Retrograde renal hilar dissection and segmental arterial clamping: a simple modification to achieve super-selective robotic partial nephrectomy.

Super-selective vascular control prior to robotic partial nephrectomy (also known as 'zero-ischemia') is a novel surgical technique that promises to reduce warm ischemia time. The technique has been shown to be feasible but adds substantial technical complexity and cost to the procedure. We present a simplified retrograde dissection of the renal hilum to achieve selective vascular control during robotic partial nephrectomy. Consecutive patients with stage 1 solid and complex cystic renal masses underwent robotic partial nephrectomies with selective vascular control using a modification to previously described super-selective robotic partial nephrectomy. In each case, the renal arterial branch supplying the mass and surrounding parenchyma was dissected in a retrograde fashion from the tumor. Intra-renal dissection of the interlobular artery was not performed. Intra-operative immunofluorescence was not utilized as assessment of parenchymal ischemia was documented before partial nephrectomy. Data was prospectively collected in an IRB-approved partial nephrectomy database. Operative variables between patients undergoing super-selective versus standard robotic partial nephrectomy were compared. Super-selective partial nephrectomy with retrograde hilar dissection was successfully completed in five consecutive patients. There were no complications or conversions to traditional partial nephrectomy. All were diagnosed with renal cell carcinoma and surgical margins were all negative. Estimated blood loss, warm ischemia time, operative time and length of stay were all comparable between patients undergoing super-selective and standard robotic partial nephrectomy. Retrograde hilar dissection appears to be a feasible and safe approach to super-selective partial nephrectomy without adding complex renovascular surgical techniques or cost to the procedure.

Intravesical therapy use in the high risk patient: practice patterns in an equal access healthcare institution before and after national guidelines.

PURPOSE: We examined patterns of intravesical therapy use in nonmuscle invasive bladder cancer over the last 10 years at our institution where there is equal access to healthcare. We further examined any affect that the introduction of national guidelines may have had on the utilization of intravesical therapy in these patients. MATERIALS AND METHODS: An Institutional Review Board (IRB) approved retrospective chart review was performed between the years 1997 and 2007. Only those with premalignant or malignant pathology, as identified using intradepartmental surgical logs and pathology reports, were included. RESULTS: Four hundred seventeen procedures, representing 228 patients, were identified that met the above criteria. A total of 170 high risk, nonmuscle invasive bladder tumors (HG, CIS and T1) were identified, or 41% of cases in whom intravesical therapy was indicated according to the 1999 American Urological Association (AUA) guidelines. One hundred nine (64.2%) received intravesical therapy and 61 (35.8%) did not. This corresponds to an underutilization rate of 19.4% (33/170 high risk tumors did not receive intravesical therapy for unknown reasons). CONCLUSIONS: We have determined that the utilization of intravesical therapy in patients with high risk nonmuscle invasive bladder cancer has improved since the introduction of the 1999 AUA guidelines in an equal access healthcare institution and that patients are compliant with this therapy.