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      Impact of “non-clamping technique” on intra- and postoperative course after laparoscopic partial nephrectomy

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          Abstract

          Introduction

          The use of kidney warm ischaemia during laparoscopic partial nephrectomy (LPN) may lead to damage of renal vessels and kidney failure. Laparoscopic partial nephrectomy done without clamping the renal pedicle is feasible and may be beneficial for the postoperative course.

          Aim

          To compare intra- and postoperative course in patients undergoing LPN with and without kidney warm ischaemia.

          Material and methods

          The material comprises 38 consecutive patients, who underwent LPN in our department during the years 2008-2009. In all cases renal vessels were identified and dissected at first, then resection of the tumour was done. Warm ischaemia was used only in case of difficulties with identification of tumour margin or with the management of bleeding. Out of 38 operations 13 were done without clamping the renal pedicle (group 1) and in the remaining 25 warm ischaemia was applied (group 2).

          Results

          Mean dimension of resected tumours in groups 1 and 2 was 31 mm and 33 mm respectively (p > 0.05), while parameters of intra- and postoperative course differed significantly between the groups: mean blood loss – 135 ml vs. 354 ml (p < 0.05), time of surgery – 72.6 min vs. 132.2 min (p < 0.05), postoperative drain leakage – 290 ml vs. 504 ml (p < 0.05), postoperative hospital stay – 3.1 days vs 5.3 days (p < 0.05). In all patients baseline creatinine levels were normal while after surgery creatinine elevation over the upper limit was found in groups 1 and 2 in one and in 6 patients respectively (p < 0.05).

          Conclusions

          Laparoscopic resection of kidney tumour without warm ischaemia is feasible and beneficial in pre- and intraoperatively selected cases. Bleeding from renal parenchyma, which requires renal pedicle clamping, may seriously deteriorate intra- and postoperative course in patients undergoing laparoscopic partial nephrectomy.

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          Most cited references30

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          Every minute counts when the renal hilum is clamped during partial nephrectomy.

          The safe duration of warm ischemia during partial nephrectomy remains controversial. Our aim was to evaluate the short- and long-term renal effects of warm ischemia in patients with a solitary kidney. Using the Cleveland Clinic and Mayo Clinic databases, we identified 362 patients with a solitary kidney who underwent open (n=319) or laparoscopic (n=43) partial nephrectomy using warm ischemia with hilar clamping. Associations of warm ischemia time with renal function were evaluated using logistic or Cox regression models first as a continuous variable and then in 5-min increments. Median tumor size was 3.4 cm (range: 0.7-18.0 cm), and median ischemia time was 21 min (range: 4-55 min). Postoperative acute renal failure (ARF) occurred in 70 patients (19%) including 58 (16%) who had a glomerular filtration rate (GFR) or=30 ml/min per 1.73 m(2) and followed >or=30 d, 38 (17%) developed new-onset stage IV chronic kidney disease during follow-up. As a continuous variable, longer warm ischemia time was associated with ARF (odds ratio: 1.05 for each 1-min increase; p<0.001) and a GFR<15 (odds ratio: 1.06; p<0.001) in the postoperative period, and it was associated with new-onset stage IV chronic kidney disease (hazard ratio: 1.06; p<0.001) during follow-up. Similar results were obtained adjusting for preoperative GFR, tumor size, and type of partial nephrectomy in a multivariable analysis. Evaluating warm ischemia in 5-min increments, a cut point of 25 min provided the best distinction between patients with and without all three of the previously mentioned end points. Limitations include the retrospective nature of the study. Longer warm ischemia time is associated with short- and long-term renal consequences. These results suggest that every minute counts when the renal hilum is clamped. (c) 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved.
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            Comparative analysis of laparoscopic versus open partial nephrectomy for renal tumors in 200 patients.

            Laparoscopic partial nephrectomy is an emerging minimally invasive, nephron sparing approach for renal cell carcinoma. We compared perioperative outcomes after laparoscopic and open nephron sparing surgery (NSS) for patients with a solitary renal tumor of 7 cm or less at a single institution. Since September 1999, 100 consecutive patients have undergone laparoscopic partial nephrectomy for a sporadic single renal tumor of 7 cm or less at our institution. A contemporary cohort of 100 consecutive patients with similar inclusion criteria have undergone open NSS since April 1998. Since our laparoscopic technique was based on our established open surgical principles, the 2 approaches were similar, including transient renal vascular control, sharp tumor excision in a bloodless field, pelvicaliceal repair when necessary, suture ligation of transected intrarenal blood vessels and suture repair of the renal parenchymal defect over a bolster. Demographic, intraoperative, postoperative and short-term followup data were retrospectively compared between the 2 groups. Median tumor size was 2.8 cm in the laparoscopic group and 3.3 cm in the open group (p = 0.005). There were significantly more tumors greater than 4 cm in the open group (p <0.001). There were more patients with a solitary kidney in the open surgical group (p = 0.002). More patients in the open group underwent NSS for a malignant tumor (p = 002). Comparing the laparoscopic versus open groups, median surgical time was 3 vs 3.9 hours (p <0.001), blood loss was 125 vs 250 ml (p <0.001) and mean warm ischemia time was 27.8 vs 17.5 minutes (p <0.001), respectively. In the laparoscopic and open groups median analgesic requirement was 20.2 vs 252.5 mg morphine sulfate equivalents (p <0.001), hospital stay was 2 vs 5 days (p <0.001) and average convalescence was 4 vs 6 weeks (p <0.001). Median preoperative serum creatinine (1.0 vs 1.0 mg/dl, p = 0.52) and postoperative serum creatinine (1.1 vs 1.2 mg/dl, p = 0.65) were similar in the 2 groups. No kidney was lost due to warm ischemic injury. Three patients in the laparoscopic group had a positive surgical margin compared to none in the open groups (3% vs 0%, p = 0.1). Laparoscopic NSS was associated with a higher rate of major intraoperative complications (5% vs 0%, p = 0.02). There were no significant differences in overall postoperative complications, although renal/urological complications were more common in the laparoscopic group (11% vs 2%, p = 0.01). Open surgical partial nephrectomy remains the established standard for nephron sparing treatment of renal tumors. When applied to small renal tumors, the laparoscopic approach is associated with longer warm renal ischemia time, more major intraoperative complications and more postoperative urological complications. Our data also suggest that more deliberate efforts to achieve a wider surgical margin are necessary with the laparoscopic approach. Nevertheless, our data suggest that laparoscopic NSS is emerging as an effective, minimally invasive therapeutic approach with respect to renal functional outcome with the additional advantages of decreased postoperative narcotic use, earlier hospital discharge and a more rapid convalescence. Continued efforts are required to develop laparoscopic renal hypothermia techniques and facilitate intrarenal suturing, while minimizing warm ischemia time.
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              Laparoscopic and open partial nephrectomy: a matched-pair comparison of 200 patients.

              Laparoscopy is currently challenging the role of the open approach for nephron-sparing surgery (NSS), yet comparative studies on this issue are scant. To compare surgical, oncologic, and functional outcomes after laparoscopic partial nephrectomy (LPN) and open partial nephrectomy (OPN). We undertook matched-pair (age, sex, tumour size) analysis of patients who underwent elective NSS for renal masses either by laparoscopic (Klagenfurt) or open (Vienna) access. Surgical data, complications, histologic and oncologic data, and short- and long-term renal function of the open and laparoscopic groups were compared. In total, 200 patients matched for age, sex, and tumour size entered the study after either LPN or OPN and were followed for a mean of 3.6 yr. Surgical, ischemia, and hospitalisation times were shorter in the LPN group (p<0.001). Blood loss and complication rates were comparable in both groups. Malignant tumours were pT1 stage renal-cell cancer only in both groups. The positive surgical margin (PSM) rate was 4% after LPN and 2% after OPN (p=0.5); positive margins were not a risk factor for disease recurrence. Kaplan-Meier estimates of 5-yr local recurrence-free survival (RFS) were 97% after LPN and 98% after OPN (p=0.8); the respective numbers for distant free survival were 99% and 96% (p=0.2). Five-year overall survival (OS) for patients with pT1 stage renal cell carcinoma (RCC) was 96% after LPN and 85% after OPN. The decline in glomerular filtration rate at the last available follow-up (LPN: 10.9%; OPN: 10.6%) was similar in both groups (p=0.8). We recognise the retrospective nature, limited follow-up, and sample size as shortcomings of this study. In experienced hands, LPN provides similar results compared to open surgery. PSM rates were comparable after LPN and OPN. Current experience questions the indication of secondary nephrectomy in these patients.
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                Author and article information

                Journal
                Wideochir Inne Tech Malo Inwazyjne
                Wideochir Inne Tech Malo Inwazyjne
                WIITM
                Videosurgery and other Miniinvasive Techniques
                Termedia Publishing House
                1895-4588
                2299-0054
                29 September 2012
                December 2012
                : 7
                : 4
                : 275-279
                Affiliations
                Department of Urology and Urological Oncology, Pomeranian Medical University, Szczecin, Poland
                Author notes
                Address for correspondence: Piotr Petrasz MD, 5 Kruczkowskiego 72-100 Goleniow, Poland. phone: +48 606 240 039. fax: +48 91 466 11 00. e-mail: petri6977@ 123456wp.pl
                Article
                19465
                10.5114/wiitm.2011.30801
                3557739
                23362427
                57040f73-3eb2-4612-9184-5a3ed49946a2
                Copyright © 2012 Sekcja Wideochirurgii TChP

                This is an Open Access article distributed under the terms of the Creative Commons Attribution-Noncommercial 3.0 Unported License, permitting all non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 13 December 2011
                : 20 March 2012
                : 05 April 2012
                Categories
                Original Paper

                Surgery
                kidney cancer,laparoscopic partial nephrectomy,haemostasis,kidney warm ischaemia
                Surgery
                kidney cancer, laparoscopic partial nephrectomy, haemostasis, kidney warm ischaemia

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