Combination of CUSA and neodymium:YAG laser for canine partial nephrectomy

A Cavitron Ultrasonic Surgical Aspirator (CUSA) was used to isolate and skeletonize parenchymal renal vessels during 20 partial nephrectomies performed on 10 dogs. After isolation of the renal vessels, hemostasis was obtained by direct application of neodymium:YAG laser energy. Blood loss and total operative time were reduced compared to a control series of partial nephrectomies performed with a scalpel. The combination of Cavitron Ultrasonic Surgical Aspirator plus a Nd:YAG laser appears to offer advantages compared to either modality used alone or to standard techniques for partial nephrectomy.     

Preliminary study of the Nd:YAG laser in canine partial nephrectomy

Partial nephrectomy is effective in the treatment of segmental renal disease but hemostasis remains a challenge. In this preliminary investigation the Nd:YAG laser was used alone or as an adjunct to the scalpel in partial nephrectomies to determine if hemostasis could be improved. A technique of 100-W laser transection with occlusion of the renal artery was effective for partial nephrectomy and achieved complete hemostasis. Conditions of patent renal artery flow or renal cooling were associated with a reduction in necrosis depth with 100-W laser partial nephrectomies. All techniques were compatible with survival over the 5-day study period.     

Clinical use of the holmium: YAG laser in laparoscopic partial nephrectomy

PURPOSE: To report on the technique and utility of the holmium: YAG laser in performing laparoscopic partial nephrectomy (LPN). PATIENTS AND METHODS: Three patients with indications for LPN (complex cyst, nonfunctioning lower pole, renal mass) underwent parenchymal-sparing procedures with the Ho:YAG laser. The kidney was identified using a transperitoneal laparoscopic technique. Gerota's fascia was opened, and the renal mass/nonfunctioning lower pole was resected using the laser. Settings of 0.2 J/pulse at 60 pulses/sec and 0.8 J/pulse at 40 pulses/sec were used. RESULTS: All three procedures were performed successfully with minimal blood loss and without the need for hilar occlusion. Although the laser alone was hemostatic, fibrin glue was applied in two cases and oxidized cellulose in one case to reinforce the tissue against delayed bleeding. There were no perioperative complications, and all patients left the hospital within 3 days. CONCLUSIONS: At high power settings, the Ho:YAG laser is an effective tool for LPN. It results in good hemostasis without the need for hilar occlusion. This technique promises to facilitate the laparoscopic management of renal tumors and nonfunctioning moieties of duplicated systems.     

Does the endoscopic incision of ureteroceles reduce the indications for partial nephrectomy?

OBJECTIVE: To determine whether the endoscopic incision of ureteroceles reduces the indications for partial nephrectomy. PATIENTS AND METHODS: Between 1987 and 1996, endoscopic incision was used as the first-line treatment of 18 children (13 boys, five girls, aged 8 days to 6 months) with a duplex-system ureterocele diagnosed antenatally (15) or in the first weeks of life during the course of a urinary infection (three). Of the 19 ureteroceles (one bilateral), four were intravesical and 15 ectopic, according to the American Academy of Paediatrics classification. Vesico-ureteric reflux into the inferior pole of the kidney was present in 10 children, seven of whom had an ectopic ureterocele. A functioning upper pole was detected by intravenous pyelography (IVP) in half the intravesical and in a third of the ectopic ureteroceles. RESULTS: Endoscopic incision resulted in decompression and reduction of dilatation in 16 cases; three with inferior pole reflux resolved on control cystography, whilst in seven with an ectopic ureterocele, reflux into the upper urinary tract was induced by endoscopic incision. In three children with an ectopic ureterocele, renal function had improved at 3 months, as assessed by IVP. Endoscopic incision was the only treatment for half the intravesical and six of 15 ectopic ureteroceles. Overall, nephrectomy was required in four of 18 patients (three partial nephrectomies for persistent dilatation and one total nephrectomy). Five nonfunctioning, undilated upper poles with no reflux were left in place. Nine vesico-ureteric reimplantations for persistent or induced reflux were carried out using the Cohen technique. CONCLUSION: Endoscopic incision can allow the deferral of nephrectomy, facilitate lower urinary tract reconstruction and reduce the indications for partial nephrectomy, if it is accepted that a nonfunctioning, undilated renal pole with no reflux can safely be left in place.     

Feasibility of laparoscopic partial nephrectomy using pledgeted compression sutures for hemostasis

PURPOSE: To develop a technique for laparoscopic partial nephrectomy (LPN) without the use of hilar occlusion that allows large renal resection and excellent hemostasis. MATERIALS AND METHODS: Five female domestic pigs underwent right laparoscopic transperitoneal lower-pole partial nephrectomy after placement of pledgeted parenchymal compression sutures tied intracorporeally to induce regional renal hypoperfusion. Postoperatively, serial serum creatinine measurements were obtained to monitor renal function. The pigs were allowed to recover and 2 weeks later underwent an identical procedure on the left side. The animals were sacrificed after the second procedure, and both renal units were removed for ex vivo retrograde urograms and histologic analysis. RESULTS: The median operative time was 154.5 minutes (range 110-305 minutes), and the median blood loss was 137.5 mL (range 100-300 mL). On average, 35% (range 31%-36.8%) of the kidney was resected. All cases required use of adjunctive hemostatic clips to control bleeding from central vessels. All animals survived 2 weeks and had no evidence of urinary extravasation clinically or on ex vivo retrograde urograms. CONCLUSIONS: In the porcine model, LPN with placement of pledgeted sutures allows resection of large renal segments, although technical refinements are required to improve hemostasis. Currently, the need for adjunctive hemostatic measures limits the initial clinical application of this technique to small, exophytic tumors.     

Hand-assisted laparoscopic nephrectomy for stage T1 and large stage T2 renal tumors

BACKGROUND AND PURPOSE: Standard laparoscopic nephrectomy (LN) has been shown to be as effective oncologically as open surgery for both stage T1 and stage T2 renal tumors. While much has been published regarding the increasing indications for laparoscopic nephrectomy, there is little in the literature regarding the advantages of hand-assisted laparoscopy (HAL) for the treatment of large (>7-cm) stage T2 renal tumors. To our knowledge, this study is the first to directly compare the results in pathologic stage T1 and stage T2 tumors. Our aim was to assess whether HAL nephrectomy for these larger tumors maintains the same advantages enjoyed by HAL for the smaller ones (<7 cm). PATIENTS AND METHODS: One hundred HAL renal extirpative procedures were performed over a 3-year period. Of these, 60 were radical nephrectomies for malignant disease, of which 50 tumors were stage T1 and 10 stage T2. Standard HAL nephrectomy was performed through a vertical midline or paramedian incision, and the specimen was sent for histologic examination and tumor staging. We retrospectively analyzed our charts to determine if HAL nephrectomy for T2 tumors was as advantageous as for T1 tumors. We collected data on patient age, ASA score, average tumor size, estimated blood loss, operative time, conversion rate, rate of complications, and length of hospital stay. Follow-up ranged from 4 to 26 months with a mean of 11 months. RESULTS: The mean size was 4.68 and 9.22 cm for stage T1 and T2 tumors, respectively. Intraoperatively, stage T2 tumors were associated with less blood loss than were T1 tumors (105 mL v 190 mL). Operative times were equivalent, at 190 and 185 minutes for stage T1 and T2, respectively. No open conversions were required in the T2 group v four (8.7%) in the T1 group. Three of these open conversions were seen in the first 25 HAL cases. No complications or conversions were seen in the stage T2 patients. Of note, the majority of the operations for stage T2 disease were performed after the learning curve had been surpassed. CONCLUSION: The HAL nephrectomy maintains the benefits associated with standard LN. Stage T1 and T2 tumors are equally amenable to HAL nephrectomy, enjoying the same perioperative advantages. The larger size of the higher-stage tumors does not appear to hinder intact organ removal via a 7-cm hand incision. For the novice laparoscopist, we recommend approaching smaller tumors first with HAL nephrectomy, as there is a learning curve. As surgical expertise with HAL nephrectomy increases, larger tumors (stage T2) can be removed safely and expeditiously with little blood loss and a low complication rate. In the short term, patients with stage T2 cancers appear to enjoy the same disease-free survival rate as those with tumors of lower stage. Longer-term follow-up is clearly needed; however, we anticipate the same excellent results as have been demonstrated by others performing conventional radical LN.     

Robotic-assisted laparoscopic cryo-partial nephrectomy: a novel technique using cryoablation in lieu of hilar clamping in a porcine model

Laparoscopic and robotic-assisted partial nephrectomy has become an increasingly viable approach for the resection of renal tumors. There are several technical limitations in performing laparoscopic partial nephrectomy, the most significant being the inability to easily obtain cold ischemia which allows for an extended operative time. In this study, we evaluated the feasibility and efficacy of cryoablation as an alternative to hilar clamping to maintain hemostasis during robotic-assisted laparoscopic partial nephrectomy in a porcine model. Twelve female swine underwent nine open and eight robotic-assisted laparoscopic partial nephrectomies using modified cryoablative methods to create hemostasis. Renal perfusion imaged with indocyanine green (ICG) and histological analysis was assessed immediately after the procedure and at 3 weeks post-operatively. With two freeze/thaw cycles, all nine open and eight robotic-assisted laparoscopic partial nephrectomies were successfully completed without the need for hilar clamping. The mean blood loss for the open and robotic-assisted groups was 230.6 and 99.4 ml, respectively. In all cases, maintenance of renal perfusion was confirmed by the presence of a renal pulse and intraoperative ICG imaging immediately and 3 weeks post-operatively. The histological anatomy was well preserved in the resected segment following cryo-resection. After 21 days following cryo-resection, histological analysis demonstrated normal viable tissue with minimal scarring in the remaining kidney. The use of cryoablation created a zone of hemostasis without compromising the vascularity of the remaining kidney, while preserving the renal cytoarchitecture of the segment remove for pathological analysis. Further studies will help to delineate its usefulness in laparoscopic partial nephrectomy.     

Application of novel hemostatic agent during laparoscopic partial nephrectomy

PURPOSE: We determined if QuikClot, a novel hemostatic agent made of a granulated mineral substance, could be used to control renal parenchymal bleeding and collecting system leakage during open and laparoscopic partial nephrectomy. MATERIALS AND METHODS: After obtaining renal hilar vascular control 2 domestic female pigs underwent bilateral open and 4 underwent unilateral laparoscopic partial nephrectomy. After excision of the lower pole without cautery the hemostatic agent was applied to the cut surface of the kidney and hilar vascular control was released. Additional QuikClot was added until complete hemostasis was achieved. One week postoperatively the animals were sacrificed and the operated kidneys were harvested for ex vivo retrograde pyelograms and histopathological analysis. RESULTS: All partial nephrectomies were performed without complication. Mean operative and warm ischemia times were 62 and 16 minutes, respectively. An average of 23% of renal mass by weight was resected with a mean blood loss of 73 ml per procedure. No cautery, additional hemostatic agents or techniques were used. No animal had clinical or radiographic evidence of urinoma or delayed hemorrhage. Histopathological analysis showed preservation of the renal parenchyma immediately beneath the QuikClot layer. CONCLUSIONS: In the porcine model QuikClot allowed the resection of large renal segments, while providing reliable hemostasis and closure of the renal collecting system. No deleterious effect on underlying renal parenchyma or surrounding tissues was observed.     

Mayo Clinic Scottsdale experience with laparoscopic nephron sparing surgery for renal tumors

PURPOSE: Nephron sparing surgery is an accepted treatment for small renal masses, of which many have been detected incidentally due to the widespread use of advanced imaging techniques. We report our experience with laparoscopic nephron sparing surgery. MATERIALS AND METHODS: From May 2000 to May 2002 a total of 20 laparoscopic partial nephrectomies were performed in 19 patients. The kidney was mobilized to allow adequate dissection, hemostasis and inspection of the kidney. Cautery, a harmonic scalpel and a TissueLink (TissueLink Medical, Inc., Dover, New Hampshire) device were variably used for dissection and hemostasis. Further hemostasis was then achieved using an argon beam laser with Fibrillar (Fibrillar Ethicon, Somerville, New Jersey), fibrin glue or the TissueLink device. Intact removal and biopsy of the lesion base were done to assess margin status. RESULTS: Mean patient age was 66 years (range 41 to 80). Mean tumor size was 2.1 cm. (range 1 to 7) and average operative time was 130 minutes (range 60 to 210). Mean hospital stay was 2.2 days. Mean estimated blood loss was 120 ml. (range 20 to 400) and no blood transfusions or conversions to an open procedure were required. Complications included intraoperative fragmentation of a tumor in 1 case, postoperative dyspnea, postoperative bleeding and pneumonia in 1. CONCLUSIONS: Laparoscopic partial nephrectomy for small renal tumors was performed safely and effectively. Technique depended on the size and location of the mass. Long-term followup is required to compare cancer control with that of open nephron sparing surgery.     

Delayed presentation of urinoma after radiofrequency ablation-assisted laparoscopic partial nephrectomy

PURPOSE: To examine the outcomes and complications of thermal ablation-assisted laparoscopic partial nephrectomy (LPN). PATIENTS AND METHODS: Radiofrequency ablation (RFA)-assisted laparoscopic partial nephrectomy was employed in 16 consecutive renal masses with a mean size of 3.0 cm over 12 months. The indications were primarily adjacent bowel, hilar location, or both. After RFA, the renal mass was laparoscopically excised and examined pathologically. RESULTS: The mean operative treatment time was 99 minutes. The estimated blood loss was 121 mL, and no patient required a blood transfusion. Urinoma was diagnosed in three patients at an average of 13 days postoperatively and resolved with conservative management or ureteral stent placement. CONCLUSIONS: Radiofrequency ablation-assisted LPN provides effective hemostasis and, in the short term, cancer control. In this setting, urinoma presents as ipsilateral flank pain 1 to 2 weeks after surgery. The proposed mechanism for the delayed presentation is thermal injury to the collecting system, although an unrecognized direct collecting-system injury is possible. Conservative management, ureteral stent placement, or both led to resolution of all of the urinomas.     

后腹腔镜无功能肾切除术的临床体会(附16例报告)

目的:总结后腹腔镜无功能肾切除术的安全性及手术方法、技巧。方法:回顾分析2013年1月至2016年1月为16例无功能肾患者行后腹腔镜肾切除术的临床资料,观察术前患肾体积、手术时间、手术出血情况、术后并发症情况。结果:16例手术均完成,无一例中转开放手术。患肾直径20~200 mm,平均(102.5±11.3)mm;手术时间105~450 min,平均(208.1±24.1)min;术中出血量40~280 ml,平均(160.0±14.3)ml;术中、术后均未输血;术后发生不全性肠梗阻1例,予以灌肠后恢复;切口拆线后均愈合良好。结论:后腹腔镜无功能肾切除术中对肾动静脉的处理是手术关键。对于积水明显的肾脏可先吸出积水,缩小肾脏体积,沿肾脏边缘分离,这是保证手术安全可靠的方法;后腹腔镜无功能肾切除术后无明显并发症发生,是微创治疗的发展方向,值得进一步推广应用。     

Hand-assisted laparoscopic nephrectomy for inflammatory renal conditions

PURPOSE: Laparoscopic surgery for large renal lesion or kidneys with chronic inflammation has proved to be technically challenging. Hand-assisted laparoscopic surgery might be useful in these complex cases, as it provides surgeons the benefits of tactile feedback, digital retraction, and facilitated dissection of the renal hilar vessels. PATIENTS AND METHODS: Twenty-two patients undergoing hand-assisted laparoscopic (HAL) nephrectomy for benign conditions were compared with patients who underwent HAL radical nephrectomy during the same period. The demographic data, laterality, operative time, estimated blood loss, conversion rate, length of stay, histopathology findings, morbidity, and mortality were reviewed. RESULTS: The main indications for surgery were chronic inflammation and xanthogranulomatous pyelonephritis. Twenty patients had unilateral nephrectomy (10 each on the right and left), and two patients had bilateral nephrectomy. The mean operative times for unilateral and bilateral nephrectomy were 163 minutes (range 55-261 minutes) and 265 minutes (range, 238-291 minutes), respectively. Nine patients (45%) with inflammation had complications (15% major and 30% minor). The mean length of hospitalization for patients undergoing HAL nephrectomy was 7.2 days (range 2-35 days). The patients with inflammatory pathology had longer mean operative times, higher estimated blood loss, longer hospital stay, and higher morbidity than patients undergoing radical nephrectomy. CONCLUSION: Compared with standard laparoscopy, the hand-assisted approach has been reported to reduce operative times and increase safety. The advantages of minimally invasive surgery, such as reduced analgesia, shorter hospital stay, and faster return to normal activity, appear to be similar to those in patients undergoing a pure laparoscopic nephrectomy. Compared with radical nephrectomy for renal tumor, HAL simple nephrectomy can often be more challenging and associated with greater morbidity. For both the community urologist as well as an experienced laparoscopist, this approach is useful in handling these challenging cases.     

Laparoscopic partial nephrectomy with a novel electrosurgical snare in a porcine model

PURPOSE: We evaluated the safety and efficacy of laparoscopic partial nephrectomy with an arcing-gap electrosurgical snare in a porcine model. MATERIALS AND METHODS: A novel electrosurgical snare, optimizing high current density arcing and parenchymal compression, was utilized for laparoscopic renal transection. Five farm pigs underwent unilateral laparoscopic polar partial nephrectomy; 6 weeks later, these same animals underwent contralateral partial nephrectomy just prior to sacrifice. Five additional animals underwent chronic (6-week follow-up) and acute open partial nephrectomies by the conventional surgical technique. RESULTS: The average time for transection with the snare was 5.6 minutes. In 9 of 10 cases, the snare provided satisfactory hemostasis. In the remaining case, additional argon-beam coagulation (ABC) controlled the minimal bleeding present after transection. In all 10 animals, the collecting system was transected. In six cases, application of the snare alone sealed the collecting system. No urinomas developed in the five animals followed for 6 weeks. At 6 weeks, the mean depth of injury at the center of the cut surface was 5.1 mm in the laparoscopic group and 3.9 mm in the open group. CONCLUSIONS: Laparoscopic partial nephrectomy with the arcing-gap electrosurgical snare is feasible in a porcine model. Application of the snare provides excellent hemostasis without the need to control the renal vasculature.     

Partial nephrectomy: Mayo clinic experience 1957–1977

Three hundred and six partial nephrectomies were performed at Mayo Clinic between 1957 and 1977. Operative and postoperative risks were analyzed according to the indication for surgery, type of partial nephrectomy performed, and other factors. The results demonstrate that partial nephrectomy performed by modern techniques is safe, with acceptable operative time, operative blood loss, and postoperative hospital stay. Complications encountered also were investigated. One death occurred, 8 delayed nephrectomies were required, in 2 patients delayed renal hemorrhage developed, 10 had urinary fistulas or urinomas, and in 16 patients wound infections developed. Study of the techniques used in those cases with postoperative complications suggests several approaches to reduce still further the morbidity of partial nephrectomy.     

Hand assisted laparoscopic partial nephrectomy for peripheral and central lesions: a review of 30 consecutive cases

PURPOSE: We reviewed our first 30 hand assisted laparoscopic partial nephrectomies and compared the results of 8 centrally located vs 22 peripherally located tumors. MATERIALS AND METHODS: Tumors were classified by computerized tomography as central (less than 5 mm from the pelvicaliceal system or hilar vessels) or peripheral. The hand assisted technique consisted of mobilization and manual parenchymal compression without vascular occlusion or ureteral stent placement. Argon beam coagulation and a fibrin glue bandage were used for hemostasis. RESULTS: Mean tumor size was 2.6 cm (range 1.0 to 4.7). Mean operative time was 199 and 271 minutes, and estimated blood loss was 240 and 894 ml for peripheral and central lesions, respectively. No case required open conversion. The final diagnoses were renal cell carcinoma in 21 patients, angiomyolipoma in 4, benign or hemorrhagic cyst in 3 and oncocytoma in 2. Initial positive margins were found in 5 of 30 specimens (16.7%) (1 central and 4 peripheral) and all final resection margins were negative. Four central (50%) and 2 peripheral (9.1%) tumor cases required transfusion. Drain creatinine was elevated in 6 patients (20%) postoperatively, of whom 3 had a central and 3 had a peripheral lesion. All responded to conservative management except 1 patient (3.3%) who required stent placement. Postoperative bleeding in a central tumor case required transfusion of 4 units. There were no short-term local recurrences and 1 patient had an asynchronous tumor. CONCLUSIONS: Hand assisted laparoscopic partial nephrectomy is safe with excellent immediate cancer control. Careful dissection and frozen section analysis are mandatory to ensure a negative tumor margin. Blood loss and transfusion rates were higher in patients with centrally located tumors and renal hilar vascular control should be considered for central lesions.     

Complications of laparoscopic nephrectomy: the Mayo clinic experience

PURPOSE: We present the incidence of complications and conversions during laparoscopic nephrectomy performed for various indications and discuss methods to help prevent future complications. MATERIALS AND METHODS: From June 1999 to February 2003 at our institution 285 laparoscopic nephrectomy cases were performed, consisting of 113 radical nephrectomies, 101 donor nephrectomies, 27 simple nephrectomies, 23 partial nephrectomies and 21 nephroureterectomies. We reviewed the data base of patients who underwent laparoscopic nephrectomy to examine complications and analyze factors related to conversion to an open surgical procedure. RESULTS: Major complications occurred in 16 patients (5.6%). Major complications were surgical in 12 patients and medical in 4. Of the major surgical complications 3, 6, 1, 1 and 1 occurred during laparoscopic radical nephrectomy, donor nephrectomy, nephroureterectomy, simple nephrectomy and partial nephrectomy, respectively. The predominant major surgical complication was bleeding requiring conversion to an open surgical procedure. The overall conversion rate was 4% (12 patients), consisting of 6 emergency and 6 elective conversions. The remaining 27 patients experienced minor surgical or postoperative medical problems, such as urinary retention or wound infection. The mortality rate in our series was 0%. CONCLUSIONS: Laparoscopic renal surgery is becoming a routine procedure in the armamentarium of many urologists. Complications that are unique to laparoscopy exist but they should decrease with time with repetition and experience. We have learned many different precautions and procedures that should help decrease the risk of future complications associated with laparoscopic renal surgery.     

Outcome of retroperitoneoscopic nephrectomy for benign nonfunctioning kidney: a single-center experience

OBJECTIVE: To analyze the feasibility and outcome of retroperitoneoscopic nephrectomy for benign nonfunctioning kidneys and compare it with open simple nephrectomy. MATERIALS AND METHODS: From January 1998 to December 2006, 505 retroperitoneoscopic nephrectomies were performed. In the same time period, 112 open nephrectomies were also performed. In the retroperitoneoscopic group, the mean age was 39 years (range 15-74 years); 204 (40.4%) were men and 301 (59.6%) were women. Forty in this group had a history of surgery. Thirty-six patients had a pyonephrotic kidney; 33 of these patients had undergone percutaneous nephrostomy preoperatively. The cause of the nonfunctioning kidney was ureteropelvic junction obstruction in 198 patients, calculus disease in 193 patients, genitourinary tuberculosis in 48 patients, renal dysplasia in 19 patients, anomalous kidney in 20 patients, and renovascular hypertension in 16 patients. In 11 patients, there were other causes for the nonfunctioning kidney. RESULTS: Retroperitoneoscopic nephrectomy was performed in 476 (94.2%) patients. Conversion to open nephrectomy was necessary in 25 patients. The mean operative time was 85 minutes (range 45-240 min) in the retroperitoneoscopic group and 70 minutes (range 35-120 min) in the open group. The mean blood loss was 110 mL (range 30-600 mL) in the retroperitoneoscopic group and 170 mL (range 70-500 mL) in the open group. Four (0.8%) patients in the retroperitoneoscopic group needed a blood transfusion, whereas 5 (4.5%) patients in the open group had a blood transfusion. The hospital stay in the retroperitoneoscopic group was 3 days (range 1-7 d) and was 5 days (range 3-12 d) in the open group. CONCLUSIONS: Retroperitoneoscopic nephrectomy, although technically challenging, is becoming a gold standard for patients with nonfunctioning kidneys caused by benign conditions.     

Advanced age is not a prohibitive factor in laparoscopic nephrectomy for renal pathology

Since the first procedure by Clayman and colleagues in 1990, laparoscopic nephrectomy has been performed at multiple institutions worldwide and is an accepted approach for benign and malignant renal pathology. We retrospectively compared the outcomes of laparoscopic nephrectomy for renal pathology in patients older than and less than 65 years of age. Data were collected for all patients undergoing elective nephrectomy (simple, radical, and nephroureterectomy) for renal pathology between November 2000 and June 2003. A total of 94 laparoscopic nephrectomies (62 hand-assisted, 32 totally laparoscopic) for renal disease were performed. Indications for surgery included renal cell carcinoma (63), transitional cell carcinoma (7), hypertension (9), chronic pyelonephritis (6), nonfunctioning kidney (4), complex cyst (3), and polycystic kidney disease (2). There were 33 elderly patients (> or = 65 years) and 61 adult patients (< 65 years). The elderly group had a mean operative time (238 min vs 234.3 min; P = 0.89) and blood loss (88.5 mL vs 149.8 mL; P = 0.68) similar to the adult group. Likewise, the incidence of perioperative complications was no different between the two groups (intra-op: 3.0% vs 0%; P = 0.35/post-op: 21.2% vs 16.4%; P = 0.56). The length of hospitalization was longer in the elderly population (5.7 days versus 5.0 days; P = 0.01) compared to the younger adult group. Laparoscopic nephrectomy is well tolerated in the elderly population. For all surgical indications, the use of a minimally invasive approach confers operative times, blood loss, and morbidity that are comparable to those of younger patients. Yet, length of stay remains longer for elderly patients undergoing nephrectomy.     

Comparison of 1,800 laparoscopic and open partial nephrectomies for single renal tumors

PURPOSE: Laparoscopic partial nephrectomy is an increasingly performed, minimally invasive alternative to open partial nephrectomy. We compared early postoperative outcomes in 1,800 patients undergoing open partial nephrectomy by experienced surgeons with the initial experience with laparoscopic partial nephrectomy in patients with a single renal tumor 7 cm or less. MATERIALS AND METHODS: Data on 1,800 consecutive open or laparoscopic partial nephrectomies were collected prospectively or retrospectively in tumor registries at 3 large referral centers. Demographic, intraoperative, postoperative and followup data were compared between the 2 groups. RESULTS: Compared to the laparoscopic partial nephrectomy group of 771 patients the 1,028 undergoing open partial nephrectomy were a higher risk group with a greater percent presenting symptomatically with decreased performance status, impaired renal function and tumor in a solitary functioning kidney (p<0.0001). More tumors in the open partial nephrectomy group were more than 4 cm and centrally located and more proved to be malignant (p<0.0001 and 0.0003, respectively). Based on multivariate analysis laparoscopic partial nephrectomy was associated with shorter operative time (p<0.0001), decreased operative blood loss (p<0.0001) and shorter hospital stay (p<0.0001). The chance of intraoperative complications was comparable in the 2 groups. However, laparoscopic partial nephrectomy was associated with longer ischemia time (p<0.0001), more postoperative complications, particularly urological (p<0.0001), and an increased number of subsequent procedures (p<0.0001). Renal functional outcomes were similar 3 months after laparoscopic and open partial nephrectomy with 97.9% and 99.6% of renal units retaining function, respectively. Three-year cancer specific survival for patients with a single cT1N0M0 renal cell carcinoma was 99.3% and 99.2% after laparoscopic and open partial nephrectomy, respectively. CONCLUSIONS: Early experience with laparoscopic partial nephrectomy is promising. Laparoscopic partial nephrectomy offered the advantages of less operative time, decreased operative blood loss and a shorter hospital stay. When applied to patients with a single renal tumor 7 cm or less, laparoscopic partial nephrectomy was associated with additional postoperative morbidity compared to open partial nephrectomy. However, equivalent functional and early oncological outcomes were achieved.     

Bilateral hand-assisted laparoscopic renal surgery in the supine position: the spleen at risk

Objective:

We evaluated the safety of simultaneous bilateral renal procedures performed using hand-assisted laparoscopy (HAL) with the patient in the supine position.

Materials and Methods:

After securely strapping the patient to the table, a hand-port device is placed via a 7-cm supraumbilical or peri-umbilical incision with two to four 5-mm to 12-mm trocars placed bilaterally. During a 3-year period, 8 bilateral HAL renal operations were initiated (upper pole partial nephrectomies, 3 nephroureterectomies, 3 bilateral nephrectomies, and right nephrectomy with left adrenalectomy).

Results:

Mean patient age was 41 years. One patient with ADPKD required conversion to open due to failure to progress secondary to excessive perirenal fat and 22-cm kidneys. The other 7 were completed successfully with a mean operative time of 417 minutes and mean EBL of 336cc. Two patients received transfusions. Two small splenic lacerations, managed conservatively, were the only complications.

Conclusions:

Bilateral hand-assisted laparoscopic renal surgery with the patient in the supine position (rolling the table side to side) is feasible in the majority of patients. However, very large kidneys (eg, ADPKD) may be better approached with the patient in the lateral decubitus position or via an open subcostal incision. Importantly, the spleen appears to be at increased risk for capsular injury due to apparent increased difficulty of left colon mobilization in the “rolled” or “airplaned” supine position.