaginal NOTES-assisted laparoscopic nephrectomy for T1–T3a N0M0 renal cancer (n = 10), lithiasis (n = 2), or renal atrophy (n = 2) at the Hospital Clinic of Barcelona, Spain.

Surgical procedure

Under general anaesthesia, female patients underwent laparoscopic nephrectomy by transvaginal NOTES using a deflectable camera by vaginal access and two additional 5- and 10-mm trocars in the abdomen. The renal artery and vein were dissected and taken separately between clips. The dissected kidney was removed via the vagina after enlarging the vaginal trocar incision.

Measurements

All data referring to patient demographics, surgery, pathology, and perioperative outcomes were recorded.

Results and limitations

The procedure was completed in all patients. The mean age of the women was 59.1 yr. The mean operative time was 132.9 min and the mean estimated blood loss was 111.2 ml. None of the patients required a blood transfusion and the use of analgesics was low. The mean hospital stay was 4 d. In one case, a major complication (a colon injury) occurred. The patient underwent surgery and a temporary colostomy was performed. The patient has already undergone reconstruction.

Conclusions

Transvaginal NOTES-assisted laparoscopic nephrectomy is feasible and reproducible and may be an alternative technique for treatment of women with renal cancer. Proper selection of patients is warranted for success of this new approach. However, longer follow-up in an increasing number of patients is needed to establish its role in the treatment of renal cancer.     

NOTES Hybrid Transvaginal Radical Nephrectomy for Tumor: Stepwise Progression Toward a First Successful Clinical Case

Background

Natural orifice translumenal endoscopic surgery (NOTES) has been used to perform nephrectomy in the laboratory; however, clinical reports to date have used multiple abdominal trocars to assist the transvaginal procedure.

Objective

To present our stepwise technique development and the first successful clinical case of NOTES transvaginal radical nephrectomy for tumor with umbilical assistance without extraumbilical skin incisions.

Design, setting, and participants

The four transvaginal NOTES procedures were performed at two institutions after obtaining institutional review board approval. Various operative steps were developed experimentally in three clinical cases, and on March 7, 2009, we performed the first successful case of NOTES hybrid transvaginal radical nephrectomy without any extraumbilical skin incisions. Using one multichannel access port in the vagina and one in the umbilicus, laparoscopic visualization, intraoperative tissue dissection, and hilar control were performed transvaginally and transumbilically. The intact specimen was extracted transvaginally.

Measurements

All perioperative data were accrued prospectively. A stepwise progression to the successful completion of the fourth case is systematically presented.

Results and limitations

Intraoperatively, at incrementally more advanced stages of the procedure, the first three NOTES clinical cases were electively converted to standard laparoscopy because of rectal injury during vaginal entry, of failure to progress, and of gradual bleeding during upper-pole dissection after transvaginal hilar control, respectively. The fourth case was successfully completed via transvaginal and umbilical access without conversion to standard laparoscopy. Operative time was 3.7 h, estimated blood loss was 150 cm³, and hospital stay was 1 d. Final pathology confirmed a 220-g, pT1b, 7-cm, grade 2, clear-cell renal cell carcinoma with negative margins. The patient was readmitted for an intraabdominal collection that responded to drainage and antibiotics.

Conclusions

We report our stepwise progression and the initial successful clinical case of NOTES hybrid transvaginal radical nephrectomy for tumor, assisted with only one umbilical trocar. Although transvaginal nephrectomy is feasible in the highly selected patient with favorable intraoperative circumstances, considerable refinements in technique and technology are necessary if this approach is to advance beyond mere anecdote.     

Surgical complications after immediate nephrectomy versus preoperative chemotherapy in non-metastatic Wilms' tumour: Findings from the 1991–2001 United Kingdom Children's Cancer Study Group UKW3 Trial

Purpose

To compare surgical complication rates after immediate nephrectomy versus delayed nephrectomy following preoperative chemotherapy in children with non-metastatic Wilms’ tumour enrolled in UKW3, both in randomised patients and in those for whom the treatment approach was defined by parental or physician choice.

Methods

Records for all patients enrolled into UKW3 were reviewed. Any record of tumour rupture or surgical complication was extracted and comparisons made between the two treatment strategies in both populations of randomised and non-randomised patients.

Results

Of 525 children enrolled, 205 patients were randomised to either immediate nephrectomy (n = 103) or pre-operative chemotherapy followed by delayed nephrectomy (n = 102). Of the 320 children not randomised, data were available on 189 cases treated with immediate nephrectomy and 103 treated with pre-operative chemotherapy. There were significantly fewer surgical complications in randomised children given pre-operative chemotherapy before surgery compared to children undergoing immediate nephrectomy (1% vs. 20.4%, P < 0.001); this difference was most marked for tumour rupture (0% vs. 14.6%, P < 0.001).

Conclusions

Delayed nephrectomy for Wilms’ tumour, preceded by pre-operative chemotherapy was associated with fewer surgical complications compared with immediate nephrectomy.     

Recovery of Renal Function After Open and Laparoscopic Partial Nephrectomy

Background

Although oncologic outcomes appear to be similar after laparoscopic partial nephrectomy (LPN) and open partial nephrectomy (OPN), data on renal function are lacking.

Objective

To evaluate the change over time in renal function after LPN and OPN.

Design, setting, and participants

We identified 987 patients with a single sporadic tumor and a normal contralateral kidney who were treated by LPN (n = 182) and OPN (n = 805) between January 2002 and July 2009.

Intervention

All patients underwent LPN or OPN at Memorial Sloan-Kettering Cancer Center.

Measurements

Estimated glomerular filtration rate (GFR) was calculated using the abbreviated Modification of Diet in Renal Disease formula. We created a multivariable generalized estimating equations linear model that predicted GFR based on the time from surgery, preoperative GFR, tumor size, American Society of Anesthesiologists score, and ischemia time.

Results and limitations

Mean patient age, tumor size, and ASA score were similar between LPN and OPN patients. The baseline preoperative GFR was lower in the laparoscopic group (67 ml/min per 1.73 m² vs 73 ml/min per 1.73 m²; p < 0.001). The mean ischemia time was shorter after LPN than OPN (35 min vs 40 min, respectively; p < 0.001). In a multivariable model, the interaction term between time from surgery and approach was statistically significant (p = 0.045), indicating that there was a differential effect on recovery of renal function over time by approach. Laparoscopically treated patients maintained a slightly higher renal function than those treated via an open approach. The 2-mo and 6-mo predicted GFR for a typical patient increased slightly from 65 ml/min per 1.73 m² to 67 ml/min per 1.73 m², respectively, for those treated laparoscopically but remained constant at 62 ml/min per 1.73 m² after OPN.

Conclusions

Our data suggest that the surgical approach has a small effect on the recovery of renal function after partial nephrectomy. Laparoscopically treated patients maintained slightly higher renal function.     

Single-Port Laparoscopic and Robotic Partial Nephrectomy

Background

Partial nephrectomy (PN) for small renal masses provides effective oncologic outcomes. Single-port laparoscopic (SPL) and robotic surgeries are evolving approaches to advance minimally invasive surgery.

Objective

To determine the feasibility of laparoscopic and robotic single-port PN.

Design, setting, and participants

Since 2007, evaluation of patients undergoing SPL and single-port robotic (SPR) PN at a primary referral center was performed. Patients with small, solitary, exophytic-enhancing renal masses were selected. Patients with a solitary kidney, endophytic or hilar tumors, and previous abdominal and/or kidney surgery were excluded. Perioperative and pathologic data were entered prospectively into an institutional review board (IRB)–approved database.

Interventions

Tumor location determined either an open Hasson transperitoneal or retroperitoneal approach. A single multichannel port or Triport provided intra-abdominal access. The Harmonic Scalpel was used for tumor excision under normal renal perfusion. The da Vinci surgical robot was used for SPR cases.

Measurements

Patient demographics, perioperative, hematologic, and pathologic data as well as pain assessment using the Visual Analog Pain Scale (VAPS) were assessed.

Results and limitations

A total of seven patients underwent single-port PN (SPL = 5, SPR = 2). One patient with a right anterior upper-pole mass required conversion from SPL to standard laparoscopy following tumor excision because of intraoperative bleeding. Pathology revealed six lesions compatible with renal cell carcinoma (RCC) and one benign cyst. One negative frozen section came back focally positive on final histopathology. All other surgical margins were negative. A mean difference of 3.0 ± 2.0 g/dl in hemoglobin was noted in all patients. Minimal pain was noted at discharge following both laparoscopic and robotic single-port surgery (VAPS = 1.7 ± 1.2 vs 1 ± 0.5/10).

Conclusions

SPL and SPR PN is feasible for select exophytic tumors. Robotics may improve surgical capabilities during single-port surgery.     

Laparoendoscopic Single-site Partial Nephrectomy: A Multi-institutional Outcome Analysis

Background

Laparoendoscopic single-site surgery (LESS) has been developed in an attempt to further reduce the surgical trauma associated with conventional laparoscopy. Partial nephrectomy (PN) represents a challenging indication for LESS.

Objective

To report a large multi-institutional series of LESS-PN and to analyze the predictors of outcomes after LESS-PN.

Design, setting, and participants

Consecutive cases of LESS-PN done between November 2007 and March 2012 at 11 participating institutions were included in this retrospective analysis.

Intervention

Each group performed LESS-PN according to its own protocols, entry criteria, and techniques.

Outcome measurements and statistical analysis

Demographic data, main perioperative outcome parameters, and perioperative complications were gathered and analyzed. A multivariable analysis was used to assess the factors predicting a short (≤20 min) warm ischemia time (WIT), the occurrence of postoperative complication of any grade, and a favorable outcome, arbitrarily defined as a combination of the following events: short WIT plus no perioperative complications plus negative surgical margins plus no conversion to open surgery or standard laparoscopy.

Results and limitations

A total of 190 cases were included in this analysis. Mean renal tumor size was 2.6, and PADUA score 7.2. Median operative time was 170 min, with median estimated blood loss (EBL) of 150 ml. A clampless technique was adopted in 70 cases (36.8%), and the median WIT was 16.5 min. PADUA score independently predicted length of WIT (low vs high score: odds ratio [OR]: 5.11 [95% confidence interval (CI), 1.50–17.41]; p = 0.009; intermediate vs high score: OR: 5.13 [95% CI, 1.56–16.88]; p = 0.007). The overall postoperative complication rate was 14.7%. The adoption of a robotic LESS technique versus conventional LESS (OR: 20.92 [95% CI, 2.66–164.64]; p = 0.003) and the occurrence of lower (≤250 ml) EBL (OR: 3.60 [95% CI, 1.35–9.56]; p = 0.010) were found to be independent predictors of no postoperative complications of any grade. A favorable outcome was obtained in 83 cases (43.68%). On multivariate analysis, the only predictive factor of a favorable outcome was the PADUA score (low vs high score: OR: 4.99 [95% CI, 1.98–12.59]; p < 0.001). Limitations of the study were the retrospective design and different selection criteria for the participating centers.

Conclusions

LESS-PN can be safely and effectively performed by experienced hands, given a high likelihood of a single additional port. Anatomic tumor characteristics as determined by the PADUA score are independent predictors of a favorable surgical outcome. Thus patients presenting tumors with low PADUA scores represent the best candidates for LESS-PN. The application of a robotic platform is likely to reduce the overall risk of postoperative complications.     

Determinants of Laparoscopic Donor Nephrectomy Outcomes

Background

Pure laparoscopic donor nephrectomy (LDN) is a unique intervention because it carries known risks and complications, yet carries no direct benefit to the donor. Therefore, it is critical to continually examine and improve quality of care.

Objective

To identify factors affecting LDN outcomes and complications.

Design, setting, and participants

A retrospective analysis of prospectively collected data for 1204 consecutive LDNs performed from March 2000 through August 2012.

Intervention

LDN performed at an academic training center.

Outcome measurements and statistical analysis

Using multivariable regression, we assessed the effect of age, sex, body mass index (BMI), laterality, and vascular variation on operative time, estimated blood loss (EBL), complications, and length of stay.

Results and limitations

The following variables were associated with longer operative time (data given as parameter estimate plus or minus the standard error): female sex (9.09 ± 2.43; p < 0.001), higher BMI (1.03 ± 0.32; p = 0.001), two (7.87 ± 2.70; p = 0.004) and three or more (22.45 ± 7.13; p = 0.002) versus one renal artery, and early renal arterial branching (5.67 ± 2.82; p = 0.045), while early renal arterial branching (7.81 ± 3.85; p = 0.043) was associated with higher EBL. Overall, 8.2% of LDNs experienced complications, and by modified Clavien classification, 74 (5.9%) were grade 1, 13 (1.1%) were grade 2a, 10 (0.8%) were grade 2b, and 2 (0.2%) were grade 2c. There were no grade 3 or 4 complications. Three or more renal arteries (odds ratio [OR]: 2.74; 95% CI, 1.05–7.16; p = 0.04) and late renal vein confluence (OR: 2.42; 95% CI, 1.50–3.91; p = 0.0003) were associated with more complications. Finally, we did not find an association of the independent variables with length of stay. A limitation is that warm ischemia time was not assessed.

Conclusions

In our series, renal vascular variation prolonged operative time and was associated with more complications. While complicated donor anatomy is not a contraindication of LDN, surgical decision-making should take into consideration these results.     

Every Minute Counts When the Renal Hilum Is Clamped During Partial Nephrectomy

Background

The safe duration of warm ischemia during partial nephrectomy remains controversial.

Objective

Our aim was to evaluate the short- and long-term renal effects of warm ischemia in patients with a solitary kidney.

Design, setting, and participants

Using the Cleveland Clinic and Mayo Clinic databases, we identified 362 patients with a solitary kidney who underwent open (n = 319) or laparoscopic (n = 43) partial nephrectomy using warm ischemia with hilar clamping.

Measurements

Associations of warm ischemia time with renal function were evaluated using logistic or Cox regression models first as a continuous variable and then in 5-min increments.

Results and limitations

Median tumor size was 3.4 cm (range: 0.7–18.0 cm), and median ischemia time was 21 min (range: 4–55 min). Postoperative acute renal failure (ARF) occurred in 70 patients (19%) including 58 (16%) who had a glomerular filtration rate (GFR) <15 ml/min per 1.73 m² within 30 d of surgery. Among the 226 patients with a preoperative GFR ≥ 30 ml/min per 1.73 m² and followed ≥30 d, 38 (17%) developed new-onset stage IV chronic kidney disease during follow-up. As a continuous variable, longer warm ischemia time was associated with ARF (odds ratio: 1.05 for each 1-min increase; p < 0.001) and a GFR < 15 (odds ratio: 1.06; p < 0.001) in the postoperative period, and it was associated with new-onset stage IV chronic kidney disease (hazard ratio: 1.06; p < 0.001) during follow-up. Similar results were obtained adjusting for preoperative GFR, tumor size, and type of partial nephrectomy in a multivariable analysis. Evaluating warm ischemia in 5-min increments, a cut point of 25 min provided the best distinction between patients with and without all three of the previously mentioned end points. Limitations include the retrospective nature of the study.

Conclusions

Longer warm ischemia time is associated with short- and long-term renal consequences. These results suggest that every minute counts when the renal hilum is clamped.     

Laparoscopic and Open Partial Nephrectomy: A Matched-Pair Comparison of 200 Patients

Background

Laparoscopy is currently challenging the role of the open approach for nephron-sparing surgery (NSS), yet comparative studies on this issue are scant.

Objective

To compare surgical, oncologic, and functional outcomes after laparoscopic partial nephrectomy (LPN) and open partial nephrectomy (OPN).

Design, setting, and participants

We undertook matched-pair (age, sex, tumour size) analysis of patients who underwent elective NSS for renal masses either by laparoscopic (Klagenfurt) or open (Vienna) access.

Measurements

Surgical data, complications, histologic and oncologic data, and short- and long-term renal function of the open and laparoscopic groups were compared.

Results and limitations

In total, 200 patients matched for age, sex, and tumour size entered the study after either LPN or OPN and were followed for a mean of 3.6 yr. Surgical, ischemia, and hospitalisation times were shorter in the LPN group (p < 0.001). Blood loss and complication rates were comparable in both groups. Malignant tumours were pT1 stage renal-cell cancer only in both groups. The positive surgical margin (PSM) rate was 4% after LPN and 2% after OPN (p = 0.5); positive margins were not a risk factor for disease recurrence. Kaplan-Meier estimates of 5-yr local recurrence-free survival (RFS) were 97% after LPN and 98% after OPN (p = 0.8); the respective numbers for distant free survival were 99% and 96% (p = 0.2). Five-year overall survival (OS) for patients with pT1 stage renal cell carcinoma (RCC) was 96% after LPN and 85% after OPN. The decline in glomerular filtration rate at the last available follow-up (LPN: 10.9%; OPN: 10.6%) was similar in both groups (p = 0.8). We recognise the retrospective nature, limited follow-up, and sample size as shortcomings of this study.

Conclusions

In experienced hands, LPN provides similar results compared to open surgery. PSM rates were comparable after LPN and OPN. Current experience questions the indication of secondary nephrectomy in these patients.     

Robotic Partial Nephrectomy with Superselective Versus Main Artery Clamping: A Retrospective Comparison

Background

Concerns have been raised regarding partial nephrectomy (PN) techniques that do not occlude the main renal artery.

Objective

Compare the perioperative outcomes of superselective versus main renal artery control during robotic PN.

Design, setting, and participants

A retrospective analysis of 121 consecutive patients undergoing robotic PN using superselective control (group 1, n = 58) or main artery clamping (group 2, n = 63).

Intervention

Group 1 underwent tumor-specific devascularization, maintaining ongoing arterial perfusion to the renal remnant at all times. Group 2 underwent main renal artery clamping, creating global renal ischemia.

Outcome measurements and statistical analysis

Perioperative and functional data were evaluated. The Pearson chi-square or Fisher exact and Wilcoxon rank sum tests were used.

Results and limitations

All robotic procedures were successful, all surgical margins were negative, and no kidneys were lost. Compared with group 2 tumors, group 1 tumors were larger (3.4 vs 2.6 cm, p = 0.004), more commonly hilar (24% vs 6%, p = 0.009), and more complex (PADUA 10 vs 8, p = 0.009). Group 1 patients had longer median operative time (p < 0.001) and transfusion rates (24% vs 6%, p < 0.01) but similar estimated blood loss (200 vs 150 ml), perioperative complications (15% vs 13%), and hospital stay. Group 1 patients had less decrease in estimated glomerular filtration rate at discharge (0% vs 11%, p = 0.01) and at last follow-up (11% vs 17%, p = 0.03). On computed tomography volumetrics, group 1 patients trended toward greater parenchymal preservation (95% vs 90%, p = 0.07) despite larger tumor size and volume (19 vs 8 ml, p = 0.002). Main limitations are the retrospective study design, small cohort, and short follow-up.

Conclusions

Robotic PN with superselective vascular control enables tumor excision without any global renal ischemia. Blood loss, complications, and positive margin rates were low and similar to main artery clamping. In this initial developmental phase, limitations included more perioperative transfusions and longer operative time. The advantage of superselective clamping for better renal function preservation requires validation by prospective randomized studies.

Patient summary

Preserving global blood flow to the kidney during robotic partial nephrectomy (PN) does not lead to a higher complication rate and may lead to better postoperative renal function compared with clamped PN techniques.     

Changes in the plasma cytokine and growth factor profile are associated with impaired healing in pediatric patients treated with INTEGRA for reconstructive procedures

Background

Large full thickness skin defects caused by trauma or surgery require skin grafting, often in conjunction with dermal scaffolds such as INTEGRA^®. Due to the size and severity of these procedures, complications such as infection may occur. This can lead to poor healing outcomes.

Objective

To identify early biomarkers of complications during INTEGRA^® healing.

Methods

Levels of EGF, TGF-β1, FGF-2, VEGF, IFN-α, GM-CSF, IL-4 and IL-8 were measured pre-surgery and at days 1, 7 and 25 post-surgery in peripheral blood of 15 pediatric patients treated with INTEGRA^® for reconstructive procedures. The levels of these molecules were analysed with respect to the occurrence of complications.

Results

Complications (local infection) occurred in a group of 4 patients. This resulted in a reduced INTEGRA^® take rate comparing to the group without complications (71.5 ± 5.4% vs. 98.1 ± 0.7%). In cases with complications there were significantly higher plasma concentrations of IL-4 and FGF-2 on day 7 (p = 0.037 and p = 0.008 respectively). Other markers were not significantly different between groups or at very low level at all time-points. WCC and CRP remained within normal ranges at all time-points.

Conclusions

This data suggests that elevated levels of IL-4 and FGF-2 at early time-points after surgery may predict the development of complications in patients with INTEGRA^®. This may enable early interventions to prevent complications in procedures involving the use of INTEGRA^®.     

Application of a Vasculature Model and Standardization of the Renal Hilar Approach in Laparoscopic Partial Nephrectomy for Precise Segmental Artery Clamping

Background

Clamping the segmental renal artery instead of the main renal artery during nephron-sparing surgery is a promising technique to decrease warm ischemia injury. Understanding vasculature characteristics and adopting an appropriate hilar approach to segmental arteries are essential to the technique.

Objective

To study the role of the vasculature model and to standardize the renal hilar approach in segmental renal artery dissection during laparoscopic partial nephrectomy (LPN).

Design, setting, and participants

A retrospective analysis of a consecutive series of 82 patients who underwent LPN with a precise clamping technique from December 2009 to June 2011 with a mean follow-up of 20 mo.

Surgical procedure

Three-dimensional dynamic renal vascular models were established based on dual-source computed tomographic angiography. Clamping number, clamping position, and a different hilar approach accessing target segmental arteries were determined preoperatively. Target arteries were dissected and clamped based on the model. Tumor excision and renorrhaphy were performed under regional parenchymal ischemia.

Outcome measurements and statistical analysis

Renal vascular characteristics and surgical outcomes were analyzed. The outcomes among different surgical approaches were compared using one-way analysis of variance test or Fisher exact test.

Results and limitations

All surgeries were performed successfully without converting to main renal artery clamping or radical nephrectomy. The median operative time was 90 min, and the mean clamping time was 24 min. The median estimated blood loss (EBL) was 200 ml, and six patients received blood transfusions. Five patients had hematuria without any intervention. One patient had a postoperative hemorrhage and received selective embolization intervention. Statistical analysis showed that appropriate surgical approaches chosen from the models led to comparable operative times, EBL, and complication rates. The limitation of the study lies on its retrospective feature.

Conclusions

A renal vasculature model provides effective orientation for a precise clamping technique. A standardized hilar approach based on the model optimizes the surgical procedure and leads to satisfactory surgical outcomes.