U J All Final for WEB.pdf 767Vol. 10 | No. 1 | Winter 2013 |U R O LO G Y J O U R N A L 1Department of Urol- ogy, George Washington University Hospital, Wash- ington, D.C., USA 2Associated Urologists of Orange County, The Center for Cancer Prevention and Treatment at St. Joseph Hospital, Orange, CA, USA Jason D. Engel,1 Stephen B. Williams2 Unclamped Hand-Assisted Laparoscopic Partial Nephrectomy for Predominantly Endophytic Renal Tumors Corresponding Author: Stephen B. Williams, MD 1801 N. Broadway, Santa Ana, 92607, CA, USA Tel: +1 714 6391915 Fax: +1 714 6391127 E-mail: williams@ocurol- ogy.com Received August 2011 Accepted May 2012 Purpose: nephrectomy for predominantly endophytic renal masses in the setting of relative contraindication Materials and Methods: - - Results: Conclusion: - population. Keywords: kidney neoplasms, hand-assisted laparoscopy, nephrectomy, ischemia LAPAROSCOPIC UROLOGY 768 | INTRODUCTION With the increased utilization of cross-sectional imaging, there has been an increased detection - that partial nephrectomy results in improved long-term renal as compared to radical nephrectomy. The American Uro- masses recommend partial nephrectomy for the manage- of preservation of renal function. It has been demonstrated (2) Laparo- scopic partial nephrectomy may offer sooner return to con- - - tion of laparoscopic partial nephrectomy, several groups have demonstrated the feasibility of robotic partial nephrectomy. The concept of zero ischemia to eliminate any damage to remaining nephrons during partial nephrectomy has been Unclamped laparoscopic partial nephrectomy - partial nephrectomy may lead to an increased utilization of laparoscopic partial nephrectomy. We describe unclamped laparoscopic hand-assisted partial nephrectomy for pre- dominantly endophytic renal masses in the setting of relative - evaluation of pathologic margins before renal reconstruction. MATERIALS AND METHODS Prior to initiation of the study, the surgeon had performed - mies as an attending surgeon. system.(6) The Chronic Kidney Disease Epidemiology Col- - (7) of the dressing. standard laparoscopic approach to small renal masses. Pa- tients are selected for unclamped hand-assisted laparoscopic - rim around the tumor on computed tomography (CT) is an important indicator of the feasibility of this approach. A hand port is placed either via a muscle-splitting Gibson in- as for radical nephrectomy. A dissection identical to that of standard hand-assisted laparoscopic radical nephrectomy is performed. The tumor is localized, and the fat overlying the specimen. A laparoscopic renal ultrasonography is performed - - dicate encapsulation. The hilum is completely dissected, but clamps are not applied. Mannitol or other diuretics are not given. The renal capsule around the tumor is then scored circum- - dle in open surgery (Figure 2). The plane typically leaves a small amount of normal parenchyma on the tumor, and fol- Laparoscopic Urology 769Vol. 10 | No. 1 | Winter 2013 |U R O LO G Y J O U R N A L Unclamped Hand-Assisted Laparoscopic Partial Nephectomy | Engel and Williams - of margins. As long as the plane has not been forced in any - ily managed by manual compression of the defect. Bleeding pathologic analysis of the specimen. In the setting of negative margins, no further resection is per- formed. If there is a positive margin, or if there is clinical blood loss to guide further resection. Nephrectomy is per- deeper resection is not safe or feasible. Bulldog clamps may be applied at this point if a more aggressive standard laparos- copy or open partial nephrectomy is deemed feasible. Figure 1. Computed tomography scan revealing a 2.2 cm enhancing lesion in the anterior mid-pole and a 1.6 cm enhancing lesion in the postero-medial lower pole. Figure 2. The lesion before and after enucleation with use of the finger fracture technique. 770 | injection of methylene blue and spot suturing of defects or pinpoint bleeding, the renal defect is closed as for all laparo- scopic partial nephrectomies at our institution. Argon beam standard closure of the renal defect is performed utilizing collagen bolsters, pro-coagulants, and capsular sutures. RESULTS unclamped hand-assisted partial nephrectomy (ie, zero is- hematocrit and eGFR. - - - - agulation. - operative decision to perform a radical nephrectomy. DISCUSSION Partial nephrectomy is emerging as the standard of care for small renal masses. Laparoscopic partial nephrectomy re- mains a technically challenging procedure and may not - perience. Robotic-assisted laparoscopic partial nephrectomy - logic results and peri-operative outcomes. - approach. Furthermore, although the goal of zero ischemia is preferred in order to preserve renal function, - laparoscopic partial nephrectomy in order to further bridge these areas of uncertainty. - - The mean operation time and blood loss - tumor and time elapsed for intra-operative frozen section analysis, there appeared to be enough compression time to - - hancing rim around the tumor on pre-operative CT imaging in these sometimes challenging cases. it had been uniformly applied. Although the safe duration of recent studies sug- gest superiority of no vascular clamping in preserving renal function. - - Laparoscopic Urology 771Vol. 10 | No. 1 | Winter 2013 |U R O LO G Y J O U R N A L Unclamped Hand-Assisted Laparoscopic Partial Nephectomy | Engel and Williams Thus, it appears logical that minimizing or eliminating any - tion during partial nephrectomy. Recent studies have sug- (2) - feel the ability to perform unclamped partial nephrectomy in this patient population should be thought of as an impor- preservation of renal function is tantamount. of angles to be unparalleled in comparison. Although no true that the ability to hold and maneuver the kidney during resec- the tumor. During standard laparoscopic or robotic partial nephrectomy a small biopsy performed at the tumor base, and the renal defect is immediately closed prior to clamp removal. Recent studies have suggested the role of anatomical vascular mi- - - - (3) to fully inspect the tumor base, obtain a margin from the re- sected specimen, and re-biopsy the tumor bed several times Demographic characteristics and peri-operative out- comes.£ Characteristic Hand-assisted laparoscopic par- tial nephrectomy (n = 8) Gender Male, n (%) Female, n(%) 4 (50) 4 (50) Age, mean (range), y 55.8 (38 to 68) Body mass index, mean (range), kg/m2 30.5 (26.5 to 37.4) ASA score, mean (range) 2.3 (2 to 3) Side Left, n (%) Right, n (%) 4 (50) 4 (50) Tumor size, mean (range), cm 3.7(1.7 to 8.5) Anterior, n (%) 5 (62.5) Posterior, n (%) 3 (37.5) Pre-operative eGFR, mean (range) 69.1 (46 to 94) Operation time, mean (range), min 236.9 (175 to 272) Estimated blood loss, mean (range), mL 368.8 (100 to 800) Warm ischemia time, mean (range), min 0 Length of stay, mean (range), day 3.3 (2 to 6) Intra-operative complications, n 0 Post-op complications, Clavien Grade* I II IIIa IIIb IV V 0 1 0 0 1 0 Post-op transfusion, n (%) 1 (12.5) Post-op hematocrit change, n (%) -3.1 (-7.5) Post-op eGFR change, n (%) -1.6 (-2.4) Pathology Clear cell, n (%) 4 (50) Papillary, n (%) 3 (37.5) Chromophobe, n (%) 1 (12.5) Positive surgical margin, n (%) 1 (12.5)** £ASA indicates American Society of Anesthesiology; and eGFR: estimated glomerular filtration rate. *Based on modified Clavien Classification.7 **Positive surgical margin was identified intra-operatively. 772 | - - proach. Initial frozen section analysis of both tumor and - residual tumor, and close inspection of the tumor bed intra- a small nest of carcinoma visualized at the deepest site of resection. Therefore, the inadvertent leaving of tumor behind - to obtain margins from both the resected specimen and the tumor bed prior to renal reconstruction are perhaps the great- est advantages afforded to the patient by the hand-assisted approach. design. First, this is a small series of patients and further stud- - eral applicability to all endophytic renal masses in all cases has not been demonstrated here. Third, the larger incision re- may lead to slightly higher morbidity and should be consid- performing an unclamped hand-assisted laparoscopic partial CONCLUSION - tial nephrectomy for predominantly endophytic renal masses higher-risk patient population. CONFLICT OF INTEREST None declared. REFERENCES 1. Campbell SC, Novick AC, Belldegrun A, et al. Guideline for management of the clinical T1 renal mass. J Urol. Vol 182; 2009:1271-9. 2. Gill IS, Kamoi K, Aron M, Desai MM. 800 Laparoscopic partial nephrectomies: a single surgeon series. J Urol. 2010;183:34-41. 3. Gill IS, Eisenberg MS, Aron M, et al. "Zero ischemia" partial nephrectomy: novel laparoscopic and robotic technique. Eur Urol. 2011;59:128-34. 4. Tan YH, Young MD, L'Esperance JO, Preminger GM, Albala DM. Hand-assisted laparoscopic partial nephrectomy with- out hilar vascular clamping using a saline-cooled, high- density monopolar radiofrequency device. J Endourol. 2004;18:883-7. 5. Thompson RH, Lane BR, Lohse CM, et al. Comparison of warm ischemia versus no ischemia during partial nephrec- tomy on a solitary kidney. Eur Urol. 2010;58:331-6. 6. Dindo D, Demartines N, Clavien PA. Classification of surgi- cal complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205-13. 7. Levey AS, Stevens LA, Schmid CH, et al. A new equation to estimate glomerular filtration rate. Ann Intern Med. 2009;150:604-12. 8. Winfield HN, Donovan JF, Lund GO, et al. Laparoscopic partial nephrectomy: initial experience and comparison to the open surgical approach. J Urol. 1995;153:1409-14. 9. Janetschek G, Daffner P, Peschel R, Bartsch G. Laparoscopic nephron sparing surgery for small renal cell carcinoma. J Urol. 1998;159:1152-5. 10. Rogers C, Sukumar S, Gill IS. Robotic partial nephrectomy: the real benefit. Curr Opin Urol. 2011;21:60-4. 11. Thompson RH, Lane BR, Lohse CM, et al. Every minute counts when the renal hilum is clamped during partial nephrectomy. Eur Urol. 2010;58:340-5. 12. Thompson RH, Leibovich BC, Lohse CM, Zincke H, Blute ML. Complications of contemporary open nephron sparing sur- gery: a single institution experience. J Urol. 2005;174:855-8. Laparoscopic Urology 773Vol. 10 | No. 1 | Winter 2013 |U R O LO G Y J O U R N A L Unclamped Hand-Assisted Laparoscopic Partial Nephectomy | Engel and Williams 13. Lane BR, Babineau DC, Poggio ED, et al. Factors predicting renal functional outcome after partial nephrectomy. J Urol. 2008;180:2363-8; discussion 8-9. 14. Gill IS, Patil MB, Abreu AL, et al. Zero ischemia ana- tomical partial nephrectomy: a novel approach. J Urol. 2012;187:807-14. 15. Ng CK, Gill IS, Patil MB, et al. Anatomic renal artery branch microdissection to facilitate zero-ischemia partial nephrec- tomy. Eur Urol. 2012;61:67-74.