- Email: [email protected]
810Laparoscopic partial nephrectomy: Oncological results and complications
810
809 LAPAROSCOPIC PARTIAL NEPHRECTOMY FOR RENAL TUMOURS: EXPERIENCE ABOUT 37 CASES
LAPAROSCOPIC PARTIAL NEPHRECTOMY: RESULTS AND COMPLICATIONS
Dujardin T., SabbaghR., Inman B.
Cathelinean X., Lorin S., Barret E., Rozet F., Cathala N., Vallancien G.
University Laval, Medical Centre, Urology, Qu6bec, Canada
Institut Montsouris, 75014, Paris, France
INTRODUCTION & OBJECTIVES: Laparoscopic partial nephrectomy (LPN) has emerged as a viable alternative to open surgery for renal tumours.We present our laparoscopic nephron sparing surgery serie at our institution. MATERIAL & METHODS: Between August 2003 and September 2004, 37 consecutive patients underwent 38 LPN for renal masses suspiciousof malignancy via a transperitoneal approach. A Bulldog was applied on the renal artery after mobilizing the entire kidney. We did not use any intra renal cooling. Through a laparoscopie applicator, fibrin glue was applied to the transeeted partial nephreetomy bed after intracorporeal freehand suturing techniques were used to close the collecting systemand for hemostasis.A Surgicel bolster was then_suture over it. RESULTS: Mean patient age was 60.6 years. The median body mass index was 29 ± 5. The tumours locations were anterior/central; anterior/peripheral; posterior; lateral; hilum, upper pole, lower pole in 6,7, 16, 3, 2, 1,3 respectively. Two patients had a solitarykidney and one patient had a 2 staged partial nephrectomy. Mean tumour size was 3.5 cm (range 1 to 5). Median warm ischemic time was 31 ± 7.3 min. The median operative time was 140 :~ 32.7 rain and no statistically significant difference was observed depending on tumour location .The median blood lost was 220 mL. 3 intra operative bleeding occurred and One blood transfusionwas required in a patient with the tumour located in the hilum. The mean preoperative, 2-days and 3-month postoperative creatinine serum was 80.7, 91.4 and 85.4 umol/L, respectively. There was no statistically significant difference between the preoperative and the 3-month creatinine level, final pathology revealed negative margins in all cases. Median hospitalizations stay 4 ± 2 days. 3 patients (7.9%) had a brief period of urine leakage which was managed successfullyby JJ ureteral stenting. Four patients had benign tumour (2 oneoeytoma, one multiloculated cystic nephroma and one angiomyolipoma). The remaining histology revealed clear cell in 21 patients, papillary in 8, ehromophobein 4, and non-hogkinslymphomain one. Final pathological stage for renal cell carcinomawas pTla in 23 patients, pTlb in 5 and pT3a (fat) in 6. No cancer recurrence developed in the patients, with a mean follow-upof 7 months (range 1 to 14). CONCLUSIONS: LPN is still an advanced procedure. It's a safe and effective treatment modality for renal mmours.It offersmany advantages, including nephron sparingand minimal linvasive surgery. Complications are more likely to occur in the presence of central, infiltrating tumours.
811 RENAL EXTRACTION AFTER LAPAROSCOPIC NEPHRECTOMY BY AN ILIAC APPROACH. PROSPECTIVE S T U D Y
ONCOLOGICAL
I N T R O D U C T I O N & OBJECTIVES: To evaluate the morbidity and oncological outcomes of laparoscopic partial nephrectomy (LPN) in patients with small renal turnouts. MATERIAL & METHODS: From December 1997 to July 2004, 85 LPN have been performed at our institution in 83 patients with a single unilateral renal turnout. Mean age was 594-10 years. Mean turnout size was 264-10 ram. Clamping of renal artery was carried out in 68 cases before excision. Tumour was excised with a margin of normal parenchyma using cold scissors. Intracorporeal suturing was used to close the collecting system when opened and to approximate the renal parenchyma. Staging, operative and postoperative data were prospectively analysed. Follow-up consisted of review of clinical, laboratory and radiological records. RESULTS: Mean operative time was 134±52 mn and mean warm ischemia time was 304- rrm. Average estimated blood loss was 2884-280 ml. The collecting system was opened in 38 cases (45%). Conversion was necessary in 1 case (1.2%) because of difficulty accessing an upper pole tumour. Major complications occurred in 13 cases (15%) including 6 hemorrhages, arteriovenous fistula in 5 and a urine leak in 2. Patients necessitated secondary nephrectomy in 2 cases (2.4%). Transfusion was required postoperatively in 10 cases (12%). Hospital stay averaged 54-3 days. Histological examination revealed 68 (80%) malignant tumours (65 pT1, 3 PT3a) including clear cell in 46 cases (68%), papillary in 17 (25%), chromophobe in 5 (7%). Final surgical margins, which were always negative on frozen section, were positive in 1 case (1.2%). After a mean followup of 194-15 months, renal function was maintained normal, all the patients are alive, and none of them has had a local recurrence or developed metatstatic disease. CONCLUSIONS: LPN is a feasible option for patients with small renal tumours and allows an oncological effectiveness. Clamping the renal pedicle is a safe technique with limited blood loss and operative time.
0i 4 NONN ~RO6~i~ ~iBiN ~ D¥SEU~CTiO N BASi~ E~EAR~Bii DOSE-DEPENDENT I M P R O V E M E N T OF U R E T H R A L PRESSURES AFTER APPLICATION OF MYOBLASTS
CLOSURE
Mitterberger M. 1, Marksteiner R. 2, Margreiter E. 2, Klima G ) , Fritsch H. 3, Pinggera G.M. 1, Raedler C. 4, Hering S. 5, Bartsch G. 1, Schuster R. 1, Strasser H. 1 Maliet R., Game X., Vaessen C., Mouzin M., Berrogain N., Sarramon J.E, Malavaud B., Rischmann R
CHU Rangueil, Dept. of Urology, Toulouse, France
INTRODUCTION & OBJECTIVES: To evaluate prospectively the iliac route for renal extraction after laparoscopic nephrectomy.
MATERIAL & METHODS: 30 laparoscopic nephrectomies (20 tumours and 10 live donor nephrectomies) were performed (lomboscopy: 10 cases, transperitoneai approach: 20 cases). Renal extraction was performed through a horizontal ipsilateral iliac route (length 5- 7 cm).
RESULTS: The iliac approach duration was 11 rnin +/- 2 min within an overall operative time of 188 +/- 50 min. It allowed the speedy extraction of large renal specimens (mean weight 571 +/- 127 g). No parietal post operative complications were observed after a mean follow-up of 9.6 +/- 1.2 months.
CONCLUSIONS: After laparoscopic nephrectomy, the extraction of the specimen can be performed through an iliac route without muscular section. There were no specific carcinological problems. This prospective study showed good anaesthetical and functional results.
1University of Innsbruck, Department of Urology, Innsbruck, Austria, 2University of Innsbruck, Department of Biochemical Pharmacology, Innsbruck, Austria, 3University of Innsbruck, Department of Anatomy, Innsbruck, Austria, 4University of Innsbmck, Department of Anaesthesiology, Innsbruck, Austria, 5University of Vienna~ Department of Pharmacoiogy, Vienna, Austria INTRODUCTION & OBJECTIVES: Transurethral ultrasound guided injection of autologous myohlasts has recently been shown to cure urinary stress incontinence. In the present study the dose-dependent changes of maximal urethral eiosure pressures (MUCP) after application of myoblasts were investigated in a porcine animal model. MATERIAL & METHODS: Myoblast cultures were obtained from one porcine muscle biopsy. The biopsy was enzymatically dissociated according to a modified cell dispersion technique. Single myoblasts in suspension were manually collected with a mieropipette under microscopic control. Fluorescence labeling was used to assess integration &the injected myoblasts into the rhabdosphincter. With the help of a transurethral ultrasound probe (23 F, 11 MHz) and injection system the myoblasts were injected into the rhabdosphincter of 5 pigs under direct sonographic control. In each pig several depots of heterologous myoblasts were injected into the rhabdosphincter in 2 different regions. The cell number in all 10 regions ranged between 7.8x107 and 1.5x106 cells. Immmaosuppressionof the pigs was achieved by means of daily injections of cortisone. Urethral pressure profiles were measured before and 2 weeks after injection to determine the postoperative changes of MUCE RESULTS: Histologic examination of the specimens revealed that the injected cells survived well and that the myoblasts fused to form myofibers. Postoperativeiy, MUCP were markedly increased (up to 312%) in the regions where higher concentrations of cells had been injected. Increase of MUCP was highest after transurethral application of 7.8x107 cells. After injection of low numbers of cells no increase in MUCP could be observed. CONCLUSIONS: The present data show that injected myoblasts survive well and that improvement of MUCP after injection of myoblasts depends on the dose of injected cells. If applied in a sufficiently high number, urethral closure pressures can be increased substantially.
European Urology Supplements 4 (2005) No. 3, pp. 205
809 LAPAROSCOPIC PARTIAL NEPHRECTOMY FOR RENAL TUMOURS: EXPERIENCE ABOUT 37 CASES
LAPAROSCOPIC PARTIAL NEPHRECTOMY: RESULTS AND COMPLICATIONS
Dujardin T., SabbaghR., Inman B.
Cathelinean X., Lorin S., Barret E., Rozet F., Cathala N., Vallancien G.
University Laval, Medical Centre, Urology, Qu6bec, Canada
Institut Montsouris, 75014, Paris, France
INTRODUCTION & OBJECTIVES: Laparoscopic partial nephrectomy (LPN) has emerged as a viable alternative to open surgery for renal tumours.We present our laparoscopic nephron sparing surgery serie at our institution. MATERIAL & METHODS: Between August 2003 and September 2004, 37 consecutive patients underwent 38 LPN for renal masses suspiciousof malignancy via a transperitoneal approach. A Bulldog was applied on the renal artery after mobilizing the entire kidney. We did not use any intra renal cooling. Through a laparoscopie applicator, fibrin glue was applied to the transeeted partial nephreetomy bed after intracorporeal freehand suturing techniques were used to close the collecting systemand for hemostasis.A Surgicel bolster was then_suture over it. RESULTS: Mean patient age was 60.6 years. The median body mass index was 29 ± 5. The tumours locations were anterior/central; anterior/peripheral; posterior; lateral; hilum, upper pole, lower pole in 6,7, 16, 3, 2, 1,3 respectively. Two patients had a solitarykidney and one patient had a 2 staged partial nephrectomy. Mean tumour size was 3.5 cm (range 1 to 5). Median warm ischemic time was 31 ± 7.3 min. The median operative time was 140 :~ 32.7 rain and no statistically significant difference was observed depending on tumour location .The median blood lost was 220 mL. 3 intra operative bleeding occurred and One blood transfusionwas required in a patient with the tumour located in the hilum. The mean preoperative, 2-days and 3-month postoperative creatinine serum was 80.7, 91.4 and 85.4 umol/L, respectively. There was no statistically significant difference between the preoperative and the 3-month creatinine level, final pathology revealed negative margins in all cases. Median hospitalizations stay 4 ± 2 days. 3 patients (7.9%) had a brief period of urine leakage which was managed successfullyby JJ ureteral stenting. Four patients had benign tumour (2 oneoeytoma, one multiloculated cystic nephroma and one angiomyolipoma). The remaining histology revealed clear cell in 21 patients, papillary in 8, ehromophobein 4, and non-hogkinslymphomain one. Final pathological stage for renal cell carcinomawas pTla in 23 patients, pTlb in 5 and pT3a (fat) in 6. No cancer recurrence developed in the patients, with a mean follow-upof 7 months (range 1 to 14). CONCLUSIONS: LPN is still an advanced procedure. It's a safe and effective treatment modality for renal mmours.It offersmany advantages, including nephron sparingand minimal linvasive surgery. Complications are more likely to occur in the presence of central, infiltrating tumours.
811 RENAL EXTRACTION AFTER LAPAROSCOPIC NEPHRECTOMY BY AN ILIAC APPROACH. PROSPECTIVE S T U D Y
ONCOLOGICAL
I N T R O D U C T I O N & OBJECTIVES: To evaluate the morbidity and oncological outcomes of laparoscopic partial nephrectomy (LPN) in patients with small renal turnouts. MATERIAL & METHODS: From December 1997 to July 2004, 85 LPN have been performed at our institution in 83 patients with a single unilateral renal turnout. Mean age was 594-10 years. Mean turnout size was 264-10 ram. Clamping of renal artery was carried out in 68 cases before excision. Tumour was excised with a margin of normal parenchyma using cold scissors. Intracorporeal suturing was used to close the collecting system when opened and to approximate the renal parenchyma. Staging, operative and postoperative data were prospectively analysed. Follow-up consisted of review of clinical, laboratory and radiological records. RESULTS: Mean operative time was 134±52 mn and mean warm ischemia time was 304- rrm. Average estimated blood loss was 2884-280 ml. The collecting system was opened in 38 cases (45%). Conversion was necessary in 1 case (1.2%) because of difficulty accessing an upper pole tumour. Major complications occurred in 13 cases (15%) including 6 hemorrhages, arteriovenous fistula in 5 and a urine leak in 2. Patients necessitated secondary nephrectomy in 2 cases (2.4%). Transfusion was required postoperatively in 10 cases (12%). Hospital stay averaged 54-3 days. Histological examination revealed 68 (80%) malignant tumours (65 pT1, 3 PT3a) including clear cell in 46 cases (68%), papillary in 17 (25%), chromophobe in 5 (7%). Final surgical margins, which were always negative on frozen section, were positive in 1 case (1.2%). After a mean followup of 194-15 months, renal function was maintained normal, all the patients are alive, and none of them has had a local recurrence or developed metatstatic disease. CONCLUSIONS: LPN is a feasible option for patients with small renal tumours and allows an oncological effectiveness. Clamping the renal pedicle is a safe technique with limited blood loss and operative time.
0i 4 NONN ~RO6~i~ ~iBiN ~ D¥SEU~CTiO N BASi~ E~EAR~Bii DOSE-DEPENDENT I M P R O V E M E N T OF U R E T H R A L PRESSURES AFTER APPLICATION OF MYOBLASTS
CLOSURE
Mitterberger M. 1, Marksteiner R. 2, Margreiter E. 2, Klima G ) , Fritsch H. 3, Pinggera G.M. 1, Raedler C. 4, Hering S. 5, Bartsch G. 1, Schuster R. 1, Strasser H. 1 Maliet R., Game X., Vaessen C., Mouzin M., Berrogain N., Sarramon J.E, Malavaud B., Rischmann R
CHU Rangueil, Dept. of Urology, Toulouse, France
INTRODUCTION & OBJECTIVES: To evaluate prospectively the iliac route for renal extraction after laparoscopic nephrectomy.
MATERIAL & METHODS: 30 laparoscopic nephrectomies (20 tumours and 10 live donor nephrectomies) were performed (lomboscopy: 10 cases, transperitoneai approach: 20 cases). Renal extraction was performed through a horizontal ipsilateral iliac route (length 5- 7 cm).
RESULTS: The iliac approach duration was 11 rnin +/- 2 min within an overall operative time of 188 +/- 50 min. It allowed the speedy extraction of large renal specimens (mean weight 571 +/- 127 g). No parietal post operative complications were observed after a mean follow-up of 9.6 +/- 1.2 months.
CONCLUSIONS: After laparoscopic nephrectomy, the extraction of the specimen can be performed through an iliac route without muscular section. There were no specific carcinological problems. This prospective study showed good anaesthetical and functional results.
1University of Innsbruck, Department of Urology, Innsbruck, Austria, 2University of Innsbruck, Department of Biochemical Pharmacology, Innsbruck, Austria, 3University of Innsbruck, Department of Anatomy, Innsbruck, Austria, 4University of Innsbmck, Department of Anaesthesiology, Innsbruck, Austria, 5University of Vienna~ Department of Pharmacoiogy, Vienna, Austria INTRODUCTION & OBJECTIVES: Transurethral ultrasound guided injection of autologous myohlasts has recently been shown to cure urinary stress incontinence. In the present study the dose-dependent changes of maximal urethral eiosure pressures (MUCP) after application of myoblasts were investigated in a porcine animal model. MATERIAL & METHODS: Myoblast cultures were obtained from one porcine muscle biopsy. The biopsy was enzymatically dissociated according to a modified cell dispersion technique. Single myoblasts in suspension were manually collected with a mieropipette under microscopic control. Fluorescence labeling was used to assess integration &the injected myoblasts into the rhabdosphincter. With the help of a transurethral ultrasound probe (23 F, 11 MHz) and injection system the myoblasts were injected into the rhabdosphincter of 5 pigs under direct sonographic control. In each pig several depots of heterologous myoblasts were injected into the rhabdosphincter in 2 different regions. The cell number in all 10 regions ranged between 7.8x107 and 1.5x106 cells. Immmaosuppressionof the pigs was achieved by means of daily injections of cortisone. Urethral pressure profiles were measured before and 2 weeks after injection to determine the postoperative changes of MUCE RESULTS: Histologic examination of the specimens revealed that the injected cells survived well and that the myoblasts fused to form myofibers. Postoperativeiy, MUCP were markedly increased (up to 312%) in the regions where higher concentrations of cells had been injected. Increase of MUCP was highest after transurethral application of 7.8x107 cells. After injection of low numbers of cells no increase in MUCP could be observed. CONCLUSIONS: The present data show that injected myoblasts survive well and that improvement of MUCP after injection of myoblasts depends on the dose of injected cells. If applied in a sufficiently high number, urethral closure pressures can be increased substantially.
European Urology Supplements 4 (2005) No. 3, pp. 205