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VID-05.01 Laparoscopic Partial Nephrectomy: “Zero-Ischemia” Technique with Controlled Hypotension
VIDEO SESSIONS
Video Session 5 Kidney & Ureteral Cancer Tuesday, October 18 13:15-14:45 VID-05.01 Laparoscopic Partial Nephrectomy: “Zero-Ischemia” Technique with Controlled Hypotension Sotelo R1, Desai M2, Giedelman C1, Carmona O1, Aron M2, Gill I2, Eisenberg M2 1 Instituto Medico La Floresta, Caracas, Venezuela; 2University of Southern California, Institute of Urology, Los Angeles, USA Introduction and Objectives: Partial nephrectomy surgery has two fundamental goals: a) negative cancer margins, and b) renal functional preservation. During partial nephrectomy, each minute increase in ischemia may compromise function of the renal remnant. Efforts to minimize, better yet, eliminate renal ischemia are imperative. Our objective is to present the video technique of the novel “zero ischemia” technique of laparoscopic partial nephrectomy (LPN) in 16 patients with a small renal mass. Methods: Sixteen patients underwent “zero ischemia” LPN with the following technique: micro-dissection of tumor-specific renal artery branches, plus controlled hypotension coinciding with tumor excision. Controlled hypotension is a specific anesthetic technique, designed to decrease intra-operative hemorrhage while providing excellent systemic perfusion. It involves reducing systolic blood pressure to 80-90mm Hg, reducing mean arterial pressure (MAP) to 50-65mm Hg or a 30% reduction of baseline MAP. Pre- and intraoperative anesthesia-related hypotensive monitoring included continuous pulmonary artery pressure measurements, transesophageal echocardiography, and brain activity measurements. Timed, pharmacologically-induced hypotension was carefully calibrated by an expert anesthesiologist, corresponding with parenchymal resection. Detailed in our video is the technique of tumor excision/hemostasis involved monopolar J-hook, cold endoshears, suturing, and Hem-o-Lok clips. Hypotension was reversed after completing resection and initial renorrhaphy. Parenchymal reconstruction was completed under normotensive conditions to assure hemostasis was achieved. Results: All cases were successfully com-
pleted without hilar clamping. Ischemia time was zero in all cases. Median tumor size was 2.7cm (0.9-4), operative time 3 hrs (1-5), blood loss 100cc (20-200), and hospital stay 3 days (2-19). Nadir mean arterial pressure ranged from 49-65mmHg (median 60), typically for 1-5 minutes. No patient had intra-operative transfusion or complication, acute or delayed renal hemorrhage, or hypotension-related sequelae. Median preoperative and postoperative serum creatinine (0.9mg/dL and 0.95mg/ dL) and estimated gFR (75.3 and 72.9) were comparable. Median absolute and percent change in discharge serum creatinine and eGFR was 0 and 0%, respectively. Conclusions: This novel “zero ischemia” hypotensive LPN technique represents a significant step in the continuum towards thegoal of eliminating surgical ischemia. Our recommended time is: NO ischemia
VID-05.02 Laparoscopic Partial Nephrectomy in Polycystic Kidney Peña J, Ramos E, Azuero J, Palou J, Villavicencio H Fundació Puigvert, Barcelona, Spain Introduction: European guidelines recommend nephron-sparing surgery for T1 tumours whenever possible. Partial nephrectomy is technically challenging in patient with autosomal dominant polycystic kidney disease (ADPKD). We present a video of a pure laparoscopic approach. Material and Methods: A 49 year-old patient diagnosed of ADPKD with normal renal function is diagnosed of bilateral renal mass in a routine control ultrasound. The CT scan shows both kidneys significantly enlarged with ADPKD and two contrast enhanced masses of 22mm in the mid-pole posterior valve of the right kidney and 16mm in the lower pole anterior valve of the left kidney. Preoperative serum creatinine concentration was 98 umol/L and the estimated glomerular filtration rate was 70 ml/min/1.73m. A laparoscopic partial nephrectomy delivered in two times is proposed. We present the right side procedure. Results: Dissection of the right kidney is performed with the help of three trocars. As the tumour is difficult to distinguish from the renal cysts, intraoperative laparoscopic ultrasonography is used. Incision of peritumoral cysts is helpful to define the dissection planes. Partial nephrectomy is done without clamping the renal helium. Surgical time was 90 minutes. There were no postoperative complications. Pa-
UROLOGY 78 (Supplement 3A), September 2011
tient was discharged 4 days after surgery. Pathology report revealed Papillary I histological subtype renal cell carcinoma. Conclusions: Nephron-sparing surgery is a feasible and reproducible technique in selected patients with ADPKD. Vascular clamping may be not necessary in all cases.
VID-05.03 Partial Nephrectomy by Retroperitoneoscopy Without Hilar Clamping Peña J, Ramos E, Villamizar J, Santillana J, Breda A, Palou J, Villavicencio H Fundació Puigvert, Barcelona, Spain Introduction: Partial nephrectomy is the technique of choice for T1a renal tumors according to the EAU guidelines as it offers oncological and functional results equal to open surgery. After more than 200 transperitoneal partial nephrectomies performed in our institution, we have started to perform partial nephrectomy by retroperitoneoscopy for posterior renal tumors. We present the video of a partial nephrectomy by retroperitoneoscopy without hilar clamping. Methods and Materials: A 59 year-old patient with smoking habit and past surgical history of inguinal hernioplasty and appendectomy was found with microscopic hematuria. A renal ultrasound was performed showing a 25mm lesion in the right kidney, suspicious for malignancy. A CT scan was performed showing a 24.5mm upper pole right posterior enhancing lesion. Due to the location of the lesion, a decision to perform a retroperitoneal partial nephrectomy was taken. Results: Four retroperitoneal trocars were positioned after digital dissection and use of a balloon for dissection. After dissecting the pedicle the posterior renal tumor was identified and freed from adjacent tissues. Partial nephrectomy was performed with a Rummel tourniquet placed around the renal artery without clamping it. During the excision, the pneumoretroperitoneum was raised to 20mmHg. The monopolar beam was proved to be usefull for hemostasis of the surgical bed. Continuous running suture with the Hem-o-lock technique was used for parenchyma closure. Conclusions: Retroperitoneal partial nephrectomy is a feasible and reproducible technique in selected patients. Posterior tumors are particularly accessible with this approach. For small completely exophitic tumours, hilar clamping may not be necessary.
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Video Session 5 Kidney & Ureteral Cancer Tuesday, October 18 13:15-14:45 VID-05.01 Laparoscopic Partial Nephrectomy: “Zero-Ischemia” Technique with Controlled Hypotension Sotelo R1, Desai M2, Giedelman C1, Carmona O1, Aron M2, Gill I2, Eisenberg M2 1 Instituto Medico La Floresta, Caracas, Venezuela; 2University of Southern California, Institute of Urology, Los Angeles, USA Introduction and Objectives: Partial nephrectomy surgery has two fundamental goals: a) negative cancer margins, and b) renal functional preservation. During partial nephrectomy, each minute increase in ischemia may compromise function of the renal remnant. Efforts to minimize, better yet, eliminate renal ischemia are imperative. Our objective is to present the video technique of the novel “zero ischemia” technique of laparoscopic partial nephrectomy (LPN) in 16 patients with a small renal mass. Methods: Sixteen patients underwent “zero ischemia” LPN with the following technique: micro-dissection of tumor-specific renal artery branches, plus controlled hypotension coinciding with tumor excision. Controlled hypotension is a specific anesthetic technique, designed to decrease intra-operative hemorrhage while providing excellent systemic perfusion. It involves reducing systolic blood pressure to 80-90mm Hg, reducing mean arterial pressure (MAP) to 50-65mm Hg or a 30% reduction of baseline MAP. Pre- and intraoperative anesthesia-related hypotensive monitoring included continuous pulmonary artery pressure measurements, transesophageal echocardiography, and brain activity measurements. Timed, pharmacologically-induced hypotension was carefully calibrated by an expert anesthesiologist, corresponding with parenchymal resection. Detailed in our video is the technique of tumor excision/hemostasis involved monopolar J-hook, cold endoshears, suturing, and Hem-o-Lok clips. Hypotension was reversed after completing resection and initial renorrhaphy. Parenchymal reconstruction was completed under normotensive conditions to assure hemostasis was achieved. Results: All cases were successfully com-
pleted without hilar clamping. Ischemia time was zero in all cases. Median tumor size was 2.7cm (0.9-4), operative time 3 hrs (1-5), blood loss 100cc (20-200), and hospital stay 3 days (2-19). Nadir mean arterial pressure ranged from 49-65mmHg (median 60), typically for 1-5 minutes. No patient had intra-operative transfusion or complication, acute or delayed renal hemorrhage, or hypotension-related sequelae. Median preoperative and postoperative serum creatinine (0.9mg/dL and 0.95mg/ dL) and estimated gFR (75.3 and 72.9) were comparable. Median absolute and percent change in discharge serum creatinine and eGFR was 0 and 0%, respectively. Conclusions: This novel “zero ischemia” hypotensive LPN technique represents a significant step in the continuum towards thegoal of eliminating surgical ischemia. Our recommended time is: NO ischemia
VID-05.02 Laparoscopic Partial Nephrectomy in Polycystic Kidney Peña J, Ramos E, Azuero J, Palou J, Villavicencio H Fundació Puigvert, Barcelona, Spain Introduction: European guidelines recommend nephron-sparing surgery for T1 tumours whenever possible. Partial nephrectomy is technically challenging in patient with autosomal dominant polycystic kidney disease (ADPKD). We present a video of a pure laparoscopic approach. Material and Methods: A 49 year-old patient diagnosed of ADPKD with normal renal function is diagnosed of bilateral renal mass in a routine control ultrasound. The CT scan shows both kidneys significantly enlarged with ADPKD and two contrast enhanced masses of 22mm in the mid-pole posterior valve of the right kidney and 16mm in the lower pole anterior valve of the left kidney. Preoperative serum creatinine concentration was 98 umol/L and the estimated glomerular filtration rate was 70 ml/min/1.73m. A laparoscopic partial nephrectomy delivered in two times is proposed. We present the right side procedure. Results: Dissection of the right kidney is performed with the help of three trocars. As the tumour is difficult to distinguish from the renal cysts, intraoperative laparoscopic ultrasonography is used. Incision of peritumoral cysts is helpful to define the dissection planes. Partial nephrectomy is done without clamping the renal helium. Surgical time was 90 minutes. There were no postoperative complications. Pa-
UROLOGY 78 (Supplement 3A), September 2011
tient was discharged 4 days after surgery. Pathology report revealed Papillary I histological subtype renal cell carcinoma. Conclusions: Nephron-sparing surgery is a feasible and reproducible technique in selected patients with ADPKD. Vascular clamping may be not necessary in all cases.
VID-05.03 Partial Nephrectomy by Retroperitoneoscopy Without Hilar Clamping Peña J, Ramos E, Villamizar J, Santillana J, Breda A, Palou J, Villavicencio H Fundació Puigvert, Barcelona, Spain Introduction: Partial nephrectomy is the technique of choice for T1a renal tumors according to the EAU guidelines as it offers oncological and functional results equal to open surgery. After more than 200 transperitoneal partial nephrectomies performed in our institution, we have started to perform partial nephrectomy by retroperitoneoscopy for posterior renal tumors. We present the video of a partial nephrectomy by retroperitoneoscopy without hilar clamping. Methods and Materials: A 59 year-old patient with smoking habit and past surgical history of inguinal hernioplasty and appendectomy was found with microscopic hematuria. A renal ultrasound was performed showing a 25mm lesion in the right kidney, suspicious for malignancy. A CT scan was performed showing a 24.5mm upper pole right posterior enhancing lesion. Due to the location of the lesion, a decision to perform a retroperitoneal partial nephrectomy was taken. Results: Four retroperitoneal trocars were positioned after digital dissection and use of a balloon for dissection. After dissecting the pedicle the posterior renal tumor was identified and freed from adjacent tissues. Partial nephrectomy was performed with a Rummel tourniquet placed around the renal artery without clamping it. During the excision, the pneumoretroperitoneum was raised to 20mmHg. The monopolar beam was proved to be usefull for hemostasis of the surgical bed. Continuous running suture with the Hem-o-lock technique was used for parenchyma closure. Conclusions: Retroperitoneal partial nephrectomy is a feasible and reproducible technique in selected patients. Posterior tumors are particularly accessible with this approach. For small completely exophitic tumours, hilar clamping may not be necessary.
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