Laparoscopic Partial Nephrectomy With Potassium-titanyl-phosphate Laser Versus Conventional Laparoscopic Partial Nephrectomy: An Animal Randomized Controlled Trial

Preclinical optimization of a diode laser-based clamp-free partial nephrectomy in a large animal model

Kidney cancer is a common urologic malignancy with either laparoscopic (LPN) or robotic partial nephrectomy as therapeutic options of choice for localized tumors. However, renal resection and suturing are challenging steps of the procedure that can lead to complications such as prolonged warm ischemia, bleeding, and urinary fistulas. LPN with a diode laser is an efficient technique due to its cutting and/or coagulation attributes. Surprisingly, key laser features such as wavelength and power remain undefined. Using a large porcine model, we evaluated the laser range of wavelength and power in a clamp-free LPN and compared it to the established gold-standard LPN technique (i.e., cold-cutting and suturing). By analyzing surgery duration, bleeding, presence of urine leak, tissue damage related to the resected renal fragment and the remaining organ, hemoglobin levels, and renal function, we show that an optimized experimental diode laser clamp-free LPN (wavelength, 980 nm; power, 15 W) had shorter surgery time with less bleeding, and better postoperative renal function recovery when compared to the well-established technique. Together, our data indicate that partial nephrectomy with a diode laser clamp-free LPN technique is an improved alternative to the gold-standard technique. Therefore, translational clinical trials towards human patient applications are readily feasible.

Lasers in laparoscopic and robotic surgery: is there a need for them

PURPOSE OF REVIEW

The application of lasers in treating urological disorders is a developing area. In the laparoscopic and robotic surgery, laser energy is not so popular as in the treatment of stone disease and benign prostatic hyperplasia. The aim of this review is to clarify the current status of laser applications in laparoscopic and robotic urology.

RECENT FINDINGS

Laser welding of the pyeloureteral anastomosis is not performed in routine clinical practice. Most investigation of laser applications in laparoscopic and robotic urology has centered on laparoscopic partial nephrectomy and robot-assisted partial nephrectomy. Much less work has been done with regard to lower tract laser laparoscopic and robotic applications. However, laser laparoscopic radical prostatectomy has been investigated.

SUMMARY

Current literature regarding lasers in laparoscopic and robotic surgery is extremely limited. Available data consist mostly of small cohorts providing a low level of evidence. Even though initial studies with currently available laser modalities demonstrated promising results, several drawbacks in each technique need to be addressed before being widely accepted as a standard care. Despite investigation, laser usage during laparoscopic and robotic urological procedures has not gained widespread acceptance and remains experimental at this time.

Retroperitoneoscopic partial nephrectomy using a 980/1470-nm dual-diode laser for small exophytic renal tumors

Laser-supported laparoscopic partial nephrectomy is a promising new technique, but remains under experiment. We presented our single institutional experience of laparoscopic partial nephrectomy using the 980/1470-nm dual-diode laser system to investigate its feasibility, and oncological and functional outcomes. The study retrospectively evaluated 25 patients with small exophytic renal tumors, who underwent laparoscopic partial nephrectomy using a 980/1470-nm dual-diode laser. The demographics, surgical data, complications, pathological variables, oncological, and functional outcomes were reviewed. The changes in hemoglobin and estimated glomerular filtration rate (eGFR) before and after surgery were statistically analyzed. The investigators operated on a total of 25 patients. The off-clamping technique was performed for 23 cases, while the other two cases required renal artery clamping due to unsatisfactory hemostasis. The tumor diameter was 24.6± 6.2 mm, and the mean operative time was 104.4± 23.4 min. The median estimated intraoperative blood loss (EBL) was 100 ml (range 50-600 ml). No major complications (Clavien-Dindo >II) occurred perioperatively. The mean change in hemoglobin before and after the operation was 9 g/l, with a P value of <0.001. The mean decrease in eGFR from before the surgery to the 6-month follow-up was 1.4 ml/min, with a P value of 0.463. The postoperative histopathology evaluation did not demonstrate a positive surgical margin. No recurrence or metastasis was found during the follow-up (mean 24 months). Laparoscopic partial nephrectomy using a 980/1470 nm dual-diode laser appears to be a feasible and oncological satisfactory technique for the treatment of small renal mass (SRM), with the advantages of reducing warm ischemia time.

Nonischemic or Ischemic Laparoscopic Partial Nephrectomy Using a Newly Developed Hybrid Energy Device in a Porcine Model

Purpose: To compare the efficacy of a newly developed hybrid pencil-type energy device (HD) generating simultaneously monopolar high-frequency electric energy and ultrasonic energy with that of a conventional device (CD) during laparoscopic partial nephrectomy (LPN). Materials and Methods: A total of 16 female pigs (32 kidneys) were divided into 4 groups of 4 animals (8 kidneys) each: nonischemic and ischemic HD-LPN groups, and nonischemic and ischemic CD-LPN groups. We performed bilateral LPN for each pig. HD alone was used in the HD-LPN group, whereas commercially available monopolar scissors and a soft coagulation system were used in the CD-LPN group. After observing the postoperative course for 14 days, we euthanized the animals and harvested the kidneys for histopathological observations. Results: We completed an LPN on a total of 32 kidneys. There were no cases of conversion to open surgery, nor were there any deaths or complications requiring treatment. For nonischemic LPN, LPN time was significantly shorter in the HD-LPN group than in the CD-LPN group (11.4 ± 4.8 vs 17.7 ± 5.3 minutes, p = 0.027). The decrease in postoperative hemoglobin was equally low in both groups. However, the frequency of TachoSil^® use was significantly higher in the CD-LPN group than in the HD-LPN group (6/8 [75%] vs 0/8 [0%], p = 0.007). For ischemic LPN, we found no significant differences in parameters such as LPN time and using TachoSil between the two groups. The depth of thermal injury was the most superficial in the nonischemic HD-LPN group in comparison with the other three groups. Conclusions: The application of an HD allowed nonischemic LPN to be performed safely in a short time with less blood loss and less thermal injury to the kidney in the porcine model. Additional clinical investigations of human kidneys are required.