Biomedical subjects

Jihad H Kaouk

Publications and source records attributed to Jihad H Kaouk.

At least 19 recordsLinked to original sources

PubMed2006

Probe-ablative nephron-sparing surgery: cryoablation versus radiofrequency ablation.

Over the past decade, a number of probe ablative therapies have emerged for the treatment of patients with localized renal tumors. Cryoablation and radiofrequency ablation (RFA) have been studied in the greatest detail. We present the results of 164 laparoscopic cryoablations and 82 percutaneous RFAs performed in our institution and compare them retrospectively in terms of complications, impact on renal function, follow-up imaging, and oncologic outcomes. Comparison of cryotherapy versus RFA revealed that mean tumor size was similar (2.56 cm vs 2.51 cm); however, the cryoablation group had a greater number of anteriorly located tumors (39% vs 10%), as well as fewer central tumors (6% vs 37%) and fewer solitary kidneys (24% vs 49%). Mean thermal treatment time was 19.3 minutes versus 32.2 minutes in the cryoablation and RFA groups, respectively. Radiologic evidence of tumor recurrence or persistence of disease was noted in 3 patients (1.8%) who underwent cryoablation and in 9 (11.1%) who were treated with RFA. All of have been successfully treated with repeat ablation/nephrectomy, or they are currently under observation. Complication rates were minimal in both groups; no significant impact on mean serum creatinine levels was noted. Cancer-specific survival following cryotherapy was 98% at a median follow-up of 3 years and 100% for RFA at 1-year median follow-up. Cryoablation and RFA are developmental nephron-sparing options. Early results are encouraging for both forms of probe ablation in terms of early oncologic control, preservation of renal function, and low complication rates. Longer-term oncologic data are necessary so that the true value of these treatment modalities can be determined.

Adult↗

PubMed2006

Cryotherapy: clinical end points and their experimental foundations.

More renal tumors are now being found at an early stage. Similarly, the treatment of patients with such small tumors is shifting away from radical nephrectomy toward nephron-sparing extirpative surgery or nonextirpative renal tumor ablation. Of the various techniques used for renal tumor ablation, cryotherapy is the most extensively studied and has the longest reported outcomes. In this article, we examine the experimental and clinical evolution of cryotherapy for small renal masses. A literature search was performed with the following key words: cryobiology, cryotherapy, cryoablation, tissue-ice interaction, temperature, monitoring, cryoinjury, renal function, blood pressure, and treatment end point. Articles that dealt with the experimental and clinical bases of current cryoablation principles and techniques were selected for review. Some recent studies representative of current clinical outcomes were also examined. Cryotherapy for the small renal tumor can be performed during open surgery, laparoscopically, or even percutaneously with use of a variety of probes and high-resolution imaging techniques to monitor therapy. In the clinical scenario, the ice ball is usually extended 1 cm beyond the visible tumor margin. Cryotherapy per se does not adversely affect renal function and blood pressure. Inadvertent cryoinjury to the collecting system rarely leads to urinary leakage. To date, only 6-month follow-up biopsy data are available. Absence of contrast enhancement on follow-up computed tomography or magnetic resonance imaging is considered oncologic success. For a sporadic unilateral renal tumor, 98% cancer-specific survival at 3 years has been reported. Cryotherapy has moved beyond the "experimental" stage, and initial outcomes are encouraging. The major criticism of this and other ablative techniques is the associated lack of histologic confirmation of complete tumor ablation. Long-term, diligently performed studies that provide detailed, meticulous, sequential 5-year radiologic and histologic data are necessary to confirm lasting efficacy. In addition, these data must be compared with those related to partial nephrectomy, which remains the reference standard.

Cryosurgery↗

PubMed2006

Nerve-sparing laparoscopic radical cystectomy: technique and initial outcomes.

OBJECTIVES: To report the technique and early outcomes of nerve-sparing laparoscopic radical cystectomy with continent orthotopic ileal neobladder in selected male and female patients with bladder cancer. METHODS: Since 2000, 52 patients have undergone laparoscopic radical cystectomy at our institution, with nerve-sparing laparoscopic radical cystectomy performed in 5 patients. In the nerve-sparing technique, transection of the lateral vascular pedicle and the posterior dissection proceeds closer to the bladder, at some distance from the rectum. Hem-o-lock clips were used for hemostasis, avoiding the need for any energy source near the neurovascular bundle (NVB). In the male, the identification and complete release of the NVB before division of the urethra minimizes damage to the NVB along the prostatic apex. In the female, preservation of the uterus, fallopian tubes, ovaries, and vagina, maintenance of the endopelvic fascia, and minimal mobilization distal to the urethra facilitates nerve sparing. RESULTS: The median operative time was 10 hours, blood loss was 400 mL, and the length of stay was 5 days. No patient required blood transfusion, and one had a postoperative complication. All patients were free of recurrence at a median follow-up of 30 months. At 12 months, nocturnal and daytime continence was preserved in 100% and 75% of patients, respectively. Sexual function was preserved in the female patient and 2 of the 4 male patients. CONCLUSIONS: With careful attention to the anatomic location of the NVBs and a precise operative technique, nerve-sparing laparoscopic radical cystectomy can be performed in appropriately selected male and female patients with organ-confined bladder cancer.

Adult↗

PubMed2006

Radical prostatectomy: a comparison of open, laparoscopic and robot-assisted laparoscopic techniques.

INTRODUCTION: Surgical approaches to prostate cancer continue to evolve and patient demand for prostatectomy continues to increase. Technical modifications have expanded beyond open surgical approaches to include laparoscopy and more recently robotics. It is important that the enthusiasm that accompanies the introduction of new technology to surgery be accompanied by tangible benefits in terms of comparable oncological or functional outcomes and treatment morbidity. MATERIALS AND METHODS: A literature review was performed comparing individual experiences in large clinical centers and where available comparisons within the same institute between open retropubic radical prostatectomy (RRP), laparoscopic radical prostatectomy (LRP) and robot-assisted laparoscopic radical prostatectomy (RALP). RESULTS: Mortality was extremely low for each approach, with low post-operative pain-scores and analgesic requirements. Oncological outcomes as assessed by positive surgical margin rate were comparable between RRP (13%-21%), LRP (16%-26%) and RALP (6%-23%). Differences in the manner of data accrual and definition for continence and erectile dysfunction make comparison difficult between patient series, however in single institution series comparable continence rates and time to recovery of continence have been shown. CONCLUSIONS: Early data from LRP and RALP series are comparable to RRP in terms of margin-positivity and functional outcomes. Blood loss and transfusion rates appear to be lower for LRP and RALP compared to RRP, while financial costs remain higher than RRP. Long-term oncological results are keenly awaited. Ideally direct comparison between equally experienced surgeons in similar population groups will be required to demonstrate any inherent advantages or disadvantages of individual surgical approaches.

Adenocarcinoma↗

PubMed2005

Simultaneous vs. sequential laparoscopic bilateral native nephrectomy and renal transplantation.

We reviewed our experience with simultaneous single incision bilateral native nephrectomy and renal transplantation in 11 patients (Group 1), compared to seven recipients who underwent staged laparoscopic bilateral nephrectomy followed by kidney transplantation (Group 2). Mean age, donor source, sex, cause of ESRD, and specimen size were similar in both groups (P=0.1). All Group 2 patients and 9 of 11 Group 1 patients had autosomal-dominant polycystic kidney disease. Perioperative Group 1 complications included: bowel injury, transplant urine leak, necrotic pancreatitis, delayed bowel movement, and severe shoulder pain secondary to diaphragmatic irritation. Seven (63.6%) Group 1 patients required an additional surgical procedure: midline incisional hernia, repair ureteral fistula, and repair enterocutaneous fistula. One Group 1 patient lost his graft secondary to bowel injury and intra-abdominal sepsis. No major complications, reoperations, or graft loss occurred in Group 2. For simultaneous bilateral native nephrectomy and kidney transplantation, over 60% of patients required an additional surgical procedure. Laparoscopic bilateral nephrectomy followed by kidney transplantation is a safe and feasible alternative.

Adult↗

PubMed2005

Acute obstructive renal failure after laparoscopic cryoablation of multiple renal tumors in a solitary kidney.

A 67-year-old man with a solitary left kidney and baseline serum creatinine of 3.3 ng/mL (normal range 0.7 to 1.4) underwent laparoscopic cryoablation of two enhancing, solid renal tumors. Postoperatively, the case was complicated by a large blood clot in the renal collecting system causing obstruction and anuria. This complication of cryotherapy, never before reported to our knowledge, was treated successfully with a temporary ureteral stent. Follow-up magnetic resonance imaging at 3 months did not demonstrate any new lesions or enhancement of the treated renal masses. His serum creatinine at 3 months was 3.7 ng/mL.

Acute Disease↗

PubMed2005

Laparoscopic heminephrectomy for tumor.

OBJECTIVES: To present our experience with laparoscopic heminephrectomy. We defined heminephrectomy as excision of 30% or more of the renal parenchyma. Laparoscopic partial nephrectomy has typically been performed for smaller, exophytic tumors. With growing experience, we have performed more extensive resections for larger tumors, when indicated. METHODS: Since August 1999, we have performed laparoscopic partial nephrectomy in more than 300 patients. Of these, 41 patients were deemed to have undergone laparoscopic heminephrectomy (group 1). A contemporary group of 41 consecutive patients who underwent laparoscopic partial nephrectomy (less than 30% resection) were retrospectively identified for comparison (group 2). RESULTS: The preoperative patient demographics were similar, except for a greater body mass index (P = 0.02) in group 1. Group 1 had larger tumors (3.7 cm versus 2.3 cm, P <0.001) that were more commonly centrally located (41% versus 9.8%, P = 0.001) and more deeply infiltrating (P <0.001) compared with group 2. Group 1 underwent larger parenchymal resections (P <0.001) and routine pelvicaliceal suture repair (P = 0.002). The warm ischemia time was longer in group 1 (39 versus 33 minutes, P = 0.02); however, the amount of blood loss (150 versus 100 mL, P = 0.28) and total operative time (220 versus 190 minutes, P = 0.09) were comparable between the groups. The analgesic requirements, hospital stay, overall complications, and postoperative serum creatinine were comparable between the groups. Histopathologic examination showed that all 82 surgical margins were negative. CONCLUSIONS: Laparoscopic heminephrectomy is an advanced procedure that can be performed efficaciously with equivalent outcomes to those of less substantial resections. To our knowledge, experience with laparoscopic heminephrectomy has not been previously described.

Adult↗

PubMed2005

Improved hemostasis during laparoscopic partial nephrectomy using gelatin matrix thrombin sealant.

OBJECTIVES: To evaluate whether using a biologic hemostatic sealant facilitates hemostasis during laparoscopic partial nephrectomy. Secure and durable parenchymal hemostasis is a critical requirement during laparoscopic partial nephrectomy. METHODS: Since September 1999, laparoscopic partial nephrectomy has been performed in more than 300 patients by a single surgeon, duplicating open surgical principles. Recently, from patient 225 onward, we modified our technique by incorporating topical application of a gelatin matrix thrombin sealant (FloSeal) to cover the partial nephrectomy bed before sutured renorrhaphy over a Surgicel bolster. The impact of FloSeal on reducing hemorrhagic complications was evaluated by comparing two sequential groups of patients: group 1 consisted of 68 patients in whom FloSeal was not used (patients 156 to 224) and group 2 consisted of 63 patients in whom it was used (patients 225 to 288). RESULTS: Groups 1 (no FloSeal) and 2 (FloSeal) were comparable in tumor size, number of central tumors, and performance of pelvicaliceal suture repair (84% versus 92%; P = 0.16). Intraoperative variables were also comparable in terms of mean warm ischemia time (36.1 versus 37.2 minutes; P = 0.55), blood loss (150 versus 106 mL; P = 0.36), operative time, and hospital stay. However, the FloSeal group had significantly fewer overall complications (37% versus 16%; P = 0.008) and tended toward a lower rate of hemorrhagic complications (12% versus 3%), although this did not achieve statistical significance (P = 0.08). CONCLUSIONS: The results of this study have shown that adjunctive use of gelatin matrix thrombin sealant substantially enhances parenchymal hemostasis and has decreased our procedural and hemorrhagic complications to levels comparable with contemporary open partial nephrectomy series. This gelatin matrix-thrombin tissue sealant is now a routine part of laparoscopic partial nephrectomy at our institution.

Gelatin Sponge, Absorbable↗

PubMed2005

Outpatient laparoscopic pyeloplasty.

OBJECTIVES: To assess the feasibility of ambulatory laparoscopic pyeloplasty. Laparoscopic pyeloplasty aims to reproduce the excellent functional outcomes of open pyeloplasty while diminishing procedural morbidity. METHODS: Six patients fulfilled specific inclusion criteria for outpatient laparoscopic pyeloplasty: informed consent, body mass index of 40 kg/m2 or less, primary ureteropelvic junction obstruction, uncomplicated laparoscopic surgery completed by 12:00 pm, and postoperative pain control by oral analgesics. All patients had a double-J ureteral stent placed cystoscopically before laparoscopic access. No drains were placed postoperatively. RESULTS: All 6 patients successfully underwent laparoscopic dismembered pyeloplasty (3 left, 3 right) using the retroperitoneal (n = 5) or transperitoneal (n = 1) approach. The average patient age was 22 years. The mean surgical time was 223 minutes (range 165 to 270), the mean blood loss was 82 mL (range 10 to 250), and the mean postoperative hospital stay was 359 minutes (range 226 to 424). Postoperative analgesia comprised a mean of 6 mg morphine sulfate and 32 mg of ketorolac. No complications or readmissions occurred postoperatively. Intravenous urography and Lasix technetium-99m mercaptoacetyltriglycine renal scans documented resolution of obstruction. With long-term follow-up (mean 38.4 months), no recurrences have developed. CONCLUSIONS: We report our initial series of ambulatory laparoscopic pyeloplasty. In this well-selected patient population, outpatient pyeloplasty was feasible and safe.

Adolescent↗

PubMed2005

Dismembered percutaneous endopyeloplasty: a new procedure.

PURPOSE: We recently described a novel technique of percutaneous non-dismembered endopyeloplasty (Fenger type). Herein, we extend this transrenal technique further and report percutaneous dismembered endopyeloplasty (Anderson-Hynes type). MATERIALS AND METHODS: In five pigs with unilateral ureteropelvic junction (UPJ) obstruction created 3 to 6 weeks earlier, percutaneous dismembered endopyeloplasty was performed. Percutaneous transrenal access to the UPJ was obtained, and the UPJ was completely dismembered from within the renal pelvis through the solitary percutaneous tract. The dismembered proximal ureter was circumferentially mobilized, and in two animals, the UPJ segment was completely excised and removed. A spatulated end-to-end endopyeloplasty anastomosis (Anderson-Hynes) was created transrenally with 5 to 10 interrupted sutures using a novel nephroscopic suturing device (Sew-Right SR-5; LSI Solutions, Rochester, NY). In two animals, the entire percutaneous procedure was performed with CO2 insufflation instead of fluid irrigation. RESULTS: The technique was developed in three pigs. Subsequently, two pigs were treated and sacrificed at 2 and 5 weeks. All UPJs were dismembered successfully, and a precisely sutured mucosa-to-mucosa anastomosis was created. Intraoperative bleeding was negligible, and the operative time ranged from 3 to 5 hours, with the majority of the time dedicated to transrenal retroperitoneal dissection of the scarred, fibrotic UPJ. Carbon dioxide insufflation was efficacious because it minimized fluid extravasation and tissue edema and additionally enhanced visibility. Postoperative pyelograms revealed an adequately funneled UPJ, with good flow into the distal ureter. The two survival animals had minimal apparent morbidity from the procedure, and retrograde pyelograms at euthanasia revealed a patent anastomosis without extravasation. A 6F catheter easily crossed the reconstructed UPJ at autopsy in all animals. CONCLUSIONS: Dismembered percutaneous Anderson-Hynes endopyeloplasty is technically feasible and is promising. Further technical experience and additional functional outcome analysis in the survival model are necessary. With the technique described herein, we introduce the concept of percutaneous intrarenal reconstructive surgery (PIRS), wherein advanced intrarenal and retroperitoneal dissection with reconstruction can be performed endourologically, further broadening the horizons of conventional percutaneous techniques.

Anastomosis, Surgical↗

PubMed2005

Prospective randomized comparison of transperitoneal versus retroperitoneal laparoscopic radical nephrectomy.

PURPOSE: We report on a prospective randomized comparison of transperitoneal versus retroperitoneal laparoscopic radical nephrectomy for renal tumor. MATERIALS AND METHODS: Between June 1999 and June 2001, 102 consecutive eligible patients with a computerized tomography identified renal tumor were prospectively randomized to undergo either a transperitoneal (group 1, 50 patients) or retroperitoneal (group 2, 52 patients) laparoscopic radical nephrectomy with intact specimen extraction. Exclusion criteria for the study included body mass index greater than 35 or a history of prior major abdominal surgery in the quadrant of interest. Both groups were matched regarding age (63 versus 65 years, p = 0.69), BMI (29 versus 28, p = 0.89), American Society of Anesthesiologists class (2.7 versus 2.8, p = 0.37), laterality (right side 46% versus 48%, p = 0.85) and mean tumor size (5.3 versus 5.0 cm, p = 0.73). RESULTS: All 102 procedures were technically successful without the need for open conversion. Compared to the transperitoneal approach, the retroperitoneal approach was associated with a shorter time to renal artery control (91 versus 34 minutes, p <0.0001), shorter time to renal vein control (98 versus 45 minutes, p <0.0001) and shorter total operative time (207 versus 150 minutes, p = 0.001). However, the transperitoneal and retroperitoneal approaches were similar in terms of estimated blood loss (180 versus 242 cc, p = 0.13), hospital stay (43 versus 45 hours, p = 0.55), intraoperative complications (10% versus 7.7%, p = 0.30), postoperative complications (20% versus 13.5%, p = 0.14) and postoperative analgesia requirements (27 versus 26 mg MSO4 equivalent p = 0.13). Pathology revealed renal cell carcinoma in 84% and 75% of cases, respectively, with no positive surgical margin in any case. CONCLUSIONS: Laparoscopic radical nephrectomy can be performed efficiently and effectively with the transperitoneal or the retroperitoneal approach. While renal hilar control and total operative time may be quicker with retroperitoneoscopy, the approaches are similar in terms of other patient outcomes evaluated.

Adult↗

PubMed2005

Complications of laparoscopic partial nephrectomy in 200 cases.

PURPOSE: We analyzed complications of the initial 200 cases treated with laparoscopic partial nephrectomy for a suspected renal tumor. MATERIALS AND METHODS: Since August 1999, 200 consecutive patients have undergone laparoscopic partial nephrectomy. Mean patient age was 61.6 years, mean body mass index was 29.9 and mean tumor size was 2.9 cm (range 1 to 10). There were 51 central tumors (25%) and 15 solitary kidneys (7.5%). A central tumor was defined as any tumor infiltrating up to the collecting system or renal sinus, during the excision of which entry into and repair of the collecting system was necessary. Mean estimated blood loss was 247 cc and mean operative time was 3.3 hours. Data on complications were obtained from a prospectively maintained computerized database and via telephone calls to patients and/or local referring physicians. RESULTS: A total of 66 patients (33%) had 1 or more complications, which were intraoperative in 11 (5.5%), postoperative in 24 (12%) and delayed in 31 (15.5%). Overall 30 patients (15%) had a non-urological complication and 36 (18%) had a urological complication, including hemorrhage in 19 (9.5%) and urine leakage in 9 (4.5%). Hemorrhage occurred intraoperatively in 7 cases (3.5%) and postoperatively in 4 (2%), while it was delayed in 8 (4%). Of patients with urine leakage none required reoperation, 6 (3%) required a Double-J stent (Medical Engineering Corp., New York, New York) only, 2 (1%) required a Double-J stent with computerized tomography guided drainage and 1 required no treatment. Open conversion was necessary in 2 patients (1%), reoperation was done in 4 (2%) and elective laparoscopic radical nephrectomy was performed in 1 (0.5%). CONCLUSIONS: Laparoscopic partial nephrectomy is an advanced procedure with potential for complications. It requires considerable experience with reconstructive laparoscopy.

Adolescent↗

PubMed2005

Laparoscopic retropubic simple prostatectomy.

PURPOSE: Open retropubic simple prostatectomy is occasionally performed for symptomatic, large volume benign prostatic hyperplasia. We describe the technique of laparoscopic simple retropubic prostatectomy. MATERIALS AND METHODS: Since August 2001 at our 2 institutions laparoscopic simple retropubic prostatectomy has been performed in 17 patients with symptomatic significant prostatomegaly on transrectal ultrasonography (60 gm or greater, mean 93). Essential aspects of our 5 port technique are transverse cystotomy just proximal to the prostatovesical junction, subcapsular plane development, prostatic adenomectomy, prostatic fossa trigonization and prostatic capsule suture repair. Demographic, perioperative and outcome data were recorded. RESULTS: Mean operative time was 156 minutes (range 85 to 380), blood loss was 516 ml (range 100 to 2,500), hospital stay was 48 hours (range 15 to 110), and Foley catheter duration was 6.3 days (range 3 to 7). Mean specimen weight on pathological examination was 72 gm (range 32 to 120). Five patients (29%) required blood transfusion. Complications occurred in 3 patients (19%), that is intraoperative hemorrhage, catheter clot obstruction and duodenal ulcer bleeding in 1 each. All patients reported complete continence during a followup period of 1 month to 2 years. Considerable improvement from baseline was noted in American Urological Association score (preoperative vs postoperative 24.5 vs 9.9) and the maximum urine flow rate (preoperative vs postoperative 7 vs 22.8 cc per minute). CONCLUSIONS: Laparoscopic simple retropubic prostatectomy for large benign prostate hyperplasia is feasible. Our initial experience is presented.

Adenocarcinoma↗

PubMed2005

Renal cryoablation: outcome at 3 years.

PURPOSE: We report intermediate term oncological followup data on 56 patients undergoing laparoscopic renal cryoablation, of whom each completed a 3-year followup. MATERIALS AND METHODS: Since September 1997, 56 patients undergoing laparoscopic renal cryoablation have completed a followup of 3 years each. The postoperative followup protocol comprised serial magnetic resonance imaging (MRI) at 1 day, months 1, 3, 6, 12, 18 and 24, and yearly thereafter for 5 years. Computerized tomography guided needle biopsy of the cryolesion was performed 6 months postoperatively and repeated if MRI findings were abnormal. Followup data were obtained prospectively. RESULTS: For a mean renal tumor size of 2.3 cm mean intraoperative size of the created cryolesion was 3.6 cm. Sequential mean cryolesion size on MRI on postoperative 1 day, and at 3 and 6 months, and 1, 2 and 3 years was 3.7, 2.8, 2.3, 1.7, 1.2 and 0.9 cm, representing a 26%, 39%, 56%, 69% and 75% percent reduction in cryolesion size at 3 and 6 months, and 1, 2 and 3 years, respectively. At 3 years 17 cryolesions (38%) had completely disappeared on MRI. Postoperative needle biopsy identified locally persistent/recurrent renal tumor in 2 patients. In the 51 patients undergoing cryotherapy for a unilateral, sporadic renal tumor 3-year cancer specific survival was 98%. There was no open conversion, kidney loss, urinary fistula, dialysis requirement, or perirenal or port site recurrence in any patients. CONCLUSIONS: Three-year outcomes following renal cryoablation are encouraging. Longer term (5-year) data are necessary to determine the proper place of renal cryotherapy among minimally invasive, nephron sparing options.

Adult↗

PubMed2005

Laparoscopic partial nephrectomy for cystic masses.

PURPOSE: Although laparoscopic partial nephrectomy (LPN) has emerged as an effective treatment option in select patients with a solid renal tumor, scant data are available on cystic renal tumors. We report our experience with LPN in 50 patients with a cystic renal lesion. MATERIALS AND METHODS: Of 284 patients undergoing LPN at our institution since August 1999 preoperative computerized tomography identified a suspicious cystic lesion in 50 (17.6%) (group 1). Data were retrospectively compared with those on 50 matched, consecutive patients undergoing LPN for a solid renal mass (group 2). All patients with Bosniak II/IIF cysts were advised to undergo watchful waiting. Surgery was offered if the cyst changed in character or if that was the patient preference. RESULTS: Median tumor size was 3 cm in group 1 and 2.6 cm in group 2 (p = 0.07). Groups 1 and 2 were comparable in regard to perioperative parameters. In patients with Bosniak II (9), IIF (4), III (12) and IV (21) cysts final histopathology revealed renal cell carcinoma in 22%, 25%, 50% and 90%, respectively. All 100 patients had a negative surgical margin. No patient in group 1 had intraoperative puncture/spillage of the cystic tumor. In group 1 during a mean followup of 14 months (range 1 month to 3 years) 1 patient had retroperitoneal recurrence at 1 year despite negative surgical margins during initial LPN. CONCLUSIONS: Surgical outcomes of LPN for suspicious cystic masses are similar to those of LPN for solid tumors. However, extreme caution and refined laparoscopic technique must be exercised to avoid cyst rupture and local spillage.

Aged↗

PubMed2005

Transperitoneal versus retroperitoneal laparoscopic partial nephrectomy: patient selection and perioperative outcomes.

PURPOSE: We compared the results of transperitoneal (T) and retroperitoneal (R) approaches to laparoscopic partial nephrectomy (LPN) in regard to perioperative outcomes and technical considerations, thereby, identifying patient selection guidelines for each approach. MATERIALS AND METHODS: The choice of approach was dictated primarily by tumor location, that is TLPN for anterior or lateral lesions and RLPN for posterior or posterolateral lesions. The approaches differed primarily by the hilar control technique. During TLPN en bloc hilar control was achieved with a Satinsky clamp, while during RLPN individual vessel control was obtained with bulldog clamps. RESULTS: In a 3-year period 100 TLPNs and 63 RLPNs were performed for renal tumor. Of posterior tumors 77% were managed by RLPN, whereas 97% of anterior tumors were managed by TLPN. TLPN was associated with significantly larger tumors (3.2 vs 2.5 cm, p <0.001), more caliceal suture repairs (79% vs 57%, p = 0.004), longer ischemia time (31 vs 28 minutes, p = 0.04), longer operative time (3.5 vs 2.9 hours, p <0.001) and longer hospital stay (2.9 vs 2.2 days, p <0.01) than RLPN. Blood loss, perioperative complications, postoperative serum creatinine, analgesic requirements and histological outcomes were comparable between the groups. CONCLUSIONS: We perform TLPN for all anterior or lateral tumors as well as for large or deeply infiltrating posterior tumors that require substantive resection (heminephrectomy). The limited retroperitoneal space makes RLPN technically more challenging but provides superior access to posterior and particularly posteromedial lesions. When feasible, we prefer to perform laparoscopic partial nephrectomy by the transperitoneal approach because of its larger working area and superior instrument angles for intracorporeal renal reconstruction.

Adolescent↗

PubMed2005

The impact of warm ischaemia on renal function after laparoscopic partial nephrectomy.

UNLABELLED: Authors from Cleveland assessed the impact of warm ischaemia on renal function, using their large database of laparoscopic partial nephrectomies for tumour. While agreeing that renal hilar clamping is essential for precise excision of the tumour, and other elements of the operation, the authors indicate that warm ischaemia may potentially damage the kidney. However, they found that there were virtually no clinical sequelae from warm ischaemic of up to 30 min. They also found that advancing age and pre-existing renal damage increased the risk of postoperative renal damage. OBJECTIVE: To assess the effect of warm ischaemia on renal function after laparoscopic partial nephrectomy (LPN) for tumour, and to evaluate the influence of various risk factors on renal function. PATIENTS AND METHODS: Data were analysed from 179 patients undergoing LPN for renal tumour under warm ischaemic conditions, with clamping of the renal artery and vein. Renal function was primarily evaluated in two groups of patients: 15 with tumour in a solitary kidney, who were evaluated by serial serum creatinine measurements; and 12 with two functioning kidneys undergoing unilateral LPN, and evaluated by renal scintigraphy before and 1 month after LPN to quantify differential renal function. Also, in all 179 patients, mean serum creatinine data at baseline, 1 day after LPN, at hospital discharge, and at the last follow-up were provided as supportive evidence. Logistic regression analyses were used to assess the effect of various risk factors on renal function after LPN, i.e. patient age, baseline serum creatinine, tumour size, solitary kidney status, duration of warm ischaemia, pelvicalyceal suture repair, urine output and intravenous fluids during LPN. RESULTS: In the group of patients with a solitary kidney the mean warm ischaemia time was 29 min, kidney parenchyma excised 29%, and serum creatinine at baseline, discharge, the peak after LPN and at the last follow-up (mean 4.8 months) 1.3, 2.3, 2.8, and 1.8 mg/dL, respectively. One patient (6.6%) required temporary dialysis. In the second group, assessed by renal scintigraphy, the function of the operated kidney was reduced by a mean of 29%, commensurate with the amount of parenchyma excised. For all 179 patients, a combination of age > or = 70 years and a serum creatinine level after LPN of > or = 1.5 mg/dL correlated with a higher serum creatinine after LPN. On logistic regression, baseline serum creatinine and solitary kidney status were the only variables significant for serum creatinine status after LPN. CONCLUSIONS: The bloodless field provided by renal hilar clamping is important for precise tumour excision, pelvicalyceal suture repair and securing parenchymal haemostasis during LPN. However, renal hilar clamping causes warm ischaemia. These data indicate that the clinical sequelae of warm ischaemic renal injury of approximately 30 min are minimal. Advancing age and pre-existing azotaemia increase the risk of renal dysfunction after LPN, especially when the warm ischaemia exceeds 30 min.

Adult↗

PubMed2004

Right donor nephrectomy: a comparison of hand-assisted transperitoneal and retroperitoneal laparoscopic approaches.

BACKGROUND: We compare the anatomic and functional outcomes of right live-donor nephrectomy (LDN) using either a hand-assisted approach (HALDN) or a pure retroperitoneoscopic approach (RLDN) in two institutions. PATIENTS AND METHODS: Data were recorded prospectively in 59 patients undergoing right LDN using either hand-assisted (n=31) or pure retroperitoneoscopic (n=28) approaches. All HALDN cases were performed at the University of Cincinnati, and all RLDN cases were performed at the Cleveland Clinic Foundation. RESULTS: Demographics were similar with respect to age (41.1+/-11.5 vs. 44.5+/-8.5 years) and human leukocyte antigen mismatches (2.7+/-1.8 vs. 2.6+/-1.6). Operative times were longer for HALDN (3.4+/-0.7 vs. 3.0+/-0.7 hours, P <0.04), whereas warm ischemia time was shorter (3:55+/-1:47 vs. 4:55+/-0:55 minutes, P <0.001). Length of renal vein and artery were equivalent (2.4/3.4 vs. 2.3/3.2 cm, P =0.5). Complication rates were similar (10% vs. 7%, P =0.5), including conversion to open surgery (n=1), accessory upper pole artery transection (n=1), and swollen testicle (n=1) in the HALDN group, and a small parenchymal injury (n=1) and a capsular tear (n=1) in the RLDN group. Donor length of stay and convalescence were similar in both groups (43.5+/-14.1 vs. 45.7+/-25.3 hours, P =0.1; convalescence 23.5+/-5.3 vs. 20.2+/-4.1 days, P =0.5). One-week, 1-month, and 1-year serum creatinine levels were equivalent with both approaches. No grafts were lost in either group. CONCLUSIONS: This study confirms that the HALDN and RLDN techniques can provide kidney grafts with equivalent-length vessels and excellent function.

Adult↗