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V46 PURE LESS TRANSUMBILICAL LIVE DONOR NEPHRECTOMY
The RNM study shows contrast enhancement, suggesting diagnosis of renal tumor. Due to the tumor size and its localization, a laparoscopic tumorectomy was decided. The main difficulty in this case comes from the important fibrosis surrounding the graft that requires a long and meticulous dissection in order to avoid hemorrage and parenchimal injuries. As the tumor is not prominent, a laparoscopic ultrasound guide is required in order to identify the lesion properly. A bulldog clamp is inserted through a 12mm trocar to clamp renal artery, to reduce bleeding during tumor dissection. Results: Surgical time was 230 minutes and the warm ischemia time was 23 minutes. The final pathological analysis showed a 1,5cm oncocitoma with negative margins. The patient did not require dialysis and basal creatinine levels were reached 1 month after the surgery. Conclusions: Laparoscopic tumorectomy is feasible and reproducible in transplanted kidneys. Furthermore, the use of laparoscopic ultrasound guidance is very useful to localize not exteriorized tumors.
V46
Pure LESS transumbilical live donor nephrectomy
Sebastien S.1, Haber G.P.2, Adam E.1, Badet L.1, Colombel M.1, Fassi-Fehri H.1, Poissonnier L.1, Martin X.1 1 Edouard Herriot Hospital, Dept. of Urology, Lyon, France, 2Cleveland Clinic, Glickman Urological and Kidney Institute, Cleveland, United States of America Introduction & Objectives: To present our initial experience with pure LESS donor nephrectomy. Materials & Methods: Between 02/2010 and 10/2010, 5 consecutive patients underwent a LaparoEndoscopic Single Site (LESS) donor nephrectomy through an umbilical incision. The kidney was pre-entrapped and extracted transumbilical Results: All LESS donor nephrectomy were successfully achieved with no complication. The video describe the surgical technique of LESS live donor nephrectomy wich is duplicated the satndard laparoscopic technique. The mean operative time was 4hours and the mean warm ischemia time was 5.8 min. In one case, an additional 5mm port was used for upper pole dissection and hilar control. The final mean length of the intra-umbilical incision was 3.9cm. Hospital stay was 3.7 days and the patient-reported days to 100% physical recovery was 32.5 days. The visual analog pain scores at discharged was 2.3 with a mean length of oral pain medication was 11.5 days Conclusions: This initial experience with LESS donor nephrectomy is encouraging. Preliminary data suggest that LESS donor nephrectomy is associated with quicker convalescence.
V47
LESS partial nephrectomy – initial experience using the Gelpoint® as access platform
Flamand V.1, Sanchez-Salas R.2, Galiano M.2, Rozet F.2, Cathelineau X.2, Barret E.2, Vallancien G.2 1 CHRU Lille, Dept. of Urology, Lille, France, 2Institut Montsouris, Dept. of Urology, Paris, France Introduction & Objectives: Reliable access for LESS surgery remains a difficult task. The aim is to obtain an adequate working space in an airtight environment. Materials & Methods: A 65 years old patient presented with a 4 cm renal enhancing mass located at the lower pole of the right kidney. We performed a transperitoneal partial single port nephrectomy using the Gelpoint® system (Applied Medical) as platform access and conventional laparoscopic instruments. Patient was placed in lateral position. A single small 3 cm incision was made in the umbilicus. Four 5 mm trocars were placed through the gel for endoscope, retraction, bipolar and ultrasonic coagulation shears. Hemostasis and reconstruction were done using a running suture and haemostatic mesh. The specimen was removed in an extraction device through the umbilical incision. Results: Operating time was 130 min with a total blood loss of 100 cc. The pedicle was clamped for 17 min. Patient was discharged at day 4. No transfusion was required. Post op serum creatinine was 88 µmole/l and Hb was 13,4 gr/L. The final skin incision was 3 cm long. Final pathology revealed a pT1a Nx papillary carcinoma, Fuhrman 3 with negative surgical margins. Conclusions: The Gelpoint® system broughts a more spacious surgical field when performing LESS surgery, even when using standard laparoscopic instruments. Gelpoint® represents a potential more fitted access platform for LESS surgery.
V48
V-loc™ barbed suture renorrhaphy during robotic partial nephrectomy: Technique and outcomes
Trinh Q.D., Sukumar S., Sammon J., Petros F., Menon M., Rogers C. Vattikuti Urology Institute, Henry Ford Hospital, Dept. of Urology, Detroit, United States of America Introduction & Objectives: Robotic Assisted Partial Nephrectomy (RAPN) is a technique for minimally invasive nephron sparing surgery that may help with reducing the technical challenges of sutured renorrhaphy. We present a novel technique for knotless renorrhaphy during RAPN using barbed suture.
Materials & Methods: The V-loc 180 ™ wound closure device (Covidien, Mansfield, MA) is a unidirectional barbed variant of the absorbable copolymer polyglyconate. The first two cm of the suture is without barbs and a loop at the end allows knotless suture tying. Deep layer renorrhaphy is performed in a continuous fashion using a 6 inch 3-0 Vloc suture on a V-20 needle. Capsular layer renorrhaphy is performed in an interrrupted fashion using a 12 inch 2-0 Vloc suture on a GS-21 needle. The sliding clip technique is used to secure the sutures. We recently completed our first case series and show the comparison between a group with Vloc suture and the immediately preceding group with Vicryl sutures. Results: The renorrhaphy was completed successfully in all cases of RAPN. No instances of tearing or suture slippage occurred during renal reconstruction. The demographic and preoperative characteristics were not significantly different between the two groups. However, the warm ischemia time was significantly shorter in the V-Loc group by 6.2 min (18.5 vs. 24.7 min, p=0.008), which represents a 25.1% reduction. Two instances of postoperative bleeds requiring transfusion occurred in the Vicryl group. Conclusions: Barbed suture makes minimally invasive partial nephrectomy easier and more efficient. It enables tight renal closures and significantly improved the warm ischemia time by 25% in our study.
V49
Robot-assisted renal tumorectomy for a small renal cell cancer
Giberti C., Schenone M., Gallo F., Cortese P. San Paolo Hospital, Dept. of Surgery, Division of Urology, Savon, Italy Introduction & Objectives: To show our technique performing a robot-assisted renal tumorectomy for a left small renal cell cancer Materials & Methods: A 66 years old female patient, affected by a small (3 cm) exofitic tumor, localized in the medium part of the left kidney underwent a robot assisted renal tumorectomy at our institute. Surgical Technique: the patient was placed in a flank position. The access foresees a 12 mm camera port, 2 cm far from the umbilicus on the left pararectal line and two 8 mm robotic trocars, introduced on the left midaxillary line in a “C” configuration. A forth trocar was introduced during the procedure. After incision of the left paracolic gutter and exposure of the renal lodge, the left renal vein and artery were isolated. Gerota’s fascia was then incised with a complete isolation of the tumor and the renal capsula was scored in order to design the margin of the tumor dissection. The renal artery was then clamped with a bull-dog clamp and cold dissection of the tumor was performed during warm ischemia. After removing any blood clots, an absorbable fibrin sealant patch (Tachosil) was put into the inner defect and then a Vycril 2/0 sliding clips renorraphy was performed. The bull-dog clamp was removed after 13 minutes of warm ischemia. The Gerota’s fascia was sutured. The specimen was retrieved into the endo-bag through the camera port. Operative time was 120 minutes. Blood loss was minimal. Results: No peri or postoperative complications occurred. Patient was discharged on fourth day after surgery. Pathological examination reported a pTaG1 RCC. Follow-up was regular. Conclusions: Da Vinci Robot helps significantly the surgeon during the tumor dissection and the suture of renal parenchima, shortening the warm ischemia time and providing a easier reproducibility of this laparoscopic technique.
V50
Is laparoscopic radical nephrectomy justified in central renal masses herniating into the hilum? Our technique and results with open nephron-sparing surgery
Onol S.Y.1, Onol F.F.2, Erdem M.R.1, Topaktas R.1, Ersoz C.1 1 Bezmi Alem Vakif University, Dept. of Urology, Istanbul, Turkey, 2Sakarya Trainig and Research Hospital, Dept. of Urology, Sakarya, Turkey Introduction & Objectives: Laparoscopic radical nephrectomy is over-utilized for central renal masses due to the technical challenge and increased ischemia times with laparoscopic nephron-sparing surgery (NSS). We herein present our technique and results with open NSS and question the rationale for the former approach. Materials & Methods: Eleven patients (7 males and 4 females, mean age: 58 years, range: 42 to 82) underwent open NSS between 2006 and 2010 for central tumors, defined as a lesion completely surrounded by normal parenchyma herniating into the renal hilum in contact with major renal vessels. Three lesions were truly intrahilar. Mean tumor largest diameter was 4.5 cm (range: 3 to 8). The indication was absolute in 2 (1 solitary kidney and 1 contralateral atrophic kidney). Extrapleural extraperitoneal flank approach with 9th to 11th rib resection was used in all cases. Resection was done with renal hypothermia (with ice slush) and warm ischemia (with clamping of the artery and vein) in 5 and 6 patients, respectively, after complete mobilization of the kidney. Blunt “finger-tip” started towards the hilum after transparenchymal incision that circumscribed the lesion. Tissue resistance during enucleo-resection was indicative of an artery that was to be isolated and ligated before progressive dissection. Entry to the collecting system or inadvertent dissection of vessels were repaired as soon as encountered with continuous 4/0 polyglactin suturing. The defect was closed with approximation of the parenchymal edges over embedded homeostatic packings. Ischemia time,
Eur Urol Suppl 2011;10(2):355
V46
Pure LESS transumbilical live donor nephrectomy
Sebastien S.1, Haber G.P.2, Adam E.1, Badet L.1, Colombel M.1, Fassi-Fehri H.1, Poissonnier L.1, Martin X.1 1 Edouard Herriot Hospital, Dept. of Urology, Lyon, France, 2Cleveland Clinic, Glickman Urological and Kidney Institute, Cleveland, United States of America Introduction & Objectives: To present our initial experience with pure LESS donor nephrectomy. Materials & Methods: Between 02/2010 and 10/2010, 5 consecutive patients underwent a LaparoEndoscopic Single Site (LESS) donor nephrectomy through an umbilical incision. The kidney was pre-entrapped and extracted transumbilical Results: All LESS donor nephrectomy were successfully achieved with no complication. The video describe the surgical technique of LESS live donor nephrectomy wich is duplicated the satndard laparoscopic technique. The mean operative time was 4hours and the mean warm ischemia time was 5.8 min. In one case, an additional 5mm port was used for upper pole dissection and hilar control. The final mean length of the intra-umbilical incision was 3.9cm. Hospital stay was 3.7 days and the patient-reported days to 100% physical recovery was 32.5 days. The visual analog pain scores at discharged was 2.3 with a mean length of oral pain medication was 11.5 days Conclusions: This initial experience with LESS donor nephrectomy is encouraging. Preliminary data suggest that LESS donor nephrectomy is associated with quicker convalescence.
V47
LESS partial nephrectomy – initial experience using the Gelpoint® as access platform
Flamand V.1, Sanchez-Salas R.2, Galiano M.2, Rozet F.2, Cathelineau X.2, Barret E.2, Vallancien G.2 1 CHRU Lille, Dept. of Urology, Lille, France, 2Institut Montsouris, Dept. of Urology, Paris, France Introduction & Objectives: Reliable access for LESS surgery remains a difficult task. The aim is to obtain an adequate working space in an airtight environment. Materials & Methods: A 65 years old patient presented with a 4 cm renal enhancing mass located at the lower pole of the right kidney. We performed a transperitoneal partial single port nephrectomy using the Gelpoint® system (Applied Medical) as platform access and conventional laparoscopic instruments. Patient was placed in lateral position. A single small 3 cm incision was made in the umbilicus. Four 5 mm trocars were placed through the gel for endoscope, retraction, bipolar and ultrasonic coagulation shears. Hemostasis and reconstruction were done using a running suture and haemostatic mesh. The specimen was removed in an extraction device through the umbilical incision. Results: Operating time was 130 min with a total blood loss of 100 cc. The pedicle was clamped for 17 min. Patient was discharged at day 4. No transfusion was required. Post op serum creatinine was 88 µmole/l and Hb was 13,4 gr/L. The final skin incision was 3 cm long. Final pathology revealed a pT1a Nx papillary carcinoma, Fuhrman 3 with negative surgical margins. Conclusions: The Gelpoint® system broughts a more spacious surgical field when performing LESS surgery, even when using standard laparoscopic instruments. Gelpoint® represents a potential more fitted access platform for LESS surgery.
V48
V-loc™ barbed suture renorrhaphy during robotic partial nephrectomy: Technique and outcomes
Trinh Q.D., Sukumar S., Sammon J., Petros F., Menon M., Rogers C. Vattikuti Urology Institute, Henry Ford Hospital, Dept. of Urology, Detroit, United States of America Introduction & Objectives: Robotic Assisted Partial Nephrectomy (RAPN) is a technique for minimally invasive nephron sparing surgery that may help with reducing the technical challenges of sutured renorrhaphy. We present a novel technique for knotless renorrhaphy during RAPN using barbed suture.
Materials & Methods: The V-loc 180 ™ wound closure device (Covidien, Mansfield, MA) is a unidirectional barbed variant of the absorbable copolymer polyglyconate. The first two cm of the suture is without barbs and a loop at the end allows knotless suture tying. Deep layer renorrhaphy is performed in a continuous fashion using a 6 inch 3-0 Vloc suture on a V-20 needle. Capsular layer renorrhaphy is performed in an interrrupted fashion using a 12 inch 2-0 Vloc suture on a GS-21 needle. The sliding clip technique is used to secure the sutures. We recently completed our first case series and show the comparison between a group with Vloc suture and the immediately preceding group with Vicryl sutures. Results: The renorrhaphy was completed successfully in all cases of RAPN. No instances of tearing or suture slippage occurred during renal reconstruction. The demographic and preoperative characteristics were not significantly different between the two groups. However, the warm ischemia time was significantly shorter in the V-Loc group by 6.2 min (18.5 vs. 24.7 min, p=0.008), which represents a 25.1% reduction. Two instances of postoperative bleeds requiring transfusion occurred in the Vicryl group. Conclusions: Barbed suture makes minimally invasive partial nephrectomy easier and more efficient. It enables tight renal closures and significantly improved the warm ischemia time by 25% in our study.
V49
Robot-assisted renal tumorectomy for a small renal cell cancer
Giberti C., Schenone M., Gallo F., Cortese P. San Paolo Hospital, Dept. of Surgery, Division of Urology, Savon, Italy Introduction & Objectives: To show our technique performing a robot-assisted renal tumorectomy for a left small renal cell cancer Materials & Methods: A 66 years old female patient, affected by a small (3 cm) exofitic tumor, localized in the medium part of the left kidney underwent a robot assisted renal tumorectomy at our institute. Surgical Technique: the patient was placed in a flank position. The access foresees a 12 mm camera port, 2 cm far from the umbilicus on the left pararectal line and two 8 mm robotic trocars, introduced on the left midaxillary line in a “C” configuration. A forth trocar was introduced during the procedure. After incision of the left paracolic gutter and exposure of the renal lodge, the left renal vein and artery were isolated. Gerota’s fascia was then incised with a complete isolation of the tumor and the renal capsula was scored in order to design the margin of the tumor dissection. The renal artery was then clamped with a bull-dog clamp and cold dissection of the tumor was performed during warm ischemia. After removing any blood clots, an absorbable fibrin sealant patch (Tachosil) was put into the inner defect and then a Vycril 2/0 sliding clips renorraphy was performed. The bull-dog clamp was removed after 13 minutes of warm ischemia. The Gerota’s fascia was sutured. The specimen was retrieved into the endo-bag through the camera port. Operative time was 120 minutes. Blood loss was minimal. Results: No peri or postoperative complications occurred. Patient was discharged on fourth day after surgery. Pathological examination reported a pTaG1 RCC. Follow-up was regular. Conclusions: Da Vinci Robot helps significantly the surgeon during the tumor dissection and the suture of renal parenchima, shortening the warm ischemia time and providing a easier reproducibility of this laparoscopic technique.
V50
Is laparoscopic radical nephrectomy justified in central renal masses herniating into the hilum? Our technique and results with open nephron-sparing surgery
Onol S.Y.1, Onol F.F.2, Erdem M.R.1, Topaktas R.1, Ersoz C.1 1 Bezmi Alem Vakif University, Dept. of Urology, Istanbul, Turkey, 2Sakarya Trainig and Research Hospital, Dept. of Urology, Sakarya, Turkey Introduction & Objectives: Laparoscopic radical nephrectomy is over-utilized for central renal masses due to the technical challenge and increased ischemia times with laparoscopic nephron-sparing surgery (NSS). We herein present our technique and results with open NSS and question the rationale for the former approach. Materials & Methods: Eleven patients (7 males and 4 females, mean age: 58 years, range: 42 to 82) underwent open NSS between 2006 and 2010 for central tumors, defined as a lesion completely surrounded by normal parenchyma herniating into the renal hilum in contact with major renal vessels. Three lesions were truly intrahilar. Mean tumor largest diameter was 4.5 cm (range: 3 to 8). The indication was absolute in 2 (1 solitary kidney and 1 contralateral atrophic kidney). Extrapleural extraperitoneal flank approach with 9th to 11th rib resection was used in all cases. Resection was done with renal hypothermia (with ice slush) and warm ischemia (with clamping of the artery and vein) in 5 and 6 patients, respectively, after complete mobilization of the kidney. Blunt “finger-tip” started towards the hilum after transparenchymal incision that circumscribed the lesion. Tissue resistance during enucleo-resection was indicative of an artery that was to be isolated and ligated before progressive dissection. Entry to the collecting system or inadvertent dissection of vessels were repaired as soon as encountered with continuous 4/0 polyglactin suturing. The defect was closed with approximation of the parenchymal edges over embedded homeostatic packings. Ischemia time,
Eur Urol Suppl 2011;10(2):355