Search

Background and Purpose: Laparoscopic pyeloplasty has emerged as the gold standard for repair of ureteropelvic junction obstruction. Microlaparoscopic (MLP, <3 mm) instrumentation has improved markedly and can now be used for suturing and complex dissection needed during laparoscopic pyeloplasty. We present our experience with microlaparoscopy compared with conventional laparoscopy for transperitoneal pyeloplasty., Methods: We performed a retrospective analysis of hybrid MLP, using a 5-mm camera in a hidden umbilical incision, and 1.9 or 3 mm working instruments and compared with patients undergoing conventional laparoscopic pyeloplasty (CLP). The data for MLP and CLP were compared using the Student t test, Pearson chi-square test, and Fisher exact test, where appropriate., Results: Between January 2009 and May 2013, there were 19 MLP and 27 CLP procedures performed. The MLP group mean age was younger than the CLP group (34 vs 50 years; P=0.0003). Body mass index, previous treatment rates, operative time, length of stay, ureteral stent duration, and complication rates were not statistically different between the MLP and CLP groups. Strict success rates (indicated by follow-up renal scan T½<20 min) were similar between MLP and CLP groups (89.5% vs 88.9%; P=0.95). No MLP procedures were converted to CLP or open approaches., Conclusions: From technical, perioperative, and outcome perspectives, transperitoneal pyeloplasty with microlaparoscopy is both safe and feasible in our hands compared with conventional laparoscopy, and results in subjectively superior cosmesis. This is the largest MLP series to date and contains, to our knowledge, the only cases described using prototype 1.9 mm instruments.

Purpose: We describe our multi-institutional experience using a laparoscopic clamp to induce selective regional ischemia during robot-assisted laparoscopic partial nephrectomy (RALPN) without hilar occlusion., Patients and Methods: A retrospective review of Institutional Revew Board-approved databases of patients who underwent selective regional clamping during RALPN at four institutions was performed., Results: In 20 patients who were treated for elective indications, RALPN with parenchymal clamping was successful in 17 (85%). Mean age was 63 years (24-78 y). Median tumor diameter was 2.2 cm (1.1-7.2 cm). Mass location was polar in 13 (76%) and interpolar in 4 (24%). Median R.E.N.A.L. nephrometry score was 6 (4-10). Median overall operative time was 190 minutes (129-309 min), while selective clamp time was 26 minutes (19-52 min). Collecting system repair occurred in 8 (47%) patients. No patients needed a blood transfusion. There was no significant difference in preoperative (median 86 mL/min/1.73 m(2)) and immediate postoperative glomerular filtration rate (GFR) (median 78 mL/min/1.73 m(2), P=0.33) or with the most recent GFR (median 78 mL/min/1.73 m(2), P=0.54) at a mean follow-up of 6.1 months (1.2-11.9 mos). Final pathology determination revealed renal-cell carcinoma in 71% with no positive margins on frozen or final evaluation. In three additional patients who were undergoing RALPN, bleeding because of incomplete distal clamp compression necessitated subsequent central hilar clamping for the completion of the procedure., Conclusions: In our preliminary multi-institutional experience, regional ischemia using a laparoscopic parenchymal clamp is feasible during RALPN for hemostasis. Careful preoperative selection of patients is needed to determine ideal patient and tumor characteristics. Further comparison studies are necessary to determine the true utility of this technique.

Purpose: We previously described the use of cold saline surface irrigation to achieve protective renal hypothermia in a laparoscopic partial nephrectomy porcine model. We now present our clinical application of this technique and characterization of the hypothermic effect during laparoscopic partial nephrectomy., Materials and Methods: Seven patients underwent elective laparoscopic partial nephrectomy augmented with our hypothermia technique. Parenchymal temperature sensors were placed to confirm cooling efficacy and efficiency. After transperitoneal exposure of the kidney we performed temporary hilar vascular occlusion. Surface cooling with almost freezing normal saline was delivered with a laparoscopic suction/irrigation device. Tumor laparoscopic resection and renal reconstruction were completed. Outcome measures included intraoperative changes with hypothermia and postoperative estimated glomerular filtration rate changes., Results: All patients successfully underwent laparoscopic partial nephrectomy without complications or evidence of residual disease. A protective renal parenchymal temperature of less than 20C was achieved at a mean application time of 8.3 minutes. The hypothermic window of 15C to 25C was maintained an average of 30.4 minutes. In 2 cases cooling was repeated and 4 minutes were required to lower the temperature below 20C. The overall mean core body temperature decrease was 1.28C. At a mean followup of 22.4 months the median preoperative, immediate postoperative and final estimated glomerular filtration rate was 75, 65 and 71 ml/minute/1.73 m(2), respectively. There was no evidence of disease recurrence on followup imaging., Conclusions: Our technique involving cold saline surface irrigation to achieve protective renal hypothermia is reproducible, and uses readily available laparoscopic instruments and equipment. This technique can be done simply and effectively, and may expand the use of laparoscopic partial nephrectomy., (Copyright © 2010 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Ureteral stent placement during adult laparoscopic pyeloplasty for ureteropelvic junction obstruction can be performed preoperatively or intraoperatively either in a retrograde or antegrade approach. Intraoperative retrograde stent placement is the most commonly used technique. Comparative studies, however, suggest that there is a significant component added to the overall operative times because of the need for patient repositioning from the lithotomy to the flank position before pyeloplasty. During our laparoscopic pyeloplasty surgery, we position the patient in the lateral decubitus position and incorporate a lower extremity support device for female patients. This allows initial open-ended catheter placement and subsequent access to the perineum and final stent placement throughout the procedure without need for patient repositioning. In addition, our technique allows for intraoperative fluoroscopy to delineate the complete ureteral anatomy. Since 2004, we have used this approach in 111 consecutive patients without complications. We describe our technique for intraoperative ureteral stent placement in the flank position during adult laparoscopic pyeloplasty without need for patient repositioning.

Objectives: To describe our early experience using a laparoscopic clamp to induce selective regional ischemia during robotic-assisted partial nephrectomy without hilar occlusion. The creation of a bloodless field during minimally invasive approaches to nephron-sparing surgery often requires complete warm ischemia with renal hilar clamping that can potentially result in subsequent renal damage., Methods: After transperitoneal renal mobilization and delineation of the renal tumor margin using laparoscopic ultrasound, the laparoscopic clamp is placed across the renal parenchyma 2-3 cm proximal to the resection line. After tumor excision, the renal defect is repaired robotically and hemostatic agents are used to aid in achieving compressive hemostasis., Results: Three patients with predominantly exophytic renal masses underwent this procedure for elective indications. Mean tumor diameter was 4.9 cm (range 1.2-7.0). Mean selective clamp time was 37 minutes (range 20-52). Estimated blood loss was minimal and no patients required renal hilar clamping. There were no perioperative complications. Mean change in preoperative and postoperative creatinine was 0.1 (±0.09). Final pathology revealed clear cell and papillary renal carcinomas with no positive margins on frozen or final evaluation., Conclusions: Regional renal parenchymal clamping during robotic partial nephrectomy can be safely and effectively used to create a bloodless operative field in select patients with optimally located renal tumors. Our early experience with this technique allows for frozen pathologic evaluation of the tumor and margin status without concern for warm ischemia and represents another tool for surgeons performing minimally invasive nephron-sparing surgery., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Objectives: Radiofrequency ablation (RFA)-assisted laparoscopic partial nephrectomy (LPN) may allow for improved hemostasis without need for renal hilar vessel clamping and elimination of warm ischemia to the kidney. We compare outcomes in patients undergoing radiofrequency ablation-assisted robotic clampless partial nephrectomy (RF-RCPN) and LPN., Methods: Thirty-six patients and 42 patients underwent LPN and RF-RCPN, respectively. In the RF-RCPN group, the Habib 4x RFA device was used to coagulate a margin of normal parenchyma around the renal mass to allow excision of the mass within a bloodless plane. Unlike in the LPN group, renal hilar vascular occlusion was not performed in the RF-RCPN group., Results: Tumors treated in the RF-RCPN group tended to be larger (2.8 vs. 2.0 cm) and more often endophytic (52.6% vs. 16.1%). Collecting system reconstruction occurred more often in the RF-RCPN group (78.6% vs. 30.6%). Operative duration was longer in the RF-RCPN group (373 vs. 250 minutes), but this included time for cystoscopy, ureteral stenting, and repositioning of the patient. Blood loss, transfusion rates, renal function, and complication rates did not differ between the two groups. No patients required renal hilar vessel clamping or nephrectomy to control bleeding in the RF-RCPN group., Conclusions: The use of RFA-assistance during robotic partial nephrectomy allows excision of renal tumors without hilar vascular clamping, thus eliminating renal warm ischemia. Larger and more centrally located tumors were excised with RF-RCPN. No differences in blood loss, complication rate, postoperative bleeding, renal function, or recurrence rate were noted compared with LPN.