974 LAPAROSCOPIC PARTIAL NEPHRECTOMY (LPN). BICENTERIC RESULTS ABOUT 200 CASES

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974

Oncological results of Nephron Sparing Surgery for hilar tumours

Laparoscopic partial nephrectomy (LPN). Bicenteric results about 200 cases

Bernhard J.C.1, Ferrière J.M.1, Crepel M.2, Pasticier G.1, Lacroix B.3, Bellec L.4, Lopes D.5, Albouy B.6, Colombel M.7, Tostain J.3, Pfister C.6, Soulié M.4, Salomon L.5, De La Taille A.5, Abbou C.C.5, Pantuck A.J.8, Lam J.8, Belldegrun A.8, Guillé F.2, Patard J.J.2

Dujardin T.1, Massoud W.2, Rebai N.2, Saheb N.2, Alamé W.2, Dumonceau O.2, Molinier V.2, Baumert H.2

University Hospital, Urology, Bordeaux, France, 2University Hospital, Urology, Rennes, France, University Hospital, Urology, Saint-Etienne, France, 4University Hospital, Urology, Toulouse, France, 5University Hospital, Urology, Créteil, France, 6University Hospital, Urology, Rouen, France, 7University Hospital, Urology, Lyon, France, 8UCLA, Urology, Los Angeles, United States of America

1

1 3

Introduction & Objectives: To assess whether renal tumours hilar location has an impact on cancer control after Nephron Sparing Surgery (NSS). Material & Methods: 796 NSS procedures performed at 8 academic institutions were retrospectively analyzed. Positive surgical margin, local recurrence and cancer-specific death rates were compared according to tumour location. The impact in term of cancer control of both tumour size (smaller vs larger than 4cm) and indication (elective vs imperative) was also determined. A Chi-square test was used for comparing qualitative variables. Results: Among 796 NSS procedures, 90 had been performed for hilar tumours (11.3%). Mean follow up was 39 and 37 months for hilar and non hilar tumours respectively. The 2 groups were comparable for age, gender, tumour size, TNM stage, Fuhrman grade and histology. But not for indication. 48% of NSS procedures for hilar tumours were imperative compared to 31% for non hilar (p=0.002). As shown in the following table, no significant difference was observed between the 2 groups for positive margins, recurrence rates and cancer specific survival. Hilar NSS (n=90) Positive surgical 6.6% margin Local recurrence 5.5% Cancer specific death 3.3%

Non hilar NSS (n=706) 3%

p value

2.7% 4.4%

ns ns

ns

Finally, neither tumour size nor indication appeared to unfavourably impact cancer control after NSS for hilar tumours. Conclusions: Although hilar tumours are technically more challenging, NSS appears to be a valid option in this location as well. After a mean follow up of more than 3 years neither local recurrence nor cancer specific death was significantly different among hilar and non hilar tumours in this large retrospective study. With increasing experience in NSS, it appears that conservative surgery in well selected hilar tumours cases is a safe option.



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University Hospital Quebec, Urology, Quebec, Canada, 2Saint-Joseph Hospital, Urology, Paris, France Introduction & Objectives: LPN is gaining a remarkable place in the management of small renal tumours. Our study exposed the results of LPN in a series of 200 procedures performed in 2 different centers. Material & Methods: Between October 2001 and October 2006, LPN for small solid renal tumours were performed in 200 patients by 2 experimented laparoscopists (TG, HB). Data were recorded prospectively and analysed : operative time, warm ischemia time (WIT), blood loss, hospital stay, overall complication rate and pathology. Results: The conversion rate was 0.5% (1/200). The mean operative time was 125 min (range 55-240). Mean WIT was 26 min (range 6-66). WIT was longer than 40 minutes in 8 patients (4 %). In 25 patients (12,5 %), the renal artery wasn’t clamped. The mean blood loss was 228 cc (range 5-2000) and the transfusion rate was 6.5 %. The mean hospital stay was 4.75 days (range 1-30). The overall complication rate was 33.5 % (67/200). The histological examination demonstrated renal cell carcinoma (55 %), tubulopapillary carcinoma (21 %), chromophobic carcinoma (11 %), oncocytoma (7.5 %), angiomyolipoma (5 %) and miscellaneous tumours (0.5 %). Positive margin rate was 1% (2/200). Conclusions: LPN seems to be a safe and efficient minimally invasive technique. It is a valid option for the management of small renal tumour, when performed by experimented laparoscopist.



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Single center experience and extended follow-up of robot-assisted laparoscopic partial nephrectomy

Morbidity of Nephron Sparing Surgery for hilar tumours

Schwentner C., Lunacek A., Pelzer A., Steiner H., Neururer R., Bartsch G., Peschel R.

Bernhard J.C.1, Patard J.J.2, Pasticier G.1, Crepel M.2, Lacroix B.3, Bellec L.4, Lopes D.5, Albouy B.6, Colombel M.7, Tostain J.3, Pfister C.6, Soulié M.4, Salomon L.5, De La Taille A.5, Abbou C.C.5, Pantuck A.J.8, Lam J.8, Belldegrun A.8, Guillé F.8, Ferrière J.M.1

Medical University, Urology, Innsbruck, Austria Introduction & Objectives: Modern abdominal imaging discovers an increasing amount of small renal masses. Even in the presence of a normal contralateral kidney nephron-sparing partial nephrectomy is the standard of care. Technical difficulties – particularly intracorporeal suturing - and limitations considering hemostasis hamper the regular use of conventional laparoscopy. However, robotic laparoscopic surgery facilitates suturing and preparation allowing to imitate open surgery. Consequently, the learning curve is significantly reduced. Herein we present our 5-year experience with robot-assisted laparoscopic partial nephrectomy. Material & Methods: Between 2001 and 2006 a total of 26 patients (17 men and 9 women, mean 57.92 years) underwent robotic partial nephrectomy using the DaVinciR-system. Indications for surgery were either solid or cystic contrast-enhancing renal masses mainly located in the organ`s periphery. A total of 4 ports were used for the procedure. In 12 cases, an intra-arterial catheter was inserted for renal cooling before occlusion of the renal artery. The remaining 14 patients underwent partial nephrectomy after the renal hilum had been clamped in warm ischemia. Tumor excision and intracorporeal suturing were performed entirely with telerobotics. Following closure of the collecting system, FlosealR as well as classic bolstering sutures were applied to guarantee sufficient hemostasis. Results: Laparoscopy was successfully completed in all but one patient requiring open conversion. Mean operative time - including the set-up of the robot – was 147 minutes (100 to 262) substantially decreasing with surgical expertise. Namely, the last 10 cases required only a mean of 112 minutes (p<0.05). Mean cold ischemia time was 33 minutes (18-43) and warm ischemia was 23 minutes (14-30), respectively. Average hospital stay was 5.35 days (4-8) while no patient required intraoperative transfusions. Pathological stage was pT1a in 17, pT1b in 4 patients whereas 5 exhibited benign disease (onkocytoma, scar). A positive resection margin was found in only one single patient who required subsequent nephrectomy for local recurrence. Another patient developed local recurrence after 2 years leaving an oncological success in 93%. There was no prolonged urine extravasation or urinoma requiring further interventions. Conclusions: Robot-assisted laparoscopic partial nephrectomy is a valid approach. It safely allows to recapitulate the steps of the open technique implying comparable oncological results. Postoperative convalescence is significantly shorter leading to shorter hospital stays. In addition to that, robotic intracorporeal suturing guarantees adequate hemostasis as well as a water-tight closure of the collecting system. Finally, the robot-assisted technique offers substantially shorter learning curves making laparoscopic partial nephrectomy accessible to less skilled laparoscopic surgeons.

Eur Urol Suppl 2007;6(2):266

University Hospital, Urology, Bordeaux, France, 2University Hospital, Urology, Rennes, France, University Hospital, Urology, Saint-Etienne, France, 4University Hospital, Urology, Toulouse, France, University Hospital, Urology, Créteil, France, 6University Hospital, Urology, Rouen, France, 7University Hospital, Urology, Lyon, France, 8UCLA, Urology, Los Angeles, United States of America 1 3 5

Introduction & Objectives: To assess Nephron Sparing Surgery (NSS) peri-operative morbidity in hilar renal tumours. Material & Methods: 1005 NSS procedures performed at 8 academic institutions were retrospectively analyzed. Hilar and non hilar tumours were compared for variables such as renal vessels clamping duration, operative time, medical and surgical complications, blood loss, blood transfusion, urinary fistula rate and length of hospital stay. The impact on morbidity of tumour size (smaller or greater than 4cm) and indication (elective vs imperative) was also analyzed. Chi-square and Student t tests were used for comparing qualitative and quantitative variables respectively. Results: Among 1005 NSS cases, 108 were performed for hilar tumours (10.7%).

Renal vessels clamping time (mn) Mean Blood loss (mL) Mean Operative time (mn) Medical complications Surgical complications Urinary fistula Blood transfusion Length of hospital stay (days)

Hilar tumours (n=108) 24.5 629 171 min 20.4% 15.7% 5.6% 16.7% 9.8

Non hilar tumours (n=897) 19 481 153 min 11.4% 11.6% 2.9% 13.6% 8

p value ns 0.03 0.01 < 0.01 ns ns ns < 0.01

In 31% of hilar tumours measuring more than 4cm, surgical complications occurred compared to 10.1% in tumours ≤ 4cm (p=0.01). Finally, in the subset of hilar tumours, mean operative time (198 minutes vs 154 minutes), mean blood loss, (875 mL vs 415 mL) and blood transfusion rates (31.1% vs 6.35%) were all significantly increased when comparing imperative vs elective indications (p<0.01). Conclusions: Performing NSS in hilar tumours exposes to significantly increased intra-operative blood loss, medical complications rates and length of hospital stay. Tumour size and surgery indication also impact unfavourably NSS morbidity in such cases. Although overall NSS morbidity for hilar tumours remains acceptable in experienced hands, patient should be aware of such risks before undergoing surgery.