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THE LEARNING CURVE OF ROBOTIC-ASSISTED LAPAROSCOPIC PARTIAL NEPHRECTOMY: A SINGLE CENTRE'S 6-YEARS EXPERIENCE
THE JOURNAL OF UROLOGY®
Vol. 181, No. 4, Supplement, Tuesday, April 28, 2009
535
1496
1497
KNOTLESS CLOSURE OF COLLECTING SYSTEM AND RENAL PARENCHYMA WITH A NOVEL BARBED SUTURE DURING LAPAROSCOPIC PARTIAL NEPHRECTOMY
THE LEARNING CURVE OF ROBOTIC-ASSISTED LAPAROSCOPIC PARTIAL NEPHRECTOMY: A SINGLE CENTRE’S 6-YEARS EXPERIENCE.
Sergey Shikanov*, Mark Wille, Michael C Large, David A Lifshitz, Kevin C Zorn, Scott E Eggener, Chicago, IL
Henry Ho*, Martin Harbicher, Richard Neururer, Hannes Steiner, Georg Bartsch, Reinhard Peschel, Innsbruck, Austria
INTRODUCTION AND OBJECTIVES: Closure of the urinary collecting system and renal parenchyma is a technically challenging aspect of nephron-sparing laparoscopic surgery and is an obstacle to its more widespread use. A novel barbed polydioxanone suture (Quill SRS, Angiotech, Reading, PA) (Fig.1) has been introduced for knot-free tissue approximation. Following laparoscopic partial nephrectomy, we compared kidney and collecting system closure between the barbed suture and a more conventional technique. METHODS: The study protocol was approved by Institutional Animal Care and Use Committee. Ten female pigs underwent bilateral transperitoneal laparoscopic lower pole hemi-nephrectomy under warm ischemia by two surgeons (SEE, SS). Closure of the collecting system and approximation of the renal parenchyma was performed in two layers using continuous knotless barbed suture for one kidney and polyglactin (Vicryl) with absorbable polydioxanone clips (LapraTy, Ethicon, Picataway, NJ) on the contralateral kidney. For both techniques, the collecting system was closed with 2-0 suture and the renal parenchyma with #1 suture. Warm ischemia and suturing time were recorded and resected tissue weighed. All animals were sacrificed one week following surgery. Serum hemoglobin and visual inspection at necropsy were used to assess for bleeding. Serum creatinine, visual inspection, and bilateral retrograde pyelography at necropsy were used to assess for urinary leak. RESULTS: Mean (SD) weight of resected tissue (barbed: 34 ± 13 grams, clips: 34 ± 11 grams, p=0.6), mean (SD) ischemia time (barbed: 34 ± 8 minutes, clips: 34 ± 10 minutes, p=0.7), and mean suturing time (barbed: 21 ± 4 minutes, clips: 22 ± 7 minutes, p=0.7) were similar between groups. No animal had a visible hematoma or urinoma at necropsy. On retrograde pyelography, a small urinary leak was found in two renal units in each group (p=0.6). CONCLUSIONS: In a porcine model of renal collecting system and parenchyma closure, it appears that knotless barbed suture is effective, efficient, and safe. Further evaluation in humans is required.
INTRODUCTION AND OBJECTIVES: Laparoscopic partial nephrectomy is a technically challenging treatment option for small renal tumour. Increasingly, robotic-assisted laparoscopic partial nephrectomy (RPN) is an alternative option. We describe our centre’s learning curve. METHODS: From February 2003 till September 2008, we included all consecutive RPN performed for enhancing renal mass on CT scan. We excluded patients with tumours more than 7 cm and those with abdominal surgery that precluded transperitoneal approach. A 3-arm Da Vinci robot was used in a 4-ports approach with warm ischemic time. After tumour excision and pelvicalyceal (PC) closure, the tumour bed was lined with Floseal® and the capsule was closed with a continuous absorbable suture, reinforced by Hem-o-Lok® clips. A single surgeon performed all the surgery with a patient-side assistant. Postop complication ultrasound surveillance was done on the 4th post-op day, 3 and 6 months. We recorded the following: operating time (OT) which includes robot setting-up, warm ischemic time (WIT), PC closure, estimated blood loss (EBL) and complications. In consecutive order, the patients were divided into 4 groups for comparison; using Mann-Whitney U test for continuous variable. RESULTS: The 75 patients’ demographics, operative and postoperative findings were presented in the following table. There was no statistical difference in most baseline features, except for the fewer central tumors in the first group and the higher mean pre-op serum creatinine in the last group. The mean OT, WIT and EBL progressively decreased till group 3 (p < 0.05). All three positive surgical margins occurred in the first group. There was one case of post-op hematoma and urinary leak, which occurred in the last group. Twenty tumours (29.3%) were benign. Majority (81.1%) of the malignant tumours were of the clear cell subtype. CONCLUSIONS: RPN has demonstrated to be a reliable and effective treatment option for small renal tumours. As an early centre that developed this approach, our learning curve is 35 cases. However, we believe that adopting our current evolved technique, it will be shorter. If robot availability is not an issue, this may avail minimally-invasive partial nephrectomy to more urologists. Table: Demographics, operative and post-operative findings of 75 patients
No. of patients Mean age (Range)
Group 2
Group 3
Group 4
15
20
20
20
58.3 (37-68) 58.7 (37-75) 59.6 (36-78) 61.3(43-77)
Mean ASA (Range)
1.7 (1 - 2)
1.8 (1 - 3)
1.9 (1 - 3)
2.0 (1 - 3)
Mean Pre-op creatinine (Range)
0.80(0.51 1.07)
0.83(0.56 1.23)
0.73(0.52 1.06)
0.97(0.571.55)
Mean tumor size Central tumor Cold perfusion Mean OT Mean WIT
Source of Funding: None
Group 1
3.3 (1.5-6.0) 2.9 (1.5-4.5) 2.9 (1.5-5.0) 2.8(1.5-4.4) 2
4
5
7
8
4
0
0
182.5* (120-220) 29.6* (24-35)
100* (75-140) 24.9* (15-25)
92.5* (80-100) 21.0* (15-27)
89.7 (85-130) 22.3 (18-26)
Repair of PCS
3
5
7
7
Mean EBL
265* (100-450)
102.5* (30-160)
77.5* (60-120)
69.5 (50-160)
Open Conversion
1
0
0
1
Blood transfusion
9
0
0
1
0.83 0.87 0.78 0.98 Mean Post-op creatinine (0.61 - 1.11) (0.55 - 1.24) (0.59 - 1.09) (0.58- 1.57) = Man Whitney U test; p < 0.001
Source of Funding: None
Vol. 181, No. 4, Supplement, Tuesday, April 28, 2009
535
1496
1497
KNOTLESS CLOSURE OF COLLECTING SYSTEM AND RENAL PARENCHYMA WITH A NOVEL BARBED SUTURE DURING LAPAROSCOPIC PARTIAL NEPHRECTOMY
THE LEARNING CURVE OF ROBOTIC-ASSISTED LAPAROSCOPIC PARTIAL NEPHRECTOMY: A SINGLE CENTRE’S 6-YEARS EXPERIENCE.
Sergey Shikanov*, Mark Wille, Michael C Large, David A Lifshitz, Kevin C Zorn, Scott E Eggener, Chicago, IL
Henry Ho*, Martin Harbicher, Richard Neururer, Hannes Steiner, Georg Bartsch, Reinhard Peschel, Innsbruck, Austria
INTRODUCTION AND OBJECTIVES: Closure of the urinary collecting system and renal parenchyma is a technically challenging aspect of nephron-sparing laparoscopic surgery and is an obstacle to its more widespread use. A novel barbed polydioxanone suture (Quill SRS, Angiotech, Reading, PA) (Fig.1) has been introduced for knot-free tissue approximation. Following laparoscopic partial nephrectomy, we compared kidney and collecting system closure between the barbed suture and a more conventional technique. METHODS: The study protocol was approved by Institutional Animal Care and Use Committee. Ten female pigs underwent bilateral transperitoneal laparoscopic lower pole hemi-nephrectomy under warm ischemia by two surgeons (SEE, SS). Closure of the collecting system and approximation of the renal parenchyma was performed in two layers using continuous knotless barbed suture for one kidney and polyglactin (Vicryl) with absorbable polydioxanone clips (LapraTy, Ethicon, Picataway, NJ) on the contralateral kidney. For both techniques, the collecting system was closed with 2-0 suture and the renal parenchyma with #1 suture. Warm ischemia and suturing time were recorded and resected tissue weighed. All animals were sacrificed one week following surgery. Serum hemoglobin and visual inspection at necropsy were used to assess for bleeding. Serum creatinine, visual inspection, and bilateral retrograde pyelography at necropsy were used to assess for urinary leak. RESULTS: Mean (SD) weight of resected tissue (barbed: 34 ± 13 grams, clips: 34 ± 11 grams, p=0.6), mean (SD) ischemia time (barbed: 34 ± 8 minutes, clips: 34 ± 10 minutes, p=0.7), and mean suturing time (barbed: 21 ± 4 minutes, clips: 22 ± 7 minutes, p=0.7) were similar between groups. No animal had a visible hematoma or urinoma at necropsy. On retrograde pyelography, a small urinary leak was found in two renal units in each group (p=0.6). CONCLUSIONS: In a porcine model of renal collecting system and parenchyma closure, it appears that knotless barbed suture is effective, efficient, and safe. Further evaluation in humans is required.
INTRODUCTION AND OBJECTIVES: Laparoscopic partial nephrectomy is a technically challenging treatment option for small renal tumour. Increasingly, robotic-assisted laparoscopic partial nephrectomy (RPN) is an alternative option. We describe our centre’s learning curve. METHODS: From February 2003 till September 2008, we included all consecutive RPN performed for enhancing renal mass on CT scan. We excluded patients with tumours more than 7 cm and those with abdominal surgery that precluded transperitoneal approach. A 3-arm Da Vinci robot was used in a 4-ports approach with warm ischemic time. After tumour excision and pelvicalyceal (PC) closure, the tumour bed was lined with Floseal® and the capsule was closed with a continuous absorbable suture, reinforced by Hem-o-Lok® clips. A single surgeon performed all the surgery with a patient-side assistant. Postop complication ultrasound surveillance was done on the 4th post-op day, 3 and 6 months. We recorded the following: operating time (OT) which includes robot setting-up, warm ischemic time (WIT), PC closure, estimated blood loss (EBL) and complications. In consecutive order, the patients were divided into 4 groups for comparison; using Mann-Whitney U test for continuous variable. RESULTS: The 75 patients’ demographics, operative and postoperative findings were presented in the following table. There was no statistical difference in most baseline features, except for the fewer central tumors in the first group and the higher mean pre-op serum creatinine in the last group. The mean OT, WIT and EBL progressively decreased till group 3 (p < 0.05). All three positive surgical margins occurred in the first group. There was one case of post-op hematoma and urinary leak, which occurred in the last group. Twenty tumours (29.3%) were benign. Majority (81.1%) of the malignant tumours were of the clear cell subtype. CONCLUSIONS: RPN has demonstrated to be a reliable and effective treatment option for small renal tumours. As an early centre that developed this approach, our learning curve is 35 cases. However, we believe that adopting our current evolved technique, it will be shorter. If robot availability is not an issue, this may avail minimally-invasive partial nephrectomy to more urologists. Table: Demographics, operative and post-operative findings of 75 patients
No. of patients Mean age (Range)
Group 2
Group 3
Group 4
15
20
20
20
58.3 (37-68) 58.7 (37-75) 59.6 (36-78) 61.3(43-77)
Mean ASA (Range)
1.7 (1 - 2)
1.8 (1 - 3)
1.9 (1 - 3)
2.0 (1 - 3)
Mean Pre-op creatinine (Range)
0.80(0.51 1.07)
0.83(0.56 1.23)
0.73(0.52 1.06)
0.97(0.571.55)
Mean tumor size Central tumor Cold perfusion Mean OT Mean WIT
Source of Funding: None
Group 1
3.3 (1.5-6.0) 2.9 (1.5-4.5) 2.9 (1.5-5.0) 2.8(1.5-4.4) 2
4
5
7
8
4
0
0
182.5* (120-220) 29.6* (24-35)
100* (75-140) 24.9* (15-25)
92.5* (80-100) 21.0* (15-27)
89.7 (85-130) 22.3 (18-26)
Repair of PCS
3
5
7
7
Mean EBL
265* (100-450)
102.5* (30-160)
77.5* (60-120)
69.5 (50-160)
Open Conversion
1
0
0
1
Blood transfusion
9
0
0
1
0.83 0.87 0.78 0.98 Mean Post-op creatinine (0.61 - 1.11) (0.55 - 1.24) (0.59 - 1.09) (0.58- 1.57) = Man Whitney U test; p < 0.001
Source of Funding: None