Posterior retroperitoneoscopic partial nephrectomy using microwave tissue coagulator for small renal tumors

BACKGROUND AND PURPOSE: Laparoscopic partial nephrectomy remains surgically challenging because of the potential for excessive blood loss, infection, and the development of urinary fistulas. In addition, posterior retroperitoneoscopic partial nephrectomy is not popular because of the limited space for surgical manipulation. We evaluated the usefulness of a microwave tissue coagulator in posterior retroperitoneoscopic partial nephrectomy for small posterior renal tumor. PATIENTS AND METHODS: Posterior retroperitoneoscopic partial nephrectomy was performed without renal pedicle clamping using a microwave tissue coagulator in six patients with small posterior renal tumors. RESULTS: The mean operative time was 136 minutes (range 78-180 minutes), and the blood loss was <20 mL. No serious operative complications occurred, and there was no significant deterioration of renal function. CONCLUSION: Posterior retroperitoneoscopic partial nephrectomy using a microwave tissue coagulator can be a safe and less invasive method for the treatment of small posterior renal tumors.     

Laparoscopic partial nephrectomy using microwave tissue coagulator for small renal tumors: usefulness and complications

OBJECTIVES: We evaluated the usefulness and complications of laparoscopic partial nephrectomy for small renal tumors using a microwave tissue coagulator without renal pedicle clamping. METHODS: Between September 1999 and March 2003, 19 patients with small renal tumors 11 to 45 mm in diameter underwent laparoscopic partial nephrectomy without renal ischemia. RESULTS: Six and 13 patients were treated by the transperitoneal and retroperitoneal approaches, respectively. Excluding a case with open conversion due to dense perirenal adhesions, 18 patients successfully underwent laparoscopic procedures. The mean operative time was 240 minutes with minimal blood loss in 14 patients and 100 to 400 ml in 4. In a patient, frozen sections revealed a positive surgical margin and additional resection was performed. Postoperative complications included extended urine leakage for 14 days, arteriovenous fistula and almost total loss of renal function, respectively, in a patient. With the median follow-up of 19 months, no patients showed local recurrence or distant metastasis by CT scan. CONCLUSIONS: Laparoscopic non-ischemic partial nephrectomy using a microwave tissue coagulator may be useful for treating small renal tumors because it does not require advanced laparoscopic skill. However, the indication of this procedure should be highly selective in order to minimize serious complications secondary to unexpected collateral damage to surrounding structures.     

Impact of microwave tissue coagulation during laparoscopic partial nephrectomy on postoperative renal function

Laparoscopic partial nephrectomy for small renal tumors has been performed with increasing frequency over the past few years. We prospectively evaluated preoperative and postoperative differential renal function in patients with functioning contralateral kidneys who underwent laparoscopic partial nephrectomy using a microwave tissue coagulator without hilar clamping. Seven patients (five men and two women) in this prospective protocol underwent laparoscopic partial nephrectomy for exophytic tumors using a microwave tissue coagulator when the tumor was 2 cm or less in diameter. Renal scanning with ⁹⁹technetium-labeled diethylenetetraminepentaacetic-acid scan was performed preoperatively and postoperatively at 7 days and 6 months after surgery in all patients. The mean tumor size and surgical duration were 17.0 ± 2.3 mm and 161.1 ± 20.5 min, respectively. Intraoperative blood loss was 35.6 ± 40.7 ml. The preoperative glomerular filtration rate (GFR) and differential split renal function (SF) in the affected kidney were 45.7 ± 12.8 ml/min and 50.5 ± 3.3%, respectively. On postoperative day 7 and at 6 months, GFR and SF in the affected kidney were 36.2 ± 9.0 and 36.8 ± 10.9 ml/min and 44.3 ± 4.1 and 45.0 ± 5.1%, respectively. No postoperative complications occurred. Laparoscopic nonischemic partial nephrectomy using a microwave tissue coagulator has the advantage of technical ease and adequate hemostasis. However, its indication should be restricted to small exophytic renal tumors due to the expected collateral damage causing renal impairment.     

Non-ischemic partial nephrectomy using microwave tissue coagulator

PURPOSE: The indications and the safety of non-ischemic partial nephrectomy using a microwave tissue coagulator were studied. MATERIALS AND METHODS: Non-ischemic partial nephrectomy was performed on 17 kidneys of 16 patients using a microwave tissue coagulator. The diagnosis was renal tumor and renal stones in eleven and five patients, respectively. Renal tumors were less than 4 centimeters in diameter, while the stones were associated with a caliceal diverticulum or secondary cortical atrophy. Excision of the tumors was done via the retroperitoneal approach through an oblique lumbar incision. The needle of the microwave tissue coagulator was inserted around the tumor (stone) 10 to 20 times, and the coagulator was activated. Then the tumor (stone) was excised with a sharp knife or scissors. Patients were encouraged to walk on the first postoperative day. RESULTS: Vascular clamping was necessary in one patient to reduce bleeding. Nephrectomy was done after partial nephrectomy in one patient because it was difficult to close the urinary collecting system after it was widely exposed. Although urine leakage was seen postoperatively in two patients, it ceased spontaneously at 14 and 23 days after surgery. Postoperative complications developed in one of seven patients (14%) with protruding renal tumor, in three of five patients (60%) with non-protruding renal tumor and in two patients with renal stone. Allogenic or autologous blood transfusion was not necessary, nor was any bleeding noticed post-operatively. In one patient, atrophy of the renal parenchyma occurred gradually after surgery and function was eventually lost. However, renal function was well preserved and recurrence of the problem was not observed in the other 15 patients, excluding one who died of esophageal cancer. CONCLUSIONS: The microwave tissue coagulator is a useful surgical instrument for non-ischemic partial nephrectomy, not only in patients with renal tumors but also in patients with complicated kidney stones. However, non-protruding renal tumor in a patient with solitary kidney should be avoided for this surgery. Thermal injury to the renal parenchyma or large vessels should be avoided and urine leakage from the collecting system should be meticulously treated during the operation.     

Retroperitoneoscopic nephron-sparing surgery of renal tumor using a microwave tissue coagulator without renal ischemia: comparison with open procedure

PURPOSE: It is ideal to use not a transperitoneal but a retroperitoneal approach for both open and endoscopic partial nephrectomy. We compared the results of retroperitoneoscopic nephron-sparing surgery for small renal tumors using a microwave tissue coagulator without renal pedicle clamping with those of a retroperitoneal open procedure. PATIENTS AND METHODS: Between 1996 and 2002, eight patients with small renal tumors underwent retroperitoneoscopic partial nephrectomy without renal ischemia, and nine patients with small renal tumors underwent open partial nephrectomy via a retroperitoneal approach. Both groups were operated on using a microwave tissue coagulator. RESULTS: Retroperitoneoscopic partial nephrectomy without renal ischemia was performed without any major or minor complications in any patient. The mean operation time for retroperitoneoscopic surgery was significantly longer than that for open partial nephrectomy (221.9 minutes v 145.9 minutes; P = 0.0004). However, the mean estimated blood loss for retroperitoneoscopic surgery was less than that for open partial nephrectomy (137.5 mL v 334.8 mL; P = 0.012). In addition, the retroperitoneoscopic group seemed to recover more rapidly than the open surgery group. CONCLUSIONS: Retroperitoneoscopic nephron-sparing surgery of small renal tumors using a microwave tissue coagulator without renal ischemia is feasible as minimally invasive procedure. It results in saving renal function, minimal blood loss, and rapid recovery.     

Application of the microwave tissue coagulator: is it beneficial to partial nephrectomy?

BACKGROUND/AIM: The indications of partial nephrectomy have expanded after the introduction of new techniques for preventing excessive blood loss and avoiding deterioration of the renal function after clamping the renal pedicle. We present our clinical experience of partial nephrectomy for renal tumors using a microwave tissue coagulator. PATIENTS AND METHODS: Between April 1996 and January 2000, 34 patients underwent open partial nephrectomies in the Kobe City General Hospital. The microwave tissue coagulator was used for resection of the renal parenchyma, but in deeper lesions a sharp dissection was performed. Twenty-two patients (groups 1 and 2) underwent partial nephrectomy without vascular control (14 renal pedicles were not disturbed in group 1 patients, and 8 renal pedicles were dissected but not clamped in group 2 patients). Another 12 patients (group 3) underwent vascular control with ligation of the tumor-feeding segmental arteries before parenchymal resection. The patients of group 1 underwent wedge resections, while those of groups 2 and 3 underwent segmental or transverse partial nephrectomies. RESULTS: Complete tumor resection was done in all 34 patients. In group 1, the microwave tissue coagulator was very effective to control the blood loss (mean 330 ml). In larger resections, this method only was inadequate to control the blood loss (mean 489 ml in group 2), so that we needed vascular control. However, despite vascular control, mean blood losses of about 943 ml because of deeper venous bleeding occurred in group 3, and, moreover, postoperative renal infarctions occurred in 2 patients. Other complications were urinary fistula formation in 16 patients (47%) and renal pelvic stenoses in 2 patients (5.8%). All of the urinary fistulas were easily repaired by simple suturing intraoperatively. CONCLUSIONS: Especially in wedge resection, the microwave tissue coagulator achieved safe resection without vascular control which differs from other new techniques. However, in larger resections, a combination with other techniques may be necessary to decrease blood loss and the rate of complications.     

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.     

Retroperitoneoscopic partial nephrectomy using microwave coagulation for small renal tumors

OBJECTIVES: The outcome of laparoscopic partial nephrectomy using a microwave tissue coagulator for treatment of small renal tumors was studied.PATIENTS AND METHODS: From June 1999 to May 2001, eight patients with small renal tumors of less than 5.0cm in diameter (1.0-5.0cm, T1N0M0) underwent retroperitoneoscopic partial nephrectomy. To control bleeding during the partial nephrectomy, the renal parenchyma around the tumor was coagulated using a microwave tissue coagulator with a needle of 1.5cm length. The tumor was circumscribed within the coagulated area with 8-13 punctures of the coagulation needle, and partial nephrectomy was performed using scissors and bipolar forceps.RESULTS: All eight patients successfully underwent the procedure retroperitoneoscopically. The average operative time was 295 minutes and the average blood loss was 129ml. Three patients showed urine leakage from the renal calyces, which was controlled by suturing retroperitoneoscopically. In two patients, the surgical margin was revealed to be positive for renal cell carcinoma by frozen section pathology and additional resection was performed in these individuals. The patients were discharged from the hospital with almost full convalescence on day 10 on average. Within the mean follow-up period of 10.4 months, no recurrence was found when examined with computer tomography (CT) using contrast media. As a complication, one patient experienced a decrease in function of the operated kidney caused by unknown reason.CONCLUSION: Retroperitoneal partial nephrectomy using a microwave tissue coagulator is useful for treatment of small renal tumors located at the peripheral area of the kidney. Bleeding from the renal parenchymal incision site is well controlled without occlusion of the renal artery with additional use of a bipolar coagulator, when necessary. Further experience and long-term follow-up are mandatory however, to establish the usefulness of this technique.     

The impact of warm ischaemia on renal function after laparoscopic partial nephrectomy

Authors from Cleveland assessed the impact of warm ischaemia on renal function, using their large database of laparoscopic partial nephrectomies for tumour. While agreeing that renal hilar clamping is essential for precise excision of the tumour, and other elements of the operation, the authors indicate that warm ischaemia may potentially damage the kidney. However, they found that there were virtually no clinical sequelae from warm ischaemic of up to 30 min. They also found that advancing age and pre-existing renal damage increased the risk of postoperative renal damage. OBJECTIVE: To assess the effect of warm ischaemia on renal function after laparoscopic partial nephrectomy (LPN) for tumour, and to evaluate the influence of various risk factors on renal function. PATIENTS AND METHODS: Data were analysed from 179 patients undergoing LPN for renal tumour under warm ischaemic conditions, with clamping of the renal artery and vein. Renal function was primarily evaluated in two groups of patients: 15 with tumour in a solitary kidney, who were evaluated by serial serum creatinine measurements; and 12 with two functioning kidneys undergoing unilateral LPN, and evaluated by renal scintigraphy before and 1 month after LPN to quantify differential renal function. Also, in all 179 patients, mean serum creatinine data at baseline, 1 day after LPN, at hospital discharge, and at the last follow-up were provided as supportive evidence. Logistic regression analyses were used to assess the effect of various risk factors on renal function after LPN, i.e. patient age, baseline serum creatinine, tumour size, solitary kidney status, duration of warm ischaemia, pelvicalyceal suture repair, urine output and intravenous fluids during LPN. RESULTS: In the group of patients with a solitary kidney the mean warm ischaemia time was 29 min, kidney parenchyma excised 29%, and serum creatinine at baseline, discharge, the peak after LPN and at the last follow-up (mean 4.8 months) 1.3, 2.3, 2.8, and 1.8 mg/dL, respectively. One patient (6.6%) required temporary dialysis. In the second group, assessed by renal scintigraphy, the function of the operated kidney was reduced by a mean of 29%, commensurate with the amount of parenchyma excised. For all 179 patients, a combination of age > or = 70 years and a serum creatinine level after LPN of > or = 1.5 mg/dL correlated with a higher serum creatinine after LPN. On logistic regression, baseline serum creatinine and solitary kidney status were the only variables significant for serum creatinine status after LPN. CONCLUSIONS: The bloodless field provided by renal hilar clamping is important for precise tumour excision, pelvicalyceal suture repair and securing parenchymal haemostasis during LPN. However, renal hilar clamping causes warm ischaemia. These data indicate that the clinical sequelae of warm ischaemic renal injury of approximately 30 min are minimal. Advancing age and pre-existing azotaemia increase the risk of renal dysfunction after LPN, especially when the warm ischaemia exceeds 30 min.     

Microwave tissue coagulator induces renal apoptotic damage to preserved normal renal tissue following partial nephrectomy

Background  

We assessed the extent of apoptotic damage induced by the microwave tissue coagulator (MTC) in the preserved normal renal tissue following partial nephrectomy.     

A controlled study of the argon beam coagulator for partial nephrectomy

An argon beam coagulator was evaluated in 25 canine partial nephrectomies to determine its hemostatic capabilities, safety and degree of thermal injury to renal parenchyma. Comparison was made with a control group of seven partial nephrectomies performed by standard technique. In both groups the procedure was performed without renal cooling or clamping of the renal artery. The argon beam coagulator was operated with a power output of 130 watts. Mean operative time for partial nephrectomy was 22 minutes in the control group versus 10 minutes when the argon coagulator was used (p less than 0.001). Mean blood loss was 276 cc by standard technique but only 135 cc with the argon coagulator (p less than 0.001). A regular eschar with a mean depth of tissue necrosis of 2.4 mm. was observed with the argon coagulator.     

Comparison of the Loss of Renal Function after Cold Ischemia Open Partial Nephrectomy,Warm Ischemia Laparoscopic Partial Nephrectomy and Laparoscopic Partial Nephrectomy Using Microwave Coagulation

Purpose

Nephron sparing surgery is an effective surgical option in patients with renal cell carcinoma. Laparoscopic partial nephrectomy involves clamping and unclamping techniques of the renal vasculature. This study compared the postoperative renal function of partial nephrectomy using an estimation of the glomerular filtration rate (eGFR) for a Japanese population in 3 procedures; open partial nephrectomy in cold ischemia (OPN), laparoscopic partial nephrectomy in warm ischemia (LPN), and microwave coagulation using laparoscopic partial nephrectomy without ischemia (MLPN).

Materials and Methods

A total of 57 patients underwent partial nephrectomy in Yokohama City University Hospital from July 2002 to July 2008. 18 of these patients underwent OPN, 17 patients received MLPN, and 22 patients had LPN. The renal function evaluation included eGFR, as recommended by The Japanese Society of Nephrology.

Results

There was no significant difference between the 3 groups in the reduction of eGFR. eGFR loss in the OPN group was significantly higher in patients that experienced over 20 minutes of ischemia time. eGFR loss in LPN group was significantly higher in patients that experienced over 30 minutes of ischemia time.

Conclusion

This study showed that all 3 procedures for small renal tumor resection were safe and effective for preserving postoperative renal function.Key Words: eGFR, Partial nephrectomy, Renal function, Laparoscopic partial nephrectomy     

Partial nephrectomy for renal cell carcinoma using a microwave tissue coagulator--postoperative recurrence and renal function

Nowadays, partial nephrectomy is often selected for treatment of small renal cell carcinoma (RCC) because T1a RCC shows a favorable prognosis with a 5-year overall-survival rate exceeding 90%. To determine the methodological usefulness and treatment outcome of partial nephrectomy using microwave tissue coagulator (MTC), we evaluated our series of 121 patients (124 kidneys) with T1 RCC who underwent this procedure. Ninety-nine patients were elective and 22 patients were imperative cases. This procedure was indicated for asymptomatic solitary RCC; < or =4 cm in diameter in elective cases or < or =5 cm in imperative cases, expanding outward with a clear capsule, and showing neither renal pelvis nor renal sinus invasion. The median operation time was 150 minutes and the median blood loss was 217 ml. Eight patients needed transfusion, and conservative therapy cured 4 patients of postoperative urine leakage successfully. Three patients underwent early secondary nephrectomy due to multiple RCCs, invasive spindle cell carcinoma, or prolongation of urine leakage. No significant deterioration of renal function by creatinine clearance (Ccr) was observed, and postoperative Ccr could be precisely predicted from preoperative serum creatinine value and the renal parenchymal volume estimated with 3-dimensinal image reconstruction. Five-year overall-survival rate was 91% at the mean follow-up of up to 37.9 months and 107 patients were alive without disease. One patient showed local recurrence 2 years later and underwent radical nephrectomy. We believe that non-ischemic partial nephrectmy using MTC is a simple and reliable nephron-sparing surgery for small RCC in respect of postoperative recurrence and preservation of renal function.     

Partial nephrectomy using microwave tissue coagulator--application for laparoscopic operation

We report our clinical findings on 12 tumors (11 patients) successfully resected by partial nephrectomy with a microwave tissue coagulator (MTC) without renal pedicle clamping, including laparoscopic operation in 4 patients. All patients presented with a renal tumor detected incidentally by ultrasonography or computed tomography. The mean size of renal tumor was 1.9 (range 0.8-3.4) cm. Pathological diagnosis was renal cell carcinoma in 9 tumors and hemorrhagic cyst in 3 tumors. Mean operative time was 249 minutes. Mean blood loss was 183 ml in cases with a laparoscopic operation, that was statistically less than 486 ml in cases with an open operation (p<0.05), and 376 ml in all cases. There was no significant change in the creatinine clearance of cases with laparoscopic operation, compared with that of cases with an open operation. There were no other serious complications postoperatively. These findings suggested that partial nephrectomy with the MTC can be safely and successfully carried out while sparing renal function. Moreover, partial nephrectomy with the MTC for a laparoscopic operation may provide these patients with more benefits.     

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.     

Simultaneous "cut and suture": a novel technique for laparoscopic partial nephrectomy without vascular clamping

Loss of renal units due to warm ischemia is of great concern in laparoscopic partial nephrectomy (LPN). We describe a technique for performing LPN without vascular clamping with optimal results and minimal blood loss, suitable for small and superficial renal masses.     

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.     

Water jet assisted laparoscopic partial nephrectomy without hilar clamping in the calf model

PURPOSE: Hemostasis represents a primary challenge during laparoscopic partial nephrectomy (LPN). We typically clamp the renal artery/vein en bloc and perform LPN expeditiously under warm ischemia conditions. We evaluated Helix Hydro-jet assisted LPN without renal hilar vascular control in the survival calf model. MATERIALS AND METHODS: Staged bilateral LPN using the Hydro-jet was performed without renal hilar vessel control in 10 survival calves (20 kidneys). Parenchymal hydrodissection was performed with a high velocity, ultracoherent saline stream at 450 psi through a small nozzle with integrated suction at the tip. The denuded intrarenal parenchymal blood vessels were precisely coagulated with a BIClamp bipolar instrument and transected. Followup involved biochemical, radiological and histopathological evaluation at designated sacrifice intervals of 1 and 2 weeks, and 1, 2 and 3 months, respectively. RESULTS: All LPNs were completed successfully without open conversion. Of 20 LPNs 18 (90%) were performed without hilar clamping. Pelvicaliceal suture repair was necessary in 5 of 10 chronic kidneys (50%). Mean Hydro-jet(R) partial nephrectomy time was 63 minutes (range 13 to 150), mean estimated blood loss was 174 cc (range 20 to 750) and mean volume of normal saline used for hydro-dissection was 260 cc (mean 50 to 1,250). No animal had a urinary leak. Histological sections from the acute specimen revealed a thin (1 mm) layer of adherent coagulum at the amputation site with minimal thermal artifact. At 2 weeks a layer of adherent fibro-inflammatory pseudomembrane with giant cell reaction was seen. CONCLUSIONS: In this more stringent and robust survival calf model Hydro-jet assisted LPN can be performed without hilar vessel control, thus, completely avoiding warm ischemia. This approach has the potential to decrease the level of technical difficulty inherent in LPN.     

Laparoscopic partial nephrectomy: an update on contemporary issues

Laparoscopic partial nephrectomy (LPN) is a technically challenging procedure with up to 5-year follow-up data. In this article, incidence of renal cell carcinoma, indications, and contraindications for LPN are presented. In addition, LPN for benign diseases such as atrophic renal segments associated with duplicated collecting systems and calyceal diverticula associated with recurrent UTIs are presented. Hilar clamping, ischemic time, positive margins, and port-site metastasis, in addition to complications and survival outcomes, are discussed. The advantages of lower cost, decreased postoperative pain, and early recovery have to be balanced with prolonged warm ischemia. Its long-term outcomes in terms of renal insufficiency or hemodialysis requirements have not been defined completely. Randomized clinical trials comparing open partial nephrectomy (OPN) versus LPN are needed.     

'Zero ischaemia', sutureless laparoscopic partial nephrectomy for renal tumours with a low nephrometry score

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Ischaemic injury produced by hilar clamping during partial nephrectomy is the main determinant of renal function loss. The exact measurement of ipsilateral renal function loss can be underestimated by serum creatinine levels and estimated GFR. Few reports of unclamped laparoscopic partial nephrectomy (LPN) are available in the literature, although this technique shows promising results. The present study includes a series of patients with the longest follow‐up of LPN without hilar clamping and without parenchymal reconstruction. Excellent cancer control and optimum renal functional preservation suggest that this technique could be performed in selected patients, i.e. those with small and peripheral tumours (also classified as low nephrometry score tumours).

OBJECTIVE

• ? To describe the technique and report the results of ‘zero ischaemia’, sutureless laparoscopic partial nephrectomy (LPN) for renal tumours with a low nephrometry score.

PATIENTS AND METHODS

• ? Between August 2003 and January 2010, data from 101 consecutive patients who underwent ‘zero ischaemia’, sutureless LPN were collected in a prospectively maintained database.
• ? Inclusion criteria were tumour size ≤4 cm, predominant exophytic growth and intraparenchymal depth ≤1.5 cm, with a minimum distance of 5 mm from the urinary collecting system.
• ? Hilar vessels were not isolated, tumour dissection was performed with 10‐mm LigaSure^TM (Covidien, Boulder, CO, USA) and haemostasis was performed with coagulation and biological haemostatic agents without reconstructing the renal parenchyma.
• ? Clinical, perioperative and follow‐up data were collected prospectively, and modifications of functional outcome variables were analysed using the paired Wilcoxon test.

RESULTS

• ? The median (range) tumour size was 2.4 (1.5–4) cm, and the median (range) intraparenchymal depth was 0.7 (0.4–1.4) cm.
• ? Hilar clamping was not necessary in any patient, and suture was performed in four patients to ensure complete haemostasis. The median (range) operation duration was 60 (45–160) min, and median (range) intraoperative blood loss was 100 (20–240) mL.
• ? Postoperative complications included fever (n= 4), low urinary output (n= 3) and haematoma, which was treated conservatively (n= 2). The median (range) hospital stay was 3 (2–5) days. The pathologist reported 30 benign tumours and renal cell carcinoma in 71 cases (pT1a in 69 patients, and pT1b in two patients).
• ? At a median follow‐up of 57 months, one patient underwent radical nephrectomy for ipsilateral recurrence. The 1‐year median (range) decrease of split renal function at renal scintigraphy was 1 (0–5) %.

CONCLUSIONS

• ? Zero ischaemia LPN is a reasonable approach to treating small and peripheral tumours, and a sutureless procedure is feasible in most cases.
• ? This technique has a low complication rate and provides excellent functional outcome without impairing oncological results.