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LAPAROSCOPIC PARTIAL NEPHRECTOMY FOR RENAL CELL TUMOURS IN WARM ISCHAEMIA
633
634
LAPAROSCOPIC PARTIAL NEPHRECTOMY FOR RENAL CELL TUMOURS IN WARM ISCHAEMIA
OPEN PARTIAL NEPHRECTOMY WITH SELECTIVE PARENCHYMAL CONTROL: A NEW RELIABLE CLAMP
Meixl H., Wakonig J., Jeschke K.
Nohra J.1, Huyghe E.1, El Khoury E.1, Khedis M.1, Soulie M.1, Roux D.2, Plante P.1
Landeskrankenhaus Klagenfurt, Department of Urology, Klagenfurt, Austria INTRODUCTION & OBJECTIVES: Laparoscopic partial nephrectomy became an alternative to open partial nephrectomy in a selected group of patients with small exophytic renal tumours. We want to present our experience and results in laparoscopic partial nephrectomy in warm ischemia in 100 patients. MATERIAL & METHODS: LPN was performed in 100 patients with arterial occlusion. The laparoscopic approach (transperitoneal versus retroperitoneal) depends on the tumour location. In a first step the hilar vessels were identified. Then the kidney was de-fatted except the region of the tumour and mobilized to get an optimal view of the resection area. Before clamping the renal artery for which we use laparoscopic bulldog clamps 100 ml of 20% Mannitol were given for nephroprotection. The resection itself was done sharply with endoscalpel and endoscissors. The collective system was sutured if necessary and haemostasis was achieved either by central sutures and fibrin glue or by closing the defect with parenchymal sutures. We made a follow up 6 weeks, 3 months and 6 months with CT-scan and serum-creatinin. RESULTS: The mean operating time was 83.9 min, the mean warm ischemia time was 21.89 min (range 12 – 37 min), and the preoperative and postoperative serum creatinin levels remained unchanged (range 0.52 – 2.42 mg/l). The mean tumour size was 2.38 cm (range 1.3 – 7 cm). The histopathological examination showed RCC in 84%. 4% showed a positive margin (R1). 9% showed AML, 3% showed an oncocytoma and 4% showed cysts without malignancy. In one case a conversion was necessary because the tumour could not be localised laparoscopically. Hemorrhagic complications occurred in 4 patients. Two of them underwent a secondary nephrectomy and in two patients haemorrhage could be managed conservative. Urinary leak occurred in two patients and was managed conservative with DJ-stenting of the ureter. CONCLUSIONS: LPN in warm ischemia could be performed save in selected patients. Our data show that in these patients renal function is not compromised and the oncological outcome is similar to open partial nephrectomy. To avoid major complications an experienced team of laparoscopic urological surgeons is necessary.
RENAL
1
Rangueil University Hospital, Urology, Toulouse, France, 2Rangueil University Hospital, Cardiovascular Surgery, Toulouse, France INTRODUCTION & OBJECTIVES: The goal of partial nephrectomy is complete local excision of the tumour with minimal complications, and optimal functional preservation of the renal remnant. We describe a technique for open partial nephrectomy with selective parenchymal clamping, using a new specially designed parenchymal clamp _Reni-Clamp®.
MATERIAL & METHODS: Between January 2002 and May 2005, Thirty three patients (mean age 63.4 years, range 34 - 83) were included. Among them, 30 underwent open partial nephrectomy with selective renal parenchymal clamping. For the 30 patients operated, the indication was imperative in four patients (solitary kidney) and relative or elective in 26 patients. The tumour was polar in 17 cases and external edge midrenal in 13. Mean tumour size was 29 mm (range 10-45). All patients had thoracoabdominal CT scan without evidence of metastasis. RESULTS: 30 patients underwent open partial nephrectomy with selective renal parenchymal clamping: mean operative time was 150 min (range 90-240), and mean parenchymal clamping time was 27 min (range 15-30). Blood loss ranged from 50 to 450 cc (means=150 cc). In all cases there was neither clamp slippage nor crushing parenchymal injury and no need to have pedicle control. Post operatively, no blood transfusion was needed, renal failure requiring permanent haemodialysis occurred in one patient with a solitary kidney and elevated preoperative creatinine level and urinary fistula successfully managed with ureteral pigtail catheter draining, which necessitated endoscopic treatment. CONCLUSIONS: Open partial nephrectomy can be safely and easily performed without renovascular occlusion using a specially designed selective renal prenchymal clamp, in almost all tumour location, except centrorenal lesions when tumour diameter is less than 40 mm.
635
636
LONGER-TERM OUTCOME OF NON-ISCHAEMIC PARTIAL NEPHRECTOMY USING MICROWAVE TISSUE COAGULATOR
PARTIAL NEPHRECTOMY FOR CENTRALLY LOCATED TUMOURS
Fujimoto K., Tanaka M., Tanaka M., Hirao Y.
Sheba Medical Centre, Urology, Ramat Gan, Israel
Nara Medical University, Urology, Kashihara, Japan
INTRODUCTION & OBJECTIVES: Partial nephrectomy has become the standard of care for tumours smaller than 4 cm in diameter. However, for centrally located tumours, radical nephrectomy is often offered to the patient in order to avoid technical difficulties and postoperative complications. The purpose of this study was to examine the complications and outcomes in patients with centrally located tumours that have originally been referred to radical nephrectomy, and eventually underwent nephron-sparing surgery at our institution.
INTRODUCTION & OBJECTIVES: Recently, partial nephrectomy is widely accepted for the nephron-sparing surgery (NSS) of small renal cell carcinoma, and a focus of controversy on NSS has shifted to considering how to do it rather than whether to do it or not. If NSS was intended, non-ischemic procedure is more preferable to minimize the loss of renal function as we had reported our favourable results previously. In this paper, we report the late sequel of non-ischemic partial nephrectomy by using a microwave tissue coagulator (MTC) which is a unique and skilful tool. MATERIAL & METHODS: Since September 1993, 124 kidneys of 121 patients with a mean age of 61 years underwent non-ischemic partial nephrectomy with an MTC.
Kleinmann N., Nadu A., Mor Y., Ramon J.
MATERIAL & METHODS: Between 2001-2005, 167 patients underwent wedge resection partial nephrectomy, 40 of them with centrally located tumours. Central tumours were defined either as tumours completely embedded in the renal parenchyma and/or as tumours reaching the renal pelvis, major calyces or major vessels near or at the hilum. Patient’s files were reviewed for data including age, location of the tumour, blood loss, duration of cold or warm ischemia, operative and post operative complications, frozen section biopsy results and histological findings (tumour size, type and status of the surgical margins).
RESULTS: A mean tumour size was 28 mm (10-70 mm) in diameter. Median values of operation time and blood loss were 150 min. and 180 ml, respectively. In all patients intended, 120 were successfully treated with this procedure, except for one elective patient who underwent immediately nephrectomy due to uncontrolled intraoperative bleeding. Nephrectomy subsequent to NSS was performed in 3 patients because of an unexpectedly concomitant RCC in an associated cyst, an aggressive RCC with high-grade spindle cell carcinoma, and persistent urinary fistula, individually. Eight patients were transfused (7%) and transient urine leakage was observed in only 5 patients. Local recurrence was observed in one patient 2 years after the MTC operation. All elective cases were alive without postoperative metastasis and 110 of 121 patients were alive. Eight patients with small RCC in the peripheral zone were successfully extirpated with non-ischemic laparoscopic MTC procedure. The detailed operative procedure will be presented in these cases.
RESULTS: The mean age was 59 years (18-83), the mean tumour-size was 2.8 cm (0.4-5) and two patients had a single kidney. Six procedures were performed laparoscopically. In 25 patients (62.5%) clamping of the renal artery was performed, and the operation was done under warm ischemia which lasted 26 minutes in average (10-50). The mean blood loss was 230 cc (50-1500) and there were no significant intra-operative complications. In 16 patients frozen section was taken, and in all cases it was negative for tumour. Two major post-operative complications were noted including pneumothorax and pulmonary emboli. Minor post-operative complications included fever (9 patients), phlebitis, atrial fibrillation, pneumonia, gout exacerbation and urinary retention in one patient each. No cases of post-operative bleeding or urinary leakage were recorded and in all cases preservation of the kidney was achieved. Histological findings demonstrated renal cell carcinoma (85%), oncocytoma (7.5%), and angiomyolipoma (7.5%). At follow-up, tumour recurrence occurred in one patient and no tumour related mortality was recorded.
CONCLUSIONS: Non-ischemic partial nephrectomy by using an MTC is a simple and reliable alternative to nephrectomy and it is quite likely that not only open approach but also laparoscopic approach is available for this procedure.
CONCLUSIONS: Nephron-sparing surgery for centrally located tumours is technically feasible and does not seem to be associated with increased morbidity. We believe that partial nephrectomy rather than radical nephrectomy should be considered in this subgroup of patients even when a normal contralateral kidney exists.
Eur Urol Suppl 2006;5(2):181
634
LAPAROSCOPIC PARTIAL NEPHRECTOMY FOR RENAL CELL TUMOURS IN WARM ISCHAEMIA
OPEN PARTIAL NEPHRECTOMY WITH SELECTIVE PARENCHYMAL CONTROL: A NEW RELIABLE CLAMP
Meixl H., Wakonig J., Jeschke K.
Nohra J.1, Huyghe E.1, El Khoury E.1, Khedis M.1, Soulie M.1, Roux D.2, Plante P.1
Landeskrankenhaus Klagenfurt, Department of Urology, Klagenfurt, Austria INTRODUCTION & OBJECTIVES: Laparoscopic partial nephrectomy became an alternative to open partial nephrectomy in a selected group of patients with small exophytic renal tumours. We want to present our experience and results in laparoscopic partial nephrectomy in warm ischemia in 100 patients. MATERIAL & METHODS: LPN was performed in 100 patients with arterial occlusion. The laparoscopic approach (transperitoneal versus retroperitoneal) depends on the tumour location. In a first step the hilar vessels were identified. Then the kidney was de-fatted except the region of the tumour and mobilized to get an optimal view of the resection area. Before clamping the renal artery for which we use laparoscopic bulldog clamps 100 ml of 20% Mannitol were given for nephroprotection. The resection itself was done sharply with endoscalpel and endoscissors. The collective system was sutured if necessary and haemostasis was achieved either by central sutures and fibrin glue or by closing the defect with parenchymal sutures. We made a follow up 6 weeks, 3 months and 6 months with CT-scan and serum-creatinin. RESULTS: The mean operating time was 83.9 min, the mean warm ischemia time was 21.89 min (range 12 – 37 min), and the preoperative and postoperative serum creatinin levels remained unchanged (range 0.52 – 2.42 mg/l). The mean tumour size was 2.38 cm (range 1.3 – 7 cm). The histopathological examination showed RCC in 84%. 4% showed a positive margin (R1). 9% showed AML, 3% showed an oncocytoma and 4% showed cysts without malignancy. In one case a conversion was necessary because the tumour could not be localised laparoscopically. Hemorrhagic complications occurred in 4 patients. Two of them underwent a secondary nephrectomy and in two patients haemorrhage could be managed conservative. Urinary leak occurred in two patients and was managed conservative with DJ-stenting of the ureter. CONCLUSIONS: LPN in warm ischemia could be performed save in selected patients. Our data show that in these patients renal function is not compromised and the oncological outcome is similar to open partial nephrectomy. To avoid major complications an experienced team of laparoscopic urological surgeons is necessary.
RENAL
1
Rangueil University Hospital, Urology, Toulouse, France, 2Rangueil University Hospital, Cardiovascular Surgery, Toulouse, France INTRODUCTION & OBJECTIVES: The goal of partial nephrectomy is complete local excision of the tumour with minimal complications, and optimal functional preservation of the renal remnant. We describe a technique for open partial nephrectomy with selective parenchymal clamping, using a new specially designed parenchymal clamp _Reni-Clamp®.
MATERIAL & METHODS: Between January 2002 and May 2005, Thirty three patients (mean age 63.4 years, range 34 - 83) were included. Among them, 30 underwent open partial nephrectomy with selective renal parenchymal clamping. For the 30 patients operated, the indication was imperative in four patients (solitary kidney) and relative or elective in 26 patients. The tumour was polar in 17 cases and external edge midrenal in 13. Mean tumour size was 29 mm (range 10-45). All patients had thoracoabdominal CT scan without evidence of metastasis. RESULTS: 30 patients underwent open partial nephrectomy with selective renal parenchymal clamping: mean operative time was 150 min (range 90-240), and mean parenchymal clamping time was 27 min (range 15-30). Blood loss ranged from 50 to 450 cc (means=150 cc). In all cases there was neither clamp slippage nor crushing parenchymal injury and no need to have pedicle control. Post operatively, no blood transfusion was needed, renal failure requiring permanent haemodialysis occurred in one patient with a solitary kidney and elevated preoperative creatinine level and urinary fistula successfully managed with ureteral pigtail catheter draining, which necessitated endoscopic treatment. CONCLUSIONS: Open partial nephrectomy can be safely and easily performed without renovascular occlusion using a specially designed selective renal prenchymal clamp, in almost all tumour location, except centrorenal lesions when tumour diameter is less than 40 mm.
635
636
LONGER-TERM OUTCOME OF NON-ISCHAEMIC PARTIAL NEPHRECTOMY USING MICROWAVE TISSUE COAGULATOR
PARTIAL NEPHRECTOMY FOR CENTRALLY LOCATED TUMOURS
Fujimoto K., Tanaka M., Tanaka M., Hirao Y.
Sheba Medical Centre, Urology, Ramat Gan, Israel
Nara Medical University, Urology, Kashihara, Japan
INTRODUCTION & OBJECTIVES: Partial nephrectomy has become the standard of care for tumours smaller than 4 cm in diameter. However, for centrally located tumours, radical nephrectomy is often offered to the patient in order to avoid technical difficulties and postoperative complications. The purpose of this study was to examine the complications and outcomes in patients with centrally located tumours that have originally been referred to radical nephrectomy, and eventually underwent nephron-sparing surgery at our institution.
INTRODUCTION & OBJECTIVES: Recently, partial nephrectomy is widely accepted for the nephron-sparing surgery (NSS) of small renal cell carcinoma, and a focus of controversy on NSS has shifted to considering how to do it rather than whether to do it or not. If NSS was intended, non-ischemic procedure is more preferable to minimize the loss of renal function as we had reported our favourable results previously. In this paper, we report the late sequel of non-ischemic partial nephrectomy by using a microwave tissue coagulator (MTC) which is a unique and skilful tool. MATERIAL & METHODS: Since September 1993, 124 kidneys of 121 patients with a mean age of 61 years underwent non-ischemic partial nephrectomy with an MTC.
Kleinmann N., Nadu A., Mor Y., Ramon J.
MATERIAL & METHODS: Between 2001-2005, 167 patients underwent wedge resection partial nephrectomy, 40 of them with centrally located tumours. Central tumours were defined either as tumours completely embedded in the renal parenchyma and/or as tumours reaching the renal pelvis, major calyces or major vessels near or at the hilum. Patient’s files were reviewed for data including age, location of the tumour, blood loss, duration of cold or warm ischemia, operative and post operative complications, frozen section biopsy results and histological findings (tumour size, type and status of the surgical margins).
RESULTS: A mean tumour size was 28 mm (10-70 mm) in diameter. Median values of operation time and blood loss were 150 min. and 180 ml, respectively. In all patients intended, 120 were successfully treated with this procedure, except for one elective patient who underwent immediately nephrectomy due to uncontrolled intraoperative bleeding. Nephrectomy subsequent to NSS was performed in 3 patients because of an unexpectedly concomitant RCC in an associated cyst, an aggressive RCC with high-grade spindle cell carcinoma, and persistent urinary fistula, individually. Eight patients were transfused (7%) and transient urine leakage was observed in only 5 patients. Local recurrence was observed in one patient 2 years after the MTC operation. All elective cases were alive without postoperative metastasis and 110 of 121 patients were alive. Eight patients with small RCC in the peripheral zone were successfully extirpated with non-ischemic laparoscopic MTC procedure. The detailed operative procedure will be presented in these cases.
RESULTS: The mean age was 59 years (18-83), the mean tumour-size was 2.8 cm (0.4-5) and two patients had a single kidney. Six procedures were performed laparoscopically. In 25 patients (62.5%) clamping of the renal artery was performed, and the operation was done under warm ischemia which lasted 26 minutes in average (10-50). The mean blood loss was 230 cc (50-1500) and there were no significant intra-operative complications. In 16 patients frozen section was taken, and in all cases it was negative for tumour. Two major post-operative complications were noted including pneumothorax and pulmonary emboli. Minor post-operative complications included fever (9 patients), phlebitis, atrial fibrillation, pneumonia, gout exacerbation and urinary retention in one patient each. No cases of post-operative bleeding or urinary leakage were recorded and in all cases preservation of the kidney was achieved. Histological findings demonstrated renal cell carcinoma (85%), oncocytoma (7.5%), and angiomyolipoma (7.5%). At follow-up, tumour recurrence occurred in one patient and no tumour related mortality was recorded.
CONCLUSIONS: Non-ischemic partial nephrectomy by using an MTC is a simple and reliable alternative to nephrectomy and it is quite likely that not only open approach but also laparoscopic approach is available for this procedure.
CONCLUSIONS: Nephron-sparing surgery for centrally located tumours is technically feasible and does not seem to be associated with increased morbidity. We believe that partial nephrectomy rather than radical nephrectomy should be considered in this subgroup of patients even when a normal contralateral kidney exists.
Eur Urol Suppl 2006;5(2):181