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Conference Coverage AUA 2004 - Selected Abstracts AUA 2004 - Advances in Laparoscopic Renal Surgery Selected Abstracts
Conference Coverage AUA 2004 - Selected Abstracts AUA 2004 - Advances in Laparoscopic Renal Surgery Selected Abstracts |
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| AUA 2004 - Advances in Laparoscopic Renal Surgery Selected Abstracts |
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| Saturday, 08 May 2004 | ||
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CURRENT TECHNIQUE OF LAPAROSCOPIC NEPHRON-SPARING SURGERY FOR T1 RENAL MASSES Saturday, May 08, 2004 Preetinder K Brar*, Jay T Bishoff, San Antonio, TXINTRODUCTION AND OBJECTIVE: The success of open nephron-sparing surgery (NSS) in T1 and T2 renal cell carcinoma has created interest in less invasive treatment options. Current laparoscopic techniques mimic open surgery allowing successful completion of NSS with excellent cancer control, low blood loss, and closure of the collecting system. METHODS: Between August 1998 and August 2003, we performed NSS in 39 patients. The transperitoneal approach was used in 26 patients and the retroperitoneal approach in 13 patients. With both approaches, the kidney was fully mobilized and the entire surface inspected for occult masses. Endoscopic scalpel was used to circumscribe the visualized mass with a margin of normal renal parenchyma. The tumor bed was treated with argon beam coagulation. The collecting system was closed with interrupted absorbable suture and fibrin sealant was placed over the renal defect. Renal vascular occlusion with intrarenal cooling was utilized. Total renal ischemia was required in 18 cases. RESULTS: No patient required conversion to open surgery. The mean tumor size was 2.1 cm (range 1.0 to 3.5). Mean operative time was 168 min (range 90-349). Mean ischemic time was 26 min (range 12-46). Mean estimated blood loss was 192 cc (50-800). Final pathology was renal cell carcinoma in 31 patients and benign pathology in 8 patients. All final surgical margins were negative with a mean margin distance of 2.4 mm (range 1-7). At a mean follow up time of 26 months (range 1-58) there have been no tumor recurrences or port site seeding. Complications included pneumothorax (N=1), respiratory failure (N=1), urinoma (N=4), and trocar site infection (N=4). CONCLUSIONS: Current laparoscopic techniques for NSS mimic open surgery. Total renal ischemia, renal hypothermia, extirpation of tissue, realization of negative tissue margins, and intracorporeal suturing of the collecting system and parenchyma are techniques that are currently available. Hemostasis during laparoscopic NSS for T1 renal masses is safely and effectively accomplished by the use of argon beam coagulation, suturing, and application of fibrin sealant. ELIMINATING KNOT TYING DURING WARM ISCHEMIA TIME FOR LAPAROSCOPIC PARTIAL NEPHRECTOMY: THE VIDEO Saturday, May 08, 2004 Marcelo A Orvieto*, Gary W Chien, R Matthew Galocy, Mitchell H Sokoloff, Gregory P Zagaja, Arieh L Shalhav, Chicago, IL.INTRODUCTION AND OBJECTIVE: Laparoscopic partial nephrectomy (LPN) is technically difficult mainly due to the need for rapid suturing skills during warm ischemia time (WIT). Knot tying is the most time consuming step in laparoscopic intracorporeal suturing. In this video we present 2 cases showing our technique eliminating knot tying when performing LPN. METHODS: From October 2002 to June 2003, 23 patients underwent LPN using the technique presented. We routinely place a 5F ureteral catheter for irrigation with 4°C saline with methylene blue. Renal hilar dissection is performed to allow isolated artery clamping and identification of the tumor. Once WIT is started, excision of the tumor is performed using cold scissors. Entry of the collecting system is precisely identified with the outflow of methylene blue and saline. Suturing of the collecting system and renal parenchyma is done using 6 inch sutures of 2/0 and 3/0 vycril that are prepared with a LapraTy clip™ 1cm before the terminal end. These clips are made of a polymer of poydioxanone (PDS), which is a biocompatible and absorbable material, therefore it can be used when suturing of the collecting system. Once the suture is passed, a second clip cinches and secures the stitch, completely avoiding the need of knot tying. Subsequent testing for water-tightness with the methylene blue solution is finally performed. Hemostasis is completed with the combined use of argon beam coagulator, Tisseel™ and bolsters compression sutures squeeze with LapraTy clips. RESULTS: Mean tumor size was 2.7cm (1.1-4.2). Total operative time was 237 minutes including preoperative stent placement. WI time was 34.9 minutes and the estimated blood loss was 262cc. Drainage was removed within the first 24 hours in 88.8% of the patients. No postoperative leakage and other complications were noticed in this series. CONCLUSIONS: Our initial experience using LapraTy™ clips when performing LPN allows the surgeon to complete a safe and reliable repair of the pelvicaliceal system and renal defect, avoiding the need of performing intracorporeal knot tying while maintaining the principles of the open technique. HAND ASSISTED LAPAROSCOPIC PARTIAL NEPHRECTOMY USING A SALINE-COOLED RADIOFREQUENCY DEVICE WITHOUT HILAR VASCULAR CONTROL Saturday, May 08, 2004 Yeh Hong Tan*, Matthew D Young, Steven A Terranova, Glenn M Preminger, David M Albala, Durham, NC.INTRODUCTION AND OBJECTIVE: Nephron-sparing surgery is now accepted as the standard of care for small renal tumor. However, hemostasis during laparoscopic partial nephrectomy can be technically challenging without hilar vascular control. The video describes our technique of hand assisted laparoscopic partial nephrectomy using a saline-cooled monopolar radiofrequency device, TissueLink, (TissueLink Medical, Dover, NH) without hilar vascular clamping. METHODS: Using the hand assisted laparoscopic approach, the kidney was mobilized transperitoneally and the Gerota's fascia was incised. The renal tumor with overlying perinephric fat was exposed. The tumor was excised with 1 cm margin using a combination of TissueLink and endoscopic scissor. The tumor and base of tumor bed were sent for frozen section for histological section. The bleeding vessels from renal parenchyma were controlled with digital compression and Tissuelink. At the end of procedure, the tumor bed was covered with FloSeal (Baxter Healthcare, Fremont, CA) or BioGlue (CryoLife, Kennesaw, GA). RESULTS: Five patients underwent hand assisted partial nephrectomy for small exophytic tumors. The mean age of the patients was 58 years. The mean operative time was 143 minutes. The estimated blood loss was 133 ml. All patients were discharged well after 2 days. CONCLUSIONS: Hand assisted laparoscopic partial nephrectomy using TissueLink is a safe and feasible technique for excision of small exophytic tumor. LAPAROSCOPIC PARTIAL NEPHRECTOMY : A NEPHRON SPARING TECHNIQUE WITHOUT ISCHEMIA Saturday, May 08, 2004 Philippe Grange*, La Rochelle, France; Hubert Mignot, Saintes, France.INTRODUCTION AND OBJECTIVE: The laparoscopic partial nephrectomy is a stressful run against the clock if the renal vessels are clamped especially on a solitary kidney. This video demonstrate our technique of laparoscopic partial nephrectomy without ischemia using harmonic scalpel for a 3 cm T1 renal cell carcinoma (RCC) tumor on a solitary remaining left kidney in a 54-year male, who presented a simultaneous bilateral tumor. METHODS: The position and the ports are standard for laparoscopic transperitoneal surgery. The colon is mobilized. First step: the renal vessels are identified if an emergency clamping is needed. Second step: the tumor is localized. Third step: the resection of the tumor. The harmonic scalpel power is set at the lowest level and the scissors must be squeeze gently and slowly. This takes time (30 to 90 seconds per bite) but it is effective as well on the parenchyma than on the hilar renal vessels or to seal the collecting system. A drain is left. No cooling technique, stent, glue or urethral catheter is needed. RESULTS: Operative time was 105 minutes. Time of ischemia: 0. The estimated blood loss was less than 100 cc. The drain was removed at day 2. The patient discharged at day 3. After 2 years the kidney is functioning normally. This technique has been performed successfully in sixteen patients without event in the post-operative course. CONCLUSIONS: Operative time was 105 minutes. Time of ischemia: 0. The estimated blood loss was less than 100 cc. The drain was removed at day 2. The patient discharged at day 3. After 2 years the kidney is functioning normally. This technique has been performed successfully in sixteen patients without event in the post-operative course. ADVANCED LAPAROSCOPIC TREATMENT FOR COMPLEX ANGIOMYOLIPOMA CASES Saturday, May 08, 2004 Cassio Andreoni*, Nelson Gattas, Homero Arruda, Valdemar Ortiz, Miguel Srougi, São Paulo, Brazil.INTRODUCTION AND OBJECTIVE: The conventional open surgery remains the prefered surgical approach for kidney angiomyolipomas, even though laparoscopic nephron sparing surgery (LNSS) is a valid and acceptable option for peripheric lesions. As the LNSS technique evolves, more complex cases can be performed safely as it is herein reported on three complex cases of angiomyolipoma. METHODS: From November 2000 to June 2003, five patients with renal angiomyolipoma that were either greater than 4 cm, symptomatic or with past hystory of bleeding underwent LNSS at our institution. Three complex cases were treated using three different techniques applied individually. Case 1: 18 year old female with an angiomyolipoma on the left middle pole, 5x4 cm, located peripherically but extending all the way to the hylum underneath the renal pelvis;through a transperitoneal approach and 4 trocars; the tumor was completely enucleated with no clamping, coming from the medial part of kidney and then from the opposite direction, dissecting the tumor out the collecting system and the intrarenal vessels; the defect was filled with surgicel and hemostasis obtained with intracorporeal suturing. Case 2: 46 year old female with a 6x5 cm angiomyolipoma on the rigth upper pole, centrally located, 1.5 cm below the renal parenchyma; a transperitoneal approach with 4 trocars was obtained and the renal artery was clamped using a laparoscopic bulldog; a nephrotomy was perfomed on the renal parenchyma just above the tumor, that was then totally enucleated; hemostasis was obtained with intracorporeal suturing including the perirenal fat within 29 minutes of warm ischemia. Case 3: 52 year old female with a 8x5 cm on the rigth lower pole requiring broad polar excision; the renal artery was clamped; the renal parenchyma excision was performed with endoshears, the collecting system was repaired as well as parenchyma hemostasis using intracorporeal suturing technique within 30 minutes of warm ischemia. RESULTS: All the five patients underwent LNSS suscessfuly. The average OR time was 146 minutes, average hospital stay was 2.6 days, average tumor size was 5.2 cm and in one case renal artery clamping was not necessary. Neither conversions nor transfusions nor reoperations were needed. Complicaion occured in one case: an insuflator malfunction during renal artery clamping. CONCLUSIONS: Advanced laparoscopic approach is feasible and safe using individualized advanced technique in complex cases of angiomyolipoma. ABSORBABLE FIBRIN ADHESIVE BANDAGE FOR HEMOSTASIS DURING LAPAROSCOPIC PARTIAL NEPHRECTOMY Saturday, May 08, 2004 Stephen V Jackman*, Bethesda, MD; Anthony H Donaldson, Lebanon, NH.INTRODUCTION AND OBJECTIVE: Obtaining reliable hemostasis remains a challenge during laparoscopic partial nephrectomy (PNx). The absorbable fibrin adhesive bandage (AFAB, American Red Cross, Holland Lab, Rockville, MD) consists of lyophilized fibrinogen and thrombin on a Vicryl mesh backing. It has been shown to be effective for hemostasis and closure of the collecting system in an open and more recently, hand-assisted laparoscopic (HAL) PNx model. A spray form was effective laparoscopically for hemostasis but did not reliably seal the collecting system. METHODS: The AFAB and its use in a swine model are demonstrated during a HAL right-sided heminephrectomy with local ischemic control only. Steps highlighted include: HAL renal mobilization, vascular control, partial nephrectomy, AFAB application, and AFAB reinforcement. RESULTS: The AFAB is effective for both hemostasis and collecting system closure in this model. CONCLUSIONS: The hand-assisted laparoscopic technique for application of the AFAB may be an appropriate compromise for performing even the most radical of partial nephrectomies while maintaining the benefits of a minimally invasive approach.
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