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805Laparoscopic partial nephrectomy without hilar vessel clamping
LAPAROSCOPIC PARTIAL VESSEL CLAMPING
NEPHRECTOMY
WITHOUT
805
806
HILAR
OUR EXPERIENCE 1N V A S C U L A R C O N T R O L U S I N G T H E H E M - O L O K CLIP IN L A P A R O S C O P I C NEPHRECTOMY: A RELIABLE METHOD TO REPLACE VASCULAR STAPLERS
Atug F ) , Mendez-Torres F. t, Burgess S. t, Thomas R. t, Davis R. t, Castle E. L, Andrews R 2, Ferrigni R.G. 2 1Tulane University Health Sciences Center, Urology, N e w Orleans, United States, 2May Clinic, Urology, Scottsdale, United States
INTRODUCTION
& O B J E C T I V E S : Partial N e p h r e c t o m y is currently recommended for surgically amenable solid renal tumours. Herein, we reviewed our initial experience with Laparoscopic Partial Nephrectomy (LPNx) for solid renal masses without clamping the renal vasculamre using a monopolar device that employs radiofrequency (RF) energy with low-volume saline irrigation for simultaneous blunt dissection, hemostatic sealing and coagulation of the renal parenchyma (TissueLinkTM). M A T E R I A L & M E T H O D S : From March 2002 to April 2004, 45 patients underwent LPNx at two institutions; 44 had solid renal masses and 1 had a complex cyst. In all cases, the renal hilum was dissected and the renal vessels isolated, but none had renal vascular clamping. Either the TissueLink DS T M dissecting sealer or the TissueLink Floating Ball T M was used to bluntly dissect the tumour free, while simultaneously sealing and coagulating the bleeders. R E S U L T S : Mean Age, 63.6 years (range: 42 - 84); tumour size, 2.9 cm (range: 1.2 - 8); O.R. time, 175.8 minutes (range: 78 - 280); blood loss, 242.6 ml (range: 20 - 1000), 3 patient had blood transfusion and all tumour margins were negative. The mean hospital stay was 2.03 days (range: 1 - 6) and pain medication usage was minimal. Two patients developed urine leaks, two had prolonged ileus, one had a small diaphragm injury and one was converted to open.
CONCLUSIONS: Laparoscopic Partial Nephrectomy can be performed without renal vascular clamping. TissueLink technology allows for adequate resection of tumour and controlled blood loss in a vast majority of cases. This is especially recommended in high risk patients who need neprhon-sparing surgery
CasaleP., Sit'noneM.. PomaraG., MilesiC., CasarosaC., FrancescaF. UrologyUnit, S. ChiaraHospital,Surgery,Pisa, Italy INTRODUCTION & OBJECTIVES: Laparoscopicnephrectomy(LN) has become a valid option in both benignand malignantdiseasesaftbe kidney(~,2).The standardtechniqueof controland divisionof the renal vein involves applicationof a stapling-transectiondevice (e.g., Endo-GIA) (3). Nevertheless,Endo-GIA malfunctionis reported in the literalm-e(4.s),with significantcomplications.Aim of this studywas to evaluate in the clinicalsettingthe use of a polymerclip for routinevessel controlduring LN, both in terms of safety and of cost containment. MATERIAL & METHODS: Between November 2002 and September 2004 20 consecutive patients (16 femaleand 4 male)underwentLN (via a transperitonealapproach),9 on the right side and 11 on the left side.Eightfor severenephroslemsis,3 due to hydronephrosis,7 for renalcell carcinoma,and 2 for transitional cell carcinoma of the ureter. The renal vessels were isolated, and then secured with the Hem-o-lokclips (WeckClosureSystem,ResearchTrianglePark,NC, USA). Eitherfor arterialand venouscontrol,two locking clips were appliedon the hilar side, while anotherone was positionedon the renal side,respectively. RESULTS: All procedureswere completedlaparoscopically;no clip dislodgementwas registeredduringor after the intervention.We achieveda meanir ful reductionof the expenditures(see table). CLIP
G.I.A.
Size ML (green) L (violet) XL (golden)
Price (6 clips) Price (singleclip) £ 46 E 7.6 (~36 C6 E 46 E 7.6 Price (device)
60 mm 45 mm 45 mm (angled) 35 nun
E 372 t~260 t2475 £ 324
Vesseldiameter 3 - 10rmn 5- 10ram 7- 16ram I Price (per cartridge) iE186 165 E 165 C155
CONCLUSIONS:The use of lockingclipsto securerenalvesselsresultedto be simple,safe and economical.
It does not require an extensivedissectionof the renal vein, as the GIA-staplerdoes. To our kalowledge,this is currentlythe largestclinical experiencein LN (no hand assistedtechnique,6-8). Moreover, a significant reductionof the expendituresin hilar vesselscontrolwas achievedin our setting:about50 versus 500 Euros for each procedure. Biblio~raDhv 1) ClaymanRM J.Urol, 146:278, 1991. 2) RassweilwrJ. J. Urol, 160:18; 1998. 3) Chan DY, Su LM, and KavoussiRL. Rapid Iigationof renal hilum during transeperitoneallaparoscopic nephrectomy.Urology,57:360, 2001. 4) Chan D. J Uroi 164:319, 2000 5) United StatesFederal DrugAdministrationManufacturerand User FacilityDeviceExperienceDatabase (MAUDE).Availableat http//www.fda.gov/cdrh/maude.html.AccessedFebr 18, 2003. 6) JanetschekG. J Urol. 2003 Oct;170(4Pt 1):1295-7 7) Yip SK. J Endourol. 2004 Feb;18(1):77-81 8) Eswar C. J Endourol.2004 Jun;18(5):459-61
807
808
LIGATION OF T H E R E N A L V E I N U S I N G T H E H E M - O - L O K P O L Y M E R
COMPARISON B E T W E E N STANDARD SUTURE T E C H N I Q U E AND TISSUE SEALANTS IN PATIENTS U N D E R G O I N G N E P H R O N SPARING SURGERY
L I G A T I N G C L I P (15 M M ) D U R I N G L A P A R O S C O P I C N E P H R E C T O M Y Apaydin E.. Altay B., Nazli O., Tuma B., Semerci B., Simsir A. Ege University Medical Faculty, Urology, Izmir, Turkey
INTRODUCTION
& O B J E C T I V E S : A crucial step in laparoscopic nephrectomy (LPN) is control and ligation of the renal pedicle, especially the renal vein. Commonly, an endovascular gastrointestinal anastomosis (GIA) stapling device and/or titanium staples is employed for vascular control. However, using Hem-o-Lok polymer ligating clips ( t 0 m m ) for renal vascular control during LPN has recently become popular. Herein, we report the preliminary experience of the use of the Hem-o-Lok polymer ligating clip (Weck Closure Systems, Research Triangle Park, NC) for the routine control of the renal vein using the Hem-o-lok polymer ligating clip (15 MM) during LPN. M A T E R I A L & M E T H O D S : From March 2004 to October 2004, 8 simple or radical laparoscopic nephrectomies were performed. The 15ram Hem-o-lok polymer ligating clips (15 mm; Weck Closure System, Research Triangle Park, NC) was utilized exclusively for ligation of the renal vein and the renal artery, with placement of two clips on the patients' side and one distally on the specimens' side. The technical difficulty in obtaining v a s c u l a r control, transfusion requirement and clinical outcome was evaluated. R E S U L T S : During our first LPNs w e used the Weck klip (10mm) to control the renal vein and had to convert to open procedure for 1 patient out of 2 patients as the 10 m m clips were not wide enough and caused significant bleeding. The 15 m m Weck clip has since been introduced onto the market and we have started to use the 15 rnm Weck klip for renal vein control for our last 8 patients. In these 8 cases we managed to control the renal vein very safely and comfortably. Neither slippage nor any other complications were experienced in these cases. Mean operating time was 150 minutes. There was no significant increase in mean operative time. No open conversion was required and none of the patients required blood transfusion. The operative costs of vein ligation were decreased.
CONCLUSIONS: Ligation of the renal vein using the Hem-o-lok polymer ligating clip (15 MM) during laparoscopic nephrectomy is a safe, reliable and cost-effective method. Therefore, we routinely use and recommend the use of the Weck clip ( i 5 mm) for vascular control of the renal pedicle during LPN.
European Urology Supplements 4 (2005) No. 3, pp. 204
Nativ O., Kastin A., Mullerad M., Issaq E., Moskovitz B. Bnai Zion Medical Center, Urology, Haifa, Israel
I N T R O D U C T I O N & O B J E C T I V E S : Bleeding, urinary leakage and ischemie renal damage are the most frequent complications of nephron sparing surgery (NSS). We evaluated the effectiveness of two tissue sealants compared to our standard suture technique during NSS. M A T E R I A L & M E T H O D S : We retrospectively analysed 192 cases of NSS performed between 1993 and 2004. O f this group in 30 patients we have used tissue sealants (BioGlue TM, in 16 cases and Coseal TM in 14 cases). Warm ischemia time, blood loss, and fistula formation were compared between patients treated with tissue sealants and those who were managed by suture of the renal parenchyma. R E S U L T S : One patient with VHL syndrome and multiple tumours was not included in the analysis. The average warm ischemia time was 19 minutes for the tissue sealants group versus 24 minutes for the suture technique cases. Initial hemostatsis was achieved in all kidneys except one in the Coseal group. Estimated blood loss and transfusion rate were 88cc' and 6% in the patients treated with sealants versus 150cc' and 17% in the standard cases (P-0.009 and P=0.002 respectively). Urinary leak was observed in three cases (1.8%) of the standard group but in none of the sealants treated patients (P=0.9).
CONCLUSIONS: Tissue sealants provide durable hemostasis and effective closure of the collecting system. Their use reduces the w a r m ischemia time and is associated with decreased bleeding and transfusion rate.
NEPHRECTOMY
WITHOUT
805
806
HILAR
OUR EXPERIENCE 1N V A S C U L A R C O N T R O L U S I N G T H E H E M - O L O K CLIP IN L A P A R O S C O P I C NEPHRECTOMY: A RELIABLE METHOD TO REPLACE VASCULAR STAPLERS
Atug F ) , Mendez-Torres F. t, Burgess S. t, Thomas R. t, Davis R. t, Castle E. L, Andrews R 2, Ferrigni R.G. 2 1Tulane University Health Sciences Center, Urology, N e w Orleans, United States, 2May Clinic, Urology, Scottsdale, United States
INTRODUCTION
& O B J E C T I V E S : Partial N e p h r e c t o m y is currently recommended for surgically amenable solid renal tumours. Herein, we reviewed our initial experience with Laparoscopic Partial Nephrectomy (LPNx) for solid renal masses without clamping the renal vasculamre using a monopolar device that employs radiofrequency (RF) energy with low-volume saline irrigation for simultaneous blunt dissection, hemostatic sealing and coagulation of the renal parenchyma (TissueLinkTM). M A T E R I A L & M E T H O D S : From March 2002 to April 2004, 45 patients underwent LPNx at two institutions; 44 had solid renal masses and 1 had a complex cyst. In all cases, the renal hilum was dissected and the renal vessels isolated, but none had renal vascular clamping. Either the TissueLink DS T M dissecting sealer or the TissueLink Floating Ball T M was used to bluntly dissect the tumour free, while simultaneously sealing and coagulating the bleeders. R E S U L T S : Mean Age, 63.6 years (range: 42 - 84); tumour size, 2.9 cm (range: 1.2 - 8); O.R. time, 175.8 minutes (range: 78 - 280); blood loss, 242.6 ml (range: 20 - 1000), 3 patient had blood transfusion and all tumour margins were negative. The mean hospital stay was 2.03 days (range: 1 - 6) and pain medication usage was minimal. Two patients developed urine leaks, two had prolonged ileus, one had a small diaphragm injury and one was converted to open.
CONCLUSIONS: Laparoscopic Partial Nephrectomy can be performed without renal vascular clamping. TissueLink technology allows for adequate resection of tumour and controlled blood loss in a vast majority of cases. This is especially recommended in high risk patients who need neprhon-sparing surgery
CasaleP., Sit'noneM.. PomaraG., MilesiC., CasarosaC., FrancescaF. UrologyUnit, S. ChiaraHospital,Surgery,Pisa, Italy INTRODUCTION & OBJECTIVES: Laparoscopicnephrectomy(LN) has become a valid option in both benignand malignantdiseasesaftbe kidney(~,2).The standardtechniqueof controland divisionof the renal vein involves applicationof a stapling-transectiondevice (e.g., Endo-GIA) (3). Nevertheless,Endo-GIA malfunctionis reported in the literalm-e(4.s),with significantcomplications.Aim of this studywas to evaluate in the clinicalsettingthe use of a polymerclip for routinevessel controlduring LN, both in terms of safety and of cost containment. MATERIAL & METHODS: Between November 2002 and September 2004 20 consecutive patients (16 femaleand 4 male)underwentLN (via a transperitonealapproach),9 on the right side and 11 on the left side.Eightfor severenephroslemsis,3 due to hydronephrosis,7 for renalcell carcinoma,and 2 for transitional cell carcinoma of the ureter. The renal vessels were isolated, and then secured with the Hem-o-lokclips (WeckClosureSystem,ResearchTrianglePark,NC, USA). Eitherfor arterialand venouscontrol,two locking clips were appliedon the hilar side, while anotherone was positionedon the renal side,respectively. RESULTS: All procedureswere completedlaparoscopically;no clip dislodgementwas registeredduringor after the intervention.We achieveda meanir ful reductionof the expenditures(see table). CLIP
G.I.A.
Size ML (green) L (violet) XL (golden)
Price (6 clips) Price (singleclip) £ 46 E 7.6 (~36 C6 E 46 E 7.6 Price (device)
60 mm 45 mm 45 mm (angled) 35 nun
E 372 t~260 t2475 £ 324
Vesseldiameter 3 - 10rmn 5- 10ram 7- 16ram I Price (per cartridge) iE186 165 E 165 C155
CONCLUSIONS:The use of lockingclipsto securerenalvesselsresultedto be simple,safe and economical.
It does not require an extensivedissectionof the renal vein, as the GIA-staplerdoes. To our kalowledge,this is currentlythe largestclinical experiencein LN (no hand assistedtechnique,6-8). Moreover, a significant reductionof the expendituresin hilar vesselscontrolwas achievedin our setting:about50 versus 500 Euros for each procedure. Biblio~raDhv 1) ClaymanRM J.Urol, 146:278, 1991. 2) RassweilwrJ. J. Urol, 160:18; 1998. 3) Chan DY, Su LM, and KavoussiRL. Rapid Iigationof renal hilum during transeperitoneallaparoscopic nephrectomy.Urology,57:360, 2001. 4) Chan D. J Uroi 164:319, 2000 5) United StatesFederal DrugAdministrationManufacturerand User FacilityDeviceExperienceDatabase (MAUDE).Availableat http//www.fda.gov/cdrh/maude.html.AccessedFebr 18, 2003. 6) JanetschekG. J Urol. 2003 Oct;170(4Pt 1):1295-7 7) Yip SK. J Endourol. 2004 Feb;18(1):77-81 8) Eswar C. J Endourol.2004 Jun;18(5):459-61
807
808
LIGATION OF T H E R E N A L V E I N U S I N G T H E H E M - O - L O K P O L Y M E R
COMPARISON B E T W E E N STANDARD SUTURE T E C H N I Q U E AND TISSUE SEALANTS IN PATIENTS U N D E R G O I N G N E P H R O N SPARING SURGERY
L I G A T I N G C L I P (15 M M ) D U R I N G L A P A R O S C O P I C N E P H R E C T O M Y Apaydin E.. Altay B., Nazli O., Tuma B., Semerci B., Simsir A. Ege University Medical Faculty, Urology, Izmir, Turkey
INTRODUCTION
& O B J E C T I V E S : A crucial step in laparoscopic nephrectomy (LPN) is control and ligation of the renal pedicle, especially the renal vein. Commonly, an endovascular gastrointestinal anastomosis (GIA) stapling device and/or titanium staples is employed for vascular control. However, using Hem-o-Lok polymer ligating clips ( t 0 m m ) for renal vascular control during LPN has recently become popular. Herein, we report the preliminary experience of the use of the Hem-o-Lok polymer ligating clip (Weck Closure Systems, Research Triangle Park, NC) for the routine control of the renal vein using the Hem-o-lok polymer ligating clip (15 MM) during LPN. M A T E R I A L & M E T H O D S : From March 2004 to October 2004, 8 simple or radical laparoscopic nephrectomies were performed. The 15ram Hem-o-lok polymer ligating clips (15 mm; Weck Closure System, Research Triangle Park, NC) was utilized exclusively for ligation of the renal vein and the renal artery, with placement of two clips on the patients' side and one distally on the specimens' side. The technical difficulty in obtaining v a s c u l a r control, transfusion requirement and clinical outcome was evaluated. R E S U L T S : During our first LPNs w e used the Weck klip (10mm) to control the renal vein and had to convert to open procedure for 1 patient out of 2 patients as the 10 m m clips were not wide enough and caused significant bleeding. The 15 m m Weck clip has since been introduced onto the market and we have started to use the 15 rnm Weck klip for renal vein control for our last 8 patients. In these 8 cases we managed to control the renal vein very safely and comfortably. Neither slippage nor any other complications were experienced in these cases. Mean operating time was 150 minutes. There was no significant increase in mean operative time. No open conversion was required and none of the patients required blood transfusion. The operative costs of vein ligation were decreased.
CONCLUSIONS: Ligation of the renal vein using the Hem-o-lok polymer ligating clip (15 MM) during laparoscopic nephrectomy is a safe, reliable and cost-effective method. Therefore, we routinely use and recommend the use of the Weck clip ( i 5 mm) for vascular control of the renal pedicle during LPN.
European Urology Supplements 4 (2005) No. 3, pp. 204
Nativ O., Kastin A., Mullerad M., Issaq E., Moskovitz B. Bnai Zion Medical Center, Urology, Haifa, Israel
I N T R O D U C T I O N & O B J E C T I V E S : Bleeding, urinary leakage and ischemie renal damage are the most frequent complications of nephron sparing surgery (NSS). We evaluated the effectiveness of two tissue sealants compared to our standard suture technique during NSS. M A T E R I A L & M E T H O D S : We retrospectively analysed 192 cases of NSS performed between 1993 and 2004. O f this group in 30 patients we have used tissue sealants (BioGlue TM, in 16 cases and Coseal TM in 14 cases). Warm ischemia time, blood loss, and fistula formation were compared between patients treated with tissue sealants and those who were managed by suture of the renal parenchyma. R E S U L T S : One patient with VHL syndrome and multiple tumours was not included in the analysis. The average warm ischemia time was 19 minutes for the tissue sealants group versus 24 minutes for the suture technique cases. Initial hemostatsis was achieved in all kidneys except one in the Coseal group. Estimated blood loss and transfusion rate were 88cc' and 6% in the patients treated with sealants versus 150cc' and 17% in the standard cases (P-0.009 and P=0.002 respectively). Urinary leak was observed in three cases (1.8%) of the standard group but in none of the sealants treated patients (P=0.9).
CONCLUSIONS: Tissue sealants provide durable hemostasis and effective closure of the collecting system. Their use reduces the w a r m ischemia time and is associated with decreased bleeding and transfusion rate.