Laparoscopic partial nephrectomy in cold ischemia: A novel technique

217 ABLATION RENAL TUMOURS RADIOFREQUENCY FOR TREATMENT IN POOR SURGICAL RISK PATIENTS: PRELIMINARY RESULTS IN 8 PATIENTS Badet L.‘, Paparel P.‘, Rouviere 0.‘. Lezrek M.‘, Marechal l.yonnet D:, Martin X.‘, Gelct A.’ s+lerriot Hospital University, ‘Herriot Hospital University, Urology, Meknes, Marocco

J.‘, C‘olombcl M.‘.

218 LAPAROSCOPIC RADICAL NEPHRECTOMY TECHNIQUES, AND ONCOLOGICAL OUTCOME WillcA.H.,

MATERIAL & METHODS: From June 2000 to August 2002, 8 patients with 12 small I-enal tumours were treated by radiofrequency. The mean patients’ age was 59 years and mean tumour diameter was 23 mm. 4 patients had a unique kidney, 2 patlent had chronic renal failure, I patient had Von Hippel Lindau disease and I patient had multiple angiornyolipomas. 5 patients were treated through a lomhotomy approach and 3 had a percutaneous access (2 by ultrasound guidance and 1 by computerized tomography (CT) guidance). Follow up was performed by CT and/or magnetic resonance imaging (MRI) with contrast agent injectIon to assess the tumoural devascularisation. RESULTS: l’he mean opemtive time was 1X0 min (with less than one bout when percutaneous access with ultrasound guidance). There were intraopcrative complications in one patient. The mean global hospitalisation time was 9 days (4 days for precutaneous access). Total devascularisation of the tumour was achieved in I I tumours (7 patients) after one single session. One of the two patients treated with percutaneous access by ultrasound guidance had an incomplete tumour necrosis (identified by CT-SCAN) and another radiofrequency treatment, 4 months later, reached complete tumour necrosis. One patient developed a severe urological complication with acute renal failure by renal pelvis sclerosis treated by double J stent The mean follo\v up was I I months (3 to 26 months). CONCLUSIONS: Radiofrcquency is an effective and feasible technique to treat small renal tumour7. with preservation of renal function when nephronsparing surgery is necessary. Howcvcr, further follow up and studies arc required to define tumour necrosis unaging criteria and to evaluate long-term results. This therapy must he used only in sclcctcd cases.

Roigas J.. Dcger S., Tiirk I

INTRODUCTION & OBJECTIVES: Renal cell carcinoma is likely to become one of the most important mdicatlons for laparoscopic surgery worldwide. The laparoscopic technique combines the benefits of the minimal invasive approach with the established surgical principles. In our institution the laparoscopic transpcritoneal approach with intact specimen extraction has hecomc the standard technique for radical nephrectomies. We report the indications, techniques and oncological outcome in a single centre experience. MATERIAL & METHODS: Between May 2000 and July 2002 we performed laparoscopic radical nephrectomies for renal cell cancer in 85 patients. To date 60 patients were available for follow up data and has been analysed for initial htaglng. complications and oncologlcal outcome. Patients with primark mctastatic disease were cxcludcd from this analysis. RESULTS: The mean tumour six was 5.3 cm (range 2 to I4 cm), the blood loss was 220 ml. The mean surgical time was 211 min, including the learning curves of 5 surgeons. Histological tindmgs were pTl in 43 (70”/0), pT2 in 3 (5%) and pT3 in 13 (22%) patients. In 2 cases (3%) histology did not proof malignant disease. Positive lymph nodes were detected in 3 cases (So/), surgical margins were negative for tumour in all patients. Follow up was between I and 30 months with an average of 12.9 months. Progressive disease occurred in 2 cases, one patient with a multifocal tmnour, the other one with positive lymph nodes. No cases of local recurrence occurred during observation. CONCLUSIONS: Laparoscoplc treatment for patients with pTl-2 grade of experience a tumour sire all the henetits of minimal surgery up is a\ailahle our follow-up data laparoscopic radical nephrectomy

radical nephrectomy is a routine, effective NOM0 renal cell carcinoma. With a higher up to IO-I? cm can be managed safely giving to the patients. Although no long-term follo\l up to 30 months confirm the cffectiveners of in terms of surgicalprinciples and oncological

oUtCoIllC.

220

219 NEPHRECTOMY

IN <‘OI,D ISCHEMIA:

KH der Ellaabethmen. Urology. tin/. Linr. Au&a.

‘KH dcr Flx~bcthincn.

Austria, ‘KH der Ellsahcthincn. Aneslhesiologb. t-in/. At&a

A

Radiology.

INTRODUCTIOR & OBJECTIVES: The ohjcctl\cs of nephrectomy fat- renal cell carcmoma (KC‘<‘)should be Grnilar Cold ischemla permits optimal tumour excision and renal prcscrvmg renal function. Ho~+cver, cold ischacmia with nephrectomy remains unsolved. WC dcacrihe our initial technique obtaining cold ischaemia during laparoscopy.

laparoscoplc partial to the open tcchniqoc reconstruction while laparoscoplc partial expcriencc with a new

MATERIAL & METHODS: BetweenNovember 0 I and Scptcmhcr 02 nine patients (RCC: 8, pyeloncphritic lower pole: 1) were operated using this technique. There were 6 men and 3 women with a mean age of 52 years (29-67). Mean tumour size wab 2.4 cm (2-3.5). Cold ischaemia wab achieved by cold arterial renal perfusion. Prior to laparoscopy an angiocathetcr was passed into the main renal artcry through a femoral Puncture. The renal artery wa\ clamped by a tourniquet. The renal vein was secured with an umbilical tape, but never occluded. Pcrfubion wnb initiated with iced Ringct Lactate at 4 degrees Celsius at a rate of 50 cc/min. Renal temperature was continuously monitored with a thcrmoprobe residing in the parenchyma. When a Parcnchymal tcmperaturc of 25” was reached perfusion was reduced to lmaintam a steady state. Tumour excision wa\ perfommcd in a hloodlcss field with biopsy taken from the tumour bed. The collecting system was repaired If needed. and renill

reconstruction was performed using parenchymal sutures over a haemostatic bolster. AlI steps were done sinxlar to the open partial ncphl-ectomy. in X casc~ and minor oozmg from an accessory renal artery occurred In one case. lotal ischacmia time was 27 to 71 minutes (mean 36 mm). Renal hypothenma was maintained at 25 degrees Celsius. Estimated blood loss was 30-650 cc (mean 135 cc); only one patient required kansfusions. Adequate tumour excision wuh negative margins was achieved in all

RESULTS:

Blood&s

INDICATIONS,

C’haritC Hospital, Urology. Berlin. Germany

Urology and Transplantation. Lyon, France, Radiology. Lyon, France. ‘Mckncs Hospital,

INTRODUCTION & OBJECTIVES: Radiofrequency is a recent altemativc to treat small renal turnours. In this preliminary study we report our experience for treatment of small renal lumours in 8 patients.

LAPAROSCOPlC PARTIAL NOVEL TECHNlQlJE

-

field was achlcvcd

cases. One patient had a delayed bleeding, which was managed by laparoscopic rcexPloration. No other postoperative complications were encountered. Postoperarive renal funcrion could bc investigated m 4 patients with isotope ncphrography and was essentially unchanged in all of them. cold i,chaemia into CDNCLU~~~)~~: o ur inltlal expencncc of Incorporating laParoscoplc partlnl nephrcctamy shows the fcasihdlly and safety of this technique. we bclievc this approach \\ill allow duplicatmn of the principlea of the open procedure and make, laparoacopic partial ncphl-cctirm) lbr RC’C’and complex renal Pathology safe and rchahlc.

IMPROVEMENT OF HEMOSTASIS OPEN PARTIAL NEPHRECTOMIES 1IATRIX (FI.OSE.ZL)

IN LAPAROSCOPICAL AND BY A GELATINE-THROMBIN-

I tillmann M.. Schnorr D.. Tiirh I.. Degcr S.. Richter F. (‘harite Hcrltn, Urology. Berlin. Germany lICl‘RODUC’I‘ION & OBJECTIVES: Long-term I\>llow-up \tudlcs have demonstrated that et’fectlvc tumour control and long-term progression free burVl\,al can he achicbcd by nephron sparing surgery. Ilowever. hemostasis is a major issue and the lack of effective means ofhemostasis has limited a wider use of the laparoscopic approach to nephron xparing surgery. MATERIAL & METHODS: Between January 2001 and August 2002. a torat of 36 patients with renal cell carcinomas were treated by partial ncphrectomy. using a two-component tissue sealant (FloSeal) for hemostasis. The median age was 55.2 years. Follow-up time was I IX months (median 5.5 months). The tumour diameter ranged from 2-5 cm (mean 2.9 cm). Seventeen cases wcrc pcrfortncd by open retroperitoncal surgery nineteen casts were pcl-formed laparoscopically. The t‘otlowing parameters were recorded: (I) Time until complctc hcmosrasis was achiebcd. (2) Decrease in postopereuve haemoglobin level. (3) Intraoperativc blood loss. (4) Postoperative bleeding. (5) Presence or absence of a pcrirenal hematoma 24 hours and IO days postoperatively by ultrasound. RESULTS: After application of tbc tissue sealant for I-2 minutes to the moist rcscctlon sltc, the hemostasis was Immediate in all cases. During the laparoscopically performed partial nephrcctomies. a laparoscopic applicator was used, that allowed to avoid wasting the tissue sealant within the dead space of the instrument. When reperfusion of the kidney was rc-established, hemostasis was maintained m all casts. The decrease in haemoglobin level ranged from 0.3 to 1.2 pomts (median 0.X points). None of the patient required blood transfusions. There were no casts of early or late postoperative bleeding. An ultrasound examination 24 hours and IO day5 postoperatively demonstrated the absence of significant pcrircnal hcmatomas. CONCLUSIONS: The two-component tissue scalant FloSeal provided illnxdiatc and durable hemostasis in open and lapal-oacopically performed i&al ncphrcctomics. Ihe Iissuc xalanl may pro\ldc a tool to c~pand the pussihilitles of laparoscopic nephron sparing surgery. European

Urology

Supplements

2 (2003) No. 1, pp. 57