Utility of the harmonic scalpel for laparoscopic partial nephrectomy

Evaluation of the validated intraoperative bleeding scale in liver surgery: study protocol for a multicenter prospective study

Background

Surgical hemostasis has become one of the key principles in the advancement of surgery. Hemostatic agents are commonly administered in many surgical specialties, although the lack of consensus on the definition of intraoperative bleeding or of a standardized system for its classification means that often the most suitable agent is not selected. The recommendations of international organizations highlight the need for a bleeding severity scale, validated in clinical studies, that would allow the selection of the best hemostatic agent in each case. The primary objective of this study is to evaluate the VIBe scale (Validated Intraoperative Bleeding Scale) in humans. Secondary objectives are to evaluate the scale's usefulness in liver surgery; to determine the relationship between the extent of bleeding and the hemostatic agent used; and to assess the relationship between the grade of bleeding and postoperative complications.

Methods

Prospective multicenter observational study including 259 liver resections that meet the inclusion criteria: patients scheduled for liver surgery at one of 10 medium-high volume Spanish HPB centers using an open or minimally invasive approach (robotic/laparoscopic/hybrid), regardless of diagnosis, ASA score <4, age ≥18, and who provide signed informed consent during the study period (September 2023 until the required sample size has been recruited). The participating researchers will be responsible for collecting the data and for reporting them to the study coordinators.

Discussion

This study will allow us to evaluate the VIBe scale for intraoperative bleeding in humans, with a view to its subsequent incorporation in daily clinical practice.

Clinical Trial Registration

https://clinicaltrials.gov/ct2/show/NCT05369988?term = serradilla&draw = 2&rank = 3, [NCT0536998].

Nephron sparing surgery for renal tumors-comparison of off-clamp partial nephrectomy with hilar clamping

Background and Objective:

Open partial nephrectomy (PN) is still considered gold standard procedure for T1 localized renal tumors. Conventional technique involves clamping of the renal artery with or without vein however, renal ischemia produces a certain level of damage to the kidneys. This study aims to investigate potential effect of off-clamp vs. hilar clamping PN on renal function.

Methods:

This is a retrospective cohort study of patients who underwent unilateral, open partial nephrectomy for renal tumors b/w January 2009 December 2016 at our institution. A total of 90 partial nephrectomies were performed of which 65 cases were eligible for analysis. Non clamping technique was used in 43 while clamp was applied in 22 patients. Variables studied were patients’ demographics, clinical variables, the laterality, tumors size and location, R.E.N.A.L nephrometry score, blood loss, tumor histology and surgical margins. Patients’ renal function (serum creatinine and eGFR) were determined pre-operatively, at 3 and 12 months follow up. Data was analyzed on SPSS v. 22.

Results:

Both the groups were comparable with regards to pre-operative renal function. Mean radiological size of tumor was 4.71±1.31 and 3.81±1.0 (0.003) in two groups respectively. Mean R.E.N.A.L nephrometry score was 6.1±1.5 in off-clamp group compared to 7.05 ± 1.7 in clamp group (p=0.04). No statistically significant difference was found in operative duration, blood loss, positive surgical margins and intra/ peri-operative complications. At three months and one year, renal function was better preserved in non-clamp group compared to clamp group (p=0.001 and 0.007 respectively).

Conclusion:

Off clamp open partial nephrectomy is safe and feasible option leading to less decline in renal function.

Retroperitoneoscopic partial nephrectomy in children: a multicentric international comparative study between lateral versus prone approach

BACKGROUND

Very limited informations are currently available about the best approach to perform retroperitoneoscopic surgery. This multicentric international study aimed to compare the outcome of lateral versus prone approach for retroperitoneoscopic partial nephrectomy (RPN) in children.

METHODS

The records of 164 patients underwent RPN in 7 international centers of pediatric surgery over the last 5 years were retrospectively reviewed. Sixty-one patients (42 girls and 19 boys, average age 3.8 years) were operated using lateral approach (G1), whereas 103 patients (66 girls and 37 boys, average age 3.0 years) underwent prone RPN (G2). The two groups were compared in regard to operative time, postoperative outcome, postoperative complications, and re-operations.

RESULTS

The average operative time was significantly shorter in G2 (99 min) compared to G1 (160 min) (p = 0.001). Only 2 lateral RPN required conversion to open surgery. There was no significant difference between the two groups as for intraoperative complications (G1:2/61, 3.3%; G2:6/103, 5.8%; p = 0.48), postoperative complications (G1:9/61, 14.7%; G2:17/103, 16.5%; p = 0.80), and re-operations (G1:2/61, 3.3%; G2:4/103, 3.8%; p = 0.85). Regarding postoperative complications, the incidence of symptomatic residual distal ureteric stumps (RDUS) was significantly higher in G2 (7/103, 6.8%) compared to G1 (1/61, 1.6%) (p = 0.001). Most re-operations (4/6, 66.6%) were performed to remove a RDUS .

CONCLUSIONS

Both lateral and prone approach are feasible and reasonably safe to perform RPN in children but the superiority of one approach over another is not still confirmed. Although prone technique resulted faster compared to lateral approach, the choice of the technique remains dependent on the surgeon's personal preference and experience. Our results would suggest that the lateral approach should be preferred to the prone technique when a longer ureterectomy is required, for example in cases of vesico-ureteral reflux into the affected kidney moiety, in order to avoid to leave a long ureteric stump that could become symptomatic and require a re-intervention.

Retroperitoneal and laparoscopic heminephrectomy in duplex kidney in infants and children

BACKGROUND

Two main techniques are adopted to perform partial nephrectomy in children: laparoscopy and retroperitoneoscopy. The aim of this paper is to review the larger multicentric experience recently published by our group to review indications, techniques and results of both approaches.

METHODS

Data of 102 patients underwent partial nephrectomy in a 5-year period using minimally invasive surgery (MIS) procedures were analyzed. Fifty-two children underwent laparoscopic partial nephrectomy (LPN), and 50 children underwent retroperitoneoscopic partial nephrectomy (RPN). Median age at surgery was 4.2 years. Statistical analysis was performed using χ² test and Student's t-test.

RESULTS

The overall complications rate was significantly higher after RPN (15/50, 30%) than after LPN (10/52, 19%) (χ² =0.05). In LPN group, complications [4 urinomas, 2 symptomatic refluxing distal ureteral stump (RDUS) and 4 urinary leakages] were conservatively managed. In RPN group, complications (6 urinomas, 8 RDUS, 1 opening of remaining calyxes) required a re-operation in 2 patients. In both groups no conversion to open surgery was reported. Operative time (LPN: 166.2 min vs. RPN: 255 min; P<0.001) and hospitalization (LPN: 3.5 days vs. RPN: 4.1 days; P<0.001) were significantly shorter in LPN group. No postoperative loss of renal function was reported in both groups.

CONCLUSIONS

MIS now represents the gold standard technique to perform partial nephrectomy in children with duplex kidney. Our results demonstrate that RPN remains a technically demanding procedure with a significantly higher complications and re-operation rate compared to LPN. In addition, length of surgery and hospitalization were significantly shorter after LPN compared to RPN. LPN seems to be a faster, safer and technically easier procedure to perform in children compared to RPN due to a larger operative space and the possibility to perform a complete ureterectomy in refluxing systems.

A comparison between laparoscopic and retroperitoneoscopic approach for partial nephrectomy in children with duplex kidney: a multicentric survey

PURPOSE

To compare the outcome of laparoscopic and retroperitoneoscopic approach for partial nephrectomy in infants and children with duplex kidneys.

METHODS

Data of 102 patients underwent partial nephrectomy in a 5-year period using MIS procedures were analyzed. Fifty-two children underwent laparoscopic partial nephrectomy (LPN), and 50 children underwent retroperitoneoscopic partial nephrectomy (RPN). Median age at surgery was 4.2 years. Statistical analysis was performed using χ (2) test and Student's t test.

RESULTS

The overall complications rate was significantly higher after RPN (15/50, 30 %) than after LPN (10/52, 19 %) [χ (2) = 0.05]. In LPN group, complications [4 urinomas, 2 symptomatic refluxing distal ureteral stumps (RDUS) and 4 urinary leakages] were conservatively managed. In RPN group, complications (6 urinomas, 8 RDUS, 1 opening of remaining calyxes) required a re-operation in 2 patients. In both groups no conversion to open surgery was reported. Operative time (LPN:166.2 min vs RPN: 255 min; p < 0.001) and hospitalization (LPN: 3.5 days vs RPN: 4.1 days; p < 0.001) were significantly shorter in LPN group. No postoperative loss of renal function was reported in both groups.

CONCLUSIONS

Our results demonstrate that RPN remains a technically demanding procedure with a significantly higher complications and re-operation rate compared to LPN. In addition, length of surgery and hospitalization were significantly shorter after LPN compared to RPN. LPN seems to be a faster, safer and technically easier procedure to perform in children compared to RPN due to a larger operative space and the possibility to perform a complete ureterectomy in refluxing systems.

Retroperitoneoscopic Heminephrectomy in Duplex Kidney in Infants and Children: Results of a Multicentric Survey

PURPOSE

Retroperitoneoscopic partial nephrectomy (RPN) in children is considered a complex technique with limited diffusion among pediatric surgeons and urologists. We aimed to report the outcome of this technique in infants and children with duplex kidney in a 5-year retrospective multicentric international survey.

MATERIALS AND METHODS

Data on 50 children who underwent RPN (41 upper-pole nephrectomies and 9 lower-pole nephrectomies) were retrospectively collected in this six-institution survey. Median age at surgery was 3.3 years. There were 35 girls and 15 boys. The left side was affected in 28 patients, versus the right side in 22 patients. We assessed intraoperative and postoperative morbidity. Follow-up (median, 2.5 years; range, 12 months-5 years) was based on clinical controls and echo color Doppler renal ultrasound scans.

RESULTS

Median duration of surgery was 255 minutes. Surgery was always performed with the patient in a lateral position. Special hemostatic devices were used for dissection and parenchymal section in all centers. Three patients from two centers (6%) required conversion to open surgery. We recorded seven complications (six peritoneal perforations, one opening of the remaining calyxes) in the 50 cases. Re-operation rate was 0%. Average length of hospital stay was 4.1 days.

CONCLUSIONS

Our survey shows that RPN remains a challenging procedure with a long learning curve, performed only in pediatric centers with huge experience in this field. In our survey operative time was longer than 4 hours. The complication rate remains high (7/50, or 14%), with complications classified as Grade II according to the Clavien-Dindo classification. They did not require further surgery, but they were associated with a prolonged hospital stay.

Decline in renal function after partial nephrectomy: etiology and prevention

PURPOSE

Partial nephrectomy is the reference standard for the management of small renal tumors and is commonly used for localized kidney cancer. A primary goal of partial nephrectomy is to preserve as much renal function as possible. New baseline glomerular filtration rate after partial nephrectomy can have prognostic significance with respect to long-term outcomes. Recent studies provide an increased understanding of the factors that determine functional outcomes after partial nephrectomy as well as preventive measures to minimize functional decline. We review these advances, highlight ongoing controversies and stimulate further research.

MATERIALS AND METHODS

A comprehensive literature review consistent with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria was performed from January 2006 to April 2014 using PubMed®, Cochrane and Ovid Medline. Key words included partial nephrectomy, renal function, warm ischemia, hypothermia, nephron mass, parenchymal volume, surgical approaches to partial nephrectomy, preoperative and intraoperative imaging, enucleation, hemostatic agents and energy based resection. Relevant reviews were also examined as well as their cited references. An additional Google Scholar search was conducted to broaden the scope of the review. Only English language articles were included in the analysis. The primary outcomes of interest were the new baseline level of function after early postoperative recovery, percent decline in function, potential etiologies and preventive measures.

RESULTS

Decline in function after partial nephrectomy averages approximately 20% in the operated kidney, and can be due to incomplete recovery from the ischemic insult or loss of nephron mass related to parenchymal excision or collateral damage during reconstruction. Compensatory hypertrophy in the contralateral kidney after partial nephrectomy in adults is marginal and decline in global renal function for patients with 2 kidneys averages about 10%, although there is some variance based on tumor size and location. Irreversible ischemic injury can be minimized by pharmacological intervention or surgical approaches such as hypothermia, limited warm ischemia, or zero or segmental ischemia. Excessive loss of nephron mass can be minimized by improved preoperative or intraoperative imaging, use of a bloodless field, enucleation and vascular microdissection. Hemostatic agents or energy based resection that minimizes the need for parenchymal and capsular suturing can also optimize preservation of the vascularized nephron mass.

CONCLUSIONS

Our understanding of the decline in renal function after partial nephrectomy has advanced considerably, including better appreciation of its magnitude and impact in various settings, possible etiologies and potential preventive measures. Many controversies persist and this remains an important area of investigation.

Nonischemic laparoscopic partial nephrectomy using a novel wet monopolar device in a porcine model

BACKGROUND AND PURPOSE

Laparoscopic partial nephrectomy (LPN) is the minimally invasive standard of care for the management of a cT(1a) renal mass. We evaluated a novel saline enhanced electrosurgical resection (SEER) device for performance of a nonischemic LPN.

MATERIALS AND METHODS

Six pigs were used in a nonsurvival pilot study. Energy penetration was characterized by applying the SEER to the lower pole of each kidney for 30 seconds, 1 minute, and 3 minutes using pure cutting energy at 100W and a drip rate of 1 drip per second. Energy testing was performed with the hilum clamped in six kidneys and without clamping in six kidneys. Subsequently, a nonischemic upper pole LPN was performed with the SEER device, and the kidneys were harvested. The areas of necrosis were sectioned and stained with hematoxylin and eosin. Depth of necrosis was visualized grossly and microscopically for each time point. We also recorded time to perform LPN, estimated blood loss (EBL), and subjective severity of bleeding.

RESULTS

The average operative time was 15.4 minutes. The mean EBL was 44.2 mL with nine (75%) cases classified as minimal, 2 (17%) moderate, and 1 (8%) severe bleeding. The mean depth of necrosis on the kidney remnants was 2.97 mm. The mean depth of necrosis for unclamped kidneys at 30 seconds, 1 minute, and 3 minutes was 0.38 mm, 0.88 mm, and 1.27 mm, respectively. The mean depths for the clamped kidneys were 2.73 mm, 3.23 mm, and 8.68 mm respectively. Depth of necrosis was significantly higher in the clamped kidneys at 3 minutes (P=0.0035).

CONCLUSIONS

In the porcine model, the SEER transected parenchyma and collecting system with low resection times and minimal blood loss. Use of coagulation during resection is the main advantage of a monopolar resection compared with cold scissors. Testing performed for 3 minutes during hilar clamping demonstrated a significantly deeper level of necrosis.

Comparison between a 1.92-μm fiber laser and a standard HF-dissection device for nephron-sparing kidney resection in a porcine in vivo study

Nephron-sparing surgery was performed in a porcine model with a 1.92-μm fiber laser dissection device in comparison to a standard high-frequency dissection device. In nine pigs, general anesthesia and a median laparotomy were performed to expose both kidneys. On six kidneys (three HF and three laser) a partial renal parenchyma resection of the lower pole without opening of the renal pelvis was performed (group A). On 12 kidneys (four HF and eight laser), a hemi nephrectomy with opening of the renal pelvis was performed (group B). Total resection time including hemostasis of the remaining tissue was 501 ± 394 s in group "A-laser " vs. 176 ± 139 s in group "A-HF". For the group "B", the total resection time was 1174 ± 501 s (B laser) vs. 960 ± 407 s (B-HF). Blood loss was 28 ± 22 ml in group "A laser " vs. 15 ± 15 ml in group "A-HF". In group "B", the blood loss was 98 ± 73 ml (B laser) vs. 137 ± 118 ml (B-HF). No ischemic time for the kidneys was needed in group "A" for both dissection devices. In group "B", ischemia of the kidneys was performed three times during the eight laser procedures (420 ± 60 s) and only once at the four HF procedures (1,260 s). Healing process was observed over 4-6 weeks, survival rate was 100%, and no renal fistulas were found after the survival period. In conclusion, no significant differences were found between the compared dissection devices. However, the laser system with the flexible transmission fiber may have an advantage for a laparoscopic approach by steerable instruments.

Laparoscopic versus open partial nephrectomy: analysis of the current literature

OBJECTIVES

To critically review the current scientific evidence about open partial nephrectomy (OPN) and laparoscopic partial nephrectomy (LPN) to define the current role of these techniques in the treatment of renal tumours.

METHODS

PubMed and Medline were searched for reports about OPN and LPN that were published from 1990 to 2007 and the most relevant papers were reviewed.

RESULTS

OPN is an established curative approach for the treatment of small renal tumours. LPN is challenging and the technique is still under development. The intermediate-term oncologic and functional outcomes of LPN are similar to those of OPN in experienced centres. However, the ischaemia time is longer in laparoscopy and a long learning curve is needed to decrease the risk of complications. In the first phase of a surgeon's experience with LPN, a careful case selection based on the tumour growth pattern is required.

CONCLUSION

OPN is today the first treatment option for small renal tumours. LPN is technically challenging, but has been shown to achieve similar intermediate-term cancer cure and renal function results in centres with advanced laparoscopic expertise. Larger series with longer follow-up and prospective randomised studies are needed to confirm the safety and efficacy of LPN.

Ultrasonically activated device for parenchymal division during open hepatectomy

BACKGROUND

The use of new technological devices has gained popularity and has been proposed to improve the safety of liver resection. This study was designed to evaluate the usefulness of the ultrasonically activated device (USAD) during open liver resection.

MATERIALS AND METHODS

Indication for surgery, type of resection, need to perform a Pringle manoeuvre, operation time, blood loss, number of blood transfusions, morbidity and mortality rate were analyzed in 60 patients undergoing a formal open liver resection by means of USAD.

RESULTS

The overall mean operation time was 172 minutes (range 120-255 min); an intermittent warm ischemia was applied in 9 cases (15%). The overall mean blood loss was 410 mL (median 400 mL, range 50-950 ml). A median of one blood transfusion was administered in six patients (10%). The mean hospital stay was 10.2 days (median 11, range 8-16). The overall morbidity rate was 20% (12 out of 60 patients). No in-hospital mortality was recorded. By subdividing the patients according to the presence or absence of cirrhosis no statistical significant differences were found between the two subgroups in all peri-and postoperative outcomes.

CONCLUSIONS

In conclusion, though there is a lack of data based on well conducted controlled studies and further on a greater number of patients are needed, the utilization of USAD may help to minimize blood loss during liver resection regardless of the condition of the liver, even in case of cirrhosis.

Energy sources for laparoscopic partial nephrectomy--critical appraisal

Laparoscopic partial nephrectomy (LPN) has emerged as a viable alternative for the conventional open nephron-sparing surgery (NSS). So far, an adequate renal parenchymal cutting and hemostasis, as well as caliceal repair remains technically challenging. Numerous investigators have developed techniques using different energy sources to simplify the technically demanding LPN. Herein we review these energy sources, discussing perceived advantages and disadvantages of each technique.

Comparison of the use of electrothermal bipolar vessel sealer with harmonic scalpel in total laparoscopic hysterectomy

AIM

The aim of the present study was to compare the use of electrothermal bipolar vessel sealer (EBVS) with harmonic scalpel (HS) during total laparoscopic hysterectomy with respect to operation time, estimated blood loss and related complications.

METHODS

A retrospective study was conducted in the university hospital. Forty patients who underwent total laparoscopic hysterectomy and bilateral salpingo-oophorectomy were enrolled. Nineteen hysterectomies were performed with HS and in 21 patients the same surgeons used EBVS. Data about the characteristics of the patients, operation time, estimated blood loss, uterine weights, related complications and length of hospital stay were registered and compared.

RESULTS

Mean procedure time and estimated blood loss were significantly less in the EBVS arm (59.57 +/- 3.71 vs 90.95 +/- 5.73 min, P < 0.001; 87.76 +/- 25.48 vs 152.63 +/- 60.90 mL; P < 0.001, respectively). The change in hemoglobin and hematocrit values was found to be more significant in the HS group.

CONCLUSION

EBVS was found to be less time-consuming and caused less bleeding when compared with HS.

Laparoscopic partial nephrectomy in rats

PURPOSE: To establish an experimental model of laparoscopic partial nephrectomy (LPN) in rats and to analyze morphological alterations in the renal parenchyma utilizing an electric cautery and harmonic scalpel. METHODS: Forty Wistar rats were used, divided in 2 experiments with 20 rats each: experiment I, LPN was performed with an electric cautery and the rats were subdivided into groups A and B; experiment II, LPN was performed with a harmonic scalpel and they were subdivided into groups C and D. The animals in groups A and C were sacrificed shortly after surgery and the remnant kidney was removed to study the following variables: necroses and degeneration. In groups B and D a laparatomy was performed for retrieval of the remnant kidney on the 14th day after surgery to analyze fibrous scarring. RESULTS: For the variables necroses and fibrous scarring, the electric cautery creates, on average, greater width than that produced by the harmonic scalpel (p=0.0002 and p=0.0068 respectively). Regarding the variable of degeneration, we found no significant difference between the two types of scalpels (p=0.1267). CONCLUSIONS: LPN in rats is an adequate and feasible experimental model. The electric cautery caused greater damage to remnant renal tissue when compared to harmonic scalpel.

Laparoscopic versus open radical nephrectomy for xanthogranulomatous pyelonephritis: Contemporary outcomes analysis

BACKGROUND AND PURPOSE

Early experience with laparoscopic nephrectomy for xanthogranulomatous pyelonephritis (XGP) was associated with high conversion and complication rates. We describe our institution's experience with this procedure compared with a contemporary cohort of patients with XGP treated by open nephrectomy.

PATIENTS AND METHODS

Retrospective review of surgical pathology reports from radical nephrectomies at our institution between 1995 and 2005 yielded a diagnosis of XGP in 12 patients, 6 of whom had undergone laparoscopic surgery. Each patient's medical records were reviewed, with intraoperative and postoperative parameters, including complications, being recorded.

RESULTS

Transperitoneal laparoscopic nephrectomy was successful in five patients (83%). Hand-assist ports were utilized in two patients because of failure to progress. The operative times were 301 +/- 106 minutes and 167 +/- 40 minutes in the laparoscopic and open-surgery groups, respectively (P = 0.03). There was no statistical difference with regard to estimated blood loss, transfusion rate, or parenteral analgesic requirements, but there was a trend toward a shorter stay for the laparoscopic group. Complications were noted in three and two patients in the laparoscopic and open-surgery groups, respectively.

CONCLUSIONS

The outcomes of nephrectomy for XGP were similar regardless of surgical approach. The results in patients with XGP were similar to initial reports in the literature and may be dependent on surgeon experience. We believe that in experienced hands, laparoscopic nephrectomy may be offered to patients with XGP.

Laparoscopic partial nephrectomy with saline-irrigated KTP laser in a porcine model

PURPOSE

To evaluate the feasibility of using the potassium titanyl phosphate (KTP) laser to perform laparoscopic partial nephrectomy in a porcine model, with saline irrigation to reduce intraoperative smoke formation.

MATERIALS AND METHODS

A high-power (80 W) KTP laser was used without hilar occlusion in 14 laparoscopic partial nephrectomies in four pigs. During laser discharge, the cutting plane was irrigated continuously with saline.

RESULTS

Thirteen partial nephrectomies were completed. Hemostasis was obtained without the need for any non-laser techniques. Only minimal smoke was produced, not affecting visibility or the progress of surgery. Histologic examination of the resection margin showed only minimal tissue destruction. One procedure failed because the laser fiber broke and occluded the suction during the operation. The mean partial nephrectomy time was 13.14 minutes (range 7-19 minutes) with a mean estimated blood lost of 28.57 mL (range 5-80 mL). The mean saline irrigation used for each operation was 2600 mL (range 1500-3400 mL), and the amount of saline drained out was 1700 mL (range 900-3200 mL).

CONCLUSION

Laparoscopic partial nephrectomy using the 80 W KTP laser is feasible and effective in the porcine model. Saline irrigation dramatically reduces smoke formation. The technique is deserving of clinical studies after the laser-application device and suction irrigation are refined.

Bloodless partial nephrectomy with a new high-intensity collimated ultrasonic coagulating applicator in the porcine model

OBJECTIVES

To evaluate the long-term hemostatic efficacy of a new high-intensity collimated ultrasonic (HICU) applicator for open subhilar partial nephrectomy (PN) in the porcine model.

METHODS

An applicator was designed with a planar 3.78-MHz HICU transducer and a reflector to optimize the delivery of acoustic energy to coagulate renal tissue. Six female pigs underwent right PN, followed at day 7 by left PN. The 6 pigs were killed on day 14. The treatment consisted of delivering HICU to a lower pole subhilar location, under a vascular clamp, then releasing the clamp, and cutting the kidney lower pole. The immediate and delayed hemostatic efficacy, treatment parameters, blood loss, complications, and renal function were evaluated at each surgical event and at necropsy.

RESULTS

Perfect hemostasis was achieved with all 12 kidneys, with a mean treatment time of 7.2 minutes (range 5 to 9.2). The mean proportion of resected parenchyma was 21% (range 14% to 32%). No renal function impairment and no major complications were recorded. At necropsy, no secondary hematoma was observed, and three urinomas (25%) were found.

CONCLUSIONS

Our HICU applicator has shown promising results during PN in the pig model with no other method of hemostasis. More studies are needed to refine our probe for laparoscopic surgery, improve its ergonomics, and extend our experiments to human laparoscopic nephron-sparing surgery.

Laparoscopic partial nephrectomy: use of the TissueLink hemostatic dissection device

Hemostasis remains the major challenge in laparoscopic partial nephrectomy (LPN). The TissueLink Floating Ball (TissueLink Medical, Inc., Dover, NH), a high-density monopolar saline-cooled radiofrequency device, is an effective coagulation and dissection device to aid in LPN. Our porcine laboratory model and human clinical experience have shown the device capable of deep renal parenchymal hemostasis without the need for hilar vascular occlusion. We review the excisional technique and initial clinical results, as well as device function, setup, and clinical literature. We find the TissueLink capable of avoiding warm ischemia for excision of selected endophytic masses and, in combination with other techniques, a valuable adjunct for even deeper lesions.

Renal-Tissue Damage Induced by Laparoscopic Partial Nephrectomy Using Microwave Tissue Coagulator

BACKGROUND AND PURPOSE

The microwave coagulator is a useful instrument that enables surgeons to perform partial nephrectomy without vascular clamping. The extent of postoperative thermal damage in surgically spared renal tissue has not been well examined. The present study was conducted to evaluate the tissue damage caused by microwave coagulation in laparoscopic partial nephrectomy (LPN) for small renal tumors.

MATERIALS AND METHODS

Seven cases of LPN with a microwave tissue coagulator were entered in the present study. The median tumor diameter was 1.5 cm, and the median size of the resected specimen was 2.2 cm. Postoperative tissue damage was evaluated by contrast-enhanced CT 1 month after surgery. Surgically spared renal-tissue volume and functioning renal-tissue volume were estimated from the images by NIH Image 1.62 software.

RESULTS

Postoperative CT revealed unenhanced renal tissue adjacent to the surgical margin. The median estimated volumes of surgically spared and functioning renal tissue were 96.1% (range 74.3%-99.8%) and 88.4% (range 68.0%-92.7%) of preoperative normal renal tissue, respectively. The percentile volume of functioning to surgically spared renal tissue ranged from 89.9% to 96.0% (median 92.8%).

CONCLUSIONS

The microwave coagulator enables us to carry out partial nephrectomy without vascular clamping. Although 96% of normal renal tissue was surgically spared, 4% to 10% of this tissue was nonfunctioning as a result of microwave-induced thermal damage.

FIBRIN GLUE V SUTURED BOLSTER: LESSONS LEARNED DURING 100 LAPAROSCOPIC PARTIAL NEPHRECTOMIES

PURPOSE

Laparoscopic partial nephrectomy (LPN) is performed with marked technical variations. We defined the limits of sutureless LPN and determined which closure technique is best in a particular situation.

MATERIALS AND METHODS

During 100 consecutive LPNs fibrin glue products were used for closure in the first 75 (group 1) and sutured bolsters were applied when the collecting system (CS) or renal sinus was entered in the final 25 (group 2).

RESULTS

In groups 1 and 2 hand assisted laparoscopy was used in 72% vs 40% of cases and hilar clamping was used in 27% vs 92%, respectively. Mean tumor size was 25 vs 26 mm, tumor depth was 11 vs 13 mm, distance to the renal sinus was 9 vs 5 mm, operating room time was 185 vs 210 minutes, estimated blood loss was 398 vs 247 cc and hospital stay was 2.9 vs 2.6 days in groups 1 and 2, respectively. Overall postoperative hemorrhage and urine leakage occurred in 9% and 2% of patients, respectively. Tumors associated with postoperative hemorrhage/leakage tended to be larger (35 vs 24 mm, p = 0.007) and closer to the renal sinus (0.5 vs 8.2 mm, p = 0.02). Postoperative hemorrhage or urine leakage occurred in 41% of the 17 patients in group 1 with CS or renal sinus entry but in only 2 of the 58 (3.4%) without entry (p <0.0001). In group 2 hemorrhage/leakage occurred in 11% of the 18 patients with CS or renal sinus entry (vs same subset in group 1, p = 0.04).

CONCLUSIONS

LPN with closure using fibrin glue products provides adequate hemostasis when the CS or renal sinus is not entered. When the CS or renal sinus is entered, a sutured bolster is recommended.

Laparoscopic Partial Nephrectomy: Hand-Assisted Technique

Laparoscopic partial nephrectomy (LPN) is a challenging procedure that has become more popular as techniques have evolved and made the procedure more standardized. We present our hand-assisted technique for LPN. In order to meet the challenges of larger, deeper lesions and to address complications, our technique has evolved from pure hand assistance to hand assistance with hilar clamping and hemostatic adjuncts. We discuss patient selection, preparation and access, renal exposure, preparation of hemostatic agents, resection of the mass, hemostasis, and closure. The results of 76 hand-assisted LPNs (HALPNs) are summarized. While our technique will undoubtedly continue to evolve, HALPN appears to be safe and effective for minimally invasive nephron-sparing surgery.

Use of an Ultrasonically Activated Scalpel for Splenectomy in 10 Dogs with Naturally Occurring Splenic Disease

OBJECTIVE

To evaluate the safety and efficacy of an ultrasonically activated scalpel for performing splenectomy, with minimal ligation, in dogs.

STUDY DESIGN

Prospective clinical study.

ANIMALS

Dogs (10) with naturally occurring splenic disease.

METHODS

Between October 2003 and February 2004, splenectomy was performed using an ultrasonically activated scalpel and a double seal method, in 10 dogs with naturally occurring splenic disease. Time for splenectomy and number of ligatures required were recorded. Intraoperative hemostasis, device ease of use, postoperative hemorrhage, and short-term survival were evaluated.

RESULTS

Mean operative time for splenectomy, exclusive of celiotomy and closure, was 18 minutes (range, 8-25 minutes). The mean number of ligatures needed to perform splenectomy was 1 (range, 0-2 ligatures). One dog hemorrhaged from the splenic vein after ultrasonic scalpel transection of a vessel >5-mm diameter and required a ligature. The ultrasonic scalpel was easy to use, with a minimal learning curve. None of the dogs had postoperative abdominal hemorrhage; 9 dogs were discharged and 1 dog was euthanatized because of septicemia.

CONCLUSION

Ultrasonic activated scalpel may be used to achieve efficient and safe hemostasis of the splenic vascular pedicle in dogs with minimal need for vascular ligation.

CLINICAL RELEVANCE

Ultrasonic scalpels can be used to perform splenectomy in dogs with naturally occurring splenic disease.

Laparoscopic partial nephrectomy: Technique, oncologic efficacy, and safety

Laparoscopic partial nephrectomy is emerging as an attractive approach for selected renal masses, but has been performed with significant variability in technique. The procedure's evolution, a merger of proven open techniques with applicable laparoscopic techniques and limitations, is very much a work in progress. Just as long-term follow-up for open nephron-sparing surgery for selected renal masses has demonstrated recurrence-free survival equivalent to radical nephrectomy, a few large series of laparoscopic partial nephrectomy are beginning to surface that demonstrate its clinical efficacy, although duration of follow-up is still too short to make definitive statements. This article reviews the literature and the authors share their experience and preferences in technique, derived from 100 consecutive laparoscopic partial nephrectomies and from their assessment of the acute sealant effectiveness for partial nephrectomy in a large, hypertensive, porcine model that approximates clinical situations. This review aims to assist the urologic surgeon in determining which renal tumors to approach laparoscopically and which surgical approach best fits their laparoscopic expertise.

LAPAROSCOPIC PARTIAL NEPHRECTOMY TECHNIQUES: DEVELOPMENTS AND TRANSLATION

PURPOSE

Laparoscopic partial nephrectomy has recently emerged as a potential surgical option for select renal masses. Several new techniques and devices that may aid in laparoscopic partial nephrectomy are reviewed.

MATERIALS AND METHODS

I review several techniques studied and/or developed in our laboratory. Each technique was evaluated for effectiveness in the porcine model and is in translation to clinical practice.

RESULTS

Three techniques are reviewed. A hand assisted approach incorporating renal hilar clamping with hypothermia has proven successful for complex and multifocal lesions. Recent clinical studies, and our laboratory and clinical experience have shown a saline cooled monopolar dissector to be a valuable adjunct. A new and simple technique of achieving rapid hypothermia using a pure laparoscopic approach is described.

CONCLUSIONS

Laparoscopic partial nephrectomy continues to develop as a standard of care for select renal masses. New devices and techniques will continue to make the procedure safer and reproducible.

Laparoscopic partial nephrectomy: contemporary technique and results

An increasing number of incidental small renal masses are being detected currently. In select patients, nephron-sparing surgery affords excellent oncologic outcomes with preservation of renal function. With the current trend towards minimally invasive surgery, development of a reliable laparoscopic partial nephrectomy technique has become a key issue. Over the past 4 years, the senior author has performed over 300 laparoscopic partial nephrectomies at the Cleveland Clinic. Herein we present our current technique and review contemporary results from the urologic literature.

Retroperitoneoscopic partial nephrectomy with transient occlusion of renal artery for treatment of small renal tumors

OBJECTIVES

To evaluate the results of retroperitoneoscopic partial nephrectomy with transient occlusion of the renal artery for treatment of patients with small renal tumors.

METHODS

From May 2002 to March 2003, 12 consecutive patients with T1N0M0 renal tumors with a median diameter of 3.0 cm underwent retroperitoneoscopic partial nephrectomy. The renal artery was clamped transiently without occlusion of the renal vein and the tumor was excised with scissors. Intracorporeal renal cooling was achieved by cold saline perfusion of the renal pelvis through a single-J ureteral catheter. Hemostasis was achieved by approximating the renal parenchyma over the perirenal fatty tissue using a retroperitoneoscopic suturing technique.

RESULTS

Of the 12 patients, 11 successfully underwent partial nephrectomy retroperitoneoscopically. The median operative time, renal ischemic time, and amount of blood loss in the successful procedures was 220 minutes (range 132 to 340), 50 minutes (range 16 to 115), and 150 mL (range 50 to 800), respectively. The renal calix was opened and repaired in 10 patients. The surgical margin was negative in all patients. The postoperative course was uneventful in all patients, and the return to work was achieved in a median of 18 days (range 9 to 39). The renal function of the affected kidney was well preserved postoperatively, when examined by renal scintigraphy. Neither local recurrence nor distant metastasis was found during the median follow-up period of 10 months (range 1 to 18).

CONCLUSIONS

Retroperitoneoscopic partial nephrectomy with transient occlusion of the renal artery is a useful and less-invasive method for resection of small renal tumors. Additional technologic developments to reduce ischemic times and to cool the kidneys laparoscopically are required.

A simple and reliable hemostatic technique during partial nephrectomy

INTRODUCTION

To report our experience with a refined technique for hemostasis that obviates the need for vascular control and closure of the collecting system in partial nephrectomy.

TECHNICAL CONSIDERATIONS

Four to five sutures, 2 cm apart, are placed 0.5 cm from the anticipated parenchymal incision border, using a specially designed, blunt-tip, straight needle with folded 2-0 Vicryl thread. The needle is removed, leaving the Vicryl thread with the loop on one side of the kidney and two free ends on the other side. A 1.0-cm-wide Vicryl mesh strip is passed circumferentially through the loops and between the free ends on each side, tension is applied on the strip during knotting of the free ends of the thread, and the tissue is incised. No additional hemostatic sutures are necessary. No attempt is made to identify and close the open collecting system. Vascular clamping and surface cooling are avoided. Sixty-one patients have undergone this technique since 1987: initially, for complicated nephrolithiasis (n = 15), localized purulent kidney disease (n = 4), trauma (n = 3), congenital anomalies (n = 2), and resection of horseshoe kidney (n = 6) and, recently, for peripherally located renal tumor (n = 31). Upper pole resection was performed in 11 patients, lower pole resection in 45, and middle segment resection in 5. The blood loss was minimal, with only 1 patient developing gross hematuria that resolved after conservative treatment. No other complications occurred.

CONCLUSIONS

A simple and easily performed hemostatic method suitable for peripherally located and, particularly, polar renal tumors is described. The Vicryl mesh strip prevents tears of the parenchymal sutures and ensures good hemostasis without closing the collecting system separately.

Hand-Assisted Laparoscopic Partial Nephrectomy

The resurgence of nephron-sparing surgery for selected renal masses has fueled interest in minimally invasive approaches. Several authors have shown that laparoscopic partial nephrectomy is feasible if two goals are met: resection of the mass with negative margins and control of bleeding. The latter is a particular challenge, but numerous options are available. The authors describe the operative technique and the available results of hand-assisted laparoscopic partial nephrectomy.

Laparoscopic nephron-sparing surgery in a Jehovah's Witness patient

An obese 76-year-old woman with type II diabetes, hypertension, coronary artery disease, and gastroesophageal reflux was found to have a 6-cm lower-pole mass in a solitary functional right kidney. Because her religious beliefs prohibited blood transfusion, minimally invasive surgery--a laparoscopic partial nephrectomy--was performed, with a good result. Minimally invasive surgery, perhaps with administration of erythropoietin, iron-dextran, or both, is often a good option for severely anemic patients or those whose religious beliefs are opposed to transfusion. Methods of minimizing blood loss intraoperatively are reviewed.

Emerging Nephron Sparing Treatments for Kidney Tumors: A Continuum of Modalities From Energy Ablation to Laparoscopic Partial Nephrectomy

PURPOSE

The current global medical trend toward minimally invasive treatment for various tumors has generated special interest in several minimally invasive options in the management of kidney tumors. We discuss the role of nephron sparing surgery by less invasive options than the time-honored partial nephrectomy, and the current multitude of energy based tumor ablative methods.

MATERIALS AND METHODS

We searched the English literature following the introduction of nephron sparing surgery, with special attention to various emerging minimally invasive surgical and ablative alternatives.

RESULTS

Laparoscopic partial nephrectomy can be performed safely following the surgical oncology principles established by open partial nephrectomy. Initial results from the various energy based modalities, most notably cryoablation, indicate that high local control rates can be achieved. However, caution is advised since viable tissue has been observed after minimally invasive ablative therapies. Available data, while promising, are still lacking for long-term followup.

CONCLUSIONS

Compared to open partial nephrectomy the laparoscopic approach offers similar cancer-free survival rates. However, the procedure requires highly skilled surgeons. Of the energy based ablative treatments cryoablation followed by radio frequency ablation offers the most meaningful results, with promising local control rates indicated in some series. These methods can be performed less invasively than partial nephrectomy and require less surgical expertise. We anticipate that these modalities will be formalized into urological practice and serve as a single continuum of care, customized according to disease and surgical expertise.

Laparoscopic partial nephrectomy with temporary arterial occlusion: description of technique and renal functional outcomes

OBJECTIVES

To report our laparoscopic partial nephrectomy experience and the impact of temporary arterial occlusion during laparoscopic partial nephrectomy on postoperative renal function. Laparoscopic partial nephrectomy is increasingly popular but remains technically challenging.

METHODS

Laparoscopic partial nephrectomy was performed in 27 patients, with arterial occlusion in 15 cases. Postoperative renal function was evaluated with serum creatinine in all patients and postoperative technetium-99m mercaptoacetyl triglycine renal scans in a subset of patients after arterial occlusion.

RESULTS

The group with arterial occlusion (n = 15) did not differ from those without arterial occlusion (n = 12) with respect to age, body mass index, American Society of Anesthesiologists score, lesion size, operative time, blood loss, or complications. In patients undergoing arterial occlusion, the mean warm ischemia time was 43 +/- 10 minutes (range 25 to 65). The preoperative and postoperative serum creatinine levels were unchanged in patients with (1.07 +/- 0.4 to 1.15 +/- 0.4 ng/dL; P = 0.24) and without (0.96 +/- 0.22 to 1.07 +/- 0.27 ng/dL; P = 0.14) arterial occlusion. The tumor size on imaging correlated with postoperative serum creatinine (r2 = 0.450, P = 0.04). Nuclear renography was performed in 9 patients (60%) after renal artery occlusion. The mean differential renal function of the operated kidney (49%) was similar to that of the contralateral kidney (51%) and was not associated with warm ischemic time or tumor size.

CONCLUSIONS

Temporary arterial occlusion during laparoscopic partial nephrectomy does not appear to affect short-term renal function adversely. We believe that this technique can be safely performed when significant bleeding or entry into the collecting system is anticipated. Additional study is warranted to identify the maximal time of warm ischemia and ways to reduce potential renal injury.

Minimally invasive nephron-sparing surgery

Open partial nephrectomy, with its excellent 5- and 10-year oncologic follow-up data, is the gold standard against which all other nephron-sparing alternatives must be compared. The evolving minimally invasive nephron-sparing alternatives can essentially be divided into three categories: excision (laparoscopic partial nephrectomy), probe ablation (eg, cryotherapy, radiofrequency ablation), and noninvasive ablation (high-intensity focused ultrasound). A proposed algorithm for the evolving indications of minimally invasive nephron-sparing surgical options is presented in Fig. 23. Currently, by emulating the established techniques of open partial nephrectomy, laparoscopic partial nephrectomy has the most immediate clinical application and relevance. Emerging data support the efficacy and reproducibility of renal cryotherapy. Five-year follow-up data should be available in the near future. Although renal radiofrequency ablation has the potential to further minimize morbidity, serious concerns remain regarding the completeness of cancer cell kill and the reliability of intraoperative monitoring. Noninvasive technologic advancements such as high-intensity focused ultrasound have considerable potential for the future.

Sutureless laparoscopic heminephrectomy using laser tissue soldering

BACKGROUND AND PURPOSE

Widespread application of laparoscopic partial nephrectomy has been limited by the lack of a reliable means of attaining hemostasis. We describe laser tissue welding using human albumin as a solder to control bleeding and seal the collecting system during laparoscopic heminephrectomy in a porcine model.

MATERIALS AND METHODS

Laparoscopic left lower-pole heminephrectomy was performed in five female domestic pigs after occluding the hilar vessels. Using an 810-nm pulsed diode laser (20 W), a 50% liquid albumin-indocyanine green solder was welded to the cut edge of the renal parenchyma to seal the collecting system and achieve hemostasis. Two weeks later, an identical procedure was performed on the right kidney, after which, the animals were sacrificed and both kidneys were harvested for ex vivo retrograde pyelograms and histopathologic analysis.

RESULTS

All 10 heminephrectomies were performed without complication. The mean operative time was 82 minutes, with an average blood loss of 43.5 mL per procedure. The mean warm ischemia time was 11.7 minutes. For each heminephrectomy, a mean of 4.2 mL of solder was welded to the cut parenchymal surface. In three of the five acute kidneys and all five 2-week kidneys, ex vivo retrograde pyelograms demonstrated no extravasation. In addition, no animal had clinical evidence of urinoma or delayed hemorrhage. Histopathologic analysis showed preservation of the renal parenchyma immediately beneath the solder.

DISCUSSION

Laser tissue welding provided reliable hemostasis and closure of the collecting system while protecting the underlying parenchyma from the deleterious effect of the laser during porcine laparoscopic heminephrectomy.

Laparoscopic partial nephrectomy: a new horizon

PURPOSE OF REVIEW

The widespread use of available imaging techniques has resulted in an increased detection of incidental small renal tumors. For these small tumors, there has been a definite trend towards nephron-sparing surgery over the past decade.

RECENT FINDINGS

With increasing experience, advanced ablative and complex reconstructive procedures are now being performed laparoscopically. Laparoscopic partial nephrectomy has lagged behind while laparoscopic radical nephrectomy is widely practiced and has become an established procedure. This lag is largely due to the technical difficulty in achieving renal hypothermia and securing renal parenchymal hemostasis.

SUMMARY

Advanced laparoscopic suturing skills and the availability of laparoscopic vascular instruments have allowed laparoscopic partial nephrectomy to become a viable option for select patients, wherein laparoscopic partial nephrectomy attempts to duplicate traditional, established open surgical techniques.

Feasibility of laparoscopic partial nephrectomy using pledgeted compression sutures for hemostasis

PURPOSE

To develop a technique for laparoscopic partial nephrectomy (LPN) without the use of hilar occlusion that allows large renal resection and excellent hemostasis.

MATERIALS AND METHODS

Five female domestic pigs underwent right laparoscopic transperitoneal lower-pole partial nephrectomy after placement of pledgeted parenchymal compression sutures tied intracorporeally to induce regional renal hypoperfusion. Postoperatively, serial serum creatinine measurements were obtained to monitor renal function. The pigs were allowed to recover and 2 weeks later underwent an identical procedure on the left side. The animals were sacrificed after the second procedure, and both renal units were removed for ex vivo retrograde urograms and histologic analysis.

RESULTS

The median operative time was 154.5 minutes (range 110-305 minutes), and the median blood loss was 137.5 mL (range 100-300 mL). On average, 35% (range 31%-36.8%) of the kidney was resected. All cases required use of adjunctive hemostatic clips to control bleeding from central vessels. All animals survived 2 weeks and had no evidence of urinary extravasation clinically or on ex vivo retrograde urograms.

CONCLUSIONS

In the porcine model, LPN with placement of pledgeted sutures allows resection of large renal segments, although technical refinements are required to improve hemostasis. Currently, the need for adjunctive hemostatic measures limits the initial clinical application of this technique to small, exophytic tumors.

Laparoscopic partial nephrectomy and minimally invasive nephron-sparing surgery

Surgical extirpation remains the most effective therapy for renal cell carcinoma. The surgical management of renal masses has evolved away from radical nephrectomy and now includes nephron-sparing surgery for small tumors. Nephron-sparing surgery has similar cure rates and does not appear to compromise cancer control. As the detection of small renal masses by widespread abdominal imaging continues to increase, so will the demand for minimally invasive nephron-sparing procedures. Despite progress in surgical techniques, laparoscopic partial nephrectomy remains a technically challenging procedure. In this review, we discuss the challenges and recent advances in laparoscopic partial nephrectomy and other minimally invasive approaches to renal masses.