Validity of the MISTELS simulator for laparoscopy training in urology.

BACKGROUND AND PURPOSE: The McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) consists of a series of five laparoscopic exercises performed in an endotrainer box. MISTELS has been validated for use in both training and evaluation of general surgery residents in fundamental laparoscopic skills. The purpose of this study was to demonstrate the construct validity of MISTELS for urology residents. SUBJECTS AND METHODS: Seventeen participants were evaluated during performance of the five MISTELS tasks (peg transfer, pattern cutting, ligating loop, and suturing with extracorporeal and intracorporeal knots) using the standardized scoring system, which rewards both speed and precision. Participants included 13 urology residents (PGY 1-5), 1 fellow, and 3 urologists experienced in laparoscopy. Results are expressed as median (range). The Mann-Whitney U-test was used to compare MISTELS scores for 9 novice (PGY 1-4) and 8 experienced urologists (PGY 5-attending). P < 0.05 was considered statistically significant. RESULTS: The median MISTELS total normalized score for novices was 52.3 (range 15-68.9) compared with 71.7 (range 56.3-82.9) for experienced urologists (P = 0.007). Although the experienced group achieved higher scores in all five individual tasks, statistically significant differences were demonstrated for the peg transfer and intracorporeal suture tasks only. CONCLUSION: These data provide evidence for construct validity of the MISTELS system for urology residents.

Ureteral tissue balloon expansion for laparoscopic bladder augmentation: survival study.

BACKGROUND AND PURPOSE: The search for the perfect urinary bladder substitute continues. Despite their inherent limitations, intestinal segments remain the commonest material for bladder reconstruction. The ureter, with its transitional epithelium, may be the ideal tissue to augment the bladder. Ikeguchi et al reported the feasibility of chronic ureteral balloon expansion by open surgery (J Urol 1998;159:1665). Herein, we propose a completely minimally invasive approach to balloon overdilate a segment of juxtavesical ureter incrementally and to use this in-line tissue-expanded ureteral patch to augment the bladder laparoscopically. MATERIALS AND METHODS: In five female pigs, a novel ureteral expansion balloon device (Microvasive, MA) was inserted percutaneously and advanced antegrade into the juxtavesical ureter. The device has two channels: one for balloon inflation and the other for draining the kidney. After progressive ureteral expansion over a 3- to 4-week period, laparoscopic augmentation ureterocystoplasty was performed. Animals were euthanized at 15 days (N = 1), 1 month (N = 1), 2 months (N = 1), and 3 months (N = 2). RESULTS: Percutaneous balloon device placement was technically successful in all five cases (mean operating room time 52 minutes). The mean volume of the tissue-expanded ureter at 1, 2, and 3 weeks was 12.9 cc, 60.3 cc, and 171.8 cc, respectively. Laparoscopic augmentation ureterocystoplasty with (N = 3) or without (N = 2) concomitant subtotal cystectomy was technically successful in all five cases without any open conversion. The mean operative time was 126.5 minutes, and the mean blood loss was 29 mL. Postoperative complications consisted of one case each of pyelonephritis and ureteral stricture. At autopsy, the mean capacity of the bladder was 574 mL, and the P(ves) at maximum capacity was 14 cm H(2)O. Histologic examination of the tissue-expanded ureter revealed regenerated transitional epithelium and muscle hypertrophy. CONCLUSIONS: Chronic ureteral tissue expansion can be carried out safely and efficaciously. The expanded tissue is thick, healthy, and vascular, with histologic features of normal transitional epithelium and muscle hypertrophy and hyperplasia. This expanded ureteral tissue can be used to augment the bladder with laparoscopic techniques. Such augmented bladders do not show significant shrinkage and possess urodynamic characteristic of normal capacity and normal compliance over a follow-up of 3 months.

Laparoscopic prostatectomy: a promising option in the treatment of prostate cancer.

It is still too soon to know if a laparoscopic approach is as good or even better than open surgical radical prostatectomy, the gold standard. Early data seem to suggest lower intraoperative bleeding rates, less postoperative pain, shorter hospital stay, and similar rates of oncologic cure, return to potency, and urinary continence.

Impact of intraoperative heparin on laparoscopic donor nephrectomy.

PURPOSE: At many centers systemic heparinization is performed during laparoscopic donor nephrectomy because of concerns regarding graft thrombosis. However, no consensus exists in this regard. We evaluated the impact of intraoperative heparin on donor and recipient outcomes. MATERIALS AND METHODS: Between September 2000 and February 2003, 79 consecutive patients underwent laparoscopic live donor left nephrectomy at our institution. They were sequentially divided into 2 groups, that is group 1-the initial 40 patients who intraoperatively received 5,000 IU heparin intravenously and group 2-subsequent patients who did not receive heparin. The 2 groups were well matched demographically. Data were compared using the paired 2-tailed t test. RESULTS: The 2 donor groups were comparable in regard to mean blood loss (139 vs 179 cc, p = 0.59), intraoperative urine output (1.6 vs 1.6 l, p = 0.74), warm ischemia time (4 vs 4.2 minutes, p = 0.52), operative time (3.5 vs 3.5 hours, p = 0.97), and cold ischemia time (75 vs 82 minutes, p = 0.38). Complications occurred in 1 patient in group 1 (rhabdomyolysis induced acute renal failure) and in 2 in group 2 (chylous ascites and lumbar vein injury, respectively). No graft was lost due to vascular thrombosis in either group. Recipient immediate, early and delayed (6-month) graft function was comparable between the 2 groups. Acute rejection occurred in 5 recipients in group 1 and 1 in group 2. There was 1 recipient death per group at delayed followup. CONCLUSIONS: Routine use of heparin during laparoscopic donor nephrectomy is not necessary. Because of its potential for causing intraoperative or early postoperative hemorrhage, we no longer routinely administer intraoperative heparin during laparoscopic donor nephrectomy at our institution.

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.

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.

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.

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.

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.

Retroperitoneoscopic radical nephrectomy in a super-obese patient (body mass index 77 kg/m2).

Although obesity was initially considered a relative contraindication for laparoscopy, the retroperitoneal approach has been reported to be safe and effective for such patients during renal and adrenal surgery. We report a case of successful retroperitoneoscopic radical nephrectomy in a super-obese patient (body mass index 77 kg/m2) with a 12-cm renal tumor. The operative time was 3 hours, and the estimated blood loss was 100 mL. The patient was discharged home 36 hours after surgery. No intraoperative or perioperative complications occurred. The pathologic examination revealed renal cell carcinoma, and all surgical margins were negative (pT2N0M0). The patient returned to normal activities 3 weeks postoperatively.

Laparoscopic injury and repair of obturator nerve during radical prostatectomy.

A 61-year-old man with bilateral Gleason score 7 (3+4) clinical Stage T1c prostate cancer was treated with laparoscopic bilateral pelvic lymphadenectomy and radical prostatectomy. The left obturator nerve was inadvertently transected during left obturator lymph node dissection and repaired by laparoscopic reapproximation.

Laparoscopic nephron-sparing surgery in the presence of renal artery disease.

INTRODUCTION: To describe the technical considerations of laparoscopic nephron-sparing surgery in 3 complicated cases involving kidneys with renal arterial disease. TECHNICAL CONSIDERATIONS: Three candidates for nephron-sparing surgery each had a renal mass, measuring 5.0, 3.5, and 2.5 cm, respectively. The renal arterial pathologic features in the tumor-bearing kidney included renal artery stenosis treated by percutaneous angioplasty and stenting in 1 patient and upper pole intrarenal aneurysm in 1 patient; the final patient had previously undergone aortorenal bypass grafting. The preoperative serum creatinine in the 3 patients was 2.1, 1.0, and 2.5 mg/dL, respectively. Two patients had a solitary functioning kidney. Laparoscopic partial nephrectomy with hilar clamping was performed in 2 patients and laparoscopic renal cryoablation in 1 patient. Laparoscopic Doppler ultrasonography was used in each case. The total operative time for the 3 patients was 2.3, 4.0, and 2.8 hours, respectively. The warm ischemia time in the first 2 cases was 28 and 39 minutes, respectively. The blood loss was 50, 400, and 100 mL. Pathologic examination revealed renal cell carcinoma in 2 cases and a calcified aneurysm in 1 case. The hospital stay was 7, 4, and 2 days. The postoperative serum creatinine level was 2.3, 1.4, and 2.5 mg/dL. CONCLUSIONS: Laparoscopic nephron-sparing surgery is a feasible alternative to open partial nephrectomy and can be successfully applied to select patients with a pathologic renal artery.

Thoracic complications during urological laparoscopy.

PURPOSE: We documented thoracic related complications during urological laparoscopic surgery. MATERIALS AND METHODS: A total of 1129 patients underwent major urological laparoscopic procedures in a 5-year period. Operative reports and postoperative radiographic reports were retrospectively reviewed to identify patients with thoracic related medical and surgical sequelae. Of the patients 619 (55%) underwent at least 1 chest x-ray in the immediate or early postoperative period. In the remaining 510 patients (45%) there was no clinical indication to perform chest x-ray. RESULTS: Of 619 patients undergoing chest x-ray 438 (71%) were completely normal. Medical pulmonary complications, surgical thoracic complications and subclinical, incidentally detected gas collections in the chest were identified in 12.6%, 0.5% and 5.5% of patients, respectively. Medical complications in 12.6% of cases included pulmonary infiltrate/atelectasis in 9.7%, pleural effusion in 4.8% and pulmonary embolus in 0.3%. Surgical complications included symptomatic pneumothorax in 4 patients (0.35%), hemothorax in 1 (0.08%) and chylothorax in 1 (0.08%). Subclinical abnormal thoracic gas collections were radiographically noted in 34 of the 619 patients (5.5%) on chest x-ray, including pneumomediastinum in 19 (3.1%), pneumothorax in 10 (1.6%) and pneumopericardium in 5 (0.8%). Overall 36 of 40 (90%) thoracic surgical complications (3) and subclinical, incidentally detected gas collections (33) occurred during retroperitoneal laparoscopy. Re-intervention was necessary in 6 patients (0.5%), namely pulmonary embolus requiring vena caval filter placement in 3 (0.3%), pneumothorax requiring a chest tube in 2 (0.17%) and hemothorax requiring emergency open thoracotomy in 1 (0.08%). No patient underwent open conversion to complete the initial proposed operation. CONCLUSIONS: Due to its high solubility the expectant management of incidental CO2 pneumothorax, pneumopericardium and pneumomediastinum is recommended initially in the clinically stable patient. Inadvertent diaphragmatic entry can be satisfactorily repaired laparoscopically without open conversion. Although it is rare, surgical thoracic complications are potentially life threatening, requiring prompt identification and management.

Laparoscopic live donor nephrectomy in the presence of circumaortic or retroaortic left renal vein.

PURPOSE: Laparoscopic live donor nephrectomy is now an accepted alternative to open surgery in donors with normal renal vasculature. However, the suitability of laparoscopy for donors with anomalous vasculature is less well known. We compared the donor and recipient outcome data of 16 patients with circumaortic or retroaortic left renal vein to 20 recent patients with normal left renal venous anatomy undergoing laparoscopic donor left nephrectomy. MATERIALS AND METHODS: Of 170 patients undergoing laparoscopic donor nephrectomy at our institution from October 1997 to October 2002, 18 (10.6%) had either a circumaortic or retroaortic left renal vein (group 1). Demographic and perioperative parameters of these donors and their recipients were retrospectively compared to a contemporary cohort of 20 recent patients with a normal single left renal vein (group 2). RESULTS: All laparoscopic procedures were completed successfully without open conversion. Groups 1 and 2 were similar in regard to operative time (199 vs 226 minutes, p = 0.90), blood loss (125 vs 100 cc, p = 0.45), warm ischemia time (3.4 vs 3.9 minutes, p = 0.14) and hospital stay (2.9 vs 3.2 days, p = 0.45). Length of allograft renal artery and vein was similar between groups. Cold ischemia and revascularization times were also comparable between groups. Recipient serum creatinine was comparable at 5 days (1.7 vs 1.6 mg/dl), 3 months (1.5 vs 1.4 mg/dl) and 1 year (1.5 vs 1.5 mg/dl). CONCLUSIONS: Presence of a circumaortic or retroaortic renal vein is not a contraindication to laparoscopic live donor left nephrectomy. A left kidney with vasculature anatomically adequate for transplantation can be achieved with excellent donor and recipient outcomes.

Laparoscopic ureterocalicostomy: initial experience.

PURPOSE: Ureterocalicostomy is a reconstructive option in the rare patient with surgically failed or difficult ureteropelvic junction (UPJ) obstruction with fibrosis and significant hydronephrosis. We introduce the technique of laparoscopic ureterocalicostomy. MATERIALS AND METHODS: Laparoscopic ureterocalicostomy was performed in 2 patients, of whom 1 had UPJ obstruction and multiple secondary calculi in a dilated, dependent lower pole calix, and 1 had surgically failed UPJ obstruction with a scarred pelvis and significant hydronephrosis. Using a transperitoneal technique the UPJ was dismembered and suture ligated, the cut end of the ureter was spatulated, the attenuated lower pole renal parenchyma was amputated and mucosa-to-mucosa ureterocaliceal anastomosis was performed with running 4-zero absorbable suture over a stent. In the first case 32 renal calculi were also removed using a combination of laparoscopic nephroscopy and intraoperative ultrasonography. RESULTS: In cases 1 and 2 operative time was 5.2 and 2.5 hours, estimated blood loss was 200 and 75 cc, and hospital stay was 2 days, respectively. There were no intraoperative complications. The stent was removed at 8 and 5 weeks, respectively. Postoperative retrograde pyelogram and diuretic renal scan confirmed anastomotic patency and improved drainage in each patient. At 9 months patient 1 remains without flank symptoms and a second renal scan at 6 months showed further improvement in drainage. Patient 2, who continued to be symptomatic with flank discomfort despite objective improvement in drainage parameters, elected secondary nephrectomy at 6 months. CONCLUSIONS: Laparoscopic ureterocalicostomy is feasible and it effectively duplicates established open surgical principles. To our knowledge the initial experience in the literature is presented.

Evaluation of age and comorbidity as risk factors after laparoscopic urological surgery.

PURPOSE: Few reports in the urological literature have focused on the growing population of elderly (65 years or older) patients. Coexistent medical conditions, which are more prevalent in elderly individuals, can confound results of outcome studies in this population. This single center, retrospective study was done to determine whether age and comorbidity are predictors of outcome in patients undergoing laparoscopic renal and adrenal surgery. MATERIALS AND METHODS: From 1997 to 2001 laparoscopic radical nephrectomy, partial nephrectomy, nephroureterectomy and adrenalectomy were performed in 399 consecutive adults. Patient demographics and preoperative, intraoperative and postoperative parameters were extracted from a prospectively designed computerized database. Risk stratification was based on preoperative American Society of Anesthesiologists (ASA) score. Additional risk stratification was constructed using the Charlson comorbidity index. Univariate and multivariate analyses were also performed. RESULTS: Age 65 years or older was not associated with an increased incidence of intraoperative, postoperative or late operative complications on univariate or multivariate analyses. However, patients 65 years or older were hospitalized significantly longer than those younger than 65 years (43 vs 24 hours, p = 0.02). Blood loss and the requirement for blood transfusion were associated with longer operative time, a higher incidence of intraoperative and postoperative complications on univariate analysis, and longer hospitalization. No association of blood loss with postoperative complications was noted on multivariate analysis. Patients with a higher ASA score were more likely to receive blood transfusion. On univariate analysis risk stratification using the ASA score and the Charlson comorbidity index was not associated with intraoperative or postoperative complications. However, on multivariable analysis patients with the lowest indexes were less likely to experience postoperative complications than those with the highest indexes (less than vs greater than 3, p = 0.04). The comorbidity index had a marginal association with the incidence of late complications (p = 0.06). CONCLUSIONS: Laparoscopic renal and adrenal surgery in patients 65 years or older is well tolerated. Age 65 years or older is predictive of a significantly increased hospital stay of approximately 1 day after major renal and adrenal laparoscopic surgery and it does not appear to increase independently the risk of intraoperative, postoperative or late operative complications.

Laparoscopic nephron-sparing surgery for two or more ipsilateral renal tumors.

OBJECTIVES: To review our experience with laparoscopic nephron-sparing surgery in the management of two or more synchronous, ipsilateral renal masses. Minimally invasive nephron-sparing procedures are increasingly used for the treatment of select patients with a single, small renal tumor. METHODS: Since 1998, we have performed laparoscopic nephron-sparing surgery in 288 consecutive patients, including laparoscopic partial nephrectomy (n = 200) and renal cryotherapy (n = 88). Of these, 13 patients (4.5%) were treated for synchronous ipsilateral renal masses. RESULTS: A total of 27 renal tumors were treated in 13 patients. The patients were divided into four groups on the basis of the treatment. Group 1 (n = 3) underwent en-bloc laparoscopic partial nephrectomy encompassing both tumors; group 2 (n = 2) underwent individual laparoscopic partial nephrectomy of discrete masses during the same procedure; group 3 (n = 2) had one mass treated with partial nephrectomy and the other mass treated with cryotherapy; and group 4 (n = 6) had all tumors treated with cryotherapy. All cases were completed successfully without conversion to open surgery or laparoscopic nephrectomy. The mean overall operative time was 4.3 hours, and the mean blood loss was 169 mL. No intraoperative complications occurred. Three patients had postoperative complications, none requiring re-exploration. One patient in group 4 developed de novo tumors in the treated kidney, located distant from the cryoablated sites. CONCLUSIONS: Laparoscopic partial nephrectomy is an emerging, efficacious laparoscopic treatment option for select patients. Laparoscopic cryotherapy is a useful alternative or adjunct to partial nephrectomy. The judicious combination of these complementary techniques further extends the scope of minimally invasive nephron-sparing surgery.

Laparoscopic ice slush renal hypothermia for partial nephrectomy: the initial experience.

PURPOSE: We describe a novel technique of laparoscopic renal hypothermia with intracorporeal ice slush during partial nephrectomy as well as clinical experience with the initial 12 patients. MATERIALS AND METHODS: A total of 12 select patients with an infiltrating renal tumor who were candidates for nephron sparing surgery underwent transperitoneal laparoscopic partial nephrectomy with renal hypothermia. An Endocatch II (United States Surgical Corp., Norwalk, Connecticut) bag was placed around the mobilized kidney and its drawstring was cinched around the intact renal hilum. The renal artery and vein were occluded en bloc with a Satinsky clamp. The bottom of the engaged bag was retrieved through a 12 mm port site and opened, and ice slush was introduced within the bag to completely surround the kidney. After renal hypothermia was achieved laparoscopic partial nephrectomy was performed by duplicating open surgical techniques. Renal parenchymal temperature was measured using a thermocouple needle in 5 patients. Median tumor size was 3.2 cm (range 1.5 to 5.5), 6 tumors (50%) were central in location and an imperative indication for partial nephrectomy was present in 7 patients (58%). RESULTS: All procedures were successfully completed laparoscopically without open conversion. Median time to deploy the bag around the kidney was 7 minutes (range 5 to 20), the median volume of ice slush introduced was 600 cc (range 300 to 750) and the time needed to insert the ice slush was 4 minutes (range 3 to 10). Median blood loss was 200 cc, total ischemia time was 43.5 minutes (range 25 to 55) and total operative time was 4.3 hours (range 3 to 5.5). Nadir renal parenchymal temperature was 5C to 19C and the mean decrease in systemic temperature was 0.6C. Histopathology confirmed renal cell carcinoma in 11 patients (92%), of whom all had negative surgical margins. Intraoperative complications occurred in 2 initial patients, including partial bag slippage in 1 and Satinsky clamp malfunction in 1. Postoperatively renal scan confirmed a functioning ipsilateral kidney in all cases. CONCLUSIONS: To our knowledge we present the initial clinical report of laparoscopic renal hypothermia for partial nephrectomy. By replicating standard open surgical practice our intracorporeal ice slush technique has the potential to extend the scope of laparoscopic partial nephrectomy to more complicated renal tumors.

Laparoscopic upper pole partial nephrectomy with concomitant en bloc adrenalectomy.

OBJECTIVES: To report our experience with laparoscopic partial nephrectomy for renal tumor with concomitant adrenalectomy. An upper pole renal tumor may contiguously involve the adrenal gland, requiring concomitant adrenalectomy. Although commonly performed in the setting of laparoscopic radical nephrectomy, concomitant adrenalectomy has not been described during laparoscopic partial nephrectomy. METHODS: Four patients with an upper pole renal tumor and suspected adrenal involvement underwent laparoscopic partial nephrectomy with concomitant ipsilateral adrenalectomy. Preoperative three-dimensional computed tomography revealed the renal tumor to be closely abutting the adrenal gland in 3 patients and a 4-cm adrenal mass in 1 patient. The mean renal tumor size was 3.2 cm (range 1.4 to 6.6). To maintain oncologic principles, our transperitoneal laparoscopic technique excises the adrenal gland en bloc with the renal tumor. As such, adrenalectomy is performed first, followed by partial nephrectomy, incorporating hilar control, tumor excision, and sutured renal reconstruction. RESULTS: All four procedures were performed without open conversion or intraoperative complications. The mean renal warm ischemia time was 36 minutes, estimated blood loss 169 mL, total operating time 3.9 hours, and hospital stay 3.2 days. One patient developed a transient urinary leak postoperatively. Pathologic examination of the renal tumor revealed renal cell carcinoma (n = 1), dystrophic calcification with ectopic bone formation (n = 1), adult mesoblastic nephroma (n = 1), and subcapsular heterotopic adrenal cortex with cyst (n = 1), all with negative surgical margins. Pathologic examination of the adrenal gland revealed adenoma in 1 case and a normal adrenal gland without malignant involvement in 3 cases. All patients were disease free at last follow-up (mean 6.2 months, range 2 to 12). CONCLUSIONS: In patients with an upper pole renal tumor and radiologically suspected adrenal involvement, laparoscopic partial nephrectomy with concomitant adrenalectomy can be performed efficaciously respecting oncologic principles.

Laparoscopic radical nephrectomy for large (greater than 7 cm, T2) renal tumors.

PURPOSE: Laparoscopic radical nephrectomy has emerged as a standard of care in appropriate candidates with clinical stage T1 renal tumors (7 cm or less). Herein we present our experience with laparoscopic radical nephrectomy for clinical stage T2 tumors (greater than 7 cm). MATERIALS AND METHODS: Patients undergoing laparoscopic radical nephrectomy between September 1997 and July 2003 were retrospectively subdivided into group LAPT1-166 with tumor size 7 cm and group LAPT2-65 with tumor size greater than 7 cm. Also, group LAPT2 was compared with a group of 34 contemporary, comparable patients undergoing open radical nephrectomy for tumor greater than 7 cm (group OPENT2). RESULTS: Compared with group LAPT1, group LAPT2 had younger patients, larger tumors and greater blood loss (100 vs 200 ml) (each p <0.001). Importantly operative time, analgesic requirements, hospital stay, and convalescence and complication rates were comparable. Group LAPT2 and group OPENT2 patients had similar sized tumors (9.2 and 9.9 cm, respectively) but shorter operative time (p = 0.03), lesser blood loss (p <0.001), shorter hospital stay (p <0.001) and more rapid convalescence (p = 0.02) occurred in LAPT2. CONCLUSIONS: Laparoscopic radical nephrectomy for stage T2 renal masses (greater than 7 cm) is feasible and efficacious. Laparoscopic nephrectomy offers the advantages of decreased blood loss, shorter hospital stay and more rapid recovery over open radical nephrectomy for comparable tumors greater than 7 cm. Although surgical outcomes are comparable with laparoscopic radical nephrectomy for smaller tumors (7 cm or less), adequate laparoscopic experience is necessary before performing radical nephrectomy for large T2 tumors.