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RANDOMIZED PROSPECTIVE EVALUATION OF THE EFFECT OF PATIENT POSITIONING ON SURGICAL OUTCOMES DURING LAPAROSCOPIC RENAL AND ADRENAL SURGERY
THE JOURNAL OF UROLOGY®
534
Vol. 181, No. 4, Supplement, Tuesday, April 28, 2009
1493 RANDOMIZED PROSPECTIVE EVALUATION OF THE EFFECT OF PATIENT POSITIONING ON SURGICAL OUTCOMES DURING LAPAROSCOPIC RENAL AND ADRENAL SURGERY. Amanjot Sethi, Michelle A Lerner*, Carl Gjertson, Vani Sundaram, Chandru P Sundaram, Indianapolis, IN INTRODUCTION AND OBJECTIVES: We report a prospective comparison of operative table positioning (i.e. flexion or no flexion) and its effect on outcomes in laparoscopic renal and adrenal surgery. METHODS: 30 consecutive patients undergoing laparoscopic nephrectomy or adrenalectomy by a single surgeon (CPS) were randomized to surgery with (FL) or without (NF) a 45 degree flexion of the operative table. A single surgeon performed all operations with a transperitoneal pure laparoscopic or hand assisted approach. Operative parameters such as ease of bowel mobilization (BM), ease of renal hilar dissection (HD), and overall difficulty of dissection (DD) were recorded on a 10 point Likert scale. Operative (OT), estimated blood loss (EBL), post-operative pain and peri-operative complications were also recorded prospectively. RESULTS: There were 15 and 15 patients in the FL and NF groups respectively. There were no statistically significant differences in BM, HD, DD, OT, EBL, or post-operative pain. The two complications in the FL group which included testicular pain and a minor serosal injury during mobilization of the colon. This serosal injury was repaired laparoscopically without further sequelae. There was one trocar site infection in the NF group. CONCLUSIONS: Although flexion of the operative table during laparoscopic nephrectomy and adrenalectomy has become standard practice, the effects of such positioning on operative time, ease of exposure, post-operative pain and complications has not been previously defined. Our prospective comparison suggests that there is no benefit to table flexion during laparoscopic renal and adrenal surgery. Surgical exposure, dissection and outcomes do not appear to be affected by patient positioning in this series Table 1 Results Flexed
Unflexed
N
15
15
p-value
Age (yrs)
50.3
51.5
0.84
Weight (kg)
78.4
92.4
0.32
OR time (min)
185.4
177.5
0.61
EBL (cc)
135.4
69.4
0.06
Subjective Difficulty of Case (1-10)
5.5
4.2
0.06
Subjective Pain Score (1-10)
4.8
3.7
0.06
Post-op Morphine Eq. (mg)
66.4
53.1
0.11
LOS Complications
2.5 1.9 2 1 1. testicular pain 1. trocar site 2. serosal bowel wound infection injury
0.07
Source of Funding: None
1494 COMPARISON OF OPEN AND LAPAROSCOPIC PARTIAL NEPHRECTOMY IN OBESE AND NONOBESE PATIENTS: OUTCOMES STRATIFIED BY BODY MASS INDEX Marc T Feder*, A Ari Hakimi, Pedro Maria, David M Hoenig, Reza Ghavamian, Bronx, NY INTRODUCTION AND OBJECTIVES: Partial nephrectomy has become the standard of care for appropriately selected renal cortical neoplasms. Although obesity increases the complexity of laparoscopy and requires adjustments in operative technique, we recently published that outcomes for radical nephrectomy were improved with the laparoscopic approach. We now present our surgical outcomes and complications in patients undergoing open and laparoscopic partial nephrectomy, stratified by body mass index. METHODS: We retrospectively identified 143 patients, of whom
84 underwent laparoscopic partial nephrectomy and 59 open partial nephrectomy by a single surgeon. Patients were then stratified by their body mass index (BMI) to compare multiple perioperative end points, surgical and pathological outcomes. RESULTS: Patients in the open partial nephrectomy group were statistically younger (58.80 vs 64.28, p = 0.012) and had larger tumors (3.56 vs. 2.60 cm, p < 0.0006). Compared to the patients in the open group, patients in the laparoscopic partial nephrectomy group had a lower estimated blood loss (182.02 vs. 277.28 cc, p < 0.004), operative time (160.35 vs. 180.43 minutes, p < 0.03) and hospital stay (3.26 vs. 4.93 days, p < 0.001). When stratified by BMI less than 25 kg/m2 and 25 to 29.9 kg/m2, operative outcomes were equivalent. However, patients with a BMI over 30 kg/m2 had a statistically significant difference in operative time (159.50 vs. 191.30 minutes, p = 0.26), length of hospital stay (3.24 vs. 5.48 days, p = 0.007) and estimated blood loss (210.88 vs. 323.08 cc, p = 0.042), all in favor of the laparoscopic approach. When patients were further substratified into BMI greater than 35 kg/m2, there was a statistically significant difference in estimated blood loss (91.67 vs. 321.43 cc, p = 0.003) and operative time (129.67 vs. 192.71 minutes, p = 0.005), which were again in favor of the laparoscopic method. CONCLUSIONS: Laparoscopy has emerged as a reasonable approach for partial nephrectomy, although it appears to be more technically challenging as body mass index increases. However, laparoscopy results in overall improved perioperative outcomes compared to the open approach, especially in patients with BMI greater than 30 kg/m2. Source of Funding: None
1495 INDUCING HYPOTHERMIA WITH A NOVEL COOLING MATERIAL FOR OPEN AND LAPAROSCOPIC PARTIAL NEPHRECTOMY Maurice S Michel, Sr, Gita M Schoeppler, III*, Elena Klippstein, Christel Weiss, Sr, Axel Häcker, Sr, Lutz Trojan, Sr, Peter Alken, Sr, Mannheim, Germany INTRODUCTION AND OBJECTIVES: We developed a novel material and initial results of inducing hypothermia during open (OPN) and laparoscopic partial nephrectomy (LPN) by using gel-like ice (Freka Gelice). LPN for small renal tumours has been increasingly performed in the last years, whereas so far no standardised cooling method for achieving hypothermia has been established. METHODS: Gelice is based on modified gelatine and stored between -8° and -12°C. Ex-vivo porcine-kidneys where heated up to 37°C. Temperature measurement was performed by a digital multimeter with sensors placed 0.5 cm into the renal parenchyma. Ten kidneys were covered by crushed ice (-16°C NaCl-Solution, NaCl-ice), Gelice cut in cubes (Gelice-C) and Gelice pressed through a masticator for laparoscopic use (Gelice-M). Kidney temperature decrease over time up to 120 min and practical application have been evaluated. RESULTS: No significant difference was found for the mean value distribution at different time points for NaCl-ice, Gelice-C, Gelice-M (NaCl-ice vs. Gelice-C: p=0.79, NaCl-ice vs. Gelice-M: p=0.18). The mean temperature for NaCl-ice, Gelice-C, Gelice-M was 8.4°C (±3.1); 7.3°C (±2.7) and 10.5°C (±4,1) at 20 min, 0.7°C (±1.2); 0.9°C (±2.2) and 2.5°C (±1.4) at 60 min and -0.2°C (±0.6); 0.2°C (±1.4) and 2.4°C (±2.0) at 120 min, respectively. Gelice was easy to use due to its gel-like state. CONCLUSIONS: Gelice is a perfect material which can be used for inducing hypothermia in OPN and particularly LPN. Instead of difficult shattering of ice, Gelice is easy to use, and can be pressed through a trocar, thereby becomes an ideal tool in laparoscopic surgery. Source of Funding: None
534
Vol. 181, No. 4, Supplement, Tuesday, April 28, 2009
1493 RANDOMIZED PROSPECTIVE EVALUATION OF THE EFFECT OF PATIENT POSITIONING ON SURGICAL OUTCOMES DURING LAPAROSCOPIC RENAL AND ADRENAL SURGERY. Amanjot Sethi, Michelle A Lerner*, Carl Gjertson, Vani Sundaram, Chandru P Sundaram, Indianapolis, IN INTRODUCTION AND OBJECTIVES: We report a prospective comparison of operative table positioning (i.e. flexion or no flexion) and its effect on outcomes in laparoscopic renal and adrenal surgery. METHODS: 30 consecutive patients undergoing laparoscopic nephrectomy or adrenalectomy by a single surgeon (CPS) were randomized to surgery with (FL) or without (NF) a 45 degree flexion of the operative table. A single surgeon performed all operations with a transperitoneal pure laparoscopic or hand assisted approach. Operative parameters such as ease of bowel mobilization (BM), ease of renal hilar dissection (HD), and overall difficulty of dissection (DD) were recorded on a 10 point Likert scale. Operative (OT), estimated blood loss (EBL), post-operative pain and peri-operative complications were also recorded prospectively. RESULTS: There were 15 and 15 patients in the FL and NF groups respectively. There were no statistically significant differences in BM, HD, DD, OT, EBL, or post-operative pain. The two complications in the FL group which included testicular pain and a minor serosal injury during mobilization of the colon. This serosal injury was repaired laparoscopically without further sequelae. There was one trocar site infection in the NF group. CONCLUSIONS: Although flexion of the operative table during laparoscopic nephrectomy and adrenalectomy has become standard practice, the effects of such positioning on operative time, ease of exposure, post-operative pain and complications has not been previously defined. Our prospective comparison suggests that there is no benefit to table flexion during laparoscopic renal and adrenal surgery. Surgical exposure, dissection and outcomes do not appear to be affected by patient positioning in this series Table 1 Results Flexed
Unflexed
N
15
15
p-value
Age (yrs)
50.3
51.5
0.84
Weight (kg)
78.4
92.4
0.32
OR time (min)
185.4
177.5
0.61
EBL (cc)
135.4
69.4
0.06
Subjective Difficulty of Case (1-10)
5.5
4.2
0.06
Subjective Pain Score (1-10)
4.8
3.7
0.06
Post-op Morphine Eq. (mg)
66.4
53.1
0.11
LOS Complications
2.5 1.9 2 1 1. testicular pain 1. trocar site 2. serosal bowel wound infection injury
0.07
Source of Funding: None
1494 COMPARISON OF OPEN AND LAPAROSCOPIC PARTIAL NEPHRECTOMY IN OBESE AND NONOBESE PATIENTS: OUTCOMES STRATIFIED BY BODY MASS INDEX Marc T Feder*, A Ari Hakimi, Pedro Maria, David M Hoenig, Reza Ghavamian, Bronx, NY INTRODUCTION AND OBJECTIVES: Partial nephrectomy has become the standard of care for appropriately selected renal cortical neoplasms. Although obesity increases the complexity of laparoscopy and requires adjustments in operative technique, we recently published that outcomes for radical nephrectomy were improved with the laparoscopic approach. We now present our surgical outcomes and complications in patients undergoing open and laparoscopic partial nephrectomy, stratified by body mass index. METHODS: We retrospectively identified 143 patients, of whom
84 underwent laparoscopic partial nephrectomy and 59 open partial nephrectomy by a single surgeon. Patients were then stratified by their body mass index (BMI) to compare multiple perioperative end points, surgical and pathological outcomes. RESULTS: Patients in the open partial nephrectomy group were statistically younger (58.80 vs 64.28, p = 0.012) and had larger tumors (3.56 vs. 2.60 cm, p < 0.0006). Compared to the patients in the open group, patients in the laparoscopic partial nephrectomy group had a lower estimated blood loss (182.02 vs. 277.28 cc, p < 0.004), operative time (160.35 vs. 180.43 minutes, p < 0.03) and hospital stay (3.26 vs. 4.93 days, p < 0.001). When stratified by BMI less than 25 kg/m2 and 25 to 29.9 kg/m2, operative outcomes were equivalent. However, patients with a BMI over 30 kg/m2 had a statistically significant difference in operative time (159.50 vs. 191.30 minutes, p = 0.26), length of hospital stay (3.24 vs. 5.48 days, p = 0.007) and estimated blood loss (210.88 vs. 323.08 cc, p = 0.042), all in favor of the laparoscopic approach. When patients were further substratified into BMI greater than 35 kg/m2, there was a statistically significant difference in estimated blood loss (91.67 vs. 321.43 cc, p = 0.003) and operative time (129.67 vs. 192.71 minutes, p = 0.005), which were again in favor of the laparoscopic method. CONCLUSIONS: Laparoscopy has emerged as a reasonable approach for partial nephrectomy, although it appears to be more technically challenging as body mass index increases. However, laparoscopy results in overall improved perioperative outcomes compared to the open approach, especially in patients with BMI greater than 30 kg/m2. Source of Funding: None
1495 INDUCING HYPOTHERMIA WITH A NOVEL COOLING MATERIAL FOR OPEN AND LAPAROSCOPIC PARTIAL NEPHRECTOMY Maurice S Michel, Sr, Gita M Schoeppler, III*, Elena Klippstein, Christel Weiss, Sr, Axel Häcker, Sr, Lutz Trojan, Sr, Peter Alken, Sr, Mannheim, Germany INTRODUCTION AND OBJECTIVES: We developed a novel material and initial results of inducing hypothermia during open (OPN) and laparoscopic partial nephrectomy (LPN) by using gel-like ice (Freka Gelice). LPN for small renal tumours has been increasingly performed in the last years, whereas so far no standardised cooling method for achieving hypothermia has been established. METHODS: Gelice is based on modified gelatine and stored between -8° and -12°C. Ex-vivo porcine-kidneys where heated up to 37°C. Temperature measurement was performed by a digital multimeter with sensors placed 0.5 cm into the renal parenchyma. Ten kidneys were covered by crushed ice (-16°C NaCl-Solution, NaCl-ice), Gelice cut in cubes (Gelice-C) and Gelice pressed through a masticator for laparoscopic use (Gelice-M). Kidney temperature decrease over time up to 120 min and practical application have been evaluated. RESULTS: No significant difference was found for the mean value distribution at different time points for NaCl-ice, Gelice-C, Gelice-M (NaCl-ice vs. Gelice-C: p=0.79, NaCl-ice vs. Gelice-M: p=0.18). The mean temperature for NaCl-ice, Gelice-C, Gelice-M was 8.4°C (±3.1); 7.3°C (±2.7) and 10.5°C (±4,1) at 20 min, 0.7°C (±1.2); 0.9°C (±2.2) and 2.5°C (±1.4) at 60 min and -0.2°C (±0.6); 0.2°C (±1.4) and 2.4°C (±2.0) at 120 min, respectively. Gelice was easy to use due to its gel-like state. CONCLUSIONS: Gelice is a perfect material which can be used for inducing hypothermia in OPN and particularly LPN. Instead of difficult shattering of ice, Gelice is easy to use, and can be pressed through a trocar, thereby becomes an ideal tool in laparoscopic surgery. Source of Funding: None