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654 A NOVEL ENDOSCOPIC TECHNIQUE FOR THE MANAGEMENT OF THE JUXTA-VESICAL URETER DURING LAPAROSCOPIC NEPHROURETERECTOMY
P37 RENAL TUMOURS: VARIETY IN SURGICAL APPROACHES 1 Thursday, 22 March, 15.45-17.15, Room 15B
653
Initial experience with the EndoAssist® camera holding robot in laparoscopic urological surgery Rane A.1, Kommu S.1, Eddy B.1, Rimington P.2, Anderson C.3
East Surrey Hospital, Urology, Redhill, United Kingdom, 2Eastbourne Hospital, Urology, Eastbourne, United Kingdom, 3St George’s Hospital, Urology, London, United Kingdom 1
Introduction & Objectives: The advantages of laparoscopic surgery are well documented. However, one of the disadvantages is that, for optimised performance, an experienced camera driver is required who can provide the necessary views for the operating surgeon. In the study we describe our experience with urological laparoscopic techniques using a novel robotic camera holder (EndoAssist®, Prosurgics, High Wycombe, Bucks, UK) Material & Methods: The EndoAssist® is a unique robot that is controlled by simple head movement by the surgeon which allows for complete autonomy over camera movement. Movement is executed by a head-mounted infra-red emitter; the sensor is placed above the monitor and picks up any operator executed head movements. The foot clutch ensures that there is no unnecessary travel when movement is not required. At the time of submission, data was available for 28 urological procedures performed using the EndoAssist®. The procedures performed included radical and simple nephrectomy, pyeloplasty, radical prostatectomy and radical cystoprostatectomy. A 30class laparoscope was used for the renal surgery and a 00 scope was used for the pelvic surgery. The Harmonic® scalpel, Ethicon Endosurgery, Bracknell, UK), the Olympus SonoSurg® (Keymed, Southend, UK) or the Lotus, (SRA Developments Ashburton, UK) were used to aid circumferential specimen mobilisation. Hemolok® (Weck, High Wycombe, Bucks, UK) clips were used as appropriate for securing pedicles. The surgeon noted the extent of body comfort and muscle fatigue in each case. Other parameters documented were the ease of scope movement, necessity to clean the telescope, and whether it was necessary to change the position of the arm during the surgery. Results: All 3 surgeons involved with the evaluation felt comfortable throughout all procedures, with no loss of autonomy. It was, however, obvious that the large arc generated whilst doing a nephrectomy led to more episodes of lens cleaning, and that the arm had to be relocated on some occasions. There were fewer problems encountered whilst performing pelvic surgery or pyeloplasty, perhaps due to the fact that the arc of movement was smaller.
654
A novel endoscopic technique for the management of the juxta-vesical ureter during laparoscopic nephroureterectomy Boddy J.1, Wharton I.1, Devarajan R.1, Rane A.2
City Hospital, Department of Urology, Birmingham, United Kingdom, 2East Surrey Hospital, Department of Urology, Surrey, United Kingdom 1
Introduction & Objectives: Radical nephroureterectomy including en bloc excision of the ipsilateral ureter with the surrounding bladder cuff is the standard treatment for upper tract transitional cell carcinoma. However, the optimum technique of excising the distal ureter with surrounding bladder cuff during laparoscopic nephroureterectomy for upper tract TCC is still evolving, and a variety of endoscopic techniques have been described. The most commonly employed endoscopic technique for the lower end of the ureter is the ‘pluck’ technique. Operative time is minimised with this technique, as it is technically straightforward. However cystoscopic resection of the ureteric orifice results in the distal ureter remaining unoccluded for the duration of the laparoscopic procedure. Continued urinary extravasation from the ipsilateral cancer may result in tumour cell spillage and hence risk seeding. Here we describe an endoscopic technique, which is both simple and adheres to the principles of cancer surgery. Material & Methods: The technique involves positioning the patient as for a cystoscopy. A guide wire is inserted into the affected ureter, and a Cook 2-piece ureteral occlusion balloon is inserted over the wire into the mid ureter. The cystoscope is then removed, and the balloon is inflated to occlude the juxta-vesical ureter. A standard resectoscope is then inserted by the side of the ureteral catheter, and using the Collins’ knife, a circumferential incision is made around the ureteric orifice and deepened to fat. The occlusion balloon catheter and guide wire can be used to apply cephalad displacement of the ureteric orifice as required. Once the resection is complete, the wire is removed and the ureteral occlusion balloon catheter is taped to a urethral Foley catheter. Laparoscopic nephroureterectomy is then carried out in the preferred manner either by hand assisted or pure laparoscopic route. The ureter is clipped as low as possible before delivering it in continuity along with the balloon catheter, which is freed from the Foley’s catheter and divided close to the urethral meatus. Results: The technique has been performed successfully at the above institutions in 10 patients undergoing nephroureterectomy.
Conclusions: The Endo Assist is an effective, easy to use device for robotic camera driving, which reduces the constraint of having to have an experienced camera driver for optimal visualisation during laparoscopic urological procedures.
Conclusions: The procedure described herein adheres to the principles of cancer surgery with no theoretical risk of tumour implantation during the nephroureterectomy since the ureter remains occluded for the duration of this procedure. The completeness of the ureteric stump removal is ascertained once the whole specimen is removed in continuity at the end of the operation.
655
656
Comparison between open and laparoscopic Nephron Sparing Surgery
Laparoscopic partial nephrectomy for hilar tumors: technique and results
Crepel M.1, Bernhard J.C.2, Bellec L.3, Albouy B.4, Lopes D.5, Lacroix B.6, De La Taille A.5, Salomon L.5, Abbou C.5, Pfister C.4, Soulie M.3, Tostain J.6, Ferriere J.M.2, Guille F.1, Bensalah K.1, Vincendeau S.1, Manunta A.1, Belldegrun A.7, Pantuck A.J.7, Patard J.J.1
Lattouf J.B., Beri A., Leeb K., Janetschek G.
Rennes University Hospital, Urology, Rennes, France, Bordeaux University Hospital, Urology, Bordeaux, France, 3Toulouse University Hospital, Urology, Toulouse, France, 4Rouen University Hospital, Urology, Rouen, France, 5Henri Mondor University Hospital, Urology, Creteil, France, 6 Saint Etienne University Hospital, Urology, Saint Etienne, France, 7UCLA, Urology, Los Angeles, United States of America
Introduction & Objectives: To describe our technique and postoperative results of laparoscopic partial nephrectomy in renal hilar tumors.
1
2
Introduction & Objectives: To compare through a large multicenter series the indications and outcomes of open and laparocopic nephron sparing surgery (NSS). Material & Methods: The study included patients from 8 international academic centers. Age, gender, ECOG-PS, symptoms at presentation, ASA score, TNM stage, tumor size, histology, Fuhrman grade, were noted as well as surgical technique (open vs laparoscopic, renal vessels clamping, collecting system repair), indication for NSS (elective vs non elective), duration of the procedure, medical and surgical complication rates, mean blood loos, blood transfusion, length of hospital stay, surgical margins and post-operative serum creatinine. Results: 1119 partial nephrectomies were analysed, including 91 laparoscopic procedures (8.1%). Although the 2 surgical groups were comparable for age (p:0.3), laparoscopic procedure was more often performed in female patients (p:0.02) and in patients with good performance status (p:0.06). On the contrary, open procedures were more often performed in patients with symptomatic tumors (p:0.01) and significant co-morbidities (ASA score 3-4, 31.8% vs 24.1%, p:0.1). Tumors were smaller in size in the laparocopic group (2.7 vs 3.5 cm, p:0.003) and were more frequently removed for an elective indication (77.6% vs 68.2%, p:0.02). Mean duration of renal vessels clamping was increased during laparoscopy (35 vs 19 min, p:0.0001) while mean blood loss was reduced (363 vs 511ml, p:0.02). Mean operative time (156 vs 163 min, p:0.26), surgical complication rate, need for blood transfusion (p:0.1), positive surgical margin rates (p:0.8), post-operative serum creatinine (p:0.3) and length of hospital stay (p:0.4) were not significantly different between the 2 groups. Urinary fistula rate, although significantly increased at the beginning of the laparoscopic experience tent to be more balanced between the 2 groups in the more recent period. Interestingly, the mean size of surgical margin was in favour of laparoscopy (7.1 vs 4.5 mm, p:0.0001). Conclusions: Although it is relatively unfair to compare a large series from a well established surgical technique to a smaller series with preliminary results from a new innovative approach, it appeared from our study that laparoscopic NSS in carefully selected patients and tumors appears to be a safe an attractive alternative to open technique. It is likely that future technical improvements in laparoscopy will allow a complete duplication of open techniques, therefore leading to comparable cancer control along with improved quality of life.
Eur Urol Suppl 2007;6(2):186
Krankenhaus der Elisabethinen, Urology, Linz, Austria
Material & Methods: Between April 2000 and September 2006, 94 partial nephrectomies using a laparoscopic approach were performed at our institution. A total of 18 patients (19.1%) had hilar tumors. A hilar tumor was defined as a lesion suspicious for renal cell carcinoma adjacent to the major renal vessels on pre-operative cross-sectional imaging. All surgeries were performed by a single urologist (GJ). In 3 of the patients (16.7%), the indication for nephron-sparing surgery was imperative. Mean tumor size was 3cm (range: 2-4.5). Eight surgeries (44.4%) were performed with renal artery perfusion for cold ischemia, and the rest under warm ischemia. After occluding the renal artery and controlling the renal vein using separate rubber band tourniquets, excision of the tumor mass including delicate mobilization away from the blood vessels was performed. Running sutures to the base the tumor bed and for parenchymal reconstruction were applied. Results: All surgeries were completed laparoscopically. Mean surgical time was 238 min (range: 150-420). Mean ischemia times were 42.5 min (range 27-63) and 34.1 min (range 24 -56) for the cold and warm ischemia groups, respectively. Estimated intraoperative blood loss was 165 mL (range: 50-500). There were 2 (11%) entries into major vessels during tumor excision, namely a segmental artery in one patient and a vein in another. Both of these occurrences where managed laparoscopically. Two patients (11%) necessitated laparoscopic re-exploration: One for continuous postoperative blood oozing from the tumor bed, and another for urine extravasation in the immediate postoperative period. Postoperative nuclear scan showed functional kidney moiety in all patients. Mean split renal function was 38.6% (range: 24-50) on the operated side. Histopathological examination confirmed renal cell carcinoma in 14 of the patients (77.8%). One patient (7.1%) had a positive surgical margin on the surface that was adjacent to the renal artery. In a median follow-up of 26 months (range: 1-59) no local recurrence or systemic progression occurred. Conclusions: Laparoscopic partial nephrectomy for hilar tumors is a feasible and safe procedure in the hands of experienced laparoscopic surgeons. Oncologic results seem excellent but further follow-up is needed for accurate long term assessment of this surgical approach.
653
Initial experience with the EndoAssist® camera holding robot in laparoscopic urological surgery Rane A.1, Kommu S.1, Eddy B.1, Rimington P.2, Anderson C.3
East Surrey Hospital, Urology, Redhill, United Kingdom, 2Eastbourne Hospital, Urology, Eastbourne, United Kingdom, 3St George’s Hospital, Urology, London, United Kingdom 1
Introduction & Objectives: The advantages of laparoscopic surgery are well documented. However, one of the disadvantages is that, for optimised performance, an experienced camera driver is required who can provide the necessary views for the operating surgeon. In the study we describe our experience with urological laparoscopic techniques using a novel robotic camera holder (EndoAssist®, Prosurgics, High Wycombe, Bucks, UK) Material & Methods: The EndoAssist® is a unique robot that is controlled by simple head movement by the surgeon which allows for complete autonomy over camera movement. Movement is executed by a head-mounted infra-red emitter; the sensor is placed above the monitor and picks up any operator executed head movements. The foot clutch ensures that there is no unnecessary travel when movement is not required. At the time of submission, data was available for 28 urological procedures performed using the EndoAssist®. The procedures performed included radical and simple nephrectomy, pyeloplasty, radical prostatectomy and radical cystoprostatectomy. A 30class laparoscope was used for the renal surgery and a 00 scope was used for the pelvic surgery. The Harmonic® scalpel, Ethicon Endosurgery, Bracknell, UK), the Olympus SonoSurg® (Keymed, Southend, UK) or the Lotus, (SRA Developments Ashburton, UK) were used to aid circumferential specimen mobilisation. Hemolok® (Weck, High Wycombe, Bucks, UK) clips were used as appropriate for securing pedicles. The surgeon noted the extent of body comfort and muscle fatigue in each case. Other parameters documented were the ease of scope movement, necessity to clean the telescope, and whether it was necessary to change the position of the arm during the surgery. Results: All 3 surgeons involved with the evaluation felt comfortable throughout all procedures, with no loss of autonomy. It was, however, obvious that the large arc generated whilst doing a nephrectomy led to more episodes of lens cleaning, and that the arm had to be relocated on some occasions. There were fewer problems encountered whilst performing pelvic surgery or pyeloplasty, perhaps due to the fact that the arc of movement was smaller.
654
A novel endoscopic technique for the management of the juxta-vesical ureter during laparoscopic nephroureterectomy Boddy J.1, Wharton I.1, Devarajan R.1, Rane A.2
City Hospital, Department of Urology, Birmingham, United Kingdom, 2East Surrey Hospital, Department of Urology, Surrey, United Kingdom 1
Introduction & Objectives: Radical nephroureterectomy including en bloc excision of the ipsilateral ureter with the surrounding bladder cuff is the standard treatment for upper tract transitional cell carcinoma. However, the optimum technique of excising the distal ureter with surrounding bladder cuff during laparoscopic nephroureterectomy for upper tract TCC is still evolving, and a variety of endoscopic techniques have been described. The most commonly employed endoscopic technique for the lower end of the ureter is the ‘pluck’ technique. Operative time is minimised with this technique, as it is technically straightforward. However cystoscopic resection of the ureteric orifice results in the distal ureter remaining unoccluded for the duration of the laparoscopic procedure. Continued urinary extravasation from the ipsilateral cancer may result in tumour cell spillage and hence risk seeding. Here we describe an endoscopic technique, which is both simple and adheres to the principles of cancer surgery. Material & Methods: The technique involves positioning the patient as for a cystoscopy. A guide wire is inserted into the affected ureter, and a Cook 2-piece ureteral occlusion balloon is inserted over the wire into the mid ureter. The cystoscope is then removed, and the balloon is inflated to occlude the juxta-vesical ureter. A standard resectoscope is then inserted by the side of the ureteral catheter, and using the Collins’ knife, a circumferential incision is made around the ureteric orifice and deepened to fat. The occlusion balloon catheter and guide wire can be used to apply cephalad displacement of the ureteric orifice as required. Once the resection is complete, the wire is removed and the ureteral occlusion balloon catheter is taped to a urethral Foley catheter. Laparoscopic nephroureterectomy is then carried out in the preferred manner either by hand assisted or pure laparoscopic route. The ureter is clipped as low as possible before delivering it in continuity along with the balloon catheter, which is freed from the Foley’s catheter and divided close to the urethral meatus. Results: The technique has been performed successfully at the above institutions in 10 patients undergoing nephroureterectomy.
Conclusions: The Endo Assist is an effective, easy to use device for robotic camera driving, which reduces the constraint of having to have an experienced camera driver for optimal visualisation during laparoscopic urological procedures.
Conclusions: The procedure described herein adheres to the principles of cancer surgery with no theoretical risk of tumour implantation during the nephroureterectomy since the ureter remains occluded for the duration of this procedure. The completeness of the ureteric stump removal is ascertained once the whole specimen is removed in continuity at the end of the operation.
655
656
Comparison between open and laparoscopic Nephron Sparing Surgery
Laparoscopic partial nephrectomy for hilar tumors: technique and results
Crepel M.1, Bernhard J.C.2, Bellec L.3, Albouy B.4, Lopes D.5, Lacroix B.6, De La Taille A.5, Salomon L.5, Abbou C.5, Pfister C.4, Soulie M.3, Tostain J.6, Ferriere J.M.2, Guille F.1, Bensalah K.1, Vincendeau S.1, Manunta A.1, Belldegrun A.7, Pantuck A.J.7, Patard J.J.1
Lattouf J.B., Beri A., Leeb K., Janetschek G.
Rennes University Hospital, Urology, Rennes, France, Bordeaux University Hospital, Urology, Bordeaux, France, 3Toulouse University Hospital, Urology, Toulouse, France, 4Rouen University Hospital, Urology, Rouen, France, 5Henri Mondor University Hospital, Urology, Creteil, France, 6 Saint Etienne University Hospital, Urology, Saint Etienne, France, 7UCLA, Urology, Los Angeles, United States of America
Introduction & Objectives: To describe our technique and postoperative results of laparoscopic partial nephrectomy in renal hilar tumors.
1
2
Introduction & Objectives: To compare through a large multicenter series the indications and outcomes of open and laparocopic nephron sparing surgery (NSS). Material & Methods: The study included patients from 8 international academic centers. Age, gender, ECOG-PS, symptoms at presentation, ASA score, TNM stage, tumor size, histology, Fuhrman grade, were noted as well as surgical technique (open vs laparoscopic, renal vessels clamping, collecting system repair), indication for NSS (elective vs non elective), duration of the procedure, medical and surgical complication rates, mean blood loos, blood transfusion, length of hospital stay, surgical margins and post-operative serum creatinine. Results: 1119 partial nephrectomies were analysed, including 91 laparoscopic procedures (8.1%). Although the 2 surgical groups were comparable for age (p:0.3), laparoscopic procedure was more often performed in female patients (p:0.02) and in patients with good performance status (p:0.06). On the contrary, open procedures were more often performed in patients with symptomatic tumors (p:0.01) and significant co-morbidities (ASA score 3-4, 31.8% vs 24.1%, p:0.1). Tumors were smaller in size in the laparocopic group (2.7 vs 3.5 cm, p:0.003) and were more frequently removed for an elective indication (77.6% vs 68.2%, p:0.02). Mean duration of renal vessels clamping was increased during laparoscopy (35 vs 19 min, p:0.0001) while mean blood loss was reduced (363 vs 511ml, p:0.02). Mean operative time (156 vs 163 min, p:0.26), surgical complication rate, need for blood transfusion (p:0.1), positive surgical margin rates (p:0.8), post-operative serum creatinine (p:0.3) and length of hospital stay (p:0.4) were not significantly different between the 2 groups. Urinary fistula rate, although significantly increased at the beginning of the laparoscopic experience tent to be more balanced between the 2 groups in the more recent period. Interestingly, the mean size of surgical margin was in favour of laparoscopy (7.1 vs 4.5 mm, p:0.0001). Conclusions: Although it is relatively unfair to compare a large series from a well established surgical technique to a smaller series with preliminary results from a new innovative approach, it appeared from our study that laparoscopic NSS in carefully selected patients and tumors appears to be a safe an attractive alternative to open technique. It is likely that future technical improvements in laparoscopy will allow a complete duplication of open techniques, therefore leading to comparable cancer control along with improved quality of life.
Eur Urol Suppl 2007;6(2):186
Krankenhaus der Elisabethinen, Urology, Linz, Austria
Material & Methods: Between April 2000 and September 2006, 94 partial nephrectomies using a laparoscopic approach were performed at our institution. A total of 18 patients (19.1%) had hilar tumors. A hilar tumor was defined as a lesion suspicious for renal cell carcinoma adjacent to the major renal vessels on pre-operative cross-sectional imaging. All surgeries were performed by a single urologist (GJ). In 3 of the patients (16.7%), the indication for nephron-sparing surgery was imperative. Mean tumor size was 3cm (range: 2-4.5). Eight surgeries (44.4%) were performed with renal artery perfusion for cold ischemia, and the rest under warm ischemia. After occluding the renal artery and controlling the renal vein using separate rubber band tourniquets, excision of the tumor mass including delicate mobilization away from the blood vessels was performed. Running sutures to the base the tumor bed and for parenchymal reconstruction were applied. Results: All surgeries were completed laparoscopically. Mean surgical time was 238 min (range: 150-420). Mean ischemia times were 42.5 min (range 27-63) and 34.1 min (range 24 -56) for the cold and warm ischemia groups, respectively. Estimated intraoperative blood loss was 165 mL (range: 50-500). There were 2 (11%) entries into major vessels during tumor excision, namely a segmental artery in one patient and a vein in another. Both of these occurrences where managed laparoscopically. Two patients (11%) necessitated laparoscopic re-exploration: One for continuous postoperative blood oozing from the tumor bed, and another for urine extravasation in the immediate postoperative period. Postoperative nuclear scan showed functional kidney moiety in all patients. Mean split renal function was 38.6% (range: 24-50) on the operated side. Histopathological examination confirmed renal cell carcinoma in 14 of the patients (77.8%). One patient (7.1%) had a positive surgical margin on the surface that was adjacent to the renal artery. In a median follow-up of 26 months (range: 1-59) no local recurrence or systemic progression occurred. Conclusions: Laparoscopic partial nephrectomy for hilar tumors is a feasible and safe procedure in the hands of experienced laparoscopic surgeons. Oncologic results seem excellent but further follow-up is needed for accurate long term assessment of this surgical approach.