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SIGNIFICANCE OF POSITIVE SURGICAL MARGINS IN LAPAROSCOPIC PARTIAL NEPHRECTOMY
AUGMENTED REALITY A NEW TOOL TO IMPROVE SURGICAL ACCURACY DURING LAPAROSCOPIC PARTIAL NEPHRECTOMY
Polajnar M., Meixl H., Jeschke K.
Teber D.1, Baumhauer M.2, Simpfendoerfer T.2, Hruza M.1, Klein J.1, Rassweiler J.1
General Hospital Klagenfurt, Dept. of Urology, Klagenfurt, Austria Introduction & Objectives: All though laparoscopic partial nephrectomy IRUUHQDOWXPRXUVLVJDLQLQJPRUHDQGPRUHLPSRUWDQFHWKHVLJQLᚏFDQFHRI positive surgical margins is still on debate. We looked for the outcome of margin positive patients in our large single institutional series. Material & Methods: From December 1997 to March 2007 laparoscopic partial nephrectomy for renal tumours was performed in 200 patients in our institution. In the vast majority we used a retroperitoneal approach. In WKHᚏUVWSDWLHQWVZHUHVHFWHGZLWKRXWKLODUFODPSLQJZKLOHDOOWKHRWKHU patients have been done in warm ischemia. Median age was 56,8 years, tumor location was in 112 patients right side and in 88 patients left side. The specimen were inspected by the surgeon at the end of the operation for positive margins before inking. All margins were estimated negative by the surgeon. Results: Histologic evaluation of the specimen showed renal cell carcinoma 5&& LQ DQGDEHQLJQWXPRULQ ,Q RIWKH 5&&SDWLHQWVDSRVLWLYHVXUJLFDOPDUJLQZDVREVHUYHG,QWKHᚏUVWSDWLHQWZH GLGDQRSHQಯUHFXWರDQGIRXQGQRHYLGHQFHIRUWXPRULQWKHᚏQDOKLVWRORJLF evaluation. So all the other margin positive patients went into close follow up. One of them delivered local recurrence after one year and was treated by open radical nephrectomy. He is without evidence of disease so far. The remaining 4 patients showed no evidence of local or systemic recurrence. Conclusions: A positive surgical margin in laparoscopic partial nephrectomy for RCC does not induce local recurrence in the majority of cases. Therefore we advice a close follow up in all patients with positive surgical margins that were estimated negative by the surgeon.
1 Klinikum Heilbronn, Dept. of Urology, Heilbronn, Germany, 2German Cancer Research Centre University Heidelberg, Dept. of Medical Informatics, Heidelberg, Germany
Introduction & Objectives: Laparoscopic partial nephrectomy (Lpn) has become a standard procedure in the treatment of pT1a renal cell carcinomas. But it remains still a technically demanding procedure. We are presenting our ᚏUVWH[SHULHQFHZLWKWKHH[SHULPHQWDOEDVLVDQGRXUᚏUVWFOLQLFDODSSOLFDWLRQ of augmented reality during Lpn. Material & Methods: ,Q D ᚏUVW VWHS ZH GHYHORSHG D YLUWXDO HYDOXDWLRQ environment, which allows for the simulation of navigation targets in a pusatile organ perfusion trainer using a porcine model. In a second step the FOLQLFDOO\XVHZDVHYDOXDWHGLQSDWLHQWVZLWKDS7DUHQDOFHOOFDUFLQRPD 7KHGDWDIURPDPP&7VFDQZHUHVHJPHQWHGLQWRWKHGLᚎHUHQWUHOHYDQW structures like arteries, veins, collecting system normal parenchyma and tumour. Results: Using several real time algorithms and incorporate them into the 2SHQ6FRXUFH7RRONLW0,7.ZHZHUHDEOHDVXSHULPSRVHWKHUHDOWLPH' image onto our porcine model. It was possible to reproduce these algorithms in a clinical setting. With the help of implemented navigation aids both images could be superimposed during the entire surgery. Using this technology we could demonstrate a potential for a more precise and faster dissection. Conclusions: Augmented reality is a new tool to improve oncological safety and minimize warm ischemia time during laparoscopic partial nephrectomy. Prospective comparative studies are planed to evaluate these promising technology.
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LAPAROSCOPIC PARTIAL NEPHRECTOMY- ISCHEMIC RENAL DAMAGE IN RELATION TO TIME EVALUATED BY SPLIT RENAL FUNCTION IN 15 PATIENTS
IS THE HEM-O-LOK CLIP SAFE? BURST PRESSURE STUDIES IDENTIFY POTENTIAL PITFALLS AND GENERATE MUST-READ GUIDELINES FOR ITS USE
Bagheri Dr., Pusztai Dr., Farkas Dr.
Sooriakumaran P.1, Kommu S.S.2, Cooke J., Gordon S.2, Eddy B.2, Brown C.4, Rimington P.5, Rane A.2
8QLYHUVLW\RI3«FV0HGLFDO6FKRRO'HSWRI8URORJ\3«FV+XQJDU\ Introduction & Objectives: By means of widespread use of imaging techniques, increasing numbers of small renal cell cancers has been detected incidentally. For the majority of these WXPRXUV QHSKURQ VSDULQJ VXUJHU\ QDPHO\ RSHQ SDUWLDO QHSKUHFWRP\ LV FRQVLGHUHG DV WKH gold standard technique. Recently, laparoscopic partial nephrectomy (LPN) has emerged as a viable alternative to open partial nephrectomy while minimizing patient morbidity. Most of open surgical principles can be duplicated by means of laparoscopy. However, warm ischemia (WI) time caused by renal hilar clamping remains a critical part of the operation during LPN. 7UDGLWLRQDOO\D:,WLPHRIOHVVWKDQPLQXWHVLVFRQVLGHUHGVDIHIRUSUHVHUYLQJRSWLPDOUHQDO function. Contemporary clear data describing unilateral ischemic renal damage in relation to WLPHLVPLVVLQJRULQDGHTXDWHLQWKHOLWHUDWXUH,QRXUSDWLHQWVURXWLQHO\ZHHYDOXDWHWKHHᚎHFW of WI time on operated kidney using 99mTc-DMSA renal scintigraphy. Material & Methods: Since June 2005, we have performed 18 LPN. Split renal function scan was performed in all patients before operation, which is used as a base line value. This H[DPLQDWLRQ ZDV UHSHDWHG DW DQG PRQWKV DIWHU WKH RSHUDWLRQ ,Q DOO FDVHV 5XPHO tourniquet was used for en bloc hilar control. Tumour resection was applied in warm ischemia LQ SDWLHQWV ,Q SDWLHQWV LVFKHPLD ZDV QRW UHTXLUHG &ROOHFWLQJ V\VWHP UHSDLU DQG UHQDO parenchymal reconstruction was performed by intracorporeal running sutures. Hem-o-lok clips were used instead of knotting. Based on WI time, the patients were divided into 5 groups: Group $ZLWK:,WLPHRIOHVVWKDQPLQXWHVJURXS%EHWZHHQWRPLQXWHVJURXS&WR minutes, group D 50 to 60 minutes, and group E with no ischemia. Results: We have 15 patients with at least 6 months follow up. The unilateral renal function of the operated kidney in the 6 month scintigraphy compared to the base line value showed WKHIROORZLQJUHVXOWV,QJURXS(ZLWKQRKLODUFODPSLQJZHFRXOGVHHDGHFUHDVHRIUHQDO function. This can be considered as loss of renal parenchymal volume which has been excised and removed. In group A, B, and C, where WI is applied, larger or more endophytic tumour has been removed, which resulted in 4%, 5%, and 7% decrease of renal function, respectively. In group D, ischemic time of above 50 minutes caused a 14% loss of renal function, which is a VLJQLᚏFDQWIXQFWLRQDOGDPDJH Conclusions: LPN is feasible and safe if the surgeon has adequate prior experience with advanced laparoscopy and intracorporeal suturing. Even though the number of our patients LV WRR VPDOO WR DFKLHYH D VFLHQWLᚏF FRQVHQVXV KRZHYHU LW GUDZV RXU DWWHQWLRQ WR KDYH PRUH LQYHVWLJDWLRQRQXQLODWHUDOUHQDOIXQFWLRQDORXWFRPHVLQUHODWLRQWRGLᚎHUHQW:,WLPHV$VZDV concluded in our study, a WI time of up to 50 minutes may be considered safe.
Eur Urol Suppl 2008;7(3):258
1 Kingston Hospital, Dept. of Urology, Kingston, United Kingdom, 2East Surrey Hospital, Dept. of Urology, Redhill, United Kingdom, St. Mary’s Hospital, Dept. of Surgery, Portsmouth, United Kingdom, 4St. Peter’s Hospital, Dept. of Urology, Chertsey, United Kingdom, 5Eastbourne Hospital, Dept. of Urology, Eastbourne, United Kingdom
Introduction & Objectives: There are a variety of clips currently available for vascular ligation, the Hem-o-lokTM (Weck Closure Systems, Research Triangle Park, NC, USA), having been launched in 1999 is now one of the market leaders. Recent reports of failure of this nonabsorbable polymer self-locking clip in laparoscopic surgery with resultant deaths provided the impetus for this study. We wanted to investigate why the Hem-o-lok appeared safe in open surgery but had reported failures in laparoscopic surgery, most notably laparoscopic donor nephrectomy. Material & Methods: A group of UK urologists and general surgeons with laparoscopic experience (n=7) brainstormed potential cause for clip failure along with an experienced representative from the manufacturer. A series of ex vivo experiments were then designed, again in conjunction with the manufacturer, to test the ideas generated. Using a porcine PRGHO YHVVHOV RI GLᚎHUHQW OXPLQDO GLDPHWHUV ZHUH VNHOHWRQLVHG DQG KDUYHVWHG XVLQJ SXUH ODSDURVFRSLF KDQGDVVLVWHG DQG RSHQ VXUJLFDO WHFKQLTXHV 1RQYDVFXODU DUWLᚏFLDO WXELQJ RI GLᚎHULQJ OXPLQDO GLDPHWHUV ZDV DOVR XWLOL]HG +HPRORN FOLSV ZHUH DSSOLHG WR WKHVH YHVVHOV DQGWXELQJDWGLᚎHUHQWDQJOHVDQGWKHYHVVHOVFXWDWGLᚎHUHQWGLVWDQFHVIURPWKHFOLSV8VLQJ PDQRPHWU\WKHSUHVVXUHVUHTXLUHGIRUWKHFOLSVWROHDNRUಫEXUVWಬRᚎWKHOXPLQDZHUHPHDVXUHG 7KHVH H[SHULPHQWV ZHUH UHSHDWHG IRU GLᚎHULQJ VL]H RI FOLS YHVVHO GLDPHWHU UDWLRV 3ULRU WR all experiments, all clips were checked for damage using a low power microscope, and any damaged clips were not utilized. Results: 7KH +HPRORN FOLSV FRQVLVWHQWO\ IDLOHG ZKHQ WKH OLJDWHG WLVVXH ZDV FXW ᚐXVK ZLWK WKH FOLS LQ ERWK WKH SRUFLQH DQG DUWLᚏFLDO YHVVHOV &OLS IDLOXUH DOVR RFFXUUHG ZKHQ WKH FOLS employed was too large or too small for the vessel it was used on. Clips applied at 45 degrees to the tissue surface were more likely to fail than those applied perpendicularly. A multivariate analysis showed that all these three variables were independent predictors for clip failure. Conclusions: 7KH+HPRORNFOLSVKRXOGQRWEHFXWᚐXVKZLWKWKHWLVVXHGLYLGHGDVLVWHPSWLQJ to do in an attempt to harvest as much vessel as possible in the case of donor nephrectomy), its angle of application with the tissue should be (near to) perpendicular, and the clip employed should be sized accordingly, with regard to the diameter of the to-be-clipped vessel.