Laparoscopic partial nephrectomy: contemporary technique and outcomes

OBJECTIVES: Laparoscopic partial nephrectomy has emerged as a viable alternative to open partial nephrectomy while minimizing patient morbidity. In this article and accompanying video we describe our current technique of LPN and review our outcomes in specific patient sub-sets. METHODS: Since September 1999 more than 500 laparoscopic partial nephrectomies have been performed by the senior author. Data were collected prospectively. All patients underwent a three-dimensional CT scan prior to the operation. Our established technique involves preoperative ureteral catheterization, laparoscopic renal ultrasonography to delineate the tumor, en bloc clamping of the renal hilar vascular pedicle, tumor excision with cold endoshears, pelvicaliceal suture repair and parenchymal closure over Surgicel bolsters with biologic hemostatic agent. Renal hypothermia was achieved laparoscopically with ice slush in selected cases with anticipated long warm ischemia time. RESULTS: Mean tumor size was 2.9 cm (1-10.3 cm), 31% of the tumors were greater than 3 cm, 5% occurred in a solitary kidney, and tumor location was central in 40% and hilar in 6% of patients. Transperitoneal approach was employed in 65% of the cases. Mean warm ischemia time was 32 min. Intraoperative complications occurred in 5.5%. Pathology confirmed renal cell carcinoma in 75% of the tumors. In the initial 100 patients with a 3 years minimum follow-up, overall survival was 86% and cancer-specific survival was 100%. CONCLUSIONS: Laparoscopic partial nephrectomy is a technically challenging procedure. Adequate prior experience with laparoscopy is necessary. Long-term functional and oncological outcomes are being confirmed currently.     

Laparoscopic partial nephrectomy in cold ischemia: renal artery perfusion

PURPOSE: Laparoscopic partial nephrectomy represents a feasible option for patients with small renal masses. We describe our initial experience with laparoscopic partial nephrectomy in cold ischemia achieved by renal artery perfusion. MATERIALS AND METHODS: From November 2001 to March 2003 laparoscopic partial nephrectomy in cold ischemia was performed in 15 patients with renal cell carcinoma. Cold ischemia was achieved by continuous perfusion of Ringers lactate at 4C through the renal artery, which was clamped. Tumor excision was performed in a bloodless field with biopsy taken from the tumor bed. The collecting system was repaired if needed. Renal reconstruction was performed by suturing over hemostatic bolsters. RESULTS: All procedures were successfully completed laparoscopically by our new technique. Mean operative time was 185 minutes (range 135 to 220). Mean ischemia time was 40 minutes (range 27 to 101). Estimated mean intraoperative blood loss was 160 ml (range 30 to 650). Entry to the collecting system in 6 patients was repaired intraoperatively. Additional vascular repair was done in 2 patients. There were no significant postoperative complications. Postoperative followup in 8 patients showed that the renal parenchyma was not damaged by the ischemic period. CONCLUSIONS: Our initial experience of incorporating cold ischemia via arterial perfusion into laparoscopic partial nephrectomy shows the feasibility and safety of the technique. We believe that this approach has the potential to make laparoscopic partial nephrectomy for renal cell carcinoma safe and reliable.     

Robotic partial nephrectomy for complex renal tumors: surgical technique

OBJECTIVES: Laparoscopic partial nephrectomy requires advanced training to accomplish tumor resection and renal reconstruction while minimizing warm ischemia times. Complex renal tumors add an additional challenge to a minimally invasive approach to nephron-sparing surgery. We describe our technique, illustrated with video, of robotic partial nephrectomy for complex renal tumors, including hilar, endophytic, and multiple tumors. METHODS: Robotic assistance was used to resect 14 tumors in eight patients (mean age: 50.3 yr; range: 30-68 yr). Three patients had hereditary kidney cancer. All patients had complex tumor features, including hilar tumors (n=5), endophytic tumors (n=4), and/or multiple tumors (n=3). RESULTS: Robotic partial nephrectomy procedures were performed successfully without complications. Hilar clamping was used with a mean warm ischemia time of 31 min (range: 24-45 min). Mean blood loss was 230 ml (range: 100-450 ml). Histopathology confirmed clear-cell renal cell carcinoma (n=3), hybrid oncocytic tumor (n=2), chromophobe renal cell carcinoma (n=2), and oncocytoma (n=1). All patients had negative surgical margins. Mean index tumor size was 3.6 cm (range: 2.6-6.4 cm). Mean hospital stay was 2.6 d. At 3-mo follow-up, no patients experienced a statistically significant change in serum creatinine or estimated glomerular filtration rate and there was no evidence of tumor recurrence. CONCLUSIONS: Robotic partial nephrectomy is safe and feasible for select patients with complex renal tumors, including hilar, endophytic, and multiple tumors. Robotic assistance may facilitate a minimally invasive, nephron-sparing approach for select patients with complex renal tumors who might otherwise require open surgery or total nephrectomy.     

Impact of temporary hilar clamping during laparoscopic partial nephrectomy on postoperative renal function: a prospective study

PURPOSE: Laparoscopic partial nephrectomy for small renal tumors has been increasingly performed in the last few years. We prospectively evaluated preoperative and postoperative differential renal function by renal scan in patients with contralaterally functioning kidneys who underwent laparoscopic partial nephrectomy with hilar clamping. MATERIALS AND METHODS: From July 2002 to June 2003, 17 consecutive patients were included in this prospective protocol and underwent laparoscopic partial nephrectomy for exophytic tumors using en bloc hilar clamping. Preoperative renal scan with differential function was performed 1 month before and 3 months after surgery in all patients. technetium labeled diethylenetetraminepentaacetic acid scan was performed in all patients. RESULTS: Mean warm ischemia time was 22.50 +/- 9.78 minutes (range 10 to 44). Preoperative differential renal function and glomerular filtration rate (GFR) in the affected kidneys were 50.20% +/- 4.90% (range 43 to 58) and 75.56 +/- 16.45 ml per minutes (range 39.4 to 105). At postoperative month 3 differential renal function and GFR in the affected kidney were 48.07% +/- 7.16% (range 39% to 63%) and 72.03 +/- 18.17 ml per minutes (range 31 to 101). There was a nonsignificant negative association between hilar clamp time and change in renal function (postoperative - preoperative) of the affected kidney (r = -0.26, p = 0.31), and a positive correlation between clamp time and change in GFR (r = 0.39, p = 0.12) that did not reach statistical significance. CONCLUSIONS: In patients with contralaterally functioning kidney, temporary hilar clamping with a mean warm ischemia time of 22.5 minutes results in preservation of renal function in the affected kidney. Larger studies with longer followup are necessary to study the impact of warm ischemia further.     

Laparoscopic partial nephrectomy for hilar tumors

PURPOSE: Partial nephrectomy for hilar tumors represents a technical challenge not only for laparoscopic, but also for open surgeons. We report the technical feasibility and perioperative outcomes of laparoscopic partial nephrectomy (LPN) for hilar tumors. MATERIALS AND METHODS: Between January 2001 and September 2004, 25 of 362 patients (6.9%) undergoing LPN for tumor, as performed by a single surgeon, had a hilar tumor. We defined hilar tumor as a tumor located in the renal hilum that was demonstrated to be in actual physical contact with the renal artery and/or renal vein on preoperative 3-dimensional computerized tomography. En bloc hilar clamping with cold excision of the tumor, including its delicate mobilization from the renal vessels, followed by sutured renal reconstruction was performed routinely. RESULTS: Laparoscopic surgery was successful in all cases without any open conversions or operative re-interventions. Mean tumor size was 3.7 cm (range 1 to 10.3), 4 patients (16%) had a solitary kidney and the indication for LPN was imperative in 10 patients (40%). Pelvicaliceal repair was performed in 22 patients (88%), mean warm ischemia time was 36.4 minutes (range 27 to 48), mean blood loss was 231 cc (range 50 to 900), mean total operative time was 3.6 hours (range 2 to 5) and mean hospital stay was 3.5 days (range 1.5 to 6.7). Histopathology confirmed renal cell carcinoma in 17 patients (68%), of whom all had negative margins. In 2002 or earlier hemorrhagic complications occurred in 3 patients (12%). No kidney was lost for technical reasons. CONCLUSIONS: LPN can be performed in select patients with a hilar tumor. The technical feasibility reported further extends the scope of LPN. To our knowledge the initial experience in the literature is reported.     

Laparoscopic donor nephrectomy: single-center experience in Egypt with 400 consecutive cases

INTRODUCTION: In this study, we present our experience with laparoscopic donor nephrectomy and evaluate the outcomes of donors and recipients. PATIENTS AND METHODS: Between March 2003 and August 2006, 400 laparoscopic donor nephrectomies were performed in our institution. Donors were evaluated for renal vasculature using computed tomography angiography. We used the left kidney in 329 donors and the right kidney in 71. Donor surgeries were done transperitoneally using three trocars on the left side and four trocars on the right side. Kidneys were extracted manually through a 7-cm Pfanenstiel incision. RESULTS: All cases were completed laparoscopically. Mean operative time was 117 +/- 34 minutes. Mean blood loss was 56 +/- 28 mL. None of the donors required a blood transfusion. Mean warm ischemia time was 2.6 +/- 0.4 minutes. The mean renal artery length was 3.1 +/- 0.4 cm; the mean renal vein length was 2.4 +/- 1.2 cm. Mean hospital stay was 2.1 days. No donor required readmission. Kidneys were transplanted successfully and the mean recipient creatinine on discharge was 1.2 +/- 0.6 mg/dL. One patient had a renal artery thrombosis on postoperative day 2. Another patient with double renal arteries had thrombosis of the smaller artery just after surgery. Acute tubular necrosis was seen in 17 patients, four of whom required dialysis. Kidney function recovered thereafter in all acute tubular necrosis cases. CONCLUSION: Laparoscopic surgery is a minimally invasive approach for living donor nephrectomy with good functional outcomes. The donor benefits from lesser morbidity without compromising the anatomic or physiological outcome of the nephrectomized kidney.     

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.     

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.     

Laparoscopic ice slush renal hypothermia for partial nephrectomy: the initial experience

PURPOSE: We describe a novel technique of laparoscopic renal hypothermia with intracorporeal ice slush during partial nephrectomy as well as clinical experience with the initial 12 patients. MATERIALS AND METHODS: A total of 12 select patients with an infiltrating renal tumor who were candidates for nephron sparing surgery underwent transperitoneal laparoscopic partial nephrectomy with renal hypothermia. An Endocatch II (United States Surgical Corp., Norwalk, Connecticut) bag was placed around the mobilized kidney and its drawstring was cinched around the intact renal hilum. The renal artery and vein were occluded en bloc with a Satinsky clamp. The bottom of the engaged bag was retrieved through a 12 mm port site and opened, and ice slush was introduced within the bag to completely surround the kidney. After renal hypothermia was achieved laparoscopic partial nephrectomy was performed by duplicating open surgical techniques. Renal parenchymal temperature was measured using a thermocouple needle in 5 patients. Median tumor size was 3.2 cm (range 1.5 to 5.5), 6 tumors (50%) were central in location and an imperative indication for partial nephrectomy was present in 7 patients (58%). RESULTS: All procedures were successfully completed laparoscopically without open conversion. Median time to deploy the bag around the kidney was 7 minutes (range 5 to 20), the median volume of ice slush introduced was 600 cc (range 300 to 750) and the time needed to insert the ice slush was 4 minutes (range 3 to 10). Median blood loss was 200 cc, total ischemia time was 43.5 minutes (range 25 to 55) and total operative time was 4.3 hours (range 3 to 5.5). Nadir renal parenchymal temperature was 5C to 19C and the mean decrease in systemic temperature was 0.6C. Histopathology confirmed renal cell carcinoma in 11 patients (92%), of whom all had negative surgical margins. Intraoperative complications occurred in 2 initial patients, including partial bag slippage in 1 and Satinsky clamp malfunction in 1. Postoperatively renal scan confirmed a functioning ipsilateral kidney in all cases. CONCLUSIONS: To our knowledge we present the initial clinical report of laparoscopic renal hypothermia for partial nephrectomy. By replicating standard open surgical practice our intracorporeal ice slush technique has the potential to extend the scope of laparoscopic partial nephrectomy to more complicated renal tumors.     

Renal artery pseudoaneurysm following laparoscopic partial nephrectomy

PURPOSE: We describe the presentation, evaluation and management of hemorrhage due to renal artery pseudoaneurysm following laparoscopic partial nephrectomy. MATERIALS AND METHODS: Of the 345 laparoscopic partial nephrectomies performed by us during a 5-year period 6 patients (1.7%) had postoperative hemorrhage from a renal artery pseudoaneurysm. Patient charts were reviewed to identify pertinent preoperative, intraoperative and postoperative data. RESULTS: Median tumor size was 3.5 cm (range 2.2 to 5), intraoperative blood loss was 175 cc (range 50 to 500), warm ischemia time was 32 minutes (range 30 to 45) and operative time was 3.8 hours (range 2.5 to 5). The mean percent of kidney excised was 31% and pelvicaliceal system entry was suture repaired in all 6 patients. No patient required blood transfusion perioperatively. Average hospital stay was 3.4 days (range 2.5 to 6). Delayed postoperative hemorrhage occurred at a median of 12 days (range 8 to 15). Angiography revealed a renal artery pseudoaneurysm most commonly at a third or fourth order branch (4 and 2 patients, respectively). Percutaneous embolization was successful in each patient. CONCLUSIONS: Renal artery pseudoaneurysm is an uncommon complication following laparoscopic partial nephrectomy. These patients often present in delayed fashion. Selective angiographic embolization is the initial treatment of choice.     

Robotic ultrasound probe for tumor identification in robotic partial nephrectomy: Initial series and outcomes

Objectives: Accurate tumor identification during partial nephrectomy is essential for successful tumor control. Intraoperative laparoscopic ultrasonography is useful for tumor localization, but the ultrasound probe is controlled by the assistant rather than the surgeon. We evaluated our initial experience using a robotic ultrasound probe that is controlled by the console surgeon. Methods: Partial nephrectomy was carried out in 22 consecutive patients between November 2010 and March 2011. A robotic ultrasound probe under console surgeon control was used in all the cases. All patients had at least 1 year follow up. Results: Mean patient age was 59 years and mean tumor size was 2.7 cm. There were six hilar tumors (27%) and 21 (95%) endophytic tumors. Mean R.E.N.A.L. nephrometry score was 6.9 (range 6–9). Mean operative time was 205.7 min and mean warm ischemia time was 17.9 min (range 6–28 min). All patients had negative tumor margins and were free of disease recurrence at a mean follow up of 13 months. Conclusion: The use of a robotic ultrasound probe during partial nephrectomy allows the surgeon to optimize tumor identification with maximal autonomy, and to benefit from the precision and articulation of the robotic instrument during this key step of the partial nephrectomy procedure.     

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.     

Control de la hemostasia durante la nefrectomía parcial laparoscópica sin renorrafia parenquimatosa: la experiencia Vivostat®

ObjectiveTo present our experience using an autologous fibrin sealant prepared with the Vivostat system^® to control haemostasis without any renal parenchymal reconstruction.Material and methodsWe performed 45 laparoscopic partial nephrectomies using this haemostatic agent. The surgical steps were: colon mobilization, identification of ureter, renal vessels and renal tumor, renal artery control with Rummel tourniquet, tumor excision with harmonic scalpel, application of fibrin glue to the resection bed twice (before and after kidney reperfusion). Patients were evaluated for acute or delayed bleeding.ResultsMean age was 63.9 years (33-80); mean tumor size was 2.5 cm (1.5-4); mean operative time was 136.1 min (90-180). Mean warm ischemia time was 19.2 min (10-30). Mean blood loss was 97 ml (50-300). Individual haemostatic stitches were performed before application of the sealant if acute bleeding was observed (14 cases). We did not achieve any case of postoperative bleeding from resection bed or renal failure. 1 patient required transfusion due to an abdominal wall haematoma. 65% were clear cell carcinoma, 10% were papillary carcinoma, 20% were oncocitoma. Free margin rate was 100%. Mean hospital stay was 4 days (2-6). Mean follow-up was 14 months (5-45).ConclusionsExcluding renorrhaphy during laparoscopic partial nephrectomy is feasible and safe. Our initial experience with the vivostat system in laparoscopic partial nephrectomy has been encouraging, but longer follow-up is needed to determine the real benefit of this surgical technique in laparoscopic partial 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.     

Parenchymal sparing surgery in patients with hereditary renal cell carcinoma: 10-year experience

PURPOSE: von Hippel-Lindau disease, hereditary papillary renal cell carcinoma, the Birt-Hogg-Dubé syndrome and familial renal oncocytoma are familial renal tumor syndromes. These hereditary disorders are noteworthy for the development of multiple bilateral renal tumors and the risk of new tumors throughout life. One management strategy is observation of solid renal tumors until reaching 3 cm, then performing parenchymal sparing surgery. We present a 5-year update on our experience. MATERIALS AND METHODS: From May 1988 to October 1998, 49 patients with hereditary renal cell carcinoma, including von Hippel-Lindau disease in 44, hereditary papillary renal cell carcinoma in 4 and the Birt-Hogg-Dubé syndrome in 1, and 1 with familial renal oncocytoma underwent exploration to attempt renal parenchymal sparing surgery. Patients were followed prospectively with periodic screening for recurrence, metastasis and loss of renal function. Median followup was 79.5 months (range 0.7 to 205). RESULTS: A total of 50 patients underwent 71 operations resulting in unilateral nephrectomy in 6, bilateral nephrectomy in 1 and partial nephrectomy in 65, with 1 to 51 tumors removed from each kidney (mean 14.7). Mean patient age was 39.5 years (range 18 to 70). Of the 65 (40%) partial nephrectomies 26 were performed with cold renal ischemia. Mean blood loss was 2.9 +/- 0.5 l (range 0.15 to 23). Postoperative complications included renal atrophy in 3 patients. Mean preoperative serum creatinine was 1.05 +/- 0.03 mg/dl (range 0.6 to 1.8), and postoperative creatinine was 1.06 +/- 0.04 mg/dl (range 0.6 to 2.0). No patient who underwent renal parenchymal sparing surgery required renal replacement therapy. Metastatic disease developed in 1 patient with a 4.5 cm renal tumor. CONCLUSIONS: Parenchymal sparing surgery with a 3 cm threshold in patients with hereditary renal cancer appears to be an effective therapeutic option to maximize renal function while minimizing the risk of metastatic disease.     

Pure laparoscopic radical nephrectomy for stage T(3b) renal-cell carcinoma: more than 2-year follow-up

BACKGROUND AND PURPOSE: Renal-vein tumor thrombus associated with renal malignancy has traditionally been approached with open surgery, and preoperative diagnosis of stage T(3b) renal tumors often mandates open surgery. However, early arterial division and "milking" of the thrombus away from the inferior vena cava may facilitate laparoscopic surgery. We describe our single-surgeon experience with laparoscopic nephrectomy in patients with tumor extension into the renal vein. PATIENTS AND METHODS: Among 240 laparoscopic nephrectomies performed by a single surgeon from 2002 to 2005, six patients (2.6%) were found to have renal-vein tumor thrombus. These patients included three men and three women with a mean age of 55.8 years (range 43-78 years). Data collected prospectively were evaluated to characterize this cohort. RESULTS: All six tumors were right-sided, stage T(3b), and all were managed laparoscopically without major complications. Three tumors were suspected to have renal-vein thrombus on preoperative imaging; the other three tumor thrombi were discovered on pathologic examination. The mean tumor size was 9.5 cm (range 7.5-11.5 cm). Two tumors were grade 2, three were grade 3, and one patient had a grade 4 rhabdoid cell-type tumor. At a mean follow-up of 27 months, all patients were without evidence of disease with the exception of the patient with grade 4 disease, who developed recurrence in the chest. CONCLUSION: Laparoscopic nephrectomy for tumor with renal-vein thrombus can be accomplished safely with adherence to proper oncologic techniques.     

Complete robotic-assistance during laparoscopic living donor nephrectomies: An evaluation of 38 procedures at a single site

OBJECTIVE: To evaluate our initial experience with entirely robot-assisted laparoscopic live donor (RALD) nephrectomies. METHODS: From January 2002 to April 2006, we carried out 38 RALD nephrectomies at our institution, using four ports (three for the robotic arms and one for the assistant). The collateral veins were ligated, and the renal arteries and veins clipped, after completion of ureteral and renal dissection. The kidney was removed via a suprapubic Pfannenstiel incision. A complementary running suture was carried out on the arterial stump to secure the hemostasis. RESULTS: Mean donor age was 43 years. All nephrectomies were carried out entirely laparoscopically, without complications and with minimal blood loss. Mean surgery time was 181 min. Average warm ischemia and cold ischemia times were 5.84 min and 180 min, respectively. Average donor hospital stay was 5.5 days. None of the transplant recipients had delayed graft function. CONCLUSIONS: Robot-assisted laparoscopic live donor nephrectomy can be safely carried out. Robotics enhances the laparoscopist's skills, enables the surgeon to dissect meticulously and to prevent problematic bleeding more easily. Donor morbidity and hospitalization are reduced by the laparoscopic approach and the use of robotics allows the surgeon to work under better ergonomic conditions.     

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.     

Retrograde renal hilar dissection and segmental arterial clamping: a simple modification to achieve super-selective robotic partial nephrectomy

Super-selective vascular control prior to robotic partial nephrectomy (also known as ‘zero-ischemia’) is a novel surgical technique that promises to reduce warm ischemia time. The technique has been shown to be feasible but adds substantial technical complexity and cost to the procedure. We present a simplified retrograde dissection of the renal hilum to achieve selective vascular control during robotic partial nephrectomy. Consecutive patients with stage 1 solid and complex cystic renal masses underwent robotic partial nephrectomies with selective vascular control using a modification to previously described super-selective robotic partial nephrectomy. In each case, the renal arterial branch supplying the mass and surrounding parenchyma was dissected in a retrograde fashion from the tumor. Intra-renal dissection of the interlobular artery was not performed. Intra-operative immunofluorescence was not utilized as assessment of parenchymal ischemia was documented before partial nephrectomy. Data was prospectively collected in an IRB-approved partial nephrectomy database. Operative variables between patients undergoing super-selective versus standard robotic partial nephrectomy were compared. Super-selective partial nephrectomy with retrograde hilar dissection was successfully completed in five consecutive patients. There were no complications or conversions to traditional partial nephrectomy. All were diagnosed with renal cell carcinoma and surgical margins were all negative. Estimated blood loss, warm ischemia time, operative time and length of stay were all comparable between patients undergoing super-selective and standard robotic partial nephrectomy. Retrograde hilar dissection appears to be a feasible and safe approach to super-selective partial nephrectomy without adding complex renovascular surgical techniques or cost to the procedure.     

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.