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879 Towards zero ischaemia laparoscopic partial nephrectomy: Single centre experience
879
Towards zero ischaemia laparoscopic partial nephrectomy: Single centre experience Eur Urol Suppl 2013;12;e879
Makanjuola J.K.1, Qteishat A.1, Lynch M.1, Rao A.1, Brown C.1, Kouriefs C.1, Arya M.2, Grange P.1 1
King's College Hospital, Dept. of Urology, London, United Kingdom, 2University College London Hospitals, Dept. of
Urology, London, United Kingdom INTRODUCTION & OBJECTIVES: We present our single centre experience of’ ‘no clamp’ laparoscopic partial nephrectomy. The objective of this study is to review of our data in light of the recent trend towards ‘zero ischaemia’. In comparison to “acceptable” ischaemia and considering the limited data supporting the evaluation of the long term functional damage to the operated kidney, ‘no clamp’ is an attractive option we have adopted since 2005. MATERIAL & METHODS: Prospective data was collected for 85 patients undergoing 86 Laparoscopic Partial Nephrectomy (LPN). Pre-operative data included: demographics, haemoglobin, renal function, ASA score, tumour size and location allowing scoring. Intra-operative data included: operative time, blood loss and need for vascular control. Post-operative data included: histology, renal function, complications’ score and length of stay. In our standard ‘no clamp’ technique, 3D vascular reconstruction is obtained, feeding vessels to the tumour identified and tied whenever found. Using laparoscopic ultrasound, the resection is performed using harmonic devices according to our published planning technique. If required, further medullary haemostasis is completed with tension-free absorbable sutures. After blue dye test the collecting system is sutured if needed, without routine stenting. RESULTS: 61 male and 24 female with a mean age of 56.5 underwent LPN. Zero ischaemia was achieved in 77 procedures (89%). In the 9 remaining procedures where clamping was needed the average ischaemic time was 17.5 mins (9 – 40) Average tumour size was 4.1 cm (0.9 - 12). Feeding arteries were found in 32% of cases. Average blood loss was 457ml (50 - 3000). Average operative time including stenting for blue dye test was 302 mins (135 – 540). Average pre/post-operative eGRF was 71/66 ml/min. We have found no significant difference based on the above criteria between the ‘no clamp’ subgroup that included 5 solitary kidneys and the warm ischaemia subgroup. We report negative margins in all but one VHL disease case. Our 22% of benign histology is consistent with the literature. 2 cases required blood transfusion. Complication rates; Clavien II, IIIa and IIIb 15%. No Clavien IV or V complications. Clavien IIIb complications included 4 stent insertions, 1 laparoscopic PUJ reconstruction and 1 laparotomy for uro– peritonitis. CONCLUSIONS: In view of our results, we do not claim this is a fast or bloodless technique; however we report a safe ‘no clamp’ technique that removes the stress related to the ‘stopwatch’ effect.
Towards zero ischaemia laparoscopic partial nephrectomy: Single centre experience Eur Urol Suppl 2013;12;e879
Makanjuola J.K.1, Qteishat A.1, Lynch M.1, Rao A.1, Brown C.1, Kouriefs C.1, Arya M.2, Grange P.1 1
King's College Hospital, Dept. of Urology, London, United Kingdom, 2University College London Hospitals, Dept. of
Urology, London, United Kingdom INTRODUCTION & OBJECTIVES: We present our single centre experience of’ ‘no clamp’ laparoscopic partial nephrectomy. The objective of this study is to review of our data in light of the recent trend towards ‘zero ischaemia’. In comparison to “acceptable” ischaemia and considering the limited data supporting the evaluation of the long term functional damage to the operated kidney, ‘no clamp’ is an attractive option we have adopted since 2005. MATERIAL & METHODS: Prospective data was collected for 85 patients undergoing 86 Laparoscopic Partial Nephrectomy (LPN). Pre-operative data included: demographics, haemoglobin, renal function, ASA score, tumour size and location allowing scoring. Intra-operative data included: operative time, blood loss and need for vascular control. Post-operative data included: histology, renal function, complications’ score and length of stay. In our standard ‘no clamp’ technique, 3D vascular reconstruction is obtained, feeding vessels to the tumour identified and tied whenever found. Using laparoscopic ultrasound, the resection is performed using harmonic devices according to our published planning technique. If required, further medullary haemostasis is completed with tension-free absorbable sutures. After blue dye test the collecting system is sutured if needed, without routine stenting. RESULTS: 61 male and 24 female with a mean age of 56.5 underwent LPN. Zero ischaemia was achieved in 77 procedures (89%). In the 9 remaining procedures where clamping was needed the average ischaemic time was 17.5 mins (9 – 40) Average tumour size was 4.1 cm (0.9 - 12). Feeding arteries were found in 32% of cases. Average blood loss was 457ml (50 - 3000). Average operative time including stenting for blue dye test was 302 mins (135 – 540). Average pre/post-operative eGRF was 71/66 ml/min. We have found no significant difference based on the above criteria between the ‘no clamp’ subgroup that included 5 solitary kidneys and the warm ischaemia subgroup. We report negative margins in all but one VHL disease case. Our 22% of benign histology is consistent with the literature. 2 cases required blood transfusion. Complication rates; Clavien II, IIIa and IIIb 15%. No Clavien IV or V complications. Clavien IIIb complications included 4 stent insertions, 1 laparoscopic PUJ reconstruction and 1 laparotomy for uro– peritonitis. CONCLUSIONS: In view of our results, we do not claim this is a fast or bloodless technique; however we report a safe ‘no clamp’ technique that removes the stress related to the ‘stopwatch’ effect.