Renal hypothermia using ice slush for retroperitoneal laparoscopic partial nephrectomy

Renal hypothermia using ice slush for retroperitoneal laparoscopic partial nephrectomy was performed in 2 patients. A cylindrical device was secured in the enlarged port site. Through the device, ice slush was introduced and placed around the kidney. The nadir renal temperature under renal ischemia in the 2 patients was 18.4 degrees C and 25.8 degrees C.     

Laparoscopic partial nephrectomy with clamping of the renal parenchyma: initial experience

OBJECTIVES: Partial nephrectomy by laparoscopy offers patients conservative surgery and a mini-invasive approach; however, clamping of the renal pedicle and the induced warm ischaemia can damage the renal parenchyma. We present a technique of laparoscopic partial nephrectomy with haemostasis obtained by clamping of the renal parenchyma. METHODS: The procedure was performed by an intraperitoneal or a retroperitoneal approach. After a working space is created by pneumodissection, Gerota's fascia is incised and the kidney convexity is dissected. An endoscopic Satinsky clamp is inserted percutaneously through a 1-cm incision. The renal parenchyma is clamped and the tumour is excised in a bloodless field. The cut renal parenchyma is coated with biologic glue. RESULTS: Five patients with elective indications were operated. Mean age was 67.8 yr and mean tumour diameter 3.06 cm. One lesion was located at the upper pole and four at the lower pole. Mean preoperative serum creatinine level was 10.9 mg/l. Postoperative serum creatinine level was unchanged. Mean operative time was 238 min. There was no conversion. Mean blood loss was 250 ml; no transfusions were necessary. The collecting duct system was repaired in one patient. No complication was noticed. Resection margins were tumour free in all cases. Final pathologic examination revealed clear cell carcinoma in three cases and angiomyolipoma and oncocytoma in one case each. CONCLUSION: Laparoscopic partial nephrectomy with clamping of the renal parenchyma can be performed in selected patients with peripherally placed tumours. The procedure avoids warm ischaemia of the normal parenchyma while allowing the surgeon to operate in an almost bloodless field. This initial experience in five patients should be validated in a larger series.     

Laparoscopic ice slurry coolant for renal hypothermia

PURPOSE: We assessed the safety and efficacy of microparticulate ice slurry for laparoscopic hypothermia during renal ischemia in a single kidney porcine model. MATERIALS AND METHODS: A total of 18 farm pigs were randomized to 3 groups of 6 each. All groups underwent initial right laparoscopic nephrectomy, followed by 1 of 3 procedures on the left kidney. Group 1 underwent 90-minute hilar clamping under warm ischemia, group 2 underwent 90-minute hilar clamping under cold ischemia using laparoscopically delivered microparticulate ice slurry and control group 3 underwent hilar dissection, no clamping and no microparticulate ice slurry. Body and renal cortical temperatures were measured. Serum creatinine and the glomerular filtration rate were assessed preoperatively, and on postoperative days 1, 3, 8 and 15. RESULTS: Average time to achieve a renal temperature of 20C or less was 9.7 minutes and it remained constant during the 90-minute cold ischemia time. Mean serum creatinine was significantly higher in the warm ischemia group than in the cold ischemia and control groups on postoperative days 1 and 3. Additionally, mean serum creatinine in the cold ischemia and control groups was similar at all time points. The mean glomerular filtration rate was significantly lower in the warm ischemia group than in the cold ischemia and control groups on postoperative days 1, 3 and 8. The mean glomerular filtration rate in the cold ischemia group was lower than in the control group on postoperative day 1, while it was similar on postoperative days 3, 8 and 15. CONCLUSIONS: In the porcine model laparoscopic renal hypothermia achieved with microparticulate ice slurry was safe and efficient. It significantly decreased renal dysfunction secondary to an ischemic insult with no adverse effects or complications associated with microparticulate ice slurry use.     

Laparoscopic partial nephrectomy with selective control of the renal parenchyma: initial experience with a novel laparoscopic clamp

OBJECTIVE

To report a laparoscopic device that facilitates regional ischaemia in laparoscopic partial nephrectomy (LPN).

PATIENTS AND METHODS

Mimicking the shape of a clamp successfully applied in open PN, we developed a laparoscopic device that allows selective clamping in LPN. After obtaining transperitoneal access to the renal mass, the laparoscopic clamp was placed around the tumour 1–2 cm proximal to the line of resection. After excising the tumour, haemostasis was mainly achieved by applying a haemostyptic agent.

RESULTS

Three patients with elective indications had LPN using this novel laparoscopic clamp. The tumours were in the upper and lower pole of the kidney in one and two patients, respectively. The tumour diameter was 2.4, 2.6 and 3.2 cm, and the selective clamping time 23, 27 and 38 min. Blood loss was minimal in all three cases, with no complications after LPN. The final pathology showed a papillary and clear cell renal carcinoma in two and one patients, respectively. There were no positive margins on histological assessment.

CONCLUSION

LPN with clamping of the renal parenchyma using this novel device can be used in selected patients with peripheral tumours. Resection of the tumour in a bloodless field is possible. The main advantage is that ischaemia occurs only in the renal parenchyma next to the tumour, facilitating nephron‐sparing surgery without being pressed for time.     

Laparoscopic partial nephrectomy: the European experience.

Laparoscopic partial nephrectomy is technically difficult but oncologically effective. The operation should be performed in centers with expertise. Hemostasis can be achieved using bipolar coagulation and fibrin glue-coated cellulose. Further studies will determine whether less invasive alternatives (focused ultrasound, cryotherapy) will meet the high standard of open (or laparoscopic) nephron-sparing surgery for small renal cell carcinoma.CommentaryThe technique of laparoscopic partial nephrectomy for the treatment of renal cell carcinoma (RCC) is in its very early stages. The cumulative experience reported in the literature comprises fewer than 100 cases and these have been confounded by a lack of standardized technique and variable experience. There has been difficulty in reproducing the essential elements of open partial nephrectomy using contemporary laparoscopic instrumentation. In this large multicenter European study, hemostasis was achieved with bipolar coagulation and fibrin-coated cellulose. Notwithstanding that case selection was limited to very small (≤3 cm) peripheral renal tumors, the morbidity of partial nephrectomy in this study was greater than that of open partial nephrectomy for small peripheral tumors.At the Cleveland Clinic, we have recently developed a technique for laparoscopic partial nephrectomy which duplicates established open surgical principles. The key technical steps in this approach include:Since August 1999, this technique has been used to perform laparoscopic partial nephrectomy in 36 patients with small, exophytic renal tumors. Mean tumor size was 2.9 cm (range 1.4–7.0 cm). The operation was successful in all cases without any open conversions. Mean operative time was 2.9 h, warm ischemia time was 20 min and blood loss was 237 ml. Formal calyceal suture repair was performed in 7 patients. Mean hospital stay was 1.7 days. The final pathology revealed renal cell carcinoma in 20 patients and other tumors in the remainder. All margins of resection were negative for tumor.Our initial experience suggests that laparoscopic partial nephrectomy can be performed for small exophytic renal tumors with adherence to established principles and techniques of the open surgical approach and with significant benefits for the patient.Andrew C. Novick, M.D.     

Laparoscopic partial nephrectomy: The McMaster University experience

Introduction:

Laparoscopic partial nephrectomy (LPN) remains one of the more challenging procedures in urology. Minimizing warm ischemia time (WIT) and bleeding requires efficient intracorporeal suturing. In addition, achieving negative surgical margins requires complete excision of the tumour. We report a large Canadian series of laparoscopic partial nephrectomy with intermediate follow-up.

Methods:

Between September 2000 and August 2008, 152 consecutive laparoscopic partial nephrectomies were performed at our centre. Demographic, pathological and clinical data were collected through a retrospective review of the charts.

Results:

The average tumour size was 2.68 cm (Range: 0.5–8.8. The vast majority of tumours were malignant (80%). All margins were negative, except for 2 patients who underwent an immediate re-resection. There were no local recurrences or distant metastasis during the follow-up period of 44.3 months. Most procedures required hilar clamping (93.4%) with a mean WIT of 34 minutes, with a clear trend for declining WIT with increasing experience. Five procedures were converted to laparoscopic radical nephrectomy, 10 converted to a hand-assisted procedure, and 1 was converted to an open partial nephrectomy. The average blood loss was 162 cc. Complications related to the procedure were classified according to the Clavien grading system. The average drop in the glomerular filtration rate was calculated by the Modification of Diet in Renal Disease (MDRD) Study equation between preoperative and 2.5 months postoperative was 8.6 mL/min/1.73 m².

Conclusions:

LPN is a challenging procedure that requires advanced laparoscopic skills. LPN is feasible with excellent oncological outcomes, and an acceptable complication profile. The short-term impact on overall renal function is minimal. The most common postoperative complication was pseudo-aneurysm requiring embolization, which reinforces the intra-operative need for meticulous and a quick suture-ligation of blood vessels during LPN.     

Laparoscopic partial nephrectomy: experience in 60 cases

PURPOSE: To identify the factors associated with better outcomes in patients undergoing laparoscopic partial nephrectomy (LPN). PATIENTS AND METHODS: We retrospectively analyzed the medical records of 36 men and 24 women aged 31 to 80 years (mean 60 years) in whom LPN was attempted at our institution over a 3.5-year period. Baseline patient characteristics and operative, pathologic, and postoperative outcomes were analyzed. The median duration of follow-up was 14.2 months (range 1-38 months). RESULTS: The median pathologic tumor size was 2.1 cm (range 0.7-6.0 cm). Final pathologic review revealed renal-cell carcinoma in 73% of patients. Six patients (10%) required conversion to either an open partial nephrectomy or a laparoscopic radical nephrectomy. Dense perinephric adipose tissue in the setting of a small renal tumor and unanticipated multifocal disease were factors associated with surgical conversion. The median overall estimated blood loss was 112 mL, and the median warm-ischemia time was 30 minutes. Blood loss was greater in patients who did not undergo hilar clamping (467 v 65 mL; P = 0.008). CONCLUSION: Factors influencing successful LPN outcomes include selecting a tumor commensurate with the surgeon's laparoscopic experience, performing routine hilar clamping, adjunctive use of hemostatic agents, and renal-parenchymal suture ligation. The presence of thick, fibrotic perinephric fat overlying a small tumor increases the technical difficulty.     

Robot assisted laparoscopic partial nephrectomy: initial experience

PURPOSE: Advances in laparoscopy have made laparoscopic partial nephrectomy a technically feasible procedure but it remains challenging to even experienced laparoscopists. We hypothesized that robotic assisted laparoscopic partial nephrectomy may make this procedure more efficacious than the standard laparoscopic approach. MATERIALS AND METHODS: Ten patients with a mean age of 58 years and mean tumor size of 2.0 cm underwent robotic assisted laparoscopic partial nephrectomy and another 10 with a mean age of 61 years and mean tumor size of 2.18 cm underwent laparoscopic partial nephrectomy, as performed by a team of 2 surgeons (MS and ST) between May 2002 and January 2004. Demographic data, intraoperative parameters and postoperative data were compared between the 2 groups. RESULTS: There were no significant differences in patient demographics between the 2 groups. Intraoperative data and postoperative outcomes were statistically similar. In the 10 patients who underwent robotic assisted laparoscopic partial nephrectomy there were 2 intraoperative complications. There was 1 conversion in the laparoscopic partial nephrectomy group. CONCLUSIONS: Robotic assisted laparoscopic partial nephrectomy is a safe and feasible procedure in patients with small exophytic masses. The robotic approach to laparoscopic partial nephrectomy does not offer any clinical advantage over conventional laparoscopic nephrectomy.     

Retroperitoneoscopic partial nephrectomy for renal cell carcinoma: our initial experience and review of the literature

PURPOSE: We report our initial experiences of retroperitoneoscopic partial nephrectomy for renal cell carcinoma. MATERIALS AND METHODS: From April 2002 to October 2003, we performed 11 retroperitoneoscopic partial nephrectomy for renal cell carcinoma. Our indication was T1N0M0 renal tumors which sizes were about 4 cm or less and were exophytic and were not situated at the renal hilum. First we inserted single J catheter to the renal pelvis cystoscopically. under fluoroscopic guidance. Next 4 trocars were set at pneumoretroperitoneum and the renal artery and vein were clamped individually after cold saline was circulated from the single J catheter. Renal parenchyma was sharply cut with scissors and vessels were coagulated with bipolar coagulator. When renal collecting system was opened, cariceal suture repair was performed. We used the microwave tissue coagulator without clamping the renal pedicle when the tumor was 2 cm or less in diameter and the distance from the tumor edge to the renal collecting system was more than 1cm. RESULTS: In 9 cases renal pedicles were clamped and in 2 cases were not. Mean tumor size was 27.5 +/- 8.9 mm and mean operative time was 350 +/- 92 minutes and mean estimated blood loss was 743 +/- 998 ml, and mean warm ischemic time was 70 +/- 30 minutes. In one case bleeding from cut surface was uncontrollable, so open conversion was needed. In this case the renal artery and vein were clamed but another artery exited. The surgical margins were all negative, and no other complications were happened. Post operative serum creatinine raised soon after the operation but finally downed, and the mean up level was 0.07 ng/ml only. But RI examination revealed the residual renal damages were in proportioned to the warm ischemic times. During a mean followup of 8 months no patients has had local recurrence or metastatic disease. CONCLUSIONS: Retroperitoneoscopic partial nephrectomy for renal cell carcinoma is effective for select patients. But better cooling method and earlier suture technique and more long follow-up periods will be necessary for establishment.     

Laparoscopic partial nephrectomy for renal leiomyoma: a case report

A 60-year-old man visited our hospital with a complaint of right renal incidentaloma which was pointed out on abdominal ultrasonography for a medical check-up. Abdominal computed tomography showed a renal tumor in the right kidney, which was a slightly high-dense relative to the renal parenchyma and was enhanced in the arterial phase. The tumor had grown gradually from 1.4 to 1.7 cm in diameter. After the observation for 4 years, he underwent pure laparoscopic non-ischemic partial nephrectomy using a microwave tissue coagulator. Histological examination of the specimen revealed a leiomyoma of the kidney. This is the 5th case of successful laparoscopic partial nephrectomy for renal leiomyoma in Japan within the retrieved references.     

Laparoscopic partial nephrectomy. The European experience

Laparoscopic partial nephrectomy is technically difficult but oncologically effective. The operation should be performed in centers with expertise. Hemostasis can be achieved using bipolar coagulation and fibrin glue-coated cellulose. Further studies will determine whether less invasive alternatives (focused ultrasound, cryotherapy) will meet the high standard of open (or laparoscopic) nephron-sparing surgery for small renal cell carcinoma.     

Off-clamp robot-assisted partial nephrectomy: initial washington university experience

Abstract Background and Purpose: Because of the impact warm ischemia time may have on renal function, various surgical techniques have been proposed to minimize or eliminate warm ischemia. The purpose of this study is to evaluate our initial renal functional outcomes of off-clamp robot-assisted partial nephrectomy (RAPN), while assessing the safety profile of this unconventional surgical approach. Patients and Methods: We performed a retrospective review of our off-clamp RAPN experience between August 2007 and January 2012. All patients with baseline and postoperative serum creatinine determinations were included. Patient demographics, operative information, perioperative outcomes, and renal functional outcomes were evaluated for this cohort. Results: Forty-two patients with a mean age of 59.9 years (standard deviation [SD]=12) had a median follow-up of 100 days (range 1-1007 days). In all cases, warm ischemia time was 0 minutes. Mean operative time was 143 minutes (SD=59), and median estimated blood loss was 138?mL (range 50-1500?mL). No intraoperative complications were encountered, and all surgical margins were negative. Our postoperative complication rate was 14.3%. At the most recent follow-up, the mean estimated glomerular filtration rate (eGFR) was 76.2?mL/min/1.73?m(2) (SD=27.6), compared with 78.5?mL/min/1.73?m(2) (SD=28.9) preoperatively (P=0.11). Therefore, the mean eGFR decline of 2.3?mL/min/1.73?m(2) (SD=9.1) was not significant. Conclusions: Off-clamp RAPN is associated with minimal morbidity and minimal decline in renal function on short-term follow-up. Further studies and continued monitoring of renal function are needed to determine if off-clamp RAPN provides any advantage in renal function preservation relative to the traditional RAPN with vascular clamping.     

Laparoscopic partial nephrectomy for renal tumor: single center experience comparing clamping and no clamping techniques of the renal vasculature

PURPOSE: We performed a nonrandomized retrospective comparison of 2 techniques for laparoscopic partial nephrectomy, that is without and with clamping the renal vessels. MATERIALS AND METHODS: Between December 1997 and February 2002, 28 consecutive patients underwent transperitoneal laparoscopic partial nephrectomy for renal tumor. In group 1 (12 patients) partial nephrectomy was performed with ultrasonic shears and bipolar cautery without clamping the renal vessels, while in group 2 (16 patients) the renal pedicle was clamped before tumor excision. In group 2 patients intracorporeal kidney cooling was achieved by a ureteral catheter connected to 4C solution. Intracorporeal freehand suturing techniques were used to close the collecting system when opened and approximate the renal parenchyma. RESULTS: All procedures were successfully completed laparoscopically. Mean renal ischemia time +/- SD was 27.3 +/- 7 minutes (range 15 to 47) in group 2 patients. Mean laparoscopic operating time was 179.1 +/- 86 minutes (range 90 to 390) in group 1 compared with 121.5 +/- 37 minutes (range 60 to 210) in group 2 (p = 0.004). Mean intraoperative blood loss was significantly higher in group 1 than in group 2 (708.3 +/- 569 versus 270.3 +/- 281 ml., p = 0.014). Three patients in group 1 and 2 in group 2 required blood transfusions. Immediately postoperatively mean creatinine was 1.26 +/- 0.36 and 1.45 +/- 0.61 mg./dl. in groups 1 and 2, respectively (p = 0.075). Surgical margins were negative in all specimens. Pathological examination revealed renal cell cancer in 18 cases (stages pT1 in 17 and pT3a in 1), oncocytoma in 4, angiomyolipoma in 5 and renal adenoma in 1. CONCLUSIONS: Laparoscopic partial nephrectomy represents a feasible option for patients with small renal masses. Clamping the renal vessels during tumor resection and suturing the kidney mimics the open technique and seems to be associated with less blood loss and shorter laparoscopic operative time.