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PARTIAL NEPHRECTOMY WITH RETROPERITONEAL LAPAROSCOPY
0022-5347/99/1626-1922/0 THE JOURNAL OF UROLOGY® Copyright © 1999 by AMERICAN UROLOGICAL ASSOCIATION, INC.®
Vol. 162, 1922–1926, December 1999 Printed in U.S.A.
PARTIAL NEPHRECTOMY WITH RETROPERITONEAL LAPAROSCOPY ´ HOZNEK, LAURENT SALOMON, PATRICK ANTIPHON, CATHERINE RADIER, ANDRAS ´ MOHAMED HAFIANI, DOMINIQUE K. CHOPIN AND CLEMENT-CLAUDE ABBOU From the Service d’Urologie and Service de Radiologie et d’Imagerie Me´dicale, Centre Hospitalier Universitaire Henri Mondor, Cre´teil, France
ABSTRACT
Purpose: Laparoscopy has gradually gained acceptance for a variety of ablative procedures of the retroperitoneal organs, and the indications are being extended to more complex reconstructive and organ preserving procedures. We report our experience with retroperitoneal laparoscopic partial nephrectomy. Materials and Methods: Retroperitoneal laparoscopic partial nephrectomy was performed for benign conditions in 6, equivocal solid masses in 4 and indeterminate cysts in 3 patients. If malignancy was suspected, laparoscopic sonography was used to assess the intrarenal anatomy and the mass. To facilitate parenchymal closure during nephron sparing surgery we used a hemostatic biological glue that consisted of gelatin, resorcinol and formaldehyde. Results: Average operating time was 113 minutes and average blood loss was 72 ml. Histological examination revealed malignancy in 1 of the 3 cystic lesions and 2 of the 4 equivocal solid masses. There were 2 postoperative urinomas. Conclusions: Partial nephrectomy with retroperitoneal laparoscopy is feasible, and has a reasonable operating time and blood loss. Laparoscopic ultrasound was an important decision making aid during surgery. The use of biological glue simplified hemostasis and closure of the collecting system but good quality drainage of the collecting system is still required to decrease the risk of urinoma. The development of surgical tools that allow bloodless and nontraumatic section of the renal parenchyma is required to facilitate laparoscopic nephron sparing surgery. The ultrasonic scalpel needs further evaluation in this setting. KEY WORDS: laparoscopy, kidney neoplasms, urogenital abnormalities, tissue adhesives, hemostasis
The success of laparoscopic surgery for ablative procedures of the retroperitoneal organs has led to extension of this method toward technically more complex reconstructive and organ preserving procedures. Laparoscopic or retroperitoneoscopic partial nephrectomy has been performed successfully for benign and malignant diseases.1– 4 However, this approach raises specific technical problems in terms of intraoperative vascular control, hemostasis and closure of the collecting system. The techniques and tools used during open surgery cannot be fully adapted to laparoscopic procedures. We report our experience with 13 partial nephrectomies. Contrary to most previous series, all of our cases involved a purely extraperitoneal laparoscopic approach. Furthermore, we used gelatin resorcinol formaldehyde glue instead of sutures, which simplified hemostasis and closure of the collecting system. MATERIALS AND METHODS
Between September 1995 and March 1998, 1 man and 12 women underwent retroperitoneal laparoscopic partial nephrectomy. Patient characteristics are detailed in the table. The indication for partial nephrectomy was duplex kidney with marked parenchymal atrophy at the superior pole in 1, hydrocalix and associated parenchymal atrophy in 5, an equivocal renal cyst in 3 and an indeterminate solid renal mass in 4 patients. Depending on the presenting symptoms, patients initially underwent excretory urography and/or abdominal ultrasound examination. Before surgery all patients underwent computerized tomography (CT) with intravenous injection of contrast material. If extensive parenchymal resection was
planned, a more detailed protocol comprising arterial, parenchymatous and venous phases was followed. In these cases spiral CT consisted of 1 mm. slices with a pitch of 1.3 mm., permitting sagittal and coronal spatial reconstruction, to detect polar arteries and to evaluate extension of the tumor in the renal sinus and veins. A ureteral catheter or Double-J* stent was placed during standard cystoscopy with the patient under general anesthesia. The patient was then placed in the lateral decubitus position, with the table fully broken. The first port site was created through a 2 cm. lumbar incision in the posterior axillary line just below the 12th rib, the preperitoneal space was finger dissected and the peritoneal reflection was pushed forward. The 4 additional trocars were placed under the guidance of the index finger, which was protected with a latex finger stall (see figure). The pneumoretroperitoneum was created with carbon dioxide insufflation. Pressure limits were 15 mm. Hg during completion of the working space and 10 mm. Hg during the rest of the procedure. The first anatomical landmark was the psoas muscle. Upward dissection along this muscle led to the renal pedicle. The stented ureter was also identified and exposed. Gerota’s fascia was incised and the perirenal fat was freed from the involved segment of the kidney. Laparoscopic ultrasound scanning (7.5 MHz. flexible probe) was used in cases of borderline cysts and solid masses to assess the intrarenal anatomy better and to help determine the margin of parenchymal incision at a safe distance from the diseased portion of the kidney. The entire kidney was explored to exclude the possibility of a second localization. A color and/or spectral Doppler method was used to assess tumoral and peritumoral vascularity. The renal pedicle was not entirely dissected in cases of pronounced parenchymal atrophy (hydrocalix or duplex kid-
Accepted for publication June 25, 1999.
* Medical Engineering Corp., New York, New York. 1922
Urinary tract infection with acute orchiepididymitis Arterial hypertention
11— 52 — M
Equivocal 20 mm. renal mass on CT with minimal adipose component (lt.) 35 Mm. hypo-enhancing calcified mass on CT (lt.)
35 Mm. hypo-enhancing solid mass (lt.) 13— 44 — F Persistent lumbar pain 25 Mm. heterogeneous renal mass 2 yrs. after episode of on CT (lt.) renal colic * Does not include stenting and positioning. † Double-J stent.
History lt. pyelonephritis
12— 40 — F
Duplex kidney with upper pole parenchymal atrophy (lt.)
Preop. Diagnosis/Associated Problems (side)
Medial renal hydrocalix, bifid ureter (rt.) Recurrent urinary tract Multiple hydrocalices of lower pole infection with pyelo(rt.)/cardiac valvulopathy nephritis Rt. flank pain Stone containing excluded lower pole hydrocalix (rt.) Gross hematuria, reHydrocalix of upper pole (rt.) current urinary tract infection Recurrent urinary tract Lt. mid caliceal hydrocalix, 20 3 infection 30 mm. stone (lt.) Flank pain Bosniak II 30 mm. atypical cyst (lt.) Flank pain Bosniak III 60 mm. atypical cyst with small solid parietal mass (lt.) Abdominal pain Bosniak III incidental 20 mm. cyst with thickened wall and calcified zone (rt.)
Intermittent flank pain 1 urinary tract infection for 10 yrs. Pyelonephritis
Presenting Symptoms
10— 35 — F
9— 47 — F
8— 51 — F
7— 60 — F
6— 50 — F
5— 29 — F
4— 71 — F
3— 22 — F
2— 17 — F
1— 40 — F
Pt. No.—Age—Sex
Failed puncture under CT (proximity of colon)
Failed shock wave lithotripsy
Contralat. nephrotomy for caliceal diverticulum
Previous Surgery
Transverse resection,† harmonic scalpel Transverse resection,† harmonic scalpel
Wedge resection
Wedge resection
Transverse resection†
Wedge resection
Resection of mid portion of kidney,† hydronephrotic system Wedge resection
Partial nephrectomy, hydronephrotic system Partial nephrectomy,† hydronephrotic system
— 8
120
10
7
10
2
—
—
—
—
—
—
—
Warm Ischemia (mins.)
180
200
120
150
120
40
60
90
50
120
100
Partial nephrectomy, hydronephrotic system Partial nephrectomy,† hydronephrotic system
Operative Time (mins.)* 120
Operation Heminephrectomy†
Patient characteristics
400
200
200
100
—
—
—
—
45
—
—
—
—
Blood Loss (ml.)
Angiomyolipoma
pT1 adenoca.
pT1 tubulopapillary
Angiomyolipoma
5 Mm. pT1 renal cell CA
Thyroid-like renal dysplasia
Renal dystrophy
Parenchymal atrophy
Parenchymal atrophy
Parenchymal atrophy
Parenchymal atrophy
Parenchymal atrophy
Parenchymal atrophy
Histology
4
5
12
4 1 12/Urinary leakage, radical nephrectomy 3
9
2
5
5 1 2/Urinoma, Double-J stent 5
5
5
6
Hospitalization Days/ Complications, Treatment
PARTIAL NEPHRECTOMY WITH RETROPERITONEAL LAPAROSCOPY
1923
1924
PARTIAL NEPHRECTOMY WITH RETROPERITONEAL LAPAROSCOPY
Patient positioning and port sites for extraperitoneal laparoscopy. a, 12 mm., scissors plus carbon dioxide insufflation. b, 10 mm., suction irrigation device or vascular clamp. c, 10 mm., laparoscope with 0-degree lens. d, 5 mm., retractor. e, 10 mm., retractor. AAL, anterior axillary line. PAL, posterior axillary line.
ney, cases 1 to 6) and segmental resection of the kidney was performed with rotating tip coagulating scissors. In the other patients, when temporary arrest of the renal perfusion was planned and a large portion of parenchyma was transected, the pedicle was entirely dissected. In these cases we used bipolar coagulation for step-by-step sectioning and coagulation of the parenchyma (cases 7 to 11). A nontraumatic vascular clamp was only applied for short periods en bloc to the vascular pedicle when bleeding could not be controlled with bipolar coagulation alone. Total duration of warm ischemia never exceeded 10 minutes. In our last 2 cases (12 to 13) we used a harmonic scalpel which cut and coagulated the tissue with 55 kHz. ultrasound transmission. In 1 of these patients no vascular clamping was necessary. After resection of the lesion the cut surface was covered with oxidized regenerated cellulose mesh impregnated with gelatin resorcinol formaldehyde glue. This prepackaged mixture consisted of 15 gm. gelatin, 5 gm. resorcinol and 20 ml. water in a sterile tube. Before use the glue was heated in a water bath at 45C for 10 minutes. Polymerization took 1 to 2 minutes and was activated just before laparoscopic use by adding 1 to 2 ml. 37% formaldehyde solution. The components of the glue were blended together extracorporeally and the surgical mesh was impregnated. The resulting flexible material was introduced with a grasping forceps through the 12 mm. port site and applied to the cut surface with gentle pressure until complete adhesion was obtained. The surgical specimen was removed through the 12 mm. port site, which was slightly extended forward if necessary. If malignancy was suspected, we routinely used an endoscopic bag to avoid direct parietal contact. The pneumoretroperitoneum was exsufflated and the puncture sites were closed using 2-zero polyglycolic acid sutures. A lumbar drain was left in place for 24 to 48 hours. The Double-J stent was left in situ for 1 month and the ureteral catheter was withdrawn after retrograde pyelography the day before hospital discharge. Preoperative and postoperative creatinine levels were determined in all patients. Radiological followup was adapted to the initial disease and was usually performed 4 to 6 weeks after stent removal. Excretory urography was done in patients with hydrocalix and the remainder underwent CT. RESULTS
Average operating time was 113 minutes (60 to 200) and average intraoperative blood loss was 72 ml. (0 to 400). There were no perioperative complications and all interventions were completed as planned. Histological examination showed parenchymal atrophy in all patients with hydrocalix and in
the duplex kidney. Of the 3 indeterminate cysts 1 corresponded to a pT1 renal cell carcinoma. Among the 4 solid masses histological examination revealed 2 angiomyolipomas, 1 tubulopapillary cancer and 1 clear cell adenocarcinoma. Surgical margins, as determined on the surgical specimen, were tumor-free in all patients with suspected malignancies. No local recurrences or trocar site metastasis occurred in the 3 patients with evidence of malignancy during a mean followup of 22 months (8, 17 and 41, respectively). There were 2 complications. In patient 4, who was operated on for a lower pole hydrocalix, the ureteral catheter was withdrawn 2 days postoperatively. She was discharged home the next day but presented with homolateral flank pain 4 days later. Ultrasound and CT revealed retroperitoneal urine collection, which was treated conservatively with the insertion of a Double-J stent for 1 month. Patient 9 underwent partial nephrectomy for an indeterminate lower pole cyst (Bosniak III), during which a Double-J stent was inserted. Flank pain and fever developed 4 days postoperatively. Radiological examination showed downward dislocation of the Double-J stent and retroperitoneal urine collection. Histological examination revealed a pT1 renal cell carcinoma. Given the complication and the presence of malignancy, and after discussion with the patient, we performed open radical nephrectomy. Histological examination indicated renal infarction, obliterative endarteritis of arteriosclerotic origin and no signs of malignancy. Average hospital stay (including rehospitalization for complications) was 6.1 days. Both kidneys of all patients were normally functional before surgery, and only patient 11 had a mild and transient postoperative increase in blood creatinine to 141 mmol./l. (normal 60 to 130). DISCUSSION
Partial nephrectomy is indicated in select cases of various benign and malignant lesions. In open surgical approaches the large parietal wound is mainly responsible for postoperative morbidity. Thus, attempts to replace this route with less invasive endoscopic procedures have been made in recent years. Laparoscopic and retroperitoneoscopic partial nephrectomy has been successfully performed for benign and malignant conditions.1– 4 Benign diseases treated with laparoscopic partial nephrectomy include poorly functioning renal moieties associated with ureteral duplication or horseshoe kidney,5 hydrocalix with urolithiasis or recurrent infection.1 In recent years there has been a marked increase in the number of incidentally discovered small indeterminate renal masses. Given the equivalent tumor-free survival rates, the substantial risk of over treating a benign lesion and the possibility of cancer in the other kidney, nephron sparing surgery is increasingly preferred for patients who have a single small unilateral tumor and a normal contralateral kidney.6 – 8 Atypical renal cysts may also require surgical removal, despite extensive radiological evaluation. A 25 to 75% incidence of cancer has been reported in Bosniak type III cysts9 but open exploration or nephrectomy seems to be too aggressive in such cases. Laparoscopic evaluation of these indeterminate cysts was recommended by Bellman9 and Santiago10 et al. Depending on the underlying disease, a clear distinction should be made among different types of partial nephrectomy. In partial nephrectomy for a hydronephrotic system the margins of tissue to be removed are usually obvious. In contrast, when a significant thickness of parenchyma is transected, 3 techniques are generally used. Polar segmental nephrectomy consists of isolating the involved branch of the renal artery and identifying the corresponding renal segment with dye injection into the branch or by suppressing its perfusion. However, if the lesion encompasses more than 1
PARTIAL NEPHRECTOMY WITH RETROPERITONEAL LAPAROSCOPY
renal segment, wedge resection or transverse resection may be required. Regardless of the indication partial nephrectomy is technically demanding. As the most significant complications are intraoperative bleeding, postoperative urine leakage and infection, hemostasis and closure of the renal cavity are the most crucial steps. However, the techniques used in open surgery cannot simply be transposed to laparoscopic surgery, because regional hypothermia is not feasible and suturing is difficult. Another inherent limitation of laparoscopy is that it only shows the surface of the organs and does not allow manual palpation of the anatomical structures. Several tools are being investigated to optimize renal parenchymal surgery during laparoscopy, including intraoperative endoscopic sonography, temporary suppression of renal blood flow, bloodless section of the parenchyma and alternative tissue approximation techniques. Laparoscopic ultrasound with color and/or spectral Doppler helps improve intraoperative assessment of the intrarenal anatomy and disease process.2, 4 It can be used to determine the precise site, number, extension and texture of the lesion, and its relationship with the vasculature and the collecting system. We mainly used this tool in cases of equivocal renal masses and cysts to determine the safe distance of the parenchyma from the lesion. All patients with malignancies had a tumor-free surgical margin, as determined on the surgical specimen. As regional hypothermia of the kidney is not feasible during laparoscopy, clamping the renal artery inevitably leads to warm ischemia. To minimize the need for clamping various tools have been developed to help achieve bloodless section of the renal parenchyma.1, 2 Monopolar electrocautery necessitates high energy levels and has a risk of distant electrical injury. Janetschek et al reported satisfactory results with bipolar coagulation forceps which permitted simultaneous step-by-step dissection and hemostasis.2 To avoid the risk of electrical injury other energy sources have also been used. The argon beam coagulator uses a stream of ionized argon gas to conduct radio frequency energy to the tissues without direct contact. The gas blows blood away and extensive painting of the raw parenchymal surface provides coagulation in the vessel walls with minimal tissue destruction. Winfield et al were able to seal the transected collecting system and obtain adequate hemostasis using this device during 6 laparoscopic partial nephrectomies for benign conditions in adults.1 The ultrasonic scalpel, which vibrates at 55 kHz., can be used to incise and coagulate the parenchyma with the same instrument. It has been tested on animals and in the clinical setting but the results are inconsistent.2, 11 We used rotating tip coagulating scissors for patients with pronounced parenchymal atrophy. In the other cases the renal pedicle was dissected and clamped if necessary. We used bipolar electrocautery for section of the parenchyma. Blood loss during the procedure was controlled and warm ischemia was limited. In our last 2 patients we used the harmonic scalpel and, thus, in 1 temporary arrest of renal perfusion was avoided. This new tool seems to be advantageous because it can be used to cut and coagulate the renal parenchyma without changing the instrument through the trocars. However, further experience is needed to determine the real value of this instrument. In open surgery suturing allows hemostasis and closure of the collecting system. However, suturing via the laparoscopic approach is difficult for ergonomic reasons and prolongs operating time. Furthermore, when the parenchyma and collecting system are coagulated during excision, complete repair with suture ligation is difficult because of the fragility of coagulated tissue. The parenchyma becomes ischemic in the concavity of the sutures when they are pulled tight. Several techniques have been developed to replace sutur-
1925 12
ing during laparoscopic partial nephrectomy. Ehrlich and Riedl13 et al used an endoscopic stapler to transect the renal parenchyma during heminephrectomy. This method has the advantage of simultaneous resection, hemostasis and tissue closure but is only adapted to thin or atrophic segments of renal parenchyma. In addition, the titanium staple line extruding into the collecting system may cause stone formation. The use of surgical glues is attractive because they provide immediately watertight tissue closure suited to video assisted endoscopic procedures.14 Fibrin glue is known for the ability to stop venous oozing because it reproduces the final steps of the coagulation cascade. It has been used by numerous groups during open partial nephrectomy15, 16 and noted to be helpful during laparoscopy.2 At our institution another biological glue, a mixture of gelatin resorcinol and formaldehyde, has been routinely used since 1973 for renal parenchymal surgery in cases of diffuse hemorrhage that are difficult to control, for example during partial nephrectomy, renal trauma and renal allograft rupture.17–19 For more than 25 years this gelatin resorcinol formaldehyde glue has also been used for hepatic, cardiovascular and pulmonary surgery.20 To our knowledge there have been no documented toxic reactions. In the urological setting gelatin resorcinol formaldehyde is suitable as a parenchymal sealant because of good adhesive properties on wet and dry tissue, and high tensile strength.14 On the basis of these clinical data and our experience during open surgery we adapted gelatin resorcinol formaldehyde for laparoscopic procedures. In our 13 partial nephrectomies the cut parenchymal surface was covered with a surgical mesh impregnated with gelatin resorcinol formaldehyde glue, which yielded adequate hemostasis and immediate watertight closure of the nephrotomy. However, 2 patients had postoperative urinary leakage. In addition to late failure of gluing and tissue necrosis due to coagulation damage, insufficient drainage of the collecting system (that is premature removal of the ureteral catheter in our first and dislocation of the Double-J stent in our second case) cannot be ruled out. These complications call attention to the importance of reliable postoperative drainage for a sufficient period.4 This goal is probably better achieved with a Double-J stent than a ureteral catheter because the latter prolongs hospitalization until catheter removal. Nevertheless, even with optimal drainage, urinary leakage should always be expected after partial nephrectomy due to late necrosis of the coagulated or sutured cut surface. If a urinoma develops, the consequences are less worrisome when it is strictly confined to the retroperitoneum. We performed all procedures via a purely retroperitoneal approach and conversion to open surgery was not necessary. In contrast, most authors consider the transperitoneal approach optimal for ergonomic reasons and argue that the working space is limited with the retroperitoneal approach. In our experience the size of the working space with the retroperitoneal approach depends mainly on the extent of dissection. The number and position of the trocars have a key role in the quality of the exposure. There were no particular technical difficulties related to the retroperitoneal approach, and operating times were similar to those during open surgery.
CONCLUSIONS
Retroperitoneal laparoscopy is an appropriate approach to partial nephrectomy. Operating time and blood loss are acceptable. The laparoscopic ultrasound probe is valuable for precise intraoperative assessment of the intrarenal anatomy and disease process. The development of surgical tools that allow bloodless parenchymal section without deep tissue damage must be pursued. The use of biological glue simplifies hemostasis and closure of the collecting system but good quality drainage provides additional safety.
1926
PARTIAL NEPHRECTOMY WITH RETROPERITONEAL LAPAROSCOPY REFERENCES
1. Winfield, H. N., Donovan, J. F., Lund, G. O., Kreder, K. J., Stanley, K. E., Brown, B. P., Loening, S. A. and Clayman, R. V.: Laparoscopic partial nephrectomy: initial experience and comparison to the open surgical approach. J. Urol., 153: 1409, 1995. 2. Janetschek, G., Daffner, P., Peschel, R. and Bartsch, G.: Laparoscopic nephron sparing surgery for small renal cell carcinoma. J. Urol., 159: 1152, 1998. 3. Gill, I. S., Delworth, M. G. and Munch, L. C.: Laparoscopic retroperitoneal partial nephrectomy. J. Urol., 152: 1539, 1994. 4. McDougall, E. M., Elbahnasy, A. M. and Clayman, R. V.: Laparoscopic wedge resection and partial nephrectomy—the Washington University experience and review of the literature. J. Soc. Laparoendosc. Surg., 2: 15, 1998. 5. Janetschek, G., Seibold, J., Radmayr, C. and Bartsch, G.: Laparoscopic heminephroureterectomy in pediatric patients. J. Urol., 158: 1928, 1997. 6. Silver, D. A., Morash, C., Brenner, P., Campbell, S. and Russo, P.: Pathologic findings at the time of nephrectomy for renal mass. Ann. Surg. Oncol., 4: 570, 1997. 7. Lerner, S. E., Hawkins, C. A., Blute, M. L., Grabner, A., Wollan, P. C., Eickholt, J. T. and Zincke, H.: Disease outcome in patients with low stage renal cell carcinoma treated with nephron sparing or radical surgery. J. Urol., 155: 1868, 1996. 8. Butler, B. P., Novick, A. C., Miller, D. P., Campbell, S. A. and Licht, M. R.: Management of small unilateral renal cell carcinomas: radical versus nephron-sparing surgery. Urology, 45: 34, 1995. 9. Bellman, G. C., Yamaguchi, R. and Kaswick, J.: Laparoscopic evaluation of indeterminate renal cysts. Urology, 45: 1066, 1995. 10. Santiago, L., Yamaguchi, R., Kaswick, J. and Bellman, G. C.: Laparoscopic management of indeterminate renal cysts. Urology, 52: 379, 1998. 11. Elashry, O. M., Wolf, J. S., Jr., Rayala, H. J., McDougall, E. M. and Clayman, R. V.: Recent advances in laparoscopic partial nephrectomy: comparative study of electrosurgical snare electrode and ultrasound dissection. J. Endourol., 11: 15, 1997. 12. Ehrlich, R. M., Gershman, A. and Fuchs, G.: Laparoscopic renal surgery in children. J. Urol., 151: 735, 1994. 13. Riedl, C. R., Huebner, W. A., Schramek, P. and Pflueger, H.: Laparoscopic hemi-nephrectomy in a horseshoe kidney. Brit. J. Urol., 76: 140, 1995. 14. Eden, C. G. and Coptcoat, M. J.: Assessment of alternative tissue approximation techniques for laparoscopy. Brit. J. Urol., 78: 234, 1996. 15. Levinson, A. K., Swanson, D. A., Johnson, D. E., Greskovich, F. J., III, Stephenson, R. A. and Lichtiger, B.: Fibrin glue for partial nephrectomy. Urology, 38: 314, 1991. 16. Scott, R., Meddings, R. N. and Buckley, J. F.: Use of fibrin glue for partial nephrectomy. Urology, 39: 589, 1992. 17. Kelemen, Z., Luccioni, P., Lachand, A. T. and Auvert, J.: Etude expe´rimentale de l’effet he´mostatique de la colle biologiqueG. R. F. applique´e sur les tranches de parenchyme re´nal. Ann. Chir., 26: 807, 1972. 18. Auvert, J., Kelemen Z. S. and Weisgerber, G.: Applications de la colle he´mostatique G. R. F. en chirurgie. Nouvelle Presse Med., 4: 733, 1975. 19. Chopin, D. K., Abbou, C. C., Lottmann, H. B., Popov, Z., Lang, P. R., Buisson, C. L., Belghiti, D., Colombel, M. and Auvert, J. M.: Conservative treatment of renal allograft rupture with polyglactin 910 mesh and gelatin resorcin formaldehyde glue. J. Urol., 142: 363, 1989. 20. Bachet, J., Goudot, B., Dreyfus, G., Banfi, C., Ayle, N. A., Aota, M., Brodaty, D., Dubois, C., Delentdecker, P. and Guilmet, D.: The proper use of glue: a 20-year experience with the gelatin resorcinol formaldehyde glue in acute aortic dissection. J. Card. Surg., 12: 243, 1997. EDITORIAL COMMENT The authors report their experience with partial nephrectomy using the retroperitoneal laparoscopic approach. They performed the procedures successfully with minimal complications and in a reason-
able amount of time. However, the surgical indications for a number of patients in this series are unclear. Is it necessary to perform partial nephrectomy in patients with a hydrocalix? Flexible ultrasound probes have been an important addition to the armamentarium required for certain laparoscopic procedures (references 2 and 4 in article). The authors’ experience further underscores the importance of using laparoscopic ultrasound probes to evaluate the intrarenal anatomy and to assist in determining the margins of parenchymal incision in patients with suspected malignancy. All of the patients with malignancy in this series had tumor-free surgical margins in the retrieved specimens. I am not certain that the authors make a strong case for using the gelatin resorcinol formaldehyde glue for hemostasis and closure of the collecting system. In all of their patients the cut perenchymal surface was not sutured but rather covered with a surgical mesh impregnated with glue. However, 2 patients had postoperative urinary leakage requiring further intervention. Although these patients may have had inadequate postoperative urinary drainage, the authors state in the discussion that “even with optimal drainage, urinary leakage should always be expected after partial nephrectomy. . .”. However, this is not the predominant opinion of surgeons currently performing partial nephrectomy. A watertight anastomosis of the collecting system as well as possible testing with retrograde injection to assess for adequate closure has made urinoma formation mostly anecdotal. Further experience will be necessary with the use of gelatin resorcinol formaldehyde glue before it can be widely applied as the sole modality for tissue closure in patients undergoing partial nephrectomy. The authors add valuable experience to the growing literature for laparoscopic partial nephrectomy, especially with the retroperitoneal approach. Anthony Atala Department of Urology Children’s Hospital Boston, Massachusetts REPLY BY AUTHORS Partial nephrectomy is indicated in select cases of hydrocalix. In our patients indications for surgery comprised recurrent urinary tract infection, gross hematuria, stone formation and flank pain. Suture anastomosis is the gold standard in urology when the collecting system is opened during a surgical procedure. However, some alternative, still widely accepted methods are exceptions to this rule. For example, urologists performing Acucise* pyeloplasty rely on only draining the collecting system. During partial nephrectomy the parenchyma and collecting system are usually incised with an instrument that coagulates at the same time, which inevitably leads to some degree of coagulation necrosis. Thus, the tissues to be closed often become fragile and the sutures may further contribute to ischemic damage. For this reason a fistula can occur several days later even if the anastomosis is perfectly watertight at the end of surgery. Campbell et al observed urinary fistula in 45 patients (17%) in a series of 259 open partial nephrectomies, despite reconstruction of the collecting system as necessary.1 However, only 1 patient required open operative repair, and in the remainder the fistula resolved either spontaneously or with endoscopic management. This finding further underlines the role of draining the renal cavities. In our series at the end of surgery the glued parenchyma was always watertight when tested with retrograde injection of indigo carmine dye saline solution. On the other hand, suturing should not be systematically ruled out in laparoscopic partial nephrectomy, and additional suture anastomosis may be justified when the renal cavities are clearly seen and there is a need for major reconstruction. In these instances, the gelatin resorcinol formaldehyde glue is a useful adjunct to reinforce the suture line and help stop parenchymal oozing. Based on all of these considerations, we believe that alternative tissue approximation methods merit evaluation to determine their role in urological surgery and particularly in laparoscopy. 1. Campbell, S. C., Novick, A. C., Streem, S. B., Klein, E. and Licht, M.: Complications of nephron sparing surgery for renal tumors. J. Urol., 151: 1177, 1994. *Applied Medical Resources, Laguna Hills, California.
Vol. 162, 1922–1926, December 1999 Printed in U.S.A.
PARTIAL NEPHRECTOMY WITH RETROPERITONEAL LAPAROSCOPY ´ HOZNEK, LAURENT SALOMON, PATRICK ANTIPHON, CATHERINE RADIER, ANDRAS ´ MOHAMED HAFIANI, DOMINIQUE K. CHOPIN AND CLEMENT-CLAUDE ABBOU From the Service d’Urologie and Service de Radiologie et d’Imagerie Me´dicale, Centre Hospitalier Universitaire Henri Mondor, Cre´teil, France
ABSTRACT
Purpose: Laparoscopy has gradually gained acceptance for a variety of ablative procedures of the retroperitoneal organs, and the indications are being extended to more complex reconstructive and organ preserving procedures. We report our experience with retroperitoneal laparoscopic partial nephrectomy. Materials and Methods: Retroperitoneal laparoscopic partial nephrectomy was performed for benign conditions in 6, equivocal solid masses in 4 and indeterminate cysts in 3 patients. If malignancy was suspected, laparoscopic sonography was used to assess the intrarenal anatomy and the mass. To facilitate parenchymal closure during nephron sparing surgery we used a hemostatic biological glue that consisted of gelatin, resorcinol and formaldehyde. Results: Average operating time was 113 minutes and average blood loss was 72 ml. Histological examination revealed malignancy in 1 of the 3 cystic lesions and 2 of the 4 equivocal solid masses. There were 2 postoperative urinomas. Conclusions: Partial nephrectomy with retroperitoneal laparoscopy is feasible, and has a reasonable operating time and blood loss. Laparoscopic ultrasound was an important decision making aid during surgery. The use of biological glue simplified hemostasis and closure of the collecting system but good quality drainage of the collecting system is still required to decrease the risk of urinoma. The development of surgical tools that allow bloodless and nontraumatic section of the renal parenchyma is required to facilitate laparoscopic nephron sparing surgery. The ultrasonic scalpel needs further evaluation in this setting. KEY WORDS: laparoscopy, kidney neoplasms, urogenital abnormalities, tissue adhesives, hemostasis
The success of laparoscopic surgery for ablative procedures of the retroperitoneal organs has led to extension of this method toward technically more complex reconstructive and organ preserving procedures. Laparoscopic or retroperitoneoscopic partial nephrectomy has been performed successfully for benign and malignant diseases.1– 4 However, this approach raises specific technical problems in terms of intraoperative vascular control, hemostasis and closure of the collecting system. The techniques and tools used during open surgery cannot be fully adapted to laparoscopic procedures. We report our experience with 13 partial nephrectomies. Contrary to most previous series, all of our cases involved a purely extraperitoneal laparoscopic approach. Furthermore, we used gelatin resorcinol formaldehyde glue instead of sutures, which simplified hemostasis and closure of the collecting system. MATERIALS AND METHODS
Between September 1995 and March 1998, 1 man and 12 women underwent retroperitoneal laparoscopic partial nephrectomy. Patient characteristics are detailed in the table. The indication for partial nephrectomy was duplex kidney with marked parenchymal atrophy at the superior pole in 1, hydrocalix and associated parenchymal atrophy in 5, an equivocal renal cyst in 3 and an indeterminate solid renal mass in 4 patients. Depending on the presenting symptoms, patients initially underwent excretory urography and/or abdominal ultrasound examination. Before surgery all patients underwent computerized tomography (CT) with intravenous injection of contrast material. If extensive parenchymal resection was
planned, a more detailed protocol comprising arterial, parenchymatous and venous phases was followed. In these cases spiral CT consisted of 1 mm. slices with a pitch of 1.3 mm., permitting sagittal and coronal spatial reconstruction, to detect polar arteries and to evaluate extension of the tumor in the renal sinus and veins. A ureteral catheter or Double-J* stent was placed during standard cystoscopy with the patient under general anesthesia. The patient was then placed in the lateral decubitus position, with the table fully broken. The first port site was created through a 2 cm. lumbar incision in the posterior axillary line just below the 12th rib, the preperitoneal space was finger dissected and the peritoneal reflection was pushed forward. The 4 additional trocars were placed under the guidance of the index finger, which was protected with a latex finger stall (see figure). The pneumoretroperitoneum was created with carbon dioxide insufflation. Pressure limits were 15 mm. Hg during completion of the working space and 10 mm. Hg during the rest of the procedure. The first anatomical landmark was the psoas muscle. Upward dissection along this muscle led to the renal pedicle. The stented ureter was also identified and exposed. Gerota’s fascia was incised and the perirenal fat was freed from the involved segment of the kidney. Laparoscopic ultrasound scanning (7.5 MHz. flexible probe) was used in cases of borderline cysts and solid masses to assess the intrarenal anatomy better and to help determine the margin of parenchymal incision at a safe distance from the diseased portion of the kidney. The entire kidney was explored to exclude the possibility of a second localization. A color and/or spectral Doppler method was used to assess tumoral and peritumoral vascularity. The renal pedicle was not entirely dissected in cases of pronounced parenchymal atrophy (hydrocalix or duplex kid-
Accepted for publication June 25, 1999.
* Medical Engineering Corp., New York, New York. 1922
Urinary tract infection with acute orchiepididymitis Arterial hypertention
11— 52 — M
Equivocal 20 mm. renal mass on CT with minimal adipose component (lt.) 35 Mm. hypo-enhancing calcified mass on CT (lt.)
35 Mm. hypo-enhancing solid mass (lt.) 13— 44 — F Persistent lumbar pain 25 Mm. heterogeneous renal mass 2 yrs. after episode of on CT (lt.) renal colic * Does not include stenting and positioning. † Double-J stent.
History lt. pyelonephritis
12— 40 — F
Duplex kidney with upper pole parenchymal atrophy (lt.)
Preop. Diagnosis/Associated Problems (side)
Medial renal hydrocalix, bifid ureter (rt.) Recurrent urinary tract Multiple hydrocalices of lower pole infection with pyelo(rt.)/cardiac valvulopathy nephritis Rt. flank pain Stone containing excluded lower pole hydrocalix (rt.) Gross hematuria, reHydrocalix of upper pole (rt.) current urinary tract infection Recurrent urinary tract Lt. mid caliceal hydrocalix, 20 3 infection 30 mm. stone (lt.) Flank pain Bosniak II 30 mm. atypical cyst (lt.) Flank pain Bosniak III 60 mm. atypical cyst with small solid parietal mass (lt.) Abdominal pain Bosniak III incidental 20 mm. cyst with thickened wall and calcified zone (rt.)
Intermittent flank pain 1 urinary tract infection for 10 yrs. Pyelonephritis
Presenting Symptoms
10— 35 — F
9— 47 — F
8— 51 — F
7— 60 — F
6— 50 — F
5— 29 — F
4— 71 — F
3— 22 — F
2— 17 — F
1— 40 — F
Pt. No.—Age—Sex
Failed puncture under CT (proximity of colon)
Failed shock wave lithotripsy
Contralat. nephrotomy for caliceal diverticulum
Previous Surgery
Transverse resection,† harmonic scalpel Transverse resection,† harmonic scalpel
Wedge resection
Wedge resection
Transverse resection†
Wedge resection
Resection of mid portion of kidney,† hydronephrotic system Wedge resection
Partial nephrectomy, hydronephrotic system Partial nephrectomy,† hydronephrotic system
— 8
120
10
7
10
2
—
—
—
—
—
—
—
Warm Ischemia (mins.)
180
200
120
150
120
40
60
90
50
120
100
Partial nephrectomy, hydronephrotic system Partial nephrectomy,† hydronephrotic system
Operative Time (mins.)* 120
Operation Heminephrectomy†
Patient characteristics
400
200
200
100
—
—
—
—
45
—
—
—
—
Blood Loss (ml.)
Angiomyolipoma
pT1 adenoca.
pT1 tubulopapillary
Angiomyolipoma
5 Mm. pT1 renal cell CA
Thyroid-like renal dysplasia
Renal dystrophy
Parenchymal atrophy
Parenchymal atrophy
Parenchymal atrophy
Parenchymal atrophy
Parenchymal atrophy
Parenchymal atrophy
Histology
4
5
12
4 1 12/Urinary leakage, radical nephrectomy 3
9
2
5
5 1 2/Urinoma, Double-J stent 5
5
5
6
Hospitalization Days/ Complications, Treatment
PARTIAL NEPHRECTOMY WITH RETROPERITONEAL LAPAROSCOPY
1923
1924
PARTIAL NEPHRECTOMY WITH RETROPERITONEAL LAPAROSCOPY
Patient positioning and port sites for extraperitoneal laparoscopy. a, 12 mm., scissors plus carbon dioxide insufflation. b, 10 mm., suction irrigation device or vascular clamp. c, 10 mm., laparoscope with 0-degree lens. d, 5 mm., retractor. e, 10 mm., retractor. AAL, anterior axillary line. PAL, posterior axillary line.
ney, cases 1 to 6) and segmental resection of the kidney was performed with rotating tip coagulating scissors. In the other patients, when temporary arrest of the renal perfusion was planned and a large portion of parenchyma was transected, the pedicle was entirely dissected. In these cases we used bipolar coagulation for step-by-step sectioning and coagulation of the parenchyma (cases 7 to 11). A nontraumatic vascular clamp was only applied for short periods en bloc to the vascular pedicle when bleeding could not be controlled with bipolar coagulation alone. Total duration of warm ischemia never exceeded 10 minutes. In our last 2 cases (12 to 13) we used a harmonic scalpel which cut and coagulated the tissue with 55 kHz. ultrasound transmission. In 1 of these patients no vascular clamping was necessary. After resection of the lesion the cut surface was covered with oxidized regenerated cellulose mesh impregnated with gelatin resorcinol formaldehyde glue. This prepackaged mixture consisted of 15 gm. gelatin, 5 gm. resorcinol and 20 ml. water in a sterile tube. Before use the glue was heated in a water bath at 45C for 10 minutes. Polymerization took 1 to 2 minutes and was activated just before laparoscopic use by adding 1 to 2 ml. 37% formaldehyde solution. The components of the glue were blended together extracorporeally and the surgical mesh was impregnated. The resulting flexible material was introduced with a grasping forceps through the 12 mm. port site and applied to the cut surface with gentle pressure until complete adhesion was obtained. The surgical specimen was removed through the 12 mm. port site, which was slightly extended forward if necessary. If malignancy was suspected, we routinely used an endoscopic bag to avoid direct parietal contact. The pneumoretroperitoneum was exsufflated and the puncture sites were closed using 2-zero polyglycolic acid sutures. A lumbar drain was left in place for 24 to 48 hours. The Double-J stent was left in situ for 1 month and the ureteral catheter was withdrawn after retrograde pyelography the day before hospital discharge. Preoperative and postoperative creatinine levels were determined in all patients. Radiological followup was adapted to the initial disease and was usually performed 4 to 6 weeks after stent removal. Excretory urography was done in patients with hydrocalix and the remainder underwent CT. RESULTS
Average operating time was 113 minutes (60 to 200) and average intraoperative blood loss was 72 ml. (0 to 400). There were no perioperative complications and all interventions were completed as planned. Histological examination showed parenchymal atrophy in all patients with hydrocalix and in
the duplex kidney. Of the 3 indeterminate cysts 1 corresponded to a pT1 renal cell carcinoma. Among the 4 solid masses histological examination revealed 2 angiomyolipomas, 1 tubulopapillary cancer and 1 clear cell adenocarcinoma. Surgical margins, as determined on the surgical specimen, were tumor-free in all patients with suspected malignancies. No local recurrences or trocar site metastasis occurred in the 3 patients with evidence of malignancy during a mean followup of 22 months (8, 17 and 41, respectively). There were 2 complications. In patient 4, who was operated on for a lower pole hydrocalix, the ureteral catheter was withdrawn 2 days postoperatively. She was discharged home the next day but presented with homolateral flank pain 4 days later. Ultrasound and CT revealed retroperitoneal urine collection, which was treated conservatively with the insertion of a Double-J stent for 1 month. Patient 9 underwent partial nephrectomy for an indeterminate lower pole cyst (Bosniak III), during which a Double-J stent was inserted. Flank pain and fever developed 4 days postoperatively. Radiological examination showed downward dislocation of the Double-J stent and retroperitoneal urine collection. Histological examination revealed a pT1 renal cell carcinoma. Given the complication and the presence of malignancy, and after discussion with the patient, we performed open radical nephrectomy. Histological examination indicated renal infarction, obliterative endarteritis of arteriosclerotic origin and no signs of malignancy. Average hospital stay (including rehospitalization for complications) was 6.1 days. Both kidneys of all patients were normally functional before surgery, and only patient 11 had a mild and transient postoperative increase in blood creatinine to 141 mmol./l. (normal 60 to 130). DISCUSSION
Partial nephrectomy is indicated in select cases of various benign and malignant lesions. In open surgical approaches the large parietal wound is mainly responsible for postoperative morbidity. Thus, attempts to replace this route with less invasive endoscopic procedures have been made in recent years. Laparoscopic and retroperitoneoscopic partial nephrectomy has been successfully performed for benign and malignant conditions.1– 4 Benign diseases treated with laparoscopic partial nephrectomy include poorly functioning renal moieties associated with ureteral duplication or horseshoe kidney,5 hydrocalix with urolithiasis or recurrent infection.1 In recent years there has been a marked increase in the number of incidentally discovered small indeterminate renal masses. Given the equivalent tumor-free survival rates, the substantial risk of over treating a benign lesion and the possibility of cancer in the other kidney, nephron sparing surgery is increasingly preferred for patients who have a single small unilateral tumor and a normal contralateral kidney.6 – 8 Atypical renal cysts may also require surgical removal, despite extensive radiological evaluation. A 25 to 75% incidence of cancer has been reported in Bosniak type III cysts9 but open exploration or nephrectomy seems to be too aggressive in such cases. Laparoscopic evaluation of these indeterminate cysts was recommended by Bellman9 and Santiago10 et al. Depending on the underlying disease, a clear distinction should be made among different types of partial nephrectomy. In partial nephrectomy for a hydronephrotic system the margins of tissue to be removed are usually obvious. In contrast, when a significant thickness of parenchyma is transected, 3 techniques are generally used. Polar segmental nephrectomy consists of isolating the involved branch of the renal artery and identifying the corresponding renal segment with dye injection into the branch or by suppressing its perfusion. However, if the lesion encompasses more than 1
PARTIAL NEPHRECTOMY WITH RETROPERITONEAL LAPAROSCOPY
renal segment, wedge resection or transverse resection may be required. Regardless of the indication partial nephrectomy is technically demanding. As the most significant complications are intraoperative bleeding, postoperative urine leakage and infection, hemostasis and closure of the renal cavity are the most crucial steps. However, the techniques used in open surgery cannot simply be transposed to laparoscopic surgery, because regional hypothermia is not feasible and suturing is difficult. Another inherent limitation of laparoscopy is that it only shows the surface of the organs and does not allow manual palpation of the anatomical structures. Several tools are being investigated to optimize renal parenchymal surgery during laparoscopy, including intraoperative endoscopic sonography, temporary suppression of renal blood flow, bloodless section of the parenchyma and alternative tissue approximation techniques. Laparoscopic ultrasound with color and/or spectral Doppler helps improve intraoperative assessment of the intrarenal anatomy and disease process.2, 4 It can be used to determine the precise site, number, extension and texture of the lesion, and its relationship with the vasculature and the collecting system. We mainly used this tool in cases of equivocal renal masses and cysts to determine the safe distance of the parenchyma from the lesion. All patients with malignancies had a tumor-free surgical margin, as determined on the surgical specimen. As regional hypothermia of the kidney is not feasible during laparoscopy, clamping the renal artery inevitably leads to warm ischemia. To minimize the need for clamping various tools have been developed to help achieve bloodless section of the renal parenchyma.1, 2 Monopolar electrocautery necessitates high energy levels and has a risk of distant electrical injury. Janetschek et al reported satisfactory results with bipolar coagulation forceps which permitted simultaneous step-by-step dissection and hemostasis.2 To avoid the risk of electrical injury other energy sources have also been used. The argon beam coagulator uses a stream of ionized argon gas to conduct radio frequency energy to the tissues without direct contact. The gas blows blood away and extensive painting of the raw parenchymal surface provides coagulation in the vessel walls with minimal tissue destruction. Winfield et al were able to seal the transected collecting system and obtain adequate hemostasis using this device during 6 laparoscopic partial nephrectomies for benign conditions in adults.1 The ultrasonic scalpel, which vibrates at 55 kHz., can be used to incise and coagulate the parenchyma with the same instrument. It has been tested on animals and in the clinical setting but the results are inconsistent.2, 11 We used rotating tip coagulating scissors for patients with pronounced parenchymal atrophy. In the other cases the renal pedicle was dissected and clamped if necessary. We used bipolar electrocautery for section of the parenchyma. Blood loss during the procedure was controlled and warm ischemia was limited. In our last 2 patients we used the harmonic scalpel and, thus, in 1 temporary arrest of renal perfusion was avoided. This new tool seems to be advantageous because it can be used to cut and coagulate the renal parenchyma without changing the instrument through the trocars. However, further experience is needed to determine the real value of this instrument. In open surgery suturing allows hemostasis and closure of the collecting system. However, suturing via the laparoscopic approach is difficult for ergonomic reasons and prolongs operating time. Furthermore, when the parenchyma and collecting system are coagulated during excision, complete repair with suture ligation is difficult because of the fragility of coagulated tissue. The parenchyma becomes ischemic in the concavity of the sutures when they are pulled tight. Several techniques have been developed to replace sutur-
1925 12
ing during laparoscopic partial nephrectomy. Ehrlich and Riedl13 et al used an endoscopic stapler to transect the renal parenchyma during heminephrectomy. This method has the advantage of simultaneous resection, hemostasis and tissue closure but is only adapted to thin or atrophic segments of renal parenchyma. In addition, the titanium staple line extruding into the collecting system may cause stone formation. The use of surgical glues is attractive because they provide immediately watertight tissue closure suited to video assisted endoscopic procedures.14 Fibrin glue is known for the ability to stop venous oozing because it reproduces the final steps of the coagulation cascade. It has been used by numerous groups during open partial nephrectomy15, 16 and noted to be helpful during laparoscopy.2 At our institution another biological glue, a mixture of gelatin resorcinol and formaldehyde, has been routinely used since 1973 for renal parenchymal surgery in cases of diffuse hemorrhage that are difficult to control, for example during partial nephrectomy, renal trauma and renal allograft rupture.17–19 For more than 25 years this gelatin resorcinol formaldehyde glue has also been used for hepatic, cardiovascular and pulmonary surgery.20 To our knowledge there have been no documented toxic reactions. In the urological setting gelatin resorcinol formaldehyde is suitable as a parenchymal sealant because of good adhesive properties on wet and dry tissue, and high tensile strength.14 On the basis of these clinical data and our experience during open surgery we adapted gelatin resorcinol formaldehyde for laparoscopic procedures. In our 13 partial nephrectomies the cut parenchymal surface was covered with a surgical mesh impregnated with gelatin resorcinol formaldehyde glue, which yielded adequate hemostasis and immediate watertight closure of the nephrotomy. However, 2 patients had postoperative urinary leakage. In addition to late failure of gluing and tissue necrosis due to coagulation damage, insufficient drainage of the collecting system (that is premature removal of the ureteral catheter in our first and dislocation of the Double-J stent in our second case) cannot be ruled out. These complications call attention to the importance of reliable postoperative drainage for a sufficient period.4 This goal is probably better achieved with a Double-J stent than a ureteral catheter because the latter prolongs hospitalization until catheter removal. Nevertheless, even with optimal drainage, urinary leakage should always be expected after partial nephrectomy due to late necrosis of the coagulated or sutured cut surface. If a urinoma develops, the consequences are less worrisome when it is strictly confined to the retroperitoneum. We performed all procedures via a purely retroperitoneal approach and conversion to open surgery was not necessary. In contrast, most authors consider the transperitoneal approach optimal for ergonomic reasons and argue that the working space is limited with the retroperitoneal approach. In our experience the size of the working space with the retroperitoneal approach depends mainly on the extent of dissection. The number and position of the trocars have a key role in the quality of the exposure. There were no particular technical difficulties related to the retroperitoneal approach, and operating times were similar to those during open surgery.
CONCLUSIONS
Retroperitoneal laparoscopy is an appropriate approach to partial nephrectomy. Operating time and blood loss are acceptable. The laparoscopic ultrasound probe is valuable for precise intraoperative assessment of the intrarenal anatomy and disease process. The development of surgical tools that allow bloodless parenchymal section without deep tissue damage must be pursued. The use of biological glue simplifies hemostasis and closure of the collecting system but good quality drainage provides additional safety.
1926
PARTIAL NEPHRECTOMY WITH RETROPERITONEAL LAPAROSCOPY REFERENCES
1. Winfield, H. N., Donovan, J. F., Lund, G. O., Kreder, K. J., Stanley, K. E., Brown, B. P., Loening, S. A. and Clayman, R. V.: Laparoscopic partial nephrectomy: initial experience and comparison to the open surgical approach. J. Urol., 153: 1409, 1995. 2. Janetschek, G., Daffner, P., Peschel, R. and Bartsch, G.: Laparoscopic nephron sparing surgery for small renal cell carcinoma. J. Urol., 159: 1152, 1998. 3. Gill, I. S., Delworth, M. G. and Munch, L. C.: Laparoscopic retroperitoneal partial nephrectomy. J. Urol., 152: 1539, 1994. 4. McDougall, E. M., Elbahnasy, A. M. and Clayman, R. V.: Laparoscopic wedge resection and partial nephrectomy—the Washington University experience and review of the literature. J. Soc. Laparoendosc. Surg., 2: 15, 1998. 5. Janetschek, G., Seibold, J., Radmayr, C. and Bartsch, G.: Laparoscopic heminephroureterectomy in pediatric patients. J. Urol., 158: 1928, 1997. 6. Silver, D. A., Morash, C., Brenner, P., Campbell, S. and Russo, P.: Pathologic findings at the time of nephrectomy for renal mass. Ann. Surg. Oncol., 4: 570, 1997. 7. Lerner, S. E., Hawkins, C. A., Blute, M. L., Grabner, A., Wollan, P. C., Eickholt, J. T. and Zincke, H.: Disease outcome in patients with low stage renal cell carcinoma treated with nephron sparing or radical surgery. J. Urol., 155: 1868, 1996. 8. Butler, B. P., Novick, A. C., Miller, D. P., Campbell, S. A. and Licht, M. R.: Management of small unilateral renal cell carcinomas: radical versus nephron-sparing surgery. Urology, 45: 34, 1995. 9. Bellman, G. C., Yamaguchi, R. and Kaswick, J.: Laparoscopic evaluation of indeterminate renal cysts. Urology, 45: 1066, 1995. 10. Santiago, L., Yamaguchi, R., Kaswick, J. and Bellman, G. C.: Laparoscopic management of indeterminate renal cysts. Urology, 52: 379, 1998. 11. Elashry, O. M., Wolf, J. S., Jr., Rayala, H. J., McDougall, E. M. and Clayman, R. V.: Recent advances in laparoscopic partial nephrectomy: comparative study of electrosurgical snare electrode and ultrasound dissection. J. Endourol., 11: 15, 1997. 12. Ehrlich, R. M., Gershman, A. and Fuchs, G.: Laparoscopic renal surgery in children. J. Urol., 151: 735, 1994. 13. Riedl, C. R., Huebner, W. A., Schramek, P. and Pflueger, H.: Laparoscopic hemi-nephrectomy in a horseshoe kidney. Brit. J. Urol., 76: 140, 1995. 14. Eden, C. G. and Coptcoat, M. J.: Assessment of alternative tissue approximation techniques for laparoscopy. Brit. J. Urol., 78: 234, 1996. 15. Levinson, A. K., Swanson, D. A., Johnson, D. E., Greskovich, F. J., III, Stephenson, R. A. and Lichtiger, B.: Fibrin glue for partial nephrectomy. Urology, 38: 314, 1991. 16. Scott, R., Meddings, R. N. and Buckley, J. F.: Use of fibrin glue for partial nephrectomy. Urology, 39: 589, 1992. 17. Kelemen, Z., Luccioni, P., Lachand, A. T. and Auvert, J.: Etude expe´rimentale de l’effet he´mostatique de la colle biologiqueG. R. F. applique´e sur les tranches de parenchyme re´nal. Ann. Chir., 26: 807, 1972. 18. Auvert, J., Kelemen Z. S. and Weisgerber, G.: Applications de la colle he´mostatique G. R. F. en chirurgie. Nouvelle Presse Med., 4: 733, 1975. 19. Chopin, D. K., Abbou, C. C., Lottmann, H. B., Popov, Z., Lang, P. R., Buisson, C. L., Belghiti, D., Colombel, M. and Auvert, J. M.: Conservative treatment of renal allograft rupture with polyglactin 910 mesh and gelatin resorcin formaldehyde glue. J. Urol., 142: 363, 1989. 20. Bachet, J., Goudot, B., Dreyfus, G., Banfi, C., Ayle, N. A., Aota, M., Brodaty, D., Dubois, C., Delentdecker, P. and Guilmet, D.: The proper use of glue: a 20-year experience with the gelatin resorcinol formaldehyde glue in acute aortic dissection. J. Card. Surg., 12: 243, 1997. EDITORIAL COMMENT The authors report their experience with partial nephrectomy using the retroperitoneal laparoscopic approach. They performed the procedures successfully with minimal complications and in a reason-
able amount of time. However, the surgical indications for a number of patients in this series are unclear. Is it necessary to perform partial nephrectomy in patients with a hydrocalix? Flexible ultrasound probes have been an important addition to the armamentarium required for certain laparoscopic procedures (references 2 and 4 in article). The authors’ experience further underscores the importance of using laparoscopic ultrasound probes to evaluate the intrarenal anatomy and to assist in determining the margins of parenchymal incision in patients with suspected malignancy. All of the patients with malignancy in this series had tumor-free surgical margins in the retrieved specimens. I am not certain that the authors make a strong case for using the gelatin resorcinol formaldehyde glue for hemostasis and closure of the collecting system. In all of their patients the cut perenchymal surface was not sutured but rather covered with a surgical mesh impregnated with glue. However, 2 patients had postoperative urinary leakage requiring further intervention. Although these patients may have had inadequate postoperative urinary drainage, the authors state in the discussion that “even with optimal drainage, urinary leakage should always be expected after partial nephrectomy. . .”. However, this is not the predominant opinion of surgeons currently performing partial nephrectomy. A watertight anastomosis of the collecting system as well as possible testing with retrograde injection to assess for adequate closure has made urinoma formation mostly anecdotal. Further experience will be necessary with the use of gelatin resorcinol formaldehyde glue before it can be widely applied as the sole modality for tissue closure in patients undergoing partial nephrectomy. The authors add valuable experience to the growing literature for laparoscopic partial nephrectomy, especially with the retroperitoneal approach. Anthony Atala Department of Urology Children’s Hospital Boston, Massachusetts REPLY BY AUTHORS Partial nephrectomy is indicated in select cases of hydrocalix. In our patients indications for surgery comprised recurrent urinary tract infection, gross hematuria, stone formation and flank pain. Suture anastomosis is the gold standard in urology when the collecting system is opened during a surgical procedure. However, some alternative, still widely accepted methods are exceptions to this rule. For example, urologists performing Acucise* pyeloplasty rely on only draining the collecting system. During partial nephrectomy the parenchyma and collecting system are usually incised with an instrument that coagulates at the same time, which inevitably leads to some degree of coagulation necrosis. Thus, the tissues to be closed often become fragile and the sutures may further contribute to ischemic damage. For this reason a fistula can occur several days later even if the anastomosis is perfectly watertight at the end of surgery. Campbell et al observed urinary fistula in 45 patients (17%) in a series of 259 open partial nephrectomies, despite reconstruction of the collecting system as necessary.1 However, only 1 patient required open operative repair, and in the remainder the fistula resolved either spontaneously or with endoscopic management. This finding further underlines the role of draining the renal cavities. In our series at the end of surgery the glued parenchyma was always watertight when tested with retrograde injection of indigo carmine dye saline solution. On the other hand, suturing should not be systematically ruled out in laparoscopic partial nephrectomy, and additional suture anastomosis may be justified when the renal cavities are clearly seen and there is a need for major reconstruction. In these instances, the gelatin resorcinol formaldehyde glue is a useful adjunct to reinforce the suture line and help stop parenchymal oozing. Based on all of these considerations, we believe that alternative tissue approximation methods merit evaluation to determine their role in urological surgery and particularly in laparoscopy. 1. Campbell, S. C., Novick, A. C., Streem, S. B., Klein, E. and Licht, M.: Complications of nephron sparing surgery for renal tumors. J. Urol., 151: 1177, 1994. *Applied Medical Resources, Laguna Hills, California.