Laparoscopic partial nephrectomy

We retrospectively reviewed the clinical results of 24 patients who underwent laparoscopic partial nephrectomy by a diagnosis of renal cell carcinoma (RCC) between 1999 and 2004, including 16 elective cases and 8 imperative cases. Twenty-two were successfully treated laparoscopically; two cases in the imperative group required conversion to open surgery because of uncontrollable bleeding. A vascular clamp was used in 12 cases for an average of 26 minutes. The creatinine clearance changed from 98 to 93 ml/min in the elective cases and from 49 to 44 ml/min in the imperative cases. Pathological evaluation revealed RCC in 10 elective cases and 6 imperative cases. Local recurrence (renal hilum lymph node and ipsilateral kidney) was found in 2 patients in the imperative group. Although laparoscopic partial nephrectomy is useful, long-term follow-up is necessary for evaluating the tumor control.     

Laparoscopic partial splenectomy

Background The immunologic function of the spleen and its important role in immune defense has led to splenic-preserving surgery. This study aimed to evaluate whether laparoscopic partial splenectomy is safe. Methods Data on consecutive patients presenting with localized benign or malignant disease of the spleen were included in a prospective database. The surgical technique consisted of six steps: patient positioning and trocar placement, mobilization of the spleen, vascular dissection, parenchymal resection, sealing/tamponading of the transected edge, and removal of the specimen. Results From 1994 to 2005, 38 patients underwent laparoscopic partial splenectomy. The indications included splenomegaly of unknown origin, splenic cysts, benign tumors (hamartoma), and metastasis from ovarian carcinoma and schwannoma. The median operating time was 110 min (range, 65–148 min). The median length of hospital stay was 5 days (range, 4–7 days). There was no postoperative mortality. Postoperative pleural effusion occurred in two patients. There were no reoperations. Three patients required blood transfusions. Conclusion Laparoscopic partial splenectomy is safe for patients with localized benign or malignant disease of the spleen.     

Laparoscopic partial nephrectomy

ObjetivesTo analyze the surgical and oncologic outcome of prospective experience with laparoscopic partial nephrectomy. We describe the surgical technique and mid term oncological results achieved.Material and methods60 patients were operated with this technique between June 2005 and June 2009. The mean age of patients was 58.9 [38-77] years, being 40 (66.7%) males and 20 (33.3%) women. The average BMI was 26.8 [18-40]. Laterality was 28 (46.7%) tumors rights and 32 (53.3%) left, being located in the upper pole in 14 (23.3%) patients, in the middle third in 13 (21.7%) in the lower pole in 22 (36.7%) and hiliar region in 11 (18.3%). In 23 cases (38.3%) tumors were located in the anterior valve, in 24 (40%) in posterior valve, in 10 (16.7%) at the outer edge and 3 (5%) at the inner edge. The average size tumor on CT was 3.3 [1-6.4] cm and in the surgical specimen 3.1 [1.2-7] cm.ResultsThe mean operative time was 107.17 [50-185] min, with a warm ischemia time of 33 [0-70] min. In 56 cases (93.3%) had a single artery and 4 (6.7%) cases had 2 arteries. The artery was clamped alone in 15 patients (25%), artery and vein in 44 (73.3%) and no clamping was performed in 1 (1.7%). We repaired the urinary tract in 32 patients (53.3%), leaving ureteral catheter in all patients. 20% of patients (12) required transfusion. Intraoperative complications occurred in 5 patients (8.7%). These were: 1 splenic injury requiring splenectomy (1.7%), 1 tear in the vena cava, sutured laparoscopically (1.7%) and 3 cases of bleeding due to bulldog malfunction (5%). Postoperative complications occurred in 11 patients (18.7%) and these were: 1 wall hematoma that required reoperation (1.7%), 1 urinary fistula ending in renal atrophy and subsequent nephrectomy (1.7%), 3 intracavitary hematomas hich resolved conservatively (5%), 1 arteriovenous fistula that needed embolization (1.7%), 1 urinoma that was resolved with percutaneous drainage (1.7%) and 3 cases of postoperative fever (5%). Margins were positive in 1 patient (1.7%). In 49 cases (81.7%) histology was renal cell carcinoma, in 8 (13.3%) oncocytoma, in 2 (3.3%) angiomyolipoma and 1 (1.7%) metastasis. The average stay was 5 [3-29] days. Median follow up was 31 [12-61] months. There was a local recurrence at 16 months (hiliar primary tumor 2.5 cm) and an ipsilateral adrenal metastasis at 34 months (primary tumor 5.6 cm in left lower pole).ConclusionsIn this series of laparoscopic partial nephrectomy low rate of complications, good oncologic results and low recurrence rate in the short term are shown. More patients and further monitoring is required to strengthen the functional and oncological outcomes of this surgical technique.     

Laparoscopic partial nephrectomy

BACKGROUND AND PURPOSE: The technique of laparoscopic partial nephrectomy has matured significantly over the past decade and is emerging as an oncologically sound procedure for the management of small renal tumors. Methods of tumor excision as well as parenchymal reconstruction in a hemostatically controlled field have evolved to make this procedure safer. Improved techniques to minimize warm renal ischemia are being developed. Finally, methods to prevent positive surgical margins during laparoscopic surgery are crucial to a satisfactory oncologic outcome. These important technical issues, as well as the current results of laparoscopic partial nephrectomy, are discussed. MATERIALS AND METHODS: The urologic peer-review literature related to nephron-sparing surgery was reviewed. Controversial issues with respect to the surgical approach, methods of hemostatic control, acceptable time of warm ischemia, and cooling techniques were reviewed and collated. Perioperative results from larger series of laparoscopic and open partial nephrectomy were evaluated. RESULTS: Open nephron-sparing surgery for renal tumors < or =4 cm has cancer control equivalent to that of open radical nephrectomy. Evidence is now emerging that laparoscopic partial nephrectomy will provide similar oncologic results, although clinical follow-up is still early. Blood loss, postoperative pain, and convalescence seem to be favor the laparoscopic approach. Complication rates, primarily postoperative bleeding and urine leak, may be higher than for open nephron-sparing surgery. Methods of laparoscopic hemostatic control favor soft vascular clamping for larger tumors that are more endophytic and central. Smaller exophytic lesions may be managed without renal vascular control using a variety of coagulative and hemostatic tools. Data related to warm renal ischemia suggest that the time used for tumor excision and renal reconstruction should be 30 minutes or less. Techniques for laparoscopic renal cooling are being developed. CONCLUSIONS: Laparoscopic nephron-sparing surgery is a technique in evolution but with a promising outlook. The urologic peer-review literature reflects an exponential growth in interest, which suggests that this minimally invasive approach is practical and may benefit our patient population so as to allow them to return to normal healthy living more quickly.     

Laparoscopic partial nephrectomy

BACKGROUND AND PURPOSE: With continuing rapid changes in endourology, we conducted a new survey of practice trends and expanded our sampling to include non-American urologists. MATERIALS AND METHODS: The survey was done via the Internet using the database for the 2003 World Congress of Endourology. Approximately 1100 surveys were sent, and responses were received from 193 urologists, who had been in practice for a mean of 9.9 years (median 8 years). Of these, 52% spend >50% in endourology, and 48% devote >20% of their practice to laparoscopy. RESULTS: More than half of the respondents (56%) perform laparoscopic partial nephrectomy (LPN), and 65% chose LPN as the procedure of choice for patients with an uncomplicated 3-cm renal mass. The majority obtain vascular control, most commonly by clamping the renal artery only. Most respondents do not use ureteral stents unless the collecting system is entered. CONCLUSIONS: These results and a review of the literature indicate a growing acceptance among endourologists of LPN as the procedure of choice for patients with small renal masses who are to undergo nephron-sparing surgery. Disagreement remains concerning the role and type of vascular control, the use of hemostatic agents, and the value of stents when the collecting system is entered.     

Laparoscopic partial hepatectomy

Objective: To review the literature that addresses carrying out laparoscopic partial hepatectomy Methodology: A review and analysis of the English‐speaking literature addressing laparoscopic partial hepatectomy. Results: Laparoscopic partial hepatectomy is carried out in limited numbers and mostly on small tumours requiring wedge or segmental resections. No prospective trials have been carried out comparing laparoscopic techniques to open surgery, but case control comparisons suggest that this technique is safe and associated with shortened hospital stay and decreased incisional pain. Major hepatectomies have been carried out laparoscopically, but in very limited numbers and published experience is not sufficient to formally address this operation. Conclusions: Laparoscopic minor partial hepatectomy appears to be safe and of some benefit to patients if carried out by surgeons experienced in both laparoscopic and hepatic surgery. The ultimate utility of this novel surgical technique will have to be determined by future randomized prospective trials.     

Laparoscopic partial nephrectomy

In properly selected patients, partial nephrectomy yields oncologic efficacy similar to that of traditional radical nephrectomy. We have performed more than 415 laparoscopic radical nephrectomies over the 5-year period beginning in September 1999. All patients undergo a three-dimensional CT scan with 3-mm sections prior to the operation. We generally prefer the transperitoneal approach, although for posterior tumors, a retroperitoneal approach is preferred. The kidney is dissected using standard technique. Intraoperative hydration is given to maintain diuresis. Detailed real-time ultrasonographic delineation of the tumor is obtained to facilitate planning of the resection. We prefer en-bloc hilar clamping. The renal capsule is scored circumferentially with the "L" hook electrocautery. Parenchymal incision and tumor resection is performed using heavy reuseable scissors. The base of the resection defect is closed using a running 2-0 Vicryl on a CT-1 needle. The water-tightness of pelvicaliceal repair is tested by repeat gentle injection of indigo carmine through a ureteral catheter. Next, the parenchyma is closed with 1 Vicryl on a CTX needle placed over an oxidized cellulose bolster. The specimen is extracted within an entrapment bag. Initially, a surgeon should be highly selective, including patients with small, mostly exophytic, tumors. With increasing comfort and experience, the criteria can expand.     

Laparoscopic partial adrenalectomy

Background: Most laparoscopic adrenalectomies involve total removal of the whole adrenal gland, and reports of laparoscopic partial adrenalectomies have been very few. The criteria for performing a laparoscopic partial adrenalectomy have not been described. Methods: (a) Patients with functioning adrenal tumors smaller than 3 cm in diameter were selected. (b) The solitary adrenal tumors were evaluated by preoperative thin-slice computed tomography (CT) scan. (c) Solitary lesions were reconfirmed with intraoperative ultrasonography. (d) Partial adrenalectomy was performed with at least a 5-mm margin using a vascular stapler. Results: Laparoscopic partial adrenalectomy was performed in five patients using the vascular stapler. Hemostasis was perfect in all five patients. The tumor was located in the inferior part of the right adrenal gland in three cases and in the upper pole of the left adrenal gland in two cases. The postoperation pathologic diagnosis was adrenocortical adenoma in all five patients, and excessive hormonal levels or symptoms all disappeared. Conclusions: Laparoscopic partial adrenalectomy can be performed safely using a vascular stapler. Received: 26 May 1998/Accepted: 30 June 1998     

Laparoscopic partial nephrectomy

PURPOSE OF REVIEW: This review defines the current role, indications, contraindications, advances, complications, and outcomes of laparoscopic partial nephrectomy in the management of renal tumors. RECENT FINDINGS: Recent publications have widened the scope for the application of this technology. The new advances in the management of renal tumors and the tools for tumor excision, renal parenchymal reconstruction, hemostasis, renal vascular control to establish renal ischemia, and the ability to avoid positive surgical margins have made the procedure safe and feasible in the hands of an experienced laparoscopist. SUMMARY: The trend toward nephron-sparing surgery has become stronger even in the presence of normal contralateral functioning kidney. Data on oncologic efficacy are promising, and partial nephrectomy is becoming a standard therapy for renal tumors less than 4 cm in size in many centers. Laparoscopic partial nephrectomy has evolved significantly during the past 10 years in our experience as well as that of others. It cannot be considered as a standard yet, but it is being performed in rapidly increasing numbers with good surgical efficiency and oncologic efficacy parallel to that of open surgery.     

Laparoscopic total and partial nephrectomy

Laparoscopic radical nephrectomy has established its role as a standard of care for the management of renal neoplasms. Long term follow-up has demonstrated laparoscopic radical nephrectomy has shorter patient hospitalization and effective cancer control, with no significant difference in survival compared with open radical nephrectomy. For renal masses less than 4cm, partial nephrectomy is indicated for patients with a solitary kidney or who demonstrate impairment of contralateral renal function. The major technical issue for success of laparoscopic partial nephrectomy is bleeding control and several techniques have been developed to achieve better hemostatic control. Development of new laparoscopic techniques for partial nephrectomy can be divided into 2 categories: hilar control and warm ischemia vs. no hilar control. Development of a laparoscopic Satinsky clamp has achieved en bloc control of the renal hilum in order to allow cold knife excision of the mass, with laparoscopic repair of the collecting system, if needed. Combination of laparoscopic partial nephrectomy with ablative techniques has achieved successful excision of renal masses with adequate hemostasis without hilar clamping. Other techniques without hilar control have been investigated and included the use of a microwave tissue coagulator. In conclusion, laparoscopic radical nephrectomy for renal cell carcinoma has clearly demonstrated low morbidity and equivalent cancer control. The rates for local recurrences and metastatic spread are low and actuarial survival high. Furthermore, laparoscopic partial nephrectomy has demonstrated to be technically feasible, with low morbidity. With short term outcomes demonstrating laparoscopic partial nephrectomy as an efficacious procedure, the role of laparoscopic partial nephrectomy should continue to increase.     

Laparoscopic approach in partial nephrectomy

Except for segmental parenchymal atrophies, partial nephrectomy is more and more often indicated when treating isolated small renal tumours. During the last few years this technique has been increasingly accepted for the excision of tumours less than 4 centimetres. In order to diminish the operative morbidity, the laparoscopic approach has been proposed. During the last decade, laparoscopic partial nephrectomy "has come to maturity" and this technique is now well standardized. Knowledge and operative skills are required for both trans-peritoneal and extra-peritoneal route. Extra-peritoneal approach is more suitable for posterior lesions or at the level of the lower pole while the trans-peritoneal route is preferred in case of tumours near the renal hilum or on the anterior surface. Different methods offering temporary arrest of renal perfusion have been elaborated. There is a clear tendency for renal parenchyma sectioning without the use of any kind of thermal energy. This allows a better identification of renal lesions. Sectioned collecting system, blood vessels and renal parenchyma are systematically sutured. Despite its complexity, this technique has become reproducible and reliable in specialized laparoscopic centres.     

Laparoscopic partial nephrectomy: fifty cases

PURPOSE: Laparoscopic partial nephrectomy (LPN) is a technically challenging procedure. The goal of this study is to describe the outcomes of 50 consecutive patients undergoing LPN performed by one surgeon. MATERIALS AND METHODS: Records were reviewed for clinical, pathologic, and follow-up information for patients undergoing LPN. Clinical parameters were assessed in both the first 25 and last 25 cases to see if there was a measurable learning curve. RESULTS: Fifty-two patients underwent attempted LPN; 50 were successful and 2 were converted to open partial nephrectomy. Mean operating room time was 155 minutes, mean estimated blood loss was 172 mL, and mean pathologic size was 2.6 cm. Final pathology revealed malignancy in 60% of cases and oncocytoma in 22% of cases. Margins were clear for all of the primary lesions. Overall complications were 16%, with cardiopulmonary complications being the most common. There were no significant differences in the outcomes of the first 25 and the last 25 patients, with the exception of length of stay (3.1 days v 2.5 days). CONCLUSIONS: After laparoendoscopic fellowship training in LPN, acceptable outcomes are achievable, and the learning curve is minimal. Long-term studies are needed on the efficacy of LPN, and further studies need to be performed to optimize the learning process for this technique.