- Email: [email protected]
THE IMPACT OF WARM ISCHEMIA TIME ON PERIOPERATIVE OUTCOMES & CREATININE CLEARANCE IN PATIENTS UNDERGOING LAPAROSCOPIC PARTIAL NEPHRECTOMY
Vol. 179, No. 4, Supplement, Tuesday, May 20, 2008
and 38 minutes in each group (p=0.007). Operative blood loss (219 v. YPO S DQGGXUDWLRQRIKRVSLWDOVWD\ YY GD\V S ZHUHHTXLYDOHQW&DUFLQRPDZDVSUHVHQWLQ and 53% of cases in each group (p=0.002). Positive cancer margins occurred in 1 and 2 patients in groups 2 and 3, respectively (0.4% vs. S 7KHPHDQSRVWRSHUDWLYHVHUXPFUHDWLQLQHLQFUHDVHLQHDFK group was 0.15, 0.23, and 0.26 (p=0.12). Mean postoperative estimated GFR in each group decreased by 11, 14, and 22 ml min (p=0.01). The percentage of patients with preoperative >Stage 3 CKD in each group was 31%, 35%, and 44% (p=0.15). Postoperatively this increased to 52%, 55%, and 63% (p=0.27). Patients in Group III who had preoperative >6WDJH,,,&.'KDGLQFUHDVHGULVNIRU&.'VWDJHDGYDQFHPHQW 55 p<0.001). The intraoperative complication rate was 8% in all groups. Total postoperative complication rates for each group were 11%, 24%, and 24% (p=0.03). Patients with intraoperative complications had LQFUHDVHGUHODWLYHULVNRISRVWRSHUDWLYHXURORJLF 55 S DQG QRQXURORJLF 55 S FRPSOLFDWLRQV FRPSDUHG WR SDWLHQWV without intraoperative complications. GU complication severity and IUHTXHQF\GLGQRWFRUUHODWHZLWKWXPRUVL]H CONCLUSIONS: Appropriately selected patients with renal WXPRUV !FP LQ VL]H FDQ VDIHO\ DQG HI¿FDFLRXVO\ XQGHUJR /31 ZLWK outcomes comparable to those achieved for smaller renal tumors. Adequate laparoscopic expertise is a prerequisite. Source of Funding: None
1274 RISK FACTOR ANALYSIS OF POSTOPERATIVE COMPLICATIONS IN LAPAROSCOPIC PARTIAL NEPHRECTOMY: 507 PROCEDURES Burak Turna*, Rodrigo Frota, Kazumi Kamoi, Yi-Chia Lin, Monish Aron, Robert J Stein, Mike Nguyen, Mihir M Desai, Jihad H Kaouk, Inderbir S Gill. Cleveland, OH. INTRODUCTION AND OBJECTIVE: We evaluate our experience with laparoscopic partial nephrectomy (LPN) to determine risk factors for postoperative complications. METHODS: A prospectively maintained database of 507 LPN SURFHGXUHVVLQFH6HSWHPEHU ZDVUHWURVSHFWLYHO\DQDO\]HGZLWK emphasis on postoperative complications. Severity of complications was graded using a 5-tiered scale based on NCI-CTC reporting criteria. Complication rates were compared between the 1999-2002 and 2003-2006 eras. Multivariate analysis of baseline and perioperative variables was performed to identify risk factors associated with postoperative complications for the two eras. RESULTS: In 507 LPN procedures, 93 patients (19.7%) had 107 postoperative complications, including 49 urologic (9.7%) and 58 non-urologic (11.4%). Of the complications, 20.6% were grade I, 45% were grade II, 30% were grade III, 4.7% were grade IV and none were grade V. On multivariate analysis, presence of a solitary kidney (99-02, S S LQFUHDVHG:,7 S S DQG LQFUHDVHG (%/ S S ZHUH VLJQL¿FDQW SUHGLFWRUV RI RYHUDOO SRVWRSHUDWLYH FRPSOLFDWLRQV IRU the two eras. Compared to the 1999-2002 era, the 2003-2006 era witnessed a dramatic increase in number of total LPN procedures (100% increase) and complex tumors (132% increase), yet overall (p=0.001), urologic (p=0.03) and non-urologic (p=0.02) complications decreased VLJQL¿FDQWO\ CONCLUSIONS: Prolonged warm ischemia, increased intraoperative blood loss and solitary kidney status increase the likelihood of postoperative complications after LPN. With experience, WKH LQFLGHQFH RI FRPSOLFDWLRQV KDV GHFUHDVHG VLJQL¿FDQWO\ GHVSLWH D VLJQL¿FDQWLQFUHDVHLQWXPRUDQGSURFHGXUDOFRPSOH[LW\ Source of Funding: None
THE JOURNAL OF UROLOGY®
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1275 SIMPLE AND EFFECTIVE PURE LAPAROSCOPIC METHOD FOR SURFACE APPLICATION RENAL HYPOTHERMIA TO AID IN LAPAROSCOPIC PARTIAL NEPHRECTOMY: CLINICAL APPLICATION Kittinut Kijvikai*, Lincoln J Maynes, Paul M Milhoua, S Duke Herrell. Bangkok, Thailand, and Nashville, TN. INTRODUCTION AND OBJECTIVE: We have previously GHVFULEHGDQRYHOWHFKQLTXHRIVXUIDFHDSSOLFDWLRQRIQHDUIUHH]LQJVWHULOH VDOLQHYLDDPRGL¿HGODSDURVFRSLFLUULJDWLRQV\VWHPDQGFRQ¿UPHGLWV effectiveness in the porcine kidney model (J Endourol 2005). We now GHVFULEHRXULQLWLDOFOLQLFDOH[SHULHQFHLQXWLOL]LQJWKLVWHFKQLTXHGXULQJ pure complex laparoscopic partial nephrectomy (LPN). METHODS: Seven patients with endophytic renal masses were enrolled in an IRB approved protocol. Standard laparoscopic exposure of the kidney and renal mass was performed. Cardiac needle temperature probes were secured deep to the renal parenchyma and KLODU FODPSLQJ DSSOLHG 1HDU IUHH]LQJ VWHULOH VDOLQH ZDV GHOLYHUHG YLD powered irrigation onto the renal surface and surrounding surgical JDX]HVZKLFKLQFUHDVHVXUIDFHFRQWDFWWLPH5HQDOSDUHQFK\PDDQG patient core temperatures were monitored throughout the procedure. Masses were excised and renorrhaphy accomplished. Postoperatively patients were followed with computed tomography (CT) and monitoring of serum creatinine. RESULTS: An optimal parenchymal temperature of 20 0C was reached after a mean cooling time of 8.3 (3-13) minutes. Mean nadir parenchymal temperature of 15.1 (13.6-18.5) 0C was reached after a mean application time of 14.8 (10-17) minutes. A hypothermic window, GH¿QHGDVEHWZHHQDQG0C, was maintained for an average of 30.4 (22-36) minutes. In two cases re-cooling was applied during the extended reconstructions and temperatures less than 20 0C were achieved within 3 to 5 minutes of reapplication. Mean ischemia time including cooling was 60.2 minutes (43-75). Mean core body temperature drop was 1.28 0 & $OOPDUJLQVZHUHQHJDWLYHDQGQRVLJQL¿FDQWSRVWRSHUDWLYH complications occurred. CT revealed good function of remnant renal units with a mean change in serum creatinine of 0.11 mg/dL (.08-.16) compared to preoperative values. CONCLUSIONS: We have designed, tested, and clinically implemented a simple, effective, and reproducible technique for creating optimal hypothermic temperature for renal protection from ischemia for XVHGXULQJ/31XWLOL]LQJWKHVXUIDFHDSSOLFDWLRQRIQHDUIUHH]LQJVDOLQH irrigation. Application of this technique may increase the safety, extend the complexity level, and encourage the widespread use of laparoscopic partial nephrectomy techniques. Source of Funding: None
1276 THE IMPACT OF WARM ISCHEMIA TIME ON PERIOPERATIVE OUTCOMES & CREATININE CLEARANCE IN PATIENTS UNDERGOING LAPAROSCOPIC PARTIAL NEPHRECTOMY Mark H Katz, Andrew J Bernstein, Michael K Eng*, Sergey A Shikanov, Kevin C Zorn, Arieh L Shalhav. Chicago, IL. INTRODUCTION AND OBJECTIVE: Laparoscopic partial nephrectomy (LPN) is a complex procedure requiring advanced skills. 'XH WR GLI¿FXOW\ ZLWK REWDLQLQJ FROG LVFKHPLF FRQGLWLRQV GXULQJ KLODU clamping, LPN is generally performed under warm ischemic conditions. We sought to evaluate our series of LPNs performed by a single surgeon (ALS) and compare the perioperative outcomes of those with short (<30 min.) versus long (>30 min) warm ischemia time (WIT). In addition we evaluated the postoperative serum creatinine (SCr) as well as creatinine clearance (CrCl) to determine the impact that WIT may have on postoperative renal function. METHODS: Our prospective database of 129 laparascopic partial nephrectomies was reviewed. 48 (Group A) and 63 (Group B) patients were noted to have warm ischemia times of <30 minutes and !PLQXWHVUHVSHFWLYHO\7KHLPSDFWRIWXPRUVL]HSDWLHQWDJHERG\ mass index (BMI, kg/m2), tumor location and depth on warm ischemia time (WIT) was assessed. Perioperative complications, estimated blood loss (EBL), operative time and pathological margin status were compared between the two groups. In addition, SCr as well as CrCl (Cockroft-Gault) were assessed at postoperative intervals greater than one month.
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RESULTS: Table one depicts the characteristics of the JURXSV 3DWLHQWV LQ *URXS $ KDG VLJQL¿FDQWO\ ODUJHU WXPRUV DQG shorter operative time than those in Group B. All other variables were similar between the 2 groups, including age, BMI, preoperative renal function, tumor location and depth, and complication rates. The mean postoperative SCr and CrCl did not differ between the groups (median follow-up = 6.3 months). CONCLUSIONS: Longer WIT is associated with larger complex renal tumors. However, complication rates, conversion rates, and EBL were not statistically different when comparing <30 minutes WIT to > 30 min. Pathological margin status was not affected by WIT. Most importantly, longer WIT did not impact long-term serum creatinine and creatinine clearance. Laparoscopic Partial Nephrectomy & Warm Ischemia Time Group A (N=48) Group B (N=63) Age (years) 59.7 59.9 29.5 30.1 BMI (kg/m2) 3UHRS6L]H FP 2.2 3.1 Preop SCr (mg/dl) 1.11 1.13 Preop CrCl (ml/min/BSA) 87.75 80.89 Major Complications 6 (12.5%) 7 (11.1%) Minor Complications 2 (4.2%) 2 (3.2%) Conversion to Open 3 (6.3%) 1 (1.6%) EBL (cc) 183 184 OR Time (min.) 207.6 242.9 Positive Surgical Margins 2 (4.2%) 2 (3.2%) Postop SCr (mg/dl) 1.29 1.37 Postop CrCl (ml/min/BSA) 71.3 81.6
P-Value 0.93 0.54 0.0004 0.91 0.46
0.9669 0.0092
/DSDURVFRSLF3DUWLDO1HSKUHFWRP\DQG5HQDO/HVLRQ6L]H Group B (2-4 *URXS$ FP cm) n 45 64 Age (yrs) 59.6 60.0 Pre-op Cr ± SD (mg/dL) 1.06 ± 0.8 1.14 ± 0.48 Pre-op CrCl ± SD 86.0 ± 47 96.2 ± 147 (ml/min/BSA) Location: 11 (25.6%) 15 (25.9%) - Upper pole 17 (39.5%) 19 (32.8%) - Mid pole 15 (34.9%) 24 (41.4%) - Lower pole
1277 IMPACT OF RENAL LESION SIZE ON PERIOPERATIVE AND PATHOLOGIC OUTCOMES IN PATIENTS UNDERGOING LAPAROSCOPIC PARTIAL NEPHRECTOMY Michael K Eng*, Andrew J Bernstein, Mark H Katz, Sergey A Shikanov, Kevin C Zorn, Arieh L Shalhav. Chicago, IL. ,1752'8&7,21$1'2%-(&7,9( 7KHVL]HRIUHQDOOHVLRQV managed with laparoscopic partial nephrectomy (LPN) has been increasing, especially as surgical volume and experience matures. 7XPRUVL]HLVDQLQWHJUDOFRPSRQHQWRISDWKRORJLFVWDJLQJDVZHOODV an independent prognostic factor in oncologic outcome. The objective of this study was to assess the peri-operative and pathologic outcomes RI/31ZKHQVWUDWLI\LQJIRUVL]HRIUHQDOOHVLRQ METHODS: A retrospective review of LPN performed at the University of Chicago by a single surgeon (ALS) between October 2002 WR -XO\ ZDV SHUIRUPHG SDWLHQWV ZHUH WKHQ VWUDWL¿HG LQWR groups according to diameter of lesion on pre-operative axial imaging: < 2 cm (Group A), 2-4 cm (Group B), and > 4 cm (Group C). Perioperative, operative and pathologic data were compared using student’s t-test and chi-square test. As well, serum creatinine (SCr) and creatinine clearance (CrCl) (Cockgroft-Gault) were assessed at postoperative intervals greater than one month. RESULTS: Table 1 depicts the data from each group. With regards to operative parameters, warm ischemia time (WIT) and RSHUDWLYHWLPHZHUHVLJQL¿FDQWO\ORQJHULQUHQDOOHVLRQV!FP S As well, the need for collecting system repair was more prevalent as OHVLRQVL]HLQFUHDVHG S $OWKRXJKQRWVWDWLVWLFDOO\VLJQL¿FDQWWKHUH was a trend towards a higher complication rate with larger lesions. All other variables were similar amongst the 3 groups, including the rate of positive surgical margins, estimated blood loss (EBL), conversion and transfusion rates. Comparison of pathologic data suggests smaller lesions are more likely to be of lower grade compared to larger lesions. The mean postoperative SCr and CrCl did not differ amongst the groups with a median follow-up of 6.3 months. CONCLUSIONS: Renal masses >2cm underwent longer WIT and operative times compared to lesions <2 cm during LPN. Entry into and subsequent repair of the collecting system was more prevalent DV OHVLRQ VL]H LQFUHDVHG +RZHYHU SRVLWLYH VXUJLFDO PDUJLQ UDWHV complication rates, conversion rates and EBL were not statistically different amongst the 3 groups. Short-term post-operative renal function ZDVQRWDIIHFWHGE\OHVLRQVL]H
16 60.7 1.16 ± 0.58
> 0.79 >0.59
88.5 ± 56.7
>0.63
3 (18.8%) 2 (12.5%) 11 (68.8%)
0.15
Collecting system repair
15 (33%)
43 (67.2%)
14 (87.5%)
WIT ± SD (min)
27.8 ± 7.11
35.8 ± 8.9
33.6 ± 6.21
EBL (mL) OR Time (min) Complications - Major - Minor Transfusion Conversion Histology: - Malignant -Benign Positive surgical margin Post-op Cr ± SD (mg/dL) Post-op CrCl ± SD (ml/min/BSA)
199 198
185 241
272 243
3 (6.7%) 4 (8.9%)
8 (12.5%) 10 (15.6%)
2 (12.5%) 3 (18.8%)
0.09
4 (8.9%) 2 (4.4%)
5 (7.8%) 3 (4.7%)
2 (12.5%) 2 (12.5%)
0.77 0.83
30 (68.2%) 14 (31.8%)
48 (75%) 16 (25%)
12 (75%) 4 (25%)
0.56
1 (2.3%) 1.20 ± 1.04
2 (3.1%) 1.36 ± 0.83
0 (0%) 1.34 ± 0.68
0.47 > 0.43
79.1 ± 34.9
77.0 ± 36.7
71.3 ± 31.2
> 0.3
0.71 0.26
Source of Funding: None
*URXS&FP p-value
0.04 A vs B: <0.001 B vs C: 0.28 A vs C: 0.009 > 0.21 A vs B: <0.01
Source of Funding: None
1278 LAPAROSCOPIC DOPPLER TECHNOLOGY: APPLICATIONS IN LAPAROSCOPIC PYELOPLASTY, RADICAL AND PARTIAL NEPHRECTOMY Mark A Perlmutter*, Elias S Hyams, Michael D Stifelman. New York, NY. INTRODUCTION AND OBJECTIVE: Identification and isolation of vascular structures are crucial and technically demanding aspects of laparoscopic renal surgery. Doppler technology has been used for this purpose in laparoscopic varicocele repair, renal cryoablation, and adrenalectomy. However, its use has not been formally described in laparoscopic radical nephrectomy (RNx), laparoscopic partial nephrectomy (PNx), laparoscopic nephroureterectomy (NU) or roboticassisted laparoscopic pyeloplasty (RALP). This paper relates our current experience using a doppler probe during these procedures. METHODS: A laparoscopic doppler probe (VTI, Nashua, NH) was employed in the above mentioned laparoscopic renal surgeries. 7KH 'RSSOHU V\VWHP FRQVLVWHG RI D GLVSRVDEOH 0+] SUREH SDVVHG through a 5mm port and a battery-powered transceiver. The probe was used to guide dissection/isolation of both the renal hilum and aberrant YDVFXODWXUH LQ 51[1831[ FRQ¿UP SDUHQFK\PDO LVFKHPLD SULRU WR resection in PNx, and identify a crossing vessel (CV) during RALP. At the end of each case, the operating surgeon determined if time was saved with use of the doppler probe. 5(68/76 )RUW\¿YHSDWLHQWVXQGHUZHQWODSDURVFRSLFUHQDO VXUJHU\XWLOL]LQJWKHGRSSOHUSUREH0HDQGRSSOHUWLPHZDVPLQXWH seconds. Sixteen accessory vessels (AV) were detected in 14 patients KDYLQJ51[31[18 2IWKHVH$9ZHUHQRWVHHQRQ SUHRSHUDWLYHLPDJLQJLQSDWLHQWV ,QDQRWKHUFDVHRI31[ SHUVLVWHQW SDUHQFK\PDO ÀRZ GHVSLWH UHQDO DUWHU\ FODPSLQJ UHTXLUHG clamp repositioning. In three cases (43%) of RALP, doppler corrected preoperative imaging in detecting the presence (2) or absence (1) of a CV. Overall, the probe altered management in 27% and saved time in 76% of patients. The probe had 100% concordance with dissection. Use of the probe caused no clinical complications and had a 4% technical failure rate. CONCLUSIONS: Doppler ultrasound technology may have extended applications in laparoscopic renal surgery by facilitating the dissection and evaluation of vasculature. Prospective study with objective endpoints will be helpful in confirming the utility of this technology in these settings.
and 38 minutes in each group (p=0.007). Operative blood loss (219 v. YPO S DQGGXUDWLRQRIKRVSLWDOVWD\ YY GD\V S ZHUHHTXLYDOHQW&DUFLQRPDZDVSUHVHQWLQ and 53% of cases in each group (p=0.002). Positive cancer margins occurred in 1 and 2 patients in groups 2 and 3, respectively (0.4% vs. S 7KHPHDQSRVWRSHUDWLYHVHUXPFUHDWLQLQHLQFUHDVHLQHDFK group was 0.15, 0.23, and 0.26 (p=0.12). Mean postoperative estimated GFR in each group decreased by 11, 14, and 22 ml min (p=0.01). The percentage of patients with preoperative >Stage 3 CKD in each group was 31%, 35%, and 44% (p=0.15). Postoperatively this increased to 52%, 55%, and 63% (p=0.27). Patients in Group III who had preoperative >6WDJH,,,&.'KDGLQFUHDVHGULVNIRU&.'VWDJHDGYDQFHPHQW 55 p<0.001). The intraoperative complication rate was 8% in all groups. Total postoperative complication rates for each group were 11%, 24%, and 24% (p=0.03). Patients with intraoperative complications had LQFUHDVHGUHODWLYHULVNRISRVWRSHUDWLYHXURORJLF 55 S DQG QRQXURORJLF 55 S FRPSOLFDWLRQV FRPSDUHG WR SDWLHQWV without intraoperative complications. GU complication severity and IUHTXHQF\GLGQRWFRUUHODWHZLWKWXPRUVL]H CONCLUSIONS: Appropriately selected patients with renal WXPRUV !FP LQ VL]H FDQ VDIHO\ DQG HI¿FDFLRXVO\ XQGHUJR /31 ZLWK outcomes comparable to those achieved for smaller renal tumors. Adequate laparoscopic expertise is a prerequisite. Source of Funding: None
1274 RISK FACTOR ANALYSIS OF POSTOPERATIVE COMPLICATIONS IN LAPAROSCOPIC PARTIAL NEPHRECTOMY: 507 PROCEDURES Burak Turna*, Rodrigo Frota, Kazumi Kamoi, Yi-Chia Lin, Monish Aron, Robert J Stein, Mike Nguyen, Mihir M Desai, Jihad H Kaouk, Inderbir S Gill. Cleveland, OH. INTRODUCTION AND OBJECTIVE: We evaluate our experience with laparoscopic partial nephrectomy (LPN) to determine risk factors for postoperative complications. METHODS: A prospectively maintained database of 507 LPN SURFHGXUHVVLQFH6HSWHPEHU ZDVUHWURVSHFWLYHO\DQDO\]HGZLWK emphasis on postoperative complications. Severity of complications was graded using a 5-tiered scale based on NCI-CTC reporting criteria. Complication rates were compared between the 1999-2002 and 2003-2006 eras. Multivariate analysis of baseline and perioperative variables was performed to identify risk factors associated with postoperative complications for the two eras. RESULTS: In 507 LPN procedures, 93 patients (19.7%) had 107 postoperative complications, including 49 urologic (9.7%) and 58 non-urologic (11.4%). Of the complications, 20.6% were grade I, 45% were grade II, 30% were grade III, 4.7% were grade IV and none were grade V. On multivariate analysis, presence of a solitary kidney (99-02, S S LQFUHDVHG:,7 S S DQG LQFUHDVHG (%/ S S ZHUH VLJQL¿FDQW SUHGLFWRUV RI RYHUDOO SRVWRSHUDWLYH FRPSOLFDWLRQV IRU the two eras. Compared to the 1999-2002 era, the 2003-2006 era witnessed a dramatic increase in number of total LPN procedures (100% increase) and complex tumors (132% increase), yet overall (p=0.001), urologic (p=0.03) and non-urologic (p=0.02) complications decreased VLJQL¿FDQWO\ CONCLUSIONS: Prolonged warm ischemia, increased intraoperative blood loss and solitary kidney status increase the likelihood of postoperative complications after LPN. With experience, WKH LQFLGHQFH RI FRPSOLFDWLRQV KDV GHFUHDVHG VLJQL¿FDQWO\ GHVSLWH D VLJQL¿FDQWLQFUHDVHLQWXPRUDQGSURFHGXUDOFRPSOH[LW\ Source of Funding: None
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1275 SIMPLE AND EFFECTIVE PURE LAPAROSCOPIC METHOD FOR SURFACE APPLICATION RENAL HYPOTHERMIA TO AID IN LAPAROSCOPIC PARTIAL NEPHRECTOMY: CLINICAL APPLICATION Kittinut Kijvikai*, Lincoln J Maynes, Paul M Milhoua, S Duke Herrell. Bangkok, Thailand, and Nashville, TN. INTRODUCTION AND OBJECTIVE: We have previously GHVFULEHGDQRYHOWHFKQLTXHRIVXUIDFHDSSOLFDWLRQRIQHDUIUHH]LQJVWHULOH VDOLQHYLDDPRGL¿HGODSDURVFRSLFLUULJDWLRQV\VWHPDQGFRQ¿UPHGLWV effectiveness in the porcine kidney model (J Endourol 2005). We now GHVFULEHRXULQLWLDOFOLQLFDOH[SHULHQFHLQXWLOL]LQJWKLVWHFKQLTXHGXULQJ pure complex laparoscopic partial nephrectomy (LPN). METHODS: Seven patients with endophytic renal masses were enrolled in an IRB approved protocol. Standard laparoscopic exposure of the kidney and renal mass was performed. Cardiac needle temperature probes were secured deep to the renal parenchyma and KLODU FODPSLQJ DSSOLHG 1HDU IUHH]LQJ VWHULOH VDOLQH ZDV GHOLYHUHG YLD powered irrigation onto the renal surface and surrounding surgical JDX]HVZKLFKLQFUHDVHVXUIDFHFRQWDFWWLPH5HQDOSDUHQFK\PDDQG patient core temperatures were monitored throughout the procedure. Masses were excised and renorrhaphy accomplished. Postoperatively patients were followed with computed tomography (CT) and monitoring of serum creatinine. RESULTS: An optimal parenchymal temperature of 20 0C was reached after a mean cooling time of 8.3 (3-13) minutes. Mean nadir parenchymal temperature of 15.1 (13.6-18.5) 0C was reached after a mean application time of 14.8 (10-17) minutes. A hypothermic window, GH¿QHGDVEHWZHHQDQG0C, was maintained for an average of 30.4 (22-36) minutes. In two cases re-cooling was applied during the extended reconstructions and temperatures less than 20 0C were achieved within 3 to 5 minutes of reapplication. Mean ischemia time including cooling was 60.2 minutes (43-75). Mean core body temperature drop was 1.28 0 & $OOPDUJLQVZHUHQHJDWLYHDQGQRVLJQL¿FDQWSRVWRSHUDWLYH complications occurred. CT revealed good function of remnant renal units with a mean change in serum creatinine of 0.11 mg/dL (.08-.16) compared to preoperative values. CONCLUSIONS: We have designed, tested, and clinically implemented a simple, effective, and reproducible technique for creating optimal hypothermic temperature for renal protection from ischemia for XVHGXULQJ/31XWLOL]LQJWKHVXUIDFHDSSOLFDWLRQRIQHDUIUHH]LQJVDOLQH irrigation. Application of this technique may increase the safety, extend the complexity level, and encourage the widespread use of laparoscopic partial nephrectomy techniques. Source of Funding: None
1276 THE IMPACT OF WARM ISCHEMIA TIME ON PERIOPERATIVE OUTCOMES & CREATININE CLEARANCE IN PATIENTS UNDERGOING LAPAROSCOPIC PARTIAL NEPHRECTOMY Mark H Katz, Andrew J Bernstein, Michael K Eng*, Sergey A Shikanov, Kevin C Zorn, Arieh L Shalhav. Chicago, IL. INTRODUCTION AND OBJECTIVE: Laparoscopic partial nephrectomy (LPN) is a complex procedure requiring advanced skills. 'XH WR GLI¿FXOW\ ZLWK REWDLQLQJ FROG LVFKHPLF FRQGLWLRQV GXULQJ KLODU clamping, LPN is generally performed under warm ischemic conditions. We sought to evaluate our series of LPNs performed by a single surgeon (ALS) and compare the perioperative outcomes of those with short (<30 min.) versus long (>30 min) warm ischemia time (WIT). In addition we evaluated the postoperative serum creatinine (SCr) as well as creatinine clearance (CrCl) to determine the impact that WIT may have on postoperative renal function. METHODS: Our prospective database of 129 laparascopic partial nephrectomies was reviewed. 48 (Group A) and 63 (Group B) patients were noted to have warm ischemia times of <30 minutes and !PLQXWHVUHVSHFWLYHO\7KHLPSDFWRIWXPRUVL]HSDWLHQWDJHERG\ mass index (BMI, kg/m2), tumor location and depth on warm ischemia time (WIT) was assessed. Perioperative complications, estimated blood loss (EBL), operative time and pathological margin status were compared between the two groups. In addition, SCr as well as CrCl (Cockroft-Gault) were assessed at postoperative intervals greater than one month.
438
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RESULTS: Table one depicts the characteristics of the JURXSV 3DWLHQWV LQ *URXS $ KDG VLJQL¿FDQWO\ ODUJHU WXPRUV DQG shorter operative time than those in Group B. All other variables were similar between the 2 groups, including age, BMI, preoperative renal function, tumor location and depth, and complication rates. The mean postoperative SCr and CrCl did not differ between the groups (median follow-up = 6.3 months). CONCLUSIONS: Longer WIT is associated with larger complex renal tumors. However, complication rates, conversion rates, and EBL were not statistically different when comparing <30 minutes WIT to > 30 min. Pathological margin status was not affected by WIT. Most importantly, longer WIT did not impact long-term serum creatinine and creatinine clearance. Laparoscopic Partial Nephrectomy & Warm Ischemia Time Group A (N=48) Group B (N=63) Age (years) 59.7 59.9 29.5 30.1 BMI (kg/m2) 3UHRS6L]H FP 2.2 3.1 Preop SCr (mg/dl) 1.11 1.13 Preop CrCl (ml/min/BSA) 87.75 80.89 Major Complications 6 (12.5%) 7 (11.1%) Minor Complications 2 (4.2%) 2 (3.2%) Conversion to Open 3 (6.3%) 1 (1.6%) EBL (cc) 183 184 OR Time (min.) 207.6 242.9 Positive Surgical Margins 2 (4.2%) 2 (3.2%) Postop SCr (mg/dl) 1.29 1.37 Postop CrCl (ml/min/BSA) 71.3 81.6
P-Value 0.93 0.54 0.0004 0.91 0.46
0.9669 0.0092
/DSDURVFRSLF3DUWLDO1HSKUHFWRP\DQG5HQDO/HVLRQ6L]H Group B (2-4 *URXS$ FP cm) n 45 64 Age (yrs) 59.6 60.0 Pre-op Cr ± SD (mg/dL) 1.06 ± 0.8 1.14 ± 0.48 Pre-op CrCl ± SD 86.0 ± 47 96.2 ± 147 (ml/min/BSA) Location: 11 (25.6%) 15 (25.9%) - Upper pole 17 (39.5%) 19 (32.8%) - Mid pole 15 (34.9%) 24 (41.4%) - Lower pole
1277 IMPACT OF RENAL LESION SIZE ON PERIOPERATIVE AND PATHOLOGIC OUTCOMES IN PATIENTS UNDERGOING LAPAROSCOPIC PARTIAL NEPHRECTOMY Michael K Eng*, Andrew J Bernstein, Mark H Katz, Sergey A Shikanov, Kevin C Zorn, Arieh L Shalhav. Chicago, IL. ,1752'8&7,21$1'2%-(&7,9( 7KHVL]HRIUHQDOOHVLRQV managed with laparoscopic partial nephrectomy (LPN) has been increasing, especially as surgical volume and experience matures. 7XPRUVL]HLVDQLQWHJUDOFRPSRQHQWRISDWKRORJLFVWDJLQJDVZHOODV an independent prognostic factor in oncologic outcome. The objective of this study was to assess the peri-operative and pathologic outcomes RI/31ZKHQVWUDWLI\LQJIRUVL]HRIUHQDOOHVLRQ METHODS: A retrospective review of LPN performed at the University of Chicago by a single surgeon (ALS) between October 2002 WR -XO\ ZDV SHUIRUPHG SDWLHQWV ZHUH WKHQ VWUDWL¿HG LQWR groups according to diameter of lesion on pre-operative axial imaging: < 2 cm (Group A), 2-4 cm (Group B), and > 4 cm (Group C). Perioperative, operative and pathologic data were compared using student’s t-test and chi-square test. As well, serum creatinine (SCr) and creatinine clearance (CrCl) (Cockgroft-Gault) were assessed at postoperative intervals greater than one month. RESULTS: Table 1 depicts the data from each group. With regards to operative parameters, warm ischemia time (WIT) and RSHUDWLYHWLPHZHUHVLJQL¿FDQWO\ORQJHULQUHQDOOHVLRQV!FP S As well, the need for collecting system repair was more prevalent as OHVLRQVL]HLQFUHDVHG S $OWKRXJKQRWVWDWLVWLFDOO\VLJQL¿FDQWWKHUH was a trend towards a higher complication rate with larger lesions. All other variables were similar amongst the 3 groups, including the rate of positive surgical margins, estimated blood loss (EBL), conversion and transfusion rates. Comparison of pathologic data suggests smaller lesions are more likely to be of lower grade compared to larger lesions. The mean postoperative SCr and CrCl did not differ amongst the groups with a median follow-up of 6.3 months. CONCLUSIONS: Renal masses >2cm underwent longer WIT and operative times compared to lesions <2 cm during LPN. Entry into and subsequent repair of the collecting system was more prevalent DV OHVLRQ VL]H LQFUHDVHG +RZHYHU SRVLWLYH VXUJLFDO PDUJLQ UDWHV complication rates, conversion rates and EBL were not statistically different amongst the 3 groups. Short-term post-operative renal function ZDVQRWDIIHFWHGE\OHVLRQVL]H
16 60.7 1.16 ± 0.58
> 0.79 >0.59
88.5 ± 56.7
>0.63
3 (18.8%) 2 (12.5%) 11 (68.8%)
0.15
Collecting system repair
15 (33%)
43 (67.2%)
14 (87.5%)
WIT ± SD (min)
27.8 ± 7.11
35.8 ± 8.9
33.6 ± 6.21
EBL (mL) OR Time (min) Complications - Major - Minor Transfusion Conversion Histology: - Malignant -Benign Positive surgical margin Post-op Cr ± SD (mg/dL) Post-op CrCl ± SD (ml/min/BSA)
199 198
185 241
272 243
3 (6.7%) 4 (8.9%)
8 (12.5%) 10 (15.6%)
2 (12.5%) 3 (18.8%)
0.09
4 (8.9%) 2 (4.4%)
5 (7.8%) 3 (4.7%)
2 (12.5%) 2 (12.5%)
0.77 0.83
30 (68.2%) 14 (31.8%)
48 (75%) 16 (25%)
12 (75%) 4 (25%)
0.56
1 (2.3%) 1.20 ± 1.04
2 (3.1%) 1.36 ± 0.83
0 (0%) 1.34 ± 0.68
0.47 > 0.43
79.1 ± 34.9
77.0 ± 36.7
71.3 ± 31.2
> 0.3
0.71 0.26
Source of Funding: None
*URXS&FP p-value
0.04 A vs B: <0.001 B vs C: 0.28 A vs C: 0.009 > 0.21 A vs B: <0.01
Source of Funding: None
1278 LAPAROSCOPIC DOPPLER TECHNOLOGY: APPLICATIONS IN LAPAROSCOPIC PYELOPLASTY, RADICAL AND PARTIAL NEPHRECTOMY Mark A Perlmutter*, Elias S Hyams, Michael D Stifelman. New York, NY. INTRODUCTION AND OBJECTIVE: Identification and isolation of vascular structures are crucial and technically demanding aspects of laparoscopic renal surgery. Doppler technology has been used for this purpose in laparoscopic varicocele repair, renal cryoablation, and adrenalectomy. However, its use has not been formally described in laparoscopic radical nephrectomy (RNx), laparoscopic partial nephrectomy (PNx), laparoscopic nephroureterectomy (NU) or roboticassisted laparoscopic pyeloplasty (RALP). This paper relates our current experience using a doppler probe during these procedures. METHODS: A laparoscopic doppler probe (VTI, Nashua, NH) was employed in the above mentioned laparoscopic renal surgeries. 7KH 'RSSOHU V\VWHP FRQVLVWHG RI D GLVSRVDEOH 0+] SUREH SDVVHG through a 5mm port and a battery-powered transceiver. The probe was used to guide dissection/isolation of both the renal hilum and aberrant YDVFXODWXUH LQ 51[1831[ FRQ¿UP SDUHQFK\PDO LVFKHPLD SULRU WR resection in PNx, and identify a crossing vessel (CV) during RALP. At the end of each case, the operating surgeon determined if time was saved with use of the doppler probe. 5(68/76 )RUW\¿YHSDWLHQWVXQGHUZHQWODSDURVFRSLFUHQDO VXUJHU\XWLOL]LQJWKHGRSSOHUSUREH0HDQGRSSOHUWLPHZDVPLQXWH seconds. Sixteen accessory vessels (AV) were detected in 14 patients KDYLQJ51[31[18 2IWKHVH$9ZHUHQRWVHHQRQ SUHRSHUDWLYHLPDJLQJLQSDWLHQWV ,QDQRWKHUFDVHRI31[ SHUVLVWHQW SDUHQFK\PDO ÀRZ GHVSLWH UHQDO DUWHU\ FODPSLQJ UHTXLUHG clamp repositioning. In three cases (43%) of RALP, doppler corrected preoperative imaging in detecting the presence (2) or absence (1) of a CV. Overall, the probe altered management in 27% and saved time in 76% of patients. The probe had 100% concordance with dissection. Use of the probe caused no clinical complications and had a 4% technical failure rate. CONCLUSIONS: Doppler ultrasound technology may have extended applications in laparoscopic renal surgery by facilitating the dissection and evaluation of vasculature. Prospective study with objective endpoints will be helpful in confirming the utility of this technology in these settings.