280 UNCLAMP LESS PARTIAL NEPHRECTOMY

Poster Session 24 RCC: SILS, ALTERNATIVE TECHNOLOGIES AND TRAINING Saturday, 19 March, 16.00-17.30, Hall I/K

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LESS renal surgery: Lesson learnt after 60 procedures

Cindolo L.1, Greco F.2, Fornara P.2, Autorino R.3, Schips L.1 1 S.Pio da Pietrelcina Hospital, Dept. of Urology, Vasto, Italy, 2Martin-LutherUniversity, Dept. of Urology and Kidney Transplantation, Halle/Saale, Germany, 3 Seconda Università Degli Studi di Napoli, Dept. of Urology, Naples, Italy Introduction & Objectives: To present perioperative outcomes in an observational cohort of patients who underwent Laparo Endoscopic Single Site (LESS) urologic surgery at two European centers. Materials & Methods: A prospective study was performed to evaluate patient outcomes after LESS urologic surgery. Demographic data including age, body mass index, operative time, estimated blood loss, operative indications, complications, postoperative Visual Analog Pain Scale scores (1POD VAPS) and subjective scar satisfaction were accrued. Patients were followed postoperatively for evidence of adverse events or complications. Results: Between July 2008 and September 2010, 60 patients underwent LESS urologic surgery (mean age 60±13.9y). Specifically, the following procedures were performed: 6 adrenalectomy; 6 simple nephrectomy; 9 partial nephrectomy; 36 radical nephrectomy;1 cyst marsupialization; 1 varicocelectomy; 1 nephropexy. Mean body mass index was 27.4 ±4.1kg/m2. Mean operative time was 154± 37minutes. Mean estimated blood loss was 131±101mL. No major intraoperative complications occurred (1 intraoperative bleeding). In 4 cases an additional 3or 5 mm port was added. Four patients required conversion to standard laparoscopy. In 41 cases articulating/prebent instrument were used. Mean scar size was 4.3±1.1 cm. 1POD VAPS was 1.8±1.2/10. The mean length of hospitalization was 4.3±1.7 days. Regarding subjective scar perception, 39/60 (65%), 15/60 (25%) and 6/60 (10%) of patients were enthusiastic, very satisfied and satisfied, respectively. At a mean follow-up of 12 months, 3 Clavien Grade I (2 haematoma, 1 ileus), 2 Clavien Grade II (acute gastritis) and 2 Clavien Grade IV (cerebral stroke) surgical complications occurred, without recurrence or disease progression. Conclusions: In our experience, LESS urologic surgery is feasible, offers improved cosmesis, and may offer decreased pain. Our intraoperative and perioperative data are consistent with the published data. Proper patient selection could ensure an acceptable safety profile with low conversion and complications rates. Whether LESS urologic surgery is superior in comparison with standard laparoscopy still needs to be demonstrated.

280

Unclamp LESS partial nephrectomy

Cindolo L., Schips L. S.Pio da Pietrelcina Hospital, Dept. of Urology, Vasto, Italy Introduction & Objectives: Nephron-sparing surgery (NSS) ensures excellent oncological and functional outcomes in small renal masses. Laparo-EndoscopicSingle-Site Surgery (LESS) is one of the major advances in the evolution of minimally invasive surgery. We describe our initial surgical experience and assess the feasibility of unclamp LESS nephron-sparing surgery. Materials & Methods: From April 2009 to July 2010, patients with solitary, exophytic, enhancing, small (≤ 4.0 cm) renal masses and normal controlateral kidney were selected to receive unclamp LESS partial nephrectomy. Using a rigid 5mm, 30-degrees-lens laparoscope, rigid and articulable instruments (Roticulator Endo Dissect™ Covidien, Mansfield, MA) were used for dissection and tumor exposure. The excision under normal renal perfusion was done by the LigaSure Advance™ (Covidien, Mansfield, MA) a 5-mm laparoscopic vessel sealing instrument (in right hand) having a standard laparoscopic aspirator in the left hand. Peri-operative, pathological, hematological data together with a subjective evaluation of pain and scar were collected and evaluated. Results: 9 patients (mean age 59±5.6y) have been treated by unclamp LESS NSS. A multichannel-port provided intra-abdominal transperitoneal access: 6 Triport™ (Advanced Surgical Concepts, Ireland) and 2 Endocone (Karl Storz, Tuttlingen, Germany). With a mean operative time of 138±63min and a mean estimated blood loss of 156±63ml, all masses have been resected successfully. A good haemostasis has been successfully achieved without postoperative transfusions using bipolar cautery, cellulose bolster, haemostatic agent (Floseal) and stitches (in 4 cases). Three patients required conversion to standard laparoscopy in order to expose a posterior mass (1 case) and to control an excessive bleeding (2 cases). Postoperatively, 1 Clavien I (acute gastritis) and a Clavien IV (cerebral stroke) complications occurred. Pathology revealed 4 T1 clear cell carcinoma, 4 renal cysts and 1 angiomyolipoma (surgical margin positive). No variation in eGFR was seen at follow-up visit. A 2.1g/dl hemoglobin decrease was recorded with 1POD pain score of 1.8/10. Mean length of stay was 4.8±2.6days. All subjects

Eur Urol Suppl 2011;10(2):108

confirmed a great satisfaction about the scars (7 enthusiastic/very satisfied and 2 satisfied) with a mean skin incision of 3.3±0.7cm. Conclusions: In our opinion, in highly selected renal masses, the unclamp LESS NSS is feasible, provides postoperative outcomes overlapping the standard counterpart and ensures subjective satisfaction. Additional trocars should be considered for the haemostatic stitches and for liver retraction, nevertheless a wider experience and longer follow-up are necessary to establish the role of this technique as far functional and oncological outcomes is concerned.

281

HIFU ablation of small renal masses: Final results of phase IB trial

Klingler H.C.1, Susani M.2, Margreiter M.1, Marberger M.1 1 Medical University of Vienna, Dept. of Urology, Vienna, Austria, 2Medical University of Vienna, Dept. of Pathology, Vienna, Austria Introduction & Objectives: Objective was to evaluate safety and effectiveness of laparoscopic high intensified focused ultrasound (HIFU) for targeted ablative therapy of small renal masses. Materials & Methods: 30 kidneys with solitary renal tumours were treated with an 18mm 4.0 MHz laparoscopic HIFU probe. In the first three patients a marker lesion was performed, followed by subsequent laparoscopic nephrectomy. In two patients with central tumours the masses were HIFU ablated in duplicate, followed by intraoperative subsequent biopsy and both were followed radiologically. In further 25 patients with a peripheral tumour (mean size 25 mm, range 10-40) the tumour was completely ablated as in curative intent, followed by immediate laparoscopic partial nephrectomy. Specimens were studied by detailed and wholemount histology, including NADH stains. Results: All marker lesions demonstrate complete ablation within the targeted zone. Both tumours ablated only were without evidence of recurrent tumour during radiological follow-up. At histological evaluation of the 25 tumours treated and removed after HIFU one skip lesions was detected in one patient. After a change in the treatment protocol with duplicate insonication in the last 15 patients complete ablation of all tumours was achieved. 21 tumours showed complete ablation within the insonication zone. In three patients we were not able to cover the entire tumour with the laparoscopic ultrasound probe and final histology revealed a 1-3 mm rim of viable tissue immediately adjacent to where the HIFU probe was approximated apron. There were no intra- or postoperative complications related to HIFU. Conclusions: Targeted laparoscopic HIFU ablation with a double treatment protocol reliably ablates solid renal tumours <3cm.

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Cytoreductive radiofrequency ablation in metastatic renal cell carcinoma patients with a small primary tumor: Prospective study

Tsimafeyeu I.V.1, Chung B.2, Zart J.S.2 1 Kidney Cancer Research Bureau, Moscow Office, Moscow, Russia, 2Beijing Hospital, Dept. of Urology, Beijing, China Introduction & Objectives: Cytoreductive nephrectomy (CN) has been a standard of care in metastatic renal cell carcinoma (RCC) patients since the results of two large randomized trials showed the benefits of this approach in patients subsequently treated with interferon alpha (IFN). Critics of CN argue that perioperative morbidity or postoperative disease progression may preclude patients from receiving systemic therapy. Cytoreductive radiofrequency ablation (RFA) may allow for reduced morbidity and may increase the likelihood of patients receiving systemic therapy. Materials & Methods: This is a prospective non-randomized study. Principle eligibility criteria included histopathologically confirmed RCC before RFA; CTconfirmed metastatic measurable disease; size of primary tumor no greater than 5 cm; good prognosis by MSKCC model; no previous therapy. Patients were treated with a percutaneous RFA under the CT guide and following IFN, 9 MIU, subcutaneously, three times per week. Evaluation for response was performed according to RECIST every 2 months. The primary endpoint was a 33% increase in progression-free survival (PFS) over expected 5 months, with 80% power and 0.05 significance. Planned sample size was 38 patients. Results: Patient characteristics were: median age 67 years, 71% male, 87% one site of organ metastasis (lungs), ECOG PS 1 or less. All 38 tumors underwent complete necrosis regardless of size, although 6 (15.8%) large tumors (> 4 cm) required a second ablation session. Median tumor size was 4.6 cm (range 3.2 to 5.0). Complications were either self-limited or readily treated and included haemorrhage (major, n = 3; minor, n = 2), inflammatory track mass (n = 2), transient lumbar plexus pain (n = 5), ureteral injury (n = 1). Median hospitalization was 2 days. Postoperatively, 100% of patients were eligible for and received IFN at a median of 6 days. Residual disease was present at the first follow-up CT examination in 6 (15.8%) patients. Control disease rate was 60.5% (partial response 8%, stable disease 52.5%). Median PFS was 9.1 months. Median overall survival has not yet been reached. Conclusions: Cytoreductive RFA is a safe and effective approach for select patients with metastatic RCC. Our results have indicated that with proper patient selection, cytoreductive RFA is feasible, morbidity is minimized, and systemic therapy is delivered in a timely fashion. For the same group of patients we conducted 2 parallel studies "RFA and following sunitinib" (N=38) and "Sunitinib alone" (N=38).