845 THIRD GENERATION ABDOMINAL SURGERY BY NATURAL ORIFICES: TRANSGASTRIC AND TRANSVESICAL COMBINED APPROACH

845

Third generation abdominal surgery by natural orifices: Transgastric and transvesical combined approach

Estevao L.1, Carla R.2, José P.3, Tiago H.C.4, Jose C.4, Jorge C.P.4, Minho University Study Group of Natural Orifices Translumenal Endoscopic Surgery Hospital Geral de Santo António, Urology, Porto, Portugal, Hospital São Marcos, Gastroenterology, Braga, Portugal, 3Hospital São Marcos, Anesthesiology, Braga, Portugal, 4 Hospital São João, Pediatric Surgery, Porto, Portugal 1

2

Introduction & Objectives: Recently various authors reported successful attempts to perform intra-abdominal surgery through transgastric pathway. However, isolate transgastric port raises some limitations in performing moderately complex upper abdominal surgeries. We assessed the feasibility and safety of a novel transvesical endoscopic approach to the peritoneal cavity and we verified the feasibility and technical benefits of transgastric and transvesical combined approach to overcome the limitations of isolated transgastric port in performing cholecystectomy in porcine model. Material & Methods: In seven consecutive anesthetized female pigs, we created a transgastric and transvesical combined approach to perform cholecystectomy. Transgastric access was achieved after perforation and dilatation of gastric wall with a needle knife and 18 mm balloon, respectively. Under cystoscopic control, an open-end ureteral catheter, a 0.035 inch guide-wire and a dilator of ureteral sheath were used to place a transvesical 5 mm overtube into peritoneal cavity. Using a two working-channel gastroscope positioned transgastrically and a one-working channel ureteroscope positioned transvesically, we carried out cholecystectomy in all animals. Once closure of the gastric hole revealed unreliable using endoclips, the animals were sacrificed and necropsy was performed immediately after surgical procedure. Results: Establishment of transvesical and transgastric accesses took place without complications. Under a CO2-pneumoperitoneum controlled by the transvesical port, gallbladder identification, cystic duct and artery exposure were easily achieved in all cases. Transvesical gallbladder grasping revealed particularly valuable to enhance gastroscopeguided dissection. Excluding two cases where mild liver surface hemorrhage and bile leak secondary to the sliding of cystic clips occurred, all remaining cholecystectomies were carried out without incidents. Conclusions: The transgastric and transvesical combined approach is feasible and revealed particularly useful to perform cholecystectomy through exclusive natural orifices. These studies provides encouragement for additional preclinical studies of transvesical surgery with or without combination with other natural orifices approaches to design new intra-abdominal scarless procedures in what seems to be the 3rd generation surgery.



847

Laparoscopic Radical Nephrectomy for T2 Renal Cell Carcinomas

Kim H.T.1, Yoo E.S.1, Cho S.R.2, Park C.H.3, Chung S.K.1, Kim B.W.1, Park Y.K.1, Kwon T.G.1

Complications of Laparoscopic Renal Surgery

846

Rosales A., Darras J., Salvador J., Palou J., De Graeve N., Montlleó M., Huguet J., Gómez J.J., Segarra J., Angeri O., Villavicencio H. Fundació Puigvert, Urology, Barcelona, Spain Introduction & Objectives: A few years ago, laparoscopy entered renal surgery as a promising less invasive surgical technique, reducing incision related morbidity, decreasing operative blood loss and postoperative analgetic need and accelerating postoperative recovery. We analyzed our data to check if these advantages are at the expense of more postoperative complications. Material & Methods: Between November 2000 and November 2005, 428 laparoscopic renal surgeries were performed (simple (33), radical (186), live donor (77) and partial nephrectomies (55) and nephroureterectomies (77)). All interventions were carried out transperitoneally with 4-5 trocars and pneumoperitoneum (13-15 mm Hg) was established performing a minilaparotomy. Prophylactic measures consisted of 1gr. Cefonicid and pneumatic calf compression. Energy sources were mono- and bipolar current, Ligasure and argon beam coagulator. Haemostasis was performed using metallic clips, Hem-o-lok clips, EndoGIA, Floseal, Bioglue, Surgicel or Dexon and Prolene sutures. Specimens were extracted using an Endocatch device from 10-15 mm. Surgical incisions used were Gibson, Pfannenstiel, McBurney and median laparotomy. Fascia of all incisions larger then 10 mm was closed. Initially laparoscopic surgery was performed by two different surgeons, but up till now this number has increased to ten. Results: Global complication rate was 11.7%. Mayor complications (3.5%) consisted of intestinal perforation (1), renal laceration (1), diaphragm lesion with pneumothorax (1), intestinal obstruction (1), spleen laceration and subsequent splenectomy (1) and 10 conversions due to mayor peroperative bleeding, due to vascular lesion (9) or EndoGIA malfunction (1). Minor complications (8.2%) consisted of urinary fistula (1), acute urinary retention (1), lymphatic fistula (1), peritonism due to CO2 insufflation (1), diplopia (1), pneumonia (2), urinary infection (2), paralytic ileus (2), wound infection (5), eventration (9) and symptomatic postoperative bleeding (10). 80% of all complications occurred in the first 20 laparoscopic interventions of each surgeon, except for the eventrations, which occurred on any point of the learning curve. Conclusions: Laparoscopic renal surgery is not free from complications, but our experience shows that it is a reproducible technique with a complication rate comparable to complication rates reported by other groups.



848

Enucleoresection for the elective treatment of small renal cell carcinoma: can it be the treatment of choice? Adamakis I., Koutalellis G., Mitropoulos D., Koritsiadis G., Constantinidis C., Zervas A.

School of Medicine, Kyungpook National University, Department of Urology, Daegu, South Korea, 2Fatima Hospital, Department of Urology, Daegu, South Korea, 3College of Medicine, Keimyung University, Department of Urology, Daegu, South Korea

“Laiko” General Hospital, University of Athens, Urology Clinic, Athens, Greece

Introduction & Objectives: A laparoscopic radical nephrectomy (LRN) has emerged as the standard management in clinical stage T1 renal cell carcinomas (RCC) (7cm or less). We extended our experience of LRN to stage T2 RCC (greater than 7cm) and compared the results with those of LRN for stage T1 RCC, as well as with those of open radical nephrectomy (ORN) for stage T2 RCC.

Material & Methods: A total of 43 patients, who underwent elective nephron sparing surgery performed with enucleoresection from January 1998 to August 2005 were studied retrospectively. The tumor is enucleated using electrocautery leaving around it a thin layer of healthy tissue technically feasible, which resulted to be 2-4mm. None of the patients had preoperative or intraoperative suspicion of positive nodes and were free from distant metastases before surgery (No, Mo). All patients were followed up with mean routine blood examination, chest x-ray, ultrasound and computed tomography scan every 6 months for 2 years and annually thereafter. Patients status was last evaluated in January 2006.

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Material & Methods: Between January 2001 and May 2006, a total of 142 patients, who underwent LRN for renal cell carcinomas, were retrospectively subdivided into the LRNT1 (n=101, tumor size≤7cm) or LRNT2 (n=41, tumor size>7cm) groups. The surgical outcomes and perioperative morbidities were retrospectively evaluated. Also, the results of the LRNT2 group were compared with those of the open radical nephrectomy T2 group(ORNT2, n=44). Results: Compared with the LRNT1 group, the LRNT2 group only had larger tumors, but comparable operation time, blood loss, variation in the creatinine value (ΔCr), analgesics requirements, time to ambulation and oral intake, hospital stay and complication rates. The tumor sizes were similar in the LRNT2 and ORNT2 groups (p=0.260). However, the LRNT2 group had shorter operation time (p=0.039), lesser blood loss (p=0.044), ΔCr (p=0.027), analgesic requirements (p<0.001) and time to ambulation, oral intake and hospital stay (p<0.001, all). Conclusions: A LRN for stage T2 RCC is feasible and efficacious. The surgical outcomes were comparable with those of a LRN for stage T1 tumors, with the advantages of decreased blood loss and more rapid recovery over that of an ORN for comparable tumors greater than 7cm in size.

Eur Urol Suppl 2007;6(2):234

Introduction & Objectives: We present our findings in a series of T1 renal cell carcinoma treated with excision of the tumor surrounded by a minimal layer of grossly normal parenchyma.

Results: Median age was 58.7 (35-78). Median tumor size was 3.3 cm (1.5-7). In our series mean and median shortest distance from tumor to inked healthy tissue margin was 2.8mm and 2.1mm respectively. Intraoperative biopsy of the tumor bed was never performed but no positive margin was present at final pathologic examination. There were no major complications such as bleeding and urinary leakage/ urinoma requiring reoperation. Pathological stage was pT1a in 38 (89%), pT1b in 4 (9%) and pT3a in 1 patient (2%). Median follow up was 32 months (range 6-89). A total of 5 patients with RCC had died as of January 2006. Three patients died of diseases unrelated to the tumor and two patients died of RCC progression. Overall, 3 patients had disease progression (6.9%) of whom 2 (4.6%) were local recurrence, 1 alone and 1 associated with distant metastases. The overall cancer specific survival was 95.4% and the overall progression-free survival was 93%. Conclusions: Enucleoresection is not a simple enucleation but neither a conventional partial nephrectomy. It is associated with considerable advantages such as lower incidence of major bleeding, collecting system damage and maximal preservation of renal parenchyma. It is not associated with increased risk of local recurrence compared to partial nephrectomy. It provides excellent progression-free and cancer specific survival rates similar to those of radical nephrectomy. Also, it’s associated with minimal morbidity and preservation of renal function in patients with a solitary kidney. Enucleoresection is a safe and acceptable approach for elective nephron sparing surgery.