3-Piece Inflatable Penile Prosthesis Placement Following Radical Cystoprostatectomy and Urinary Diversion: Technique and Outcomes.

BACKGROUND: After radical cystoprostatectomy (RC), postoperative erectile dysfunction (ED) is a common consequence with multiple contributing etiologies. The inflatable penile prosthesis (IPP) offers patients a definitive treatment option when ED is refractory to medical therapies. Because of the hostile postoperative anatomy of these patients, a careful surgical approach is necessary for successful outcomes and to avoid adjacent organ injury. To date, there is no series describing the outcomes of 3-piece IPP placement in patients with urinary diversions. AIM: To present contemporary outcomes and a description of our technique in placing a 3-piece IPP for postoperative ED in patients with a history of RC with orthotopic neobladder, ileal conduit, or continent cutaneous diversion. METHODS: We retrospectively reviewed 80 patients who underwent primary placement of a 3-piece IPP (AMS 700; American Medical Systems Inc, Minnetonka, MN, USA) after RC and urinary diversion from 2003 through 2016. 79 patients underwent RC in their treatment of urologic malignancy (71 for bladder cancer, 8 for prostate cancer) and 1 underwent RC for refractory interstitial cystitis. An infrapubic approach was used in most patients, with reservoir placement in the lateral retroperitoneal space through a counterincision medial to the anterior superior iliac spine. Patient demographics, perioperative data, and postoperative outcomes including prosthetic infection and mechanical failure were examined and statistical analysis was performed. OUTCOMES: Rates of device infection, revision surgery, and reservoir complications. RESULTS: After mean follow-up of 53.9 months (6.5-150.7 months), 4 patients developed infection of the prosthesis that required explantation. 3 of those patients underwent successful IPP reimplantation. 5 patients required revision surgery (pump replacement, n = 3; pump relocation, n = 1; cylinder replacement for cylinder aneurysm, n = 1) for mechanical failure. No statistically significant associations were found between infection and comorbidities, urinary diversion, exposure to chemotherapy, radiation, or presence of an artificial urinary sphincter. CLINICAL IMPLICATIONS: The 3-piece IPP is an effective treatment option for medication-refractory ED that can be placed safely in patients with all forms of urinary diversion. STRENGTHS AND LIMITATIONS: This study represents the 1st series that describes a successful technique and long-term outcomes of patients with urinary diversion. It is limited by its single-surgeon, single-center experience and lacks validated patient satisfaction data in follow-up. CONCLUSIONS: The 3-piece IPP, with reservoir placement in the lateral retroperitoneum, can be implanted successfully in patients with all forms of urinary diversion without a significant increase in infectious complications, reservoir erosion, or mechanical failure. Loh-Doyle J, Patil MB, Sawkar H, et al. 3-Piece Inflatable Penile Prosthesis Placement Following Radical Cystoprostatectomy and Urinary Diversion: Technique and Outcomes. J Sex Med 2018;15:907-913.

Three-Piece Inflatable Penile Prosthesis Placement Following Pelvic Radiation: Technical Considerations and Contemporary Outcomes.

BACKGROUND: Pelvic radiation is a known risk factor for the development and progression of erectile dysfunction. When medical therapy fails, the 3-piece inflatable penile prosthesis (IPP) can offer patients a definitive treatment option. Because of radiation-induced vascular changes and tissue fibrosis, a careful surgical approach is necessary to avoid intraoperative complications and attain successful outcomes. Despite its widespread use in prostate cancer treatment, there are no contemporary studies examining the effects that pelvic radiation can have on 3-piece IPP placement and device survival. AIM: To present technical considerations and contemporary outcomes of placing a 3-piece IPP for refractory erectile dysfunction in patients with a history of pelvic radiation. METHODS: We retrospectively reviewed 78 patients who underwent placement of a 3-piece IPP (AMS 700; Boston Scientific, Marlborough, MA, USA) after being treated with pelvic radiotherapy from 2003 through 2016. All patients had been treated with external beam and/or brachytherapy for treatment of prostate malignancy. An infrapubic approach was used in all patients, with reservoir placement in the space of Retzius or in the lateral retroperitoneal space. Patient demographics, perioperative data, and postoperative outcomes including prosthetic infection and mechanical failure were examined and statistical analysis was performed. OUTCOMES: Rates of device infection, revision surgery, and reservoir complications. RESULTS: No intraoperative complications were observed. After a mean follow-up of 49.0 months (6.6-116.8), 2 patients developed an infection of their prosthesis that required explantation. These patients underwent successful IPP removal and immediate reimplantation. 11 patients (14.1%) required revision surgery (pump replacement, n = 4; pump relocation, n = 2; cylinder replacement, n = 4; reservoir replacement owing to leak, n = 1). No reservoir-related complications such as herniation or erosion into adjacent structures were observed. CLINICAL IMPLICATIONS: The 3-piece IPP can be placed safely in a broad range of patients treated with pelvic radiotherapy. STRENGTHS AND LIMITATIONS: This study describes contemporary long-term outcomes of the IPP in patients treated with pelvic radiation and includes patients with prior pelvic surgery and artificial urinary sphincter, which are commonly encountered in practice. It is limited by its single-center experience and lacks a comparison group of patients. Objective patient satisfaction data were not available for inclusion. CONCLUSIONS: The 3-piece IPP can be placed successfully in patients with a history of pelvic radiation without a significant increase in infectious complications, reservoir erosion, or mechanical failure compared with the global literature. Loh-Doyle J, Patil MB, Nakhoda Z, et al. Three-Piece Inflatable Penile Prosthesis Placement Following Pelvic Radiation: Technical Considerations and Contemporary Outcomes. J Sex Med 2018;15:1049-1054.

Total bladder and posterior urethral reconstruction: salvage technique for defunctionalized bladder with recalcitrant posterior urethral stenosis.

PURPOSE: Recalcitrant posterior urethral stenosis is a challenging disease. When combined with a defunctionalized bladder, cutaneous urinary diversion is the most common surgical option. We present a novel technique of total lower urinary tract reconstruction, combining salvage cystectomy, ileal neobladder formation and urethral pull-through, as an orthotopic alternative in patients with a defunctionalized bladder and recalcitrant posterior urethral stenosis. MATERIALS AND METHODS: We completed a retrospective review of 8 patients who underwent salvage cystectomy, orthotopic ileal neobladder formation and urethral pull-through. Artificial urinary sphincter placement was performed in a staged fashion. Six patients received prostate cancer treatment including radiation therapy, 1 had urethral disruption after robotic radical prostatectomy, and 1 experienced bladder rupture and urethral distraction injury during a motorcycle accident. Patient demographics, operative variables and postoperative outcomes were examined. RESULTS: No high grade complications were observed after salvage cystectomy, orthotopic neobladder formation and urethral pull-through. After staged artificial urinary sphincter placement, a median of 2 revision surgeries (range 0 to 4) was required to establish social continence. All patients maintained functional urinary storage, urethral patency and social continence at a median followup of 58 months. No patient had complications related to orthotopic neobladder formation, including ureteroileal anastomotic stricture or pyelonephritis, and no patient required cutaneous diversion. CONCLUSIONS: Total lower urinary tract reconstruction with cystectomy, ileal neobladder formation and urethral pull-through offers an orthotopic alternative for patients with recalcitrant posterior urethral stenosis and defunctionalized bladders. Although it requires staged placement of an artificial urinary sphincter, this approach can offer functional urinary storage, durable urethral patency and avoidance of cutaneous urinary diversion.

Level III-IV inferior vena caval thrombectomy without cardiopulmonary bypass: long-term experience with intrapericardial control.

PURPOSE: Inferior vena cava tumor thrombectomy requires experienced surgical teams due to complex hemodynamic considerations. The teams often use vascular bypass techniques that introduce additional risk. Inferior vena caval control in the pericardium obviates the need for cardiopulmonary bypass. We reviewed our experience with intrapericardial control during inferior vena caval tumor thrombectomy to evaluate perioperative outcomes and determine factors associated with overall survival. MATERIALS AND METHODS: We retrospectively reviewed the records of 87 patients who underwent nephrectomy with inferior vena caval tumor thrombectomy using intrapericardial inferior vena caval control from 1978 to 2012. This technique was performed in all 43 and 35 cases of intrahepatic and supradiaphragmatic thrombi, respectively, and in 9 select cases of intra-atrial thrombi. Patient demographics, operative variables and postoperative outcomes were examined. Multivariate regression analysis was used to determine associations between clinical variables and overall survival. RESULTS: Mortality 30 days perioperatively was 9.2% and the incidence of high grade complications was 19.5%. Median survival was 3.1 and 2.5 years in patients with pT3bN0 and pT3cN0, respectively. Extended regional lymphadenectomy, which was performed in all cases, revealed nodal metastasis in 38%. On multivariate analysis ECOG greater than 2 and pT3c stage were associated with worse survival. Histological grade, perinephric fat invasion and lymph node involvement were not associated with worse survival. CONCLUSIONS: Intrapericardial control of the inferior vena cava enables a single surgical team to safely perform tumor thrombectomy for intrahepatic and supradiaphragmatic thrombi, eliminating the risk and morbidity related to cardiopulmonary bypass. Although supradiaphragmatic extent and ECOG greater than 2 are associated with worse survival, complete resection with lymphadenectomy can allow for long-term survival in patients with locally advanced disease.

Concurrent and predictive validation of a novel robotic surgery simulator: a prospective, randomized study.

PURPOSE: We evaluated the concurrent and predictive validity of a novel robotic surgery simulator in a prospective, randomized study. MATERIALS AND METHODS: A total of 24 robotic surgery trainees performed virtual reality exercises on the da Vinci® Skills Simulator using the da Vinci Si™ surgeon console. Baseline simulator performance was captured. Baseline live robotic performance on ex vivo animal tissue exercises was evaluated by 3 expert robotic surgeons using validated laparoscopic assessment metrics. Trainees were then randomized to group 1-simulator training and group 2-no training while matched for baseline tissue scores. Group 1 trainees underwent a 10-week simulator curriculum. Repeat tissue exercises were done at study conclusion to assess performance improvement. Spearman's analysis was used to correlate baseline simulator performance with baseline ex vivo tissue performance (concurrent validity) and final tissue performance (predictive validity). The Kruskal-Wallis test was used to compare group performance. RESULTS: Groups 1 and 2 were comparable in pre-study surgical experience and had similar baseline scores on simulator and tissue exercises (p >0.05). Overall baseline simulator performance significantly correlated with baseline and final tissue performance (concurrent and predictive validity each r = 0.7, p <0.0001). Simulator training significantly improved tissue performance on key metrics for group 1 subjects with lower baseline tissue scores (below the 50th percentile) than their group 2 counterparts (p <0.05). Group 1 tended to outperform group 2 on final tissue performance, although the difference was not significant (p >0.05). CONCLUSIONS: Our study documents the concurrent and predictive validity of the Skills Simulator. The benefit of simulator training appears to be most substantial for trainees with low baseline robotic skills.

Zero ischemia anatomical partial nephrectomy: a novel approach.

PURPOSE: We present a novel concept of zero ischemia anatomical robotic and laparoscopic partial nephrectomy. MATERIALS AND METHODS: Our technique primarily involves anatomical vascular microdissection and preemptive control of tumor specific, tertiary or higher order renal arterial branch(es) using neurosurgical aneurysm micro-bulldog clamps. In 58 consecutive patients the majority (70%) had anatomically complex tumors including central (67%), hilar (26%), completely intrarenal (23%), pT1b (18%) and solitary kidney (7%). Data were prospectively collected and analyzed from an institutional review board approved database. RESULTS: Of 58 cases undergoing zero ischemia robotic (15) or laparoscopic (43) partial nephrectomy, 57 (98%) were completed without hilar clamping. Mean tumor size was 3.2 cm, mean ± SD R.E.N.A.L. score 7.0 ± 1.9, C-index 2.9 ± 2.4, operative time 4.4 hours, blood loss 206 cc and hospital stay 3.9 days. There were no intraoperative complications. Postoperative complications (22.8%) were low grade (Clavien grade 1 to 2) in 19.3% and high grade (Clavien grade 3 to 5) in 3.5%. All patients had negative cancer surgical margins (100%). Mean absolute and percent change in preoperative vs 4-month postoperative serum creatinine (0.2 mg/dl, 18%), estimated glomerular filtration rate (-11.4 ml/minute/1.73 m(2), 13%), and ipsilateral kidney function on radionuclide scanning at 6 months (-10%) correlated with mean percent kidney excised intraoperatively (18%). Although 21% of patients received a perioperative blood transfusion, no patient had acute or delayed renal hemorrhage, or lost a kidney. CONCLUSIONS: The concept of zero ischemia robotic and laparoscopic partial nephrectomy is presented. This anatomical vascular microdissection of the artery first and then tumor allows even complex tumors to be excised without hilar clamping. Global surgical renal ischemia is unnecessary for the majority of patients undergoing robotic and laparoscopic partial nephrectomy at our institution.

Validation of a novel robotic-assisted partial nephrectomy surgical training model.

UNLABELLED: What's known on the subject? and What does the study add? One area of particular growth for robotic surgery has been partial nephrectomy. Despite a perceived notion that robotic-assisted partial nephrectomy is more easily adaptable compared to laparoscopic partial nephrectomy, there is nonetheless an associated learning curve. Validated training models with a corresponding assessment method for robotic-assisted partial nephrectomy were previously unavailable. We have designed and validated a RAPN surgical model appropriate for resident and fellow training. OBJECTIVE: To evaluate the face, content and construct validities of a novel ex vivo surgical training model for robotic-assisted partial nephrectomy (RAPN). METHODS: We prospectively identified participants as novice (not completed any robotic console cases), intermediate (at least one robotic console case but <100 cases), and expert (≥100 robotic console cases). Each participant performed a partial nephrectomy using the da Vinci Si Surgical System on an ex vivo porcine kidney with an embedded Styrofoam ball that mimics a renal tumour. Subjects completed a post-study questionnaire assessing training model realism and utility. Participants were anonymously judged by three expert reviewers using a validated laparoscopic assessment tool. Performance between groups was compared using the tukey-kramer test. RESULTS: The 46 participants recruited for this study included 24 novices, nine intermediates, and 13 experts. Overall, expert surgeons rated the training model as 'very realistic' (median visual analogue score 7/10) (face validity). Experts also rated the model as an 'extremely useful' training tool for residents (median 9/10) and fellows (9/10) (content validity), although less so for experienced robotic surgeons (5/10). Experts outscored novices on overall performance (P = 0.0002) as well as individual metrics, including 'depth perception,''bimanual dexterity,''efficiency,''tissue handling,''autonomy,''precision,' and 'instrument and camera awareness' (P < 0.05) (construct validity). Experts similarly outperformed intermediates in most metrics (P < 0.05). CONCLUSION: Our novel ex vivo RAPN surgical model has demonstrated face, content and construct validity. Future development of this model should include simulation of haemostasis management and renal reconstruction.

Early comparison of nephrectomy options in children (open, transperitoneal laparoscopic, laparo-endoscopic single site (LESS), and robotic surgery).

OBJECTIVE: To compare the perioperative parameters of paediatric patients who underwent nephrectomy via laparo-endoscopic single site (LESS) surgery (also known as single incision laparoscopic surgery or SILS) with those who underwent nephrectomy via conventional laparoscopy (LAP), robotic-assisted laparoscopy (RALN), and open surgery (OPEN). PATIENTS AND METHODS: The medical records of 69 paediatric patients at a single institution who underwent nephrectomies for non-functioning kidneys in 72 renal units (39 OPEN, 11 LAP, 11 RALN and 11 LESS) were reviewed for patient demographics and perioperative clinical parameters. RESULTS: The minimally invasive modalities in children, including LESS nephrectomy, were associated with shorter lengths of hospital stay (P < 0.001) and decreased postoperative pain medication usage (P < 0.001) than with open surgery. Similar surgical times were noted with LESS and the other minimally invasive modalities (LAP and RALN) (P= 0.056). However, the minimally invasive modalities (LESS, LAP and RALN) were associated with slightly longer surgical times when compared with open surgery (P < 0.001), which may, in part, be secondary to learning curve factors. No differences were noted among the minimally invasive modalities for postoperative pain medication usage (P= 0.354) and length of hospital stay (P= 0.86). CONCLUSIONS: The minimally invasive modalities for nephrectomy in children, including LESS nephrectomy, are associated with shorter lengths of hospital stay and decreased postoperative pain medication use when compared with open surgery. LESS nephrectomy in children is associated with similar surgical times, lengths of hospital stay and postoperative pain medication use as the other minimally invasive modalities (LAP and RALN). Slightly longer surgical times are noted with the minimally invasive modalities, including LESS nephrectomy, when compared with open surgery, which may, in part, be secondary to learning curve factors.

Eliminating global renal ischemia during partial nephrectomy: an anatomical approach.

PURPOSE OF REVIEW: Partial nephrectomy surgery typically requires clamping the main renal artery. This creates the bloodless field necessary for precise tumor excision and reconstruction. However, hilar clamping also renders the entire kidney ischemic, an undesirable albeit unavoidable consequence. We recently developed a novel, anatomical zero-ischemia technique that eliminates global renal ischemia. Herein, we critically evaluate the outcomes of unclamped and zero-ischemia partial nephrectomy techniques. RECENT FINDINGS: Our anatomical zero-ischemia technique takes advantage of renal segmental and end-arterial anatomy to allow even substantial partial nephrectomy surgery without clamping the main renal artery/vein. Anatomic vascular microdissection is performed to super-selectively devascularize the tumor, while maintaining uninterrupted arterial blood flow to the uninvolved kidney. Global renal ischemia is thus eliminated. SUMMARY: Partial nephrectomy can now be safely performed without global renal ischemia, even for complex tumors. Initial perioperative and renal functional outcomes of anatomical zero-ischemia surgery are encouraging. Going forward, clamping the main renal artery appears unnecessary during most partial nephrectomy surgery.

Face, content and construct validity of a novel robotic surgery simulator.

PURPOSE: We evaluated the face, content and construct validity of the novel da Vinci® Skills Simulator™ using the da Vinci Si™ Surgeon Console as the surgeon interface. MATERIALS AND METHODS: We evaluated a novel robotic surgical simulator for robotic surgery using the da Vinci Si Surgeon Console and Mimic™ virtual reality. Subjects were categorized as novice-no surgical training, intermediate-surgical training with fewer than 100 robotic cases or expert-100 or more primary surgeon robotic cases. Each participant completed 10 virtual reality exercises with 3 repetitions and a questionnaire with a 1 to 10 visual analog scale to assess simulator realism (face validity) and training usefulness (content validity). The simulator recorded performance based on specific metrics. The performance of experts, intermediates and novices was compared (construct validity) using the Kruskal-Wallis test. RESULTS: We studied 16 novices, 32 intermediates with a median surgical experience of 6 years (range 1 to 37) and a median of 0 robotic cases (range 0 to 50), and 15 experts with a median of 315 robotic cases (range 100 to 800). Participants rated the virtual reality and console experience as very realistic (median visual analog scale score 8/10) while expert surgeons rated the simulator as a very useful training tool for residents (10/10) and fellows (9/10). Experts outperformed intermediates and novices in almost all metrics (median overall score 88.3% vs 75.6% and 62.1%, respectively, between group p<0.001). CONCLUSIONS: We confirmed the face, content and construct validity of a novel robotic skill simulator that uses the da Vinci Si Surgeon Console. Although it is currently limited to basic skill training, this device is likely to influence robotic surgical training across specialties.

Innovations in laparoscopic and robotic partial nephrectomy: a novel 'zero ischemia' technique.

PURPOSE OF REVIEW: To describe a novel 'zero ischemia' technique for laparoscopic and robotic partial nephrectomy. RECENT FINDINGS: Laparoscopic partial nephrectomy has been performed in 15 patients without the need for warm ischemia by utilizing pharmalogically induced hypotension. This consecutive series includes complex tumors in patients with multiple comorbidities. Herein we describe our current practice, initial results, and several practical considerations associated with the application of this novel technique. SUMMARY: Initial results with our 'zero ischemia' technique have been encouraging. Evaluation of long-term outcomes is ongoing.

Outcomes of Alternative Reservoir Placement in the Lateral Retroperitoneum During Inflatable Penile Prosthesis Placement.

OBJECTIVES: To describe outcomes of reservoir placement, exchange, and extraction from the lateral retroperitoneum (LR) in complex patients with a three-piece inflatable penile prosthesis (IPP). METHODS: A retrospective chart review was performed on all patients that underwent placement of an IPP from 2009 to 2019. Patients with placement of the reservoir in the LR were identified. Intraoperative complications during reservoir placement, exchange, or removal, reservoir-related outcomes, and secondary device-related outcomes were collated and compared to patients who underwent traditional Space of Retzius reservoir placement. RESULTS: A total of 587 men underwent primary IPP placement with 321 patients undergoing reservoir placement in the SOR and 266 in the LR. No significant differences were found in intra-operative reservoir-related outcomes (P=.272) between the 2 groups during placement, replacement, or extraction. Bowel injury occurred in 1 patient in the LR group during placement. No significant differences were found in postoperative reservoir complications (P= .534). Both groups each had one instance of patient reported bulge and pain at reservoir site (P= .6777). Two (0.6%) patients in the SOR group and 3 (1.1%) patients in the LR group had a reservoir failure or leak. There was a trend towards a lower rate of device infections in the LR group (1.9%) compared to the SOR group (4.7%) (P= .063). There were no significant differences in overall device mechanical failure rates between both groups (P= .919). CONCLUSIONS: Reservoir placement in the LR is safe in patients with complex pelvic anatomy with equivalent device durability and no difference in surgical outcomes compared to standard retropubic reservoir placement.

Vena Cavoscopy in the Assessment of Intraluminal Vena Caval Tumor Involvement.

OBJECTIVE: To improve confirmation of complete tumor thrombus removal in advanced malignancy, we report on our experience using intraoperative vena cavoscopy using a flexible cystoscope to confirm complete thrombus resection. Patients with renal cell carcinoma or testicular cancer associated with inferior vena caval tumor involvement benefit from surgical resection of the primary tumor and the tumor thrombus. Intraoperative assessment of the vena cava represents a technical challenge, particularly when the thrombus is friable and involves the hepatic veins, or there is caudal extension of thrombus toward the bifurcation. MATERIAL AND METHODS: From 2006 to 2014, 36 patients underwent tumor thrombectomy and vena cavoscopy. When residual caval thrombus was suspected, a flexible cystoscope was inserted into the vena cava for direct visual inspection of the caval lumen. Perioperative outcomes including residual tumor, changes in management, and postoperative complications were analyzed. RESULTS: All patients underwent endoscopy of the caval lumen without complications. Eight of 36 (22%) patients were found to have residual tumor thrombus visualized during cavoscopy. Five of these patients had evidence of residual mass and caval invasion within the caval lumen that ultimately resulted in cavectomy. Two patients had residual tumor thrombus that was bluntly removed. One patient was found to have significant involvement of the hepatic veins. CONCLUSION: Vena cavoscopy using a flexible cystoscope is a practical technique that may be utilized intraoperatively to ensure clearance of residual thrombus burden within the inferior vena cava and to assess for caval invasion.

Renal cell carcinoma with inferior vena cava tumor thrombus and metastatic caval wall invasion.

We present a case of renal cell carcinoma with inferior vena caval tumor thrombus and metastatic involvement of the distal inferior vena cava.

Anatomic renal artery branch microdissection to facilitate zero-ischemia partial nephrectomy.

BACKGROUND: Robot-assisted and laparoscopic partial nephrectomies (PNs) for medial tumors are technically challenging even with the hilum clamped and, until now, were impossible to perform with the hilum unclamped. OBJECTIVE: Evaluate whether targeted vascular microdissection (VMD) of renal artery branches allows zero-ischemia PN to be performed even for challenging medial tumors. DESIGN, SETTING, AND PARTICIPANTS: A prospective cohort evaluation of 44 patients with renal masses who underwent robot-assisted or laparoscopic zero-ischemia PN either with anatomic VMD (group 1; n=22) or without anatomic VMD (group 2; n=22) performed by a single surgeon from April 2010 to January 2011. INTERVENTION: Zero-ischemia PN with VMD incorporates four maneuvers: (1) preoperative computed tomographic reconstruction of renal arterial branch anatomy, (2) anatomic dissection of targeted, tumor-specific tertiary or higher-order renal arterial branches, (3) neurosurgical aneurysm microsurgical bulldog clamp(s) for superselective tumor devascularization, and (4) transient, controlled reduction of blood pressure, if necessary. MEASUREMENTS: Baseline, perioperative, and postoperative data were collected prospectively. RESULTS AND LIMITATIONS: Group 1 tumors were larger (4.3 vs 2.6 cm; p=0.011), were more often hilar (41% vs 9%; p=0.09), were medial (59% and 23%; p=0.017), were closer to the hilum (1.46 vs 3.26 cm; p=0.0002), and had a lower C index score (2.1 vs 3.9; p=0.004) and higher RENAL nephrometry scores (7.7 vs 6.2; p=0.013). Despite greater complexity, no group 1 tumor required hilar clamping, and perioperative outcomes were similar to those of group 2: operating room time (4.7 and 4.1h), median blood loss (200 and 100ml), surgical margins for cancer (all negative), major complications (0% and 9%), and minor complications (18% and 14%). The median serum creatinine level was similar 2 mo postoperatively (1.2 and 1.3mg/dl). The study was limited by the relatively small sample size. CONCLUSIONS: Anatomic targeted dissection and superselective control of tumor-specific renal arterial branches facilitate zero-ischemia PN. Even challenging medial and hilar tumors can be excised without hilar clamping. Global surgical renal ischemia has been eliminated for most patients undergoing PN at our institution.

"Zero ischemia" partial nephrectomy: novel laparoscopic and robotic technique.

BACKGROUND: Ischemic injury impacts renal function outcomes following partial nephrectomy. Efforts to minimize, better yet, eliminate renal ischemia are imperative. OBJECTIVE: Describe a novel technique of "zero ischemia" laparoscopic (LPN) and robotic-assisted (RAPN) partial nephrectomy. DESIGN, SETTING, AND PARTICIPANTS: Data were prospectively collected into an institutional review board-approved database. Fifteen consecutive patients underwent zero ischemia procedures: LPN (n=12), RAPN (n=3). Included were all candidates for LPN or RAPN, irrespective of tumor complexity, including tumors that were central (n=9; 60%), hilar (n=1), in solitary kidney (n=1), in patients with chronic kidney disease grade 3 or greater (n=3). Anesthesia-related monitoring included pulmonary artery catheter (ie, Swan-Ganz), transesophageal echocardiography, cerebral oximetry, electroencephalographic bispectral index, mixed venous oxygen measurements, and vigorous hydration/diuresis. Pharmacologically induced hypotension was carefully timed to correspond with excision of the deepest aspect of the tumor. Renal parenchymal reconstruction was completed under normotension, ensuring complete hemostasis. MEASUREMENTS: Intraoperative and early postoperative data were collected prospectively. RESULTS AND LIMITATIONS: All cases were successfully completed without hilar clamping. Ischemia time was zero in all cases. Median tumor size was 2.5 cm (range: 1-4); operative time was 3 h (range: 1.3-6); blood loss was 150 ml (range: 20-400); and hospital stay was 3 d (range: 2-19). Nadir mean arterial pressure ranged from 52-65 mm Hg (median: 60), typically for 1-5 min. No patient had intraoperative transfusion or complication, acute or delayed renal hemorrhage, or hypotension-related sequelae. Postoperative complications (n=5) included urine retention (n=1), septicemia from presumed prostatitis (n=1), atrial fibrillation (n=1), urine leak (n=2). Pathology confirmed renal cell carcinoma in 13 patients (87%), all with negative margins. Median pre- and postoperative serum creatinine (0.9 mg/dl and 0.95 mg/dl, respectively) and estimated glomerular filtration rate (eGFR) (75.3 and 72.9, respectively) were comparable. Median absolute and percent change in discharge serum creatinine and eGFR were 0 and 0%, respectively. CONCLUSIONS: A novel zero ischemia technique for RAPN and LPN for substantial renal tumors is presented. The initial experience is encouraging.