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1079 FOLLOW-UP OF UNILATERAL RENAL FUNCTION AFTER LAPAROSCOPIC PARTIAL NEPHRECTOMY
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THE JOURNAL OF UROLOGY姞
Vol. 185, No. 4S, Supplement, Monday, May 16, 2011
achieved during normotension to ensure hemostasis. This clamp-free technique is applicable even for anatomically-complex tumors. Forty nine patients underwent “zero ischemia” LPN (n⫽38) or RaPN (n⫽11). The vast majority of patients had anatomically-complex tumors: central (63%), hilar (27%), size ⬎ 4cm (pT1b, 16%), and in solitary kidney (8%). Eight patients had baseline eGFR ⬍60. RESULTS: Forty eight of 49 cases (98%) were completed with zero-ischemia. One patient with a 3.5 cm challenging, intra-renal hilar tumor required vascular clamping for 28 minutes. There were no intra-operative complications throughout the series. Post-operatively, high grade non-urologic complications occurred in 3 patients: superior epigastric artery bleed requiring re-operation (1), septicemia with respiratory failure (1), and postoperative prolonged intubation (1). Blood transfusions were necessary in 12 patients post-operatively. No patient developed renal hemorrhage, renal loss, or hypotension-related sequelae. Pathology confirmed RCC in 36 patients (73%), all with negative margins. Median absolute rise in serum creatinine (SCr) at discharge was 0.1. CONCLUSIONS: A novel “zero ischemia” technique for LPN and RaPN is presented. Our preliminary experience in 49 patients is encouraging. Further experience and long term evaluation are required. Median (Range or %) 49
N Age (years) Tumor size (cm)
56.7 (32.8–79.3) 3.1 (0.9–13.6)
Ipsilateral function (n⫽34)*
50% (32–100%)
Pre-operative SCr (mg/dL)
0.9 (0.6–1.6)
Operative time (hrs)
3.0 (1.0–6.5)
Estimated blood loss (cc)
150 (20–1500)
Resection time (min)(n⫽33)
19 (5–40)
Suturing time (min)(n⫽32)
15 (10–25)
Nadir hypotension time (min) (n⫽43)
5.0 (5–30)
Pelvicaliceal repair % Kidney spared (n⫽46) Length of stay (days) Increase in SCr (mg/dL) * On MAG-3 renal scan
36 (73%) 80% (30–95%) 3 (2–19) 0.1 (-0.2–4.9)
Source of Funding: None
1079 FOLLOW-UP OF UNILATERAL RENAL FUNCTION AFTER LAPAROSCOPIC PARTIAL NEPHRECTOMY Wansuk Kim*, Cheryn Song, Sejun Park, In Gab Jeong, Jun Hyuk Hong, Hyung Keun Park, Choung-Soo Kim, Hanjong Ahn, Seoul, Korea, Republic of INTRODUCTION AND OBJECTIVES: To asses the unilateral renal function change after LPN to determine factors affecting the course and investigate factors predictive of GFR reduction after LPN. METHODS: From a prospectively collected data of 116 patients who underwent LPN, glomerular filtration rate (GFR) of the operated kidney was evaluated from diethylenetriaminepentaacetic acid (DTPA) scans taken before and at postoperative 3 months, 1, 2, and 3 years. Kidney volume was measured from the arterial phase of dynamic CT of the kidney before and at 3 months postoperatively to calculate the volume reduction. Clinicopathological and operative factors with the potential to influence perioperative GFR reduction were analyzed. RESULTS: In all patients, GFR significantly reduced by postop. 3 months and remained significantly lower compared to preoperative function despite the trend for progressive recovery noted until 3 years. Recovery in individual patient was significantly influenced by patient age (⬍55 vs. ⱖ55 years), presence of medical co-morbidities, tumor size (⬍2.5 vs. ⱖ2.5cm), volume of the kidney reduced (⬍20 vs. ⱖ20%), and having collecting system repaired during surgery. Independent determinants of postoperative renal function were preoperative GFR (p⬍0.001, ⫽0.410, 95%CI 0.424⬃1.084), percent renal
parenchymal volume reduction (p⫽0.003,  ⫽0.273, 95%CI 0.168⬃0.766) and pelvocalyceal system repair (p⫽0.005, ⫽0.284, 95%CI 2.960⬃15.788). CONCLUSIONS: Function of the kidney undergoing LPN progressively recovers after a significant reduction immediately after surgery. Although recovery differs according to patient age, presence of comorbidities and tumor size, factors independently predictive of postop. GFR reduction were renal parenchymal volume reduction and pelvocalyceal system repair. Source of Funding: None
1080 PRE- AND POST-OPERATIVE MEASUREMENT OF SINGLE KIDNEY FUNCTION IN PARTIAL NEPHRECTOMY FOR RENAL MASSES USING MAGNETIC RESONANCE RENOGRAPHY Stella Kang, Aron Bruhn*, Hersh Chandarana, Jeff Zhang, Vivian Lee, Michael Stifelman, William Huang, New York, NY INTRODUCTION AND OBJECTIVES: Partial nephrectomy (PN) and preservation of renal function is an integral part of managing patients with localized renal tumors. Current estimates of kidney function, including estimated GFR (eGFR) based on serum creatinine, have limited sensitivity and accuracy, and cannot assess single kidney GFR (SK-GFR). Magnetic resonance renography (MRR) has been shown to accurately and reliably estimate SK-GFR. The goal of this pilot study was to determine the feasibility of using MRR in pre- and post-operative evaluation of SK GFR in patients undergoing PN. METHODS: In this IRB-approved, prospective study 13 patients with renal neoplasms underwent PN with preoperative and early (48 hrs) post-operative MRR, and 5/13 returned for 6-month postoperative MRR. eGFR was calculated using the Modification of Diet in Renal Disease equation. MRR was performed at 1.5 T using coronal TWIST after administration of 4 mL gadolinium contrast. Signal curves of the aorta, cortex, and medulla were converted to MR-GFR using a tracer kinetic model as previously described. RESULTS: Preoperative MR-GFR ranged from 43 to 112 mL/ min/1.73 m2 overall.11 patients showed decreased postoperative SKGFR (mean -45%), detected by eGFR in only 7 patients. The greatest decrease in SK-GFR was seen in patients with warm ischemia time ⬎ 40 min (Table 1). Contralateral kidney SK-GFR increased in 4 patients and decreased in 4 patients (Fig 1). Only 1/5 with pre-op CKD had a compensatory response to surgery in the contralateral kidney at 48 hours. At 6 months, 3 of 5 patients recovered function to near-baseline MR-GFR. CONCLUSIONS: MRR is useful for evaluating patients with renal masses as an adjunct to anatomic imaging, providing single kidney function with only 5 minutes of additional scan time and minimal contrast. MRR may be useful tool in assessing proper patient selection, surgical technique (warm vs. cold ischemia), as well as current and future renal protective strategies for patients undergoing PN. Table 1 Early Decrease in Operated Kidney SKGFR (%) 26⫹/-28
Ischemia Type Cold Ischemia
Baseline MR-GFR (mL/min/1.73 m2) 76
Baseline Operated Kidney SK-GFR (mL/ min/1.73 m2) 33
Warm Ischemia (all cases)
73
36
41⫹/-27
Warm Ischemia (⬍ 40 min)
69
32
34⫹/-25
Warm Ischemia (⬎ 40 min)
82
44
57⫹/-30
THE JOURNAL OF UROLOGY姞
Vol. 185, No. 4S, Supplement, Monday, May 16, 2011
achieved during normotension to ensure hemostasis. This clamp-free technique is applicable even for anatomically-complex tumors. Forty nine patients underwent “zero ischemia” LPN (n⫽38) or RaPN (n⫽11). The vast majority of patients had anatomically-complex tumors: central (63%), hilar (27%), size ⬎ 4cm (pT1b, 16%), and in solitary kidney (8%). Eight patients had baseline eGFR ⬍60. RESULTS: Forty eight of 49 cases (98%) were completed with zero-ischemia. One patient with a 3.5 cm challenging, intra-renal hilar tumor required vascular clamping for 28 minutes. There were no intra-operative complications throughout the series. Post-operatively, high grade non-urologic complications occurred in 3 patients: superior epigastric artery bleed requiring re-operation (1), septicemia with respiratory failure (1), and postoperative prolonged intubation (1). Blood transfusions were necessary in 12 patients post-operatively. No patient developed renal hemorrhage, renal loss, or hypotension-related sequelae. Pathology confirmed RCC in 36 patients (73%), all with negative margins. Median absolute rise in serum creatinine (SCr) at discharge was 0.1. CONCLUSIONS: A novel “zero ischemia” technique for LPN and RaPN is presented. Our preliminary experience in 49 patients is encouraging. Further experience and long term evaluation are required. Median (Range or %) 49
N Age (years) Tumor size (cm)
56.7 (32.8–79.3) 3.1 (0.9–13.6)
Ipsilateral function (n⫽34)*
50% (32–100%)
Pre-operative SCr (mg/dL)
0.9 (0.6–1.6)
Operative time (hrs)
3.0 (1.0–6.5)
Estimated blood loss (cc)
150 (20–1500)
Resection time (min)(n⫽33)
19 (5–40)
Suturing time (min)(n⫽32)
15 (10–25)
Nadir hypotension time (min) (n⫽43)
5.0 (5–30)
Pelvicaliceal repair % Kidney spared (n⫽46) Length of stay (days) Increase in SCr (mg/dL) * On MAG-3 renal scan
36 (73%) 80% (30–95%) 3 (2–19) 0.1 (-0.2–4.9)
Source of Funding: None
1079 FOLLOW-UP OF UNILATERAL RENAL FUNCTION AFTER LAPAROSCOPIC PARTIAL NEPHRECTOMY Wansuk Kim*, Cheryn Song, Sejun Park, In Gab Jeong, Jun Hyuk Hong, Hyung Keun Park, Choung-Soo Kim, Hanjong Ahn, Seoul, Korea, Republic of INTRODUCTION AND OBJECTIVES: To asses the unilateral renal function change after LPN to determine factors affecting the course and investigate factors predictive of GFR reduction after LPN. METHODS: From a prospectively collected data of 116 patients who underwent LPN, glomerular filtration rate (GFR) of the operated kidney was evaluated from diethylenetriaminepentaacetic acid (DTPA) scans taken before and at postoperative 3 months, 1, 2, and 3 years. Kidney volume was measured from the arterial phase of dynamic CT of the kidney before and at 3 months postoperatively to calculate the volume reduction. Clinicopathological and operative factors with the potential to influence perioperative GFR reduction were analyzed. RESULTS: In all patients, GFR significantly reduced by postop. 3 months and remained significantly lower compared to preoperative function despite the trend for progressive recovery noted until 3 years. Recovery in individual patient was significantly influenced by patient age (⬍55 vs. ⱖ55 years), presence of medical co-morbidities, tumor size (⬍2.5 vs. ⱖ2.5cm), volume of the kidney reduced (⬍20 vs. ⱖ20%), and having collecting system repaired during surgery. Independent determinants of postoperative renal function were preoperative GFR (p⬍0.001, ⫽0.410, 95%CI 0.424⬃1.084), percent renal
parenchymal volume reduction (p⫽0.003,  ⫽0.273, 95%CI 0.168⬃0.766) and pelvocalyceal system repair (p⫽0.005, ⫽0.284, 95%CI 2.960⬃15.788). CONCLUSIONS: Function of the kidney undergoing LPN progressively recovers after a significant reduction immediately after surgery. Although recovery differs according to patient age, presence of comorbidities and tumor size, factors independently predictive of postop. GFR reduction were renal parenchymal volume reduction and pelvocalyceal system repair. Source of Funding: None
1080 PRE- AND POST-OPERATIVE MEASUREMENT OF SINGLE KIDNEY FUNCTION IN PARTIAL NEPHRECTOMY FOR RENAL MASSES USING MAGNETIC RESONANCE RENOGRAPHY Stella Kang, Aron Bruhn*, Hersh Chandarana, Jeff Zhang, Vivian Lee, Michael Stifelman, William Huang, New York, NY INTRODUCTION AND OBJECTIVES: Partial nephrectomy (PN) and preservation of renal function is an integral part of managing patients with localized renal tumors. Current estimates of kidney function, including estimated GFR (eGFR) based on serum creatinine, have limited sensitivity and accuracy, and cannot assess single kidney GFR (SK-GFR). Magnetic resonance renography (MRR) has been shown to accurately and reliably estimate SK-GFR. The goal of this pilot study was to determine the feasibility of using MRR in pre- and post-operative evaluation of SK GFR in patients undergoing PN. METHODS: In this IRB-approved, prospective study 13 patients with renal neoplasms underwent PN with preoperative and early (48 hrs) post-operative MRR, and 5/13 returned for 6-month postoperative MRR. eGFR was calculated using the Modification of Diet in Renal Disease equation. MRR was performed at 1.5 T using coronal TWIST after administration of 4 mL gadolinium contrast. Signal curves of the aorta, cortex, and medulla were converted to MR-GFR using a tracer kinetic model as previously described. RESULTS: Preoperative MR-GFR ranged from 43 to 112 mL/ min/1.73 m2 overall.11 patients showed decreased postoperative SKGFR (mean -45%), detected by eGFR in only 7 patients. The greatest decrease in SK-GFR was seen in patients with warm ischemia time ⬎ 40 min (Table 1). Contralateral kidney SK-GFR increased in 4 patients and decreased in 4 patients (Fig 1). Only 1/5 with pre-op CKD had a compensatory response to surgery in the contralateral kidney at 48 hours. At 6 months, 3 of 5 patients recovered function to near-baseline MR-GFR. CONCLUSIONS: MRR is useful for evaluating patients with renal masses as an adjunct to anatomic imaging, providing single kidney function with only 5 minutes of additional scan time and minimal contrast. MRR may be useful tool in assessing proper patient selection, surgical technique (warm vs. cold ischemia), as well as current and future renal protective strategies for patients undergoing PN. Table 1 Early Decrease in Operated Kidney SKGFR (%) 26⫹/-28
Ischemia Type Cold Ischemia
Baseline MR-GFR (mL/min/1.73 m2) 76
Baseline Operated Kidney SK-GFR (mL/ min/1.73 m2) 33
Warm Ischemia (all cases)
73
36
41⫹/-27
Warm Ischemia (⬍ 40 min)
69
32
34⫹/-25
Warm Ischemia (⬎ 40 min)
82
44
57⫹/-30