Percutaneous and laparoscopic cryoablation of small renal masses.

PURPOSE: We reviewed our 4-year experience with percutaneous cryoablation and laparoscopy for treating small renal masses. MATERIALS AND METHODS: After institutional review board approval we retrospectively analyzed renal cryoablation procedures performed between March 2003 and October 2007. An in-depth analysis was performed concerning demographics, hospital course and short-term outcome with respect to percutaneous vs laparoscopic cryoablation. RESULTS: A total of 37 patients underwent treatment for 43 renal masses. Of the 37 patients 19 underwent laparoscopic cryoablation (24 tumors) and 18 underwent percutaneous cryoablation (19 tumors) using computerized tomography fluoroscopy. For percutaneous cryoablation a saline instillation was used in 58% of cases to move nonrenal vital structures away from the targeted renal mass. There were 5 cases of hemorrhage requiring transfusion, all of which were associated with the use of multiple cryoprobes. The transfusion rate in the percutaneous and laparoscopic cryoablation groups was 11.1% and 27.8%, respectively. Operative time was significantly longer in the laparoscopic cryoablation group compared to the percutaneous cryoablation group at 147 (range 89 to 209) vs 250.2 (range 151 to 360) minutes, respectively. The overall complication rate (including transfusion) was lower in the percutaneous cryoablation group compared to the laparoscopic cryoablation group (4 of 18 [22.2%] vs 8 of 20 [40%], respectively). Hospital stay was significantly shorter in the percutaneous vs laparoscopic cryoablation group at 1.3 vs 3.1 days, p <0.0001, respectively. Narcotic use in the percutaneous cryoablation group was more than half that used by the laparoscopic cryoablation group (5.1 vs 17.8 mg, p = 0.03, respectively). Among patients with biopsy proven renal cell carcinoma during a median followup of 11.4 and 13.4 months in the percutaneous and laparoscopic cryoablation groups, cancer specific survival was 100% and 100%, respectively, and the treatment failure rate was 5.3% and 4.2%, respectively. CONCLUSIONS: Percutaneous cryoablation is an efficient, minimally morbid method for the treatment of small renal masses and it appears to be superior to the laparoscopic approach. Short-term followup has shown no difference in tumor recurrence or need for re-treatment. Of note, hemorrhage was solely associated with the use of multiple probes.

High-frequency oscillatory ventilatory support during CT-guided percutaneous cryotherapy of renal masses.

PURPOSE: Computed tomography (CT)-guided percutaneous procedures are often made more difficult due to the movement of the kidney during respiration. Here we examine the use of high-frequency oscillatory ventilation (HFOV), which eliminates the movement of the kidney, potentially making cryoprobe access to the kidney simpler and possibly more efficient. METHODS: We compared seven CT-guided percutaneous procedures using a single cryoprobe and either standard mechanical ventilation (MV) (n=4) or HFOV (n=3). The variables studied included: total time of patient intubation, operative time, overall duration of interventional radiology (IR) suite time, change in hematocrit, narcotic use, and complications. The ease of the procedure was rated on a subjective scale from 1 to 3. RESULTS: The total intubation time remained nearly identical at 210 minutes for HFOV and 208 minutes for MV, but surgeon procedural time decreased by 31 minutes in the HFOV group (HFOV=99 minutes and MV=130 minutes) (P=0.40). Total IR time was 225 minutes for HFOV compared to 212 minutes for the MV group (P=0.63). There were no significant differences in the postoperative hematocrit, creatinine, or narcotic use between the two groups. There were no complications related to the procedure or anesthesia in either group. Both urology attending physicians and the interventional radiologist noted that the procedure seemed easier with HFOV. CONCLUSION: HFOV may shorten the actual procedural time required to perform cryoablation, likely due to the elimination of renal movement during the procedure, thereby facilitating targeting and access to the renal mass. In this initial experience, patients tolerated HFOV without incident, and the operating surgeons found it easier to perform the procedures.

Bipolar saline TURP for large prostate glands.

The objective of this study was to evaluate the feasibility of bipolar transurethral resection of the prostate (TURP) in patients with very large prostate glands and significant comorbidities. Four patients with prostate glands >160 cc on preoperative volume measurement and ASA class three or higher underwent bipolar TURP with the Gyrus PlasmaKinetic system. Preoperative, operative, and postoperative parameters were studied. The results showed an average ASA class 3.25 (range: 3-4). The average preoperative prostate volume was 207.4 cc (range: 163-268). The average preoperative International Prostate Symptom Score (IPSS) and bother score was 31 and 6, respectively. Mean resection time was 163 min (range: 129-215). The weight of resected tissue and percentage of vaporized tissue was 80.8 g (range: 62-115) and 10.0% (range: 3.8-15.1), respectively. An average of 61L of saline was used (range: 48-78). The mean change in hemoglobin and serum sodium was 2.1 g/dl (range: 1.4-2.7) and 3.3 meq/l (range: 2-4), respectively. Postoperative catheter time averaged 76 h (range: 40-104). Mean length of hospital stay was 12 h (range: 4-24). The mean postoperative IPSS and bother score was 2.75 and 0.25, respectively. Bipolar TURP is a feasible alternative to simple open prostatectomy in high-risk patients with massive prostate adenomas. Prostate volume is reduced by approximately 10% due to vaporization.

Athermal tension adjustable suture ligation of the vascular pedicle during robot-assisted prostatectomy.

PURPOSE: We report a simple figure-of-eight tension adjustable suture to ligate the vascular pedicle (VP) during robot-assisted radical prostatectomy (RARP). MATERIALS AND METHODS: During nerve-sparing RARP, after the rectum has been mobilized, the VP is isolated and prepared for transection. Previous reports describe placing of hemostatic clips (metallic or Hem-o-lok™) or laparoscopic bulldog clamps (30 mm) to control and oversew the VP; both techniques are quite assistant dependent. We present a bulldog clamp alternative by placing a figure-of-eight fashion, a 6-cm 3-0 poliglecaprone on an SH needle with a small loop tied in the suture end. After the needle has been placed through the VP, it is then threaded through the preformed loop and then a small Hem-o-lok clip is placed and cinched down to occlude the blood vessels. Next, the VPs are transected. The clip can be further cinched, mimicking the technique used in partial nephrectomy, to control bleeding when encountered. Data were collected prospectively to demonstrate safety. RESULTS: We report on 74 men totaling 143 VPs using this new technique. The average operative time was reduced by 15 minutes compared with using bulldog clamps. In the initial 10 cases (20 attempts), inadvertent transection of the suture occurred three times. In these three cases, hemostasis was (easily) controlled with additional sutures. CONCLUSIONS: The pedicle stitch technique offers an assistant independent alternative for a simple and precise athermal means to control the VP.

Transverse versus vertical camera port incision in robotic radical prostatectomy: effect on incisional hernias and cosmesis.

OBJECTIVE: To examine the incidence of incisional hernias (IHs) and propose a simple modification to reduce the incidence of IHs. Robot-assisted radical prostatectomy (RARP) historically uses a vertical midline camera port incision to extract the prostate. METHODS: Of 900 consecutive RARPs, the initial 735 had a vertical and subsequent 165 transverse incisions. Two methods were used to identify IHs: clinic visits noted in the prospective database and screening using electronic mail. We compared the baseline factors between the vertical IH and IH-free cohorts. The maximal scar width was recorded in 178 consecutive men presenting to our clinic: vertical (n=107) and transverse (n=71). RESULTS: IHs occurred significantly more often after a vertical incision (5.3% vs 0.6%, P=.005). The IH rates after a vertical incision could be estimated to be as great as 16.7% (18 of 108) using the electronic mail respondents or as low as 3.3% (21 of 627) according to clinic follow-up. On univariate analysis, baseline age, International Index of Erectile Function 5-item questionnaire, prostate weight, bother score (all P≤.05), and body mass index (P=.058) were associated with an increased risk of an IH. After adjusting for baseline factors on multivariate logistic regression analysis, the relative odds of developing an IH with a vertical versus transverse incision was 11 (95% confidence interval 1.5-82). The average maximal scar width was reduced from 5.5 to 2.0 mm (P<.0001). CONCLUSION: In the present sample population, the vertical IH rate was estimated to be potentially as low as 3.3% or as great as 16.7%. On multivariate analysis, a greater body mass index and larger prostate size significantly increased the risk of hernia development. Transverse incisions dramatically reduced the rate of IHs and the maximal scar width. The IH rates varied significantly by reporting method.

The UCI Seldinger technique for percutaneous renal cryoablation: protecting the tract and achieving hemostasis.

PURPOSE: To describe our Seldinger technique of percutaneous renal cryoablation that was devised to facilitate renal biopsy, cryoprobe placement, and instillation of adjunctive hemostatics while protecting surrounding tissues from cryoinjury. PATIENTS AND METHODS: This approach was used to manage 13 renal masses in 12 adult patients. Under CT-fluoroscopic guidance, an access needle was inserted to abut the surface of the tumor, followed by an Amplatz super-stiff guidewire and a customized coaxial catheter system, which was used as a conduit for needle biopsy, cryoprobe insertion, and FloSeal instillation. In addition, a porcine model was used to compare the temperature readings adjacent to the sheathed and the unsheathed cryoprobe during percutaneous renal cryoablation. RESULTS: In all patients, the use of this access approach was accomplished without incident. Two patients needed blood transfusions. No patient had significant skin, muscle, or nerve debility. At a mean follow-up of 11 months, none had evidence of persistent disease on CT or MRI contrast imaging. In the porcine model, the customized sheath protected the surrounding tissues from reaching temperatures below 5 degrees C while temperatures down to -15 degrees C were obtained when no insulating sheath was used. CONCLUSIONS: A modified Seldinger technique enabled us to perform percutaneous renal cryotherapy through a single access channel, which facilitated access for biopsy, cryoprobe placement, and instillation of hemostatic agents. This approach may provide a protective barrier against cryogenic damage to neighboring tissues and could theoretically help minimize the chance of tract seeding.

Fungal urosepsis after ureteroscopy in cirrhotic patients: a word of caution.

OBJECTIVES: Fungal sepsis after ureteroscopy (URS) is rarely reported. We report on 2 cases of acute fungemia that developed after routine ureteroscopic stone manipulation in patients with advanced liver cirrhosis. This represents a unique and high-risk population, and, to our knowledge, these are the first such cases reported. METHODS: We performed a retrospective review of the medical records of 2 patients with Child-Pugh class B and C liver cirrhosis who had undergone ureteroscopy (URS) and holmium laser lithotripsy for obstructing ureteral calculi. RESULTS: The treated stones measured 10 mm and 12 mm and were at the right ureteropelvic junction and left ureterovesical junction, respectively. Both patients had had indwelling ureteral stents in place for 1 and 2 months before URS plus holmium laser lithotripsy, with negative preoperative urine cultures. Each procedure was uncomplicated, and a ureteral stent was left in situ in each case. Within 12 hours of URS, each patient became tachycardic, hypotensive, and febrile. Blood, urine (proximal to the stone), and stone cultures were positive for Candida albicans in both patients. They were both successfully treated with intravenous fluconazole and subsequently discharged from the hospital on postoperative day 12 and 13, respectively. CONCLUSIONS: Patients with advanced liver disease appear to be at greater risk of fungal sepsis after otherwise uncomplicated URS and stone manipulation. Consideration should be given to prophylactic antifungal therapy, in addition to the standard antibacterial prophylaxis for such procedures.