Anoop M. Meraney

Laparoscopic partial nephrectomy for renal tumor: duplicating open surgical techniques.

PURPOSE We describe our technique of and single institutional experience with purely laparoscopic partial nephrectomy for renal tumor, wherein the focus is to duplicate established open techniques of oncologic nephron sparing surgery. MATERIALS AND METHODS Since August 1999 laparoscopic partial nephrectomy for renal tumor has been performed in 50 patients. Of the patients 24 (48%) had either a compromised contralateral kidney (20) or a solitary kidney (4). Mean tumor size was 3.0 cm. (range 1.4 to 7). In 9 patients (18%) the inner margin of the tumor was in close proximity to the pelvicaliceal system. Our current laparoscopic technique involves preoperative ureteral catheterization, laparoscopic renal ultrasonography, transient atraumatic clamping of the renal artery and vein, tumor excision with an approximate 0.5 cm. margin using cold endoshears and/or J-hook electrocautery, pelvicaliceal suture repair (if necessary) and suture repair of the renal parenchymal defect over surgicel bolsters. In 1 case renal surface hypothermia was achieved laparoscopically with ice slush. All suturing and knot tying were performed with free hand intracorporeal laparoscopic techniques exclusively. RESULTS All procedures were successfully completed without open conversion. Mean surgical time was 3.0 hours (range, 0.75 to 5.8) and mean blood loss was 270.4 cc (range 40 to 1,500). Mean warm ischemia time was 23 minutes (range, 9.8 to 40). Caliceal entry in 18 cases (36%) was suture repaired in a watertight manner. Following caliceal repair, none of these 18 patients had a postoperative urine leak. Hospital stay averaged 2.2 days (range 1 to 9). Major complications occurred in 3 patients (6%) including intraoperative hemorrhage in 1, delayed hemorrhage necessitating nephrectomy in 1 and urine leak in 1. Renal cell carcinoma was confirmed on pathological examination in 34 patients (68%), and all had negative inked surgical margins for cancer. During a mean followup of 7.2 months (range 1 to 17) no patient has had local or port site recurrence or metastatic disease. CONCLUSIONS Laparoscopic partial nephrectomy is a viable alternative for select patients with a renal tumor. The largest single institutional experience to date is presented wherein the open techniques of nephron sparing surgery have been duplicated laparoscopically.

Laparoscopic renal cryoablation in 32 patients

OBJECTIVES Laparoscopic renal cryoablation is a developmental minimally invasive nephron-sparing treatment alternative for highly select patients with small renal tumors. We present our evolving experience with this procedure. METHODS Thirty-two patients (34 tumors) with a mean tumor size of 2.3 cm on preoperative computed tomography underwent laparoscopic renal cryoablation. As dictated by the tumor location, cryoablation was performed by either the retroperitoneal (n = 22) or the transperitoneal (n = 10) laparoscopic approach using real-time ultrasound monitoring. A double freeze-thaw cycle was routinely performed. RESULTS The mean surgical time was 2.9 hours, cryoablation time 15.1 minutes, and blood loss 66.8 mL. For a mean intraoperative ultrasonographic tumor size of 2 cm, the mean cryolesion size was 3.2 cm. The hospital stay was less than 23 hours in 22 (69%) of 32 patients. Sequential magnetic resonance imaging scans demonstrated a gradual contraction in the mean diameter of the cryolesions. Of the 20 patients who underwent a 1-year follow-up magnetic resonance imaging scan, the cryoablated tumor was no longer visible in 5. Of note, 23 patients have now undergone a 3 to 6-month follow-up computed tomography-directed biopsy of the cryoablated tumor site; the biopsy was negative for cancer in all 23 patients. No evidence of local or port-site recurrence was found during a mean follow-up of 16.2 months. CONCLUSIONS Critical long-term data regarding laparoscopic renal cryoablation, a developmental technique, are awaited. However, our initial experience is cautiously optimistic. Despite its significant potential for false-negative results, it is encouraging that the follow-up computed tomography-directed needle biopsies at 3 to 6 months were negative for cancer in 23 of 23 patients.

Laparoscopic radical cystoprostatectomy with ileal conduit performed completely intracorporeally: the initial 2 cases

OBJECTIVES To present the initial 2 patients who underwent laparoscopic radical cystoprostatectomy, bilateral pelvic lymphadenectomy, and ileal conduit urinary diversion, with the entire procedure performed exclusively by intracorporeal laparoscopic techniques. METHODS Two male patients, 78 and 70 years old, with muscle-invasive, organ-confined, transitional cell carcinoma of the urinary bladder underwent the procedure. The entire procedure, including radical cystoprostatectomy, pelvic node dissection, isolation of the ileal loop, restoration of bowel continuity with stapled side-to-side ileoileal anastomosis, retroperitoneal transfer of the left ureter to the right side, and bilateral stented ileoureteral anastomoses were all performed exclusively by intracorporeal laparoscopic techniques. Free-hand laparoscopic suturing and in situ knot-tying techniques were used exclusively. RESULTS The surgical time was 11.5 hours in the first patient and 10 hours in the second. The respective blood loss was 1200 mL and 1000 mL. In both patients, ambulation resumed on postoperative day 2, bowel sounds on day 3, and oral intake on day 4; the hospital stay was 6 days. Narcotic analgesia comprised 108.3 mg and 16.5 mg of morphine sulfate equivalent, respectively. Pathologic examination revealed pT4N0M0 (prostate) and pT2bN0M0 transitional cell carcinoma of the bladder with the surgical margins negative for cancer in both patients. No intraoperative or postoperative complications occurred in either patient. CONCLUSIONS To our knowledge, this is the initial report of laparoscopic radical cystoprostatectomy with intracorporeal ileal conduit urinary diversion. We believe that with further experience and refinement in the operative technique, laparoscopic radical cystoprostatectomy with ileal conduit urinary diversion may become an attractive treatment option for selected candidates with localized muscle-invasive bladder cancer.

Laparoscopic Radical Cystectomy and Continent Orthotopic Ileal Neobladder Performed Completely Intracorporeally: The Initial Experience

PURPOSE We introduce the operative technique of laparoscopic radical cystectomy and orthotopic ileal neobladder with a Studer limb performed completely intracorporeally. MATERIALS AND METHODS The procedure was performed in 1 man and 1 woman. Using a 6 port transperitoneal approach, radical cystectomy in the female patient and radical cystoprostatectomy in the male patient were completed laparoscopically with the urethral sphincter preserved. Bilateral pelvic lymphadenectomy was done. A 65 cm. segment of ileum 15 cm. from the ileocecal junction was isolated, and ileo-ileal continuity was restored using Endo-GIA staplers (U.S. Surgical, Norwalk, Connecticut). The distal 45 cm. of the isolated ileal segment were detubularized, maintaining the proximal 10 cm. segment intact as an isoperistaltic Studer limb. A globular shaped ileal neobladder was constructed and anastomosed to the urethra. Bilateral stented ureteroileal anastomoses were individually performed to the Studer limb. All suturing was done exclusively using free-hand laparoscopic techniques and the entire procedure was completed intracorporeally. An additional case is described of Indiana pouch continent diversion in which the pouch was constructed extracorporeally. RESULTS Total operative time for laparoscopic radical cystectomy and orthotopic neobladder was 8.5 and 10.5 hours, respectively, with a blood loss ranging from 200 to 400 cc. Hospital stay was 5 to 12 days and surgical margins of the bladder specimen were negative in each case. Both patients with orthotopic neobladder had complete daytime continence. Postoperative renal function was normal and excretory urography revealed unobstructed upper tracts. During followup ranging from 5 to 19 months 1 patient died of metastatic disease, while the other 2 are doing well without local or systematic progression. CONCLUSIONS Laproscopic radical cystectomy and orthotopic ileal neobladder performed completely intracorporeally are feasible.

LAPAROSCOPIC RADICAL NEPHROURETERECTOMY FOR UPPER TRACT TRANSITIONAL CELL CARCINOMA: THE CLEVELAND CLINIC EXPERIENCE

PURPOSE We report our single institutional experience with retroperitoneal laparoscopic radical nephroureterectomy in patients with upper tract transitional cell carcinoma and compare results to those achieved by the open technique. MATERIALS AND METHODS A total of 77 patients underwent radical nephroureterectomy for pathologically confirmed upper tract transitional cell carcinoma. Of these patients 42 underwent laparoscopic nephroureterectomy from September 1997 through January 2000 and 35 underwent open surgery. All specimens were extracted intact. Of the laparoscopic group the juxtavesical ureter and bladder cuff were excised by our novel transvesical needlescopic technique in 27 and radical nephrectomy was performed retroperitoneoscopically in all 42. Data were compared retrospectively with 35 patients undergoing open radical nephroureterectomy from February 1991 through December 1999. RESULTS Laparoscopy was superior in regard to surgical time (3.7 versus 4.7 hours, p = 0.003), blood loss (242 versus 696 cc, p <0. 0001), specimen weight (559 versus 388 gm., p = 0.04), resumption of oral intake (1.6 versus 3.2 days, p = 0.0004), narcotic analgesia requirements (26 versus 228 mg., p <0.0001), hospital stay (2.3 versus 6.6 days, p <0.0001), normal activities (4.7 versus 8.2 weeks, p = 0.002) and convalescence (8 versus 14.1 weeks, p = 0.007). Complications occurred in 5 patients (12%) in the laparoscopic group, including open conversions in 2, and in 10 (29%) in the open group (p = 0.07). Followup was shorter in the laparoscopic group (11.1 versus 34.4 months, p <0.0001). The 2 groups were similar in regard to bladder recurrence (23% versus 37%, p = 0.42), local retroperitoneal or port site recurrence (0% versus 0%) and metastatic disease (8.6% versus 13%, p = 1.00). Mortality occurred in 2 patients (6%) in the laparoscopic group and 9 (30%) in the open group. Cancer specific survival (97% versus 87%) and crude survival (97% versus 94%) were similar between both groups (p = 0.59). CONCLUSIONS In patients with upper tract transitional cell carcinoma who are candidates for radical nephroureterectomy the retroperitoneal laparoscopic approach satisfactorily duplicates established technical principles of traditional open oncological surgery, while significantly decreasing morbidity from this major procedure. Short-term oncological and survival data of the laparoscopic technique are comparable to open surgery. Although long-term followup data are not yet available, it appears that laparoscopic radical nephroureterectomy may supplant open surgery as the standard of care in patients with muscle invasive or high grade upper tract transitional cell carcinoma.

Laparoscopic radical nephrectomy in 100 patients

The objective of the current study was to report a single‐surgeon, single‐center experience with 100 consecutive laparoscopic radical nephrectomies with intact specimen extraction, with the aim of evaluating the oncologic adequacy of the laparoscopic dissection from a technical standpoint and various parameters including the learning curve.

VAGINAL EXTRACTION OF THE INTACT SPECIMEN FOLLOWING LAPAROSCOPIC RADICAL NEPHRECTOMY

PURPOSE We report the detailed technique and results of transvaginal extraction of the intact laparoscopic radical nephrectomy specimen. MATERIALS AND METHODS Since June 2000, 10 select female patients with a median age of 67 years underwent transvaginal extraction of the intact specimen after laparoscopic radical nephrectomy. In 5 patients open surgery had previously been performed on the uterus, including transabdominal hysterectomy in 2 and cesarean section in 3. Laparoscopic nephrectomy was performed via the transperitoneal and retroperitoneal approach in 5 cases each. After completion of the primary laparoscopic procedure a sponge stick was externally inserted into the sterile prepared vagina and tautly positioned in the posterior fornix. Laparoscopically a transverse posterior colpotomy was created at the apex of the tented up posterior fornix and the drawstring of the entrapped specimen was delivered into the vagina. After laparoscopic exit was completed the patient was placed in the supine lithotomy position. The specimen was extracted intact via the vagina and the posterior colpotomy incision was repaired transvaginally. Patients were mailed a linear scale analog questionnaire to assess various aspects of recovery with responses graded from 0--no pain and/or change to 10--severe pain and/or change. RESULTS Vaginal extraction was successful in all 10 patients. Median operative time for the vaginal extraction procedure was 35 minutes. Blood loss was minimal. Median tumor size was 3.6 cm. (range 2.4 to 7.4) and median specimen weight was 327 gm. (range 152 to 484). No intraoperative complications occurred. Postoperatively blood spotting via the vagina in 1 patient resolved spontaneously. Postoperative questionnaires revealed excellent patient satisfaction and convalescence. CONCLUSIONS Vaginal extraction is an efficacious and minimally morbid technique for removing the intact entrapped specimen after laparoscopic radical nephrectomy. It has now become our preferred technique of intact specimen extraction in appropriate female patients.

ROBOTIC REMOTE LAPAROSCOPIC NEPHRECTOMY AND ADRENALECTOMY: : THE INITIAL EXPERIENCE

PURPOSE We evaluated the feasibility of performing laparoscopic nephrectomy and adrenalectomy exclusively by using robotic telepresent technology from a remote workstation and compared outcomes with those of conventional laparoscopy in an acute porcine model. MATERIALS AND METHODS Five pigs underwent bilateral laparoscopic nephrectomy (robotic in 5 and conventional in 4) and adrenalectomy (robotic in 4 and conventional in 3). In the 9 robotic laparoscopic procedures all intraoperative manipulations were completely performed telerobotically from a remote workstation without any conventional laparoscopic assistance on site. Animals were sacrificed acutely. RESULTS Robotic laparoscopic nephrectomy required significantly longer total operative (85.2 versus 38.5 minutes, p = 0.0009) and actual surgical (73.4 versus 27.5 minutes, p = 0.0002) time than conventional laparoscopy. However, blood loss and adequacy of surgical dissection were comparable in the 2 groups. Robotic laparoscopic adrenalectomy required longer total operative (51 versus 32.3 minutes, p = 0.13) and actual surgical (38.5 versus 18.7 minutes, p = 0.14) time than conventional laparoscopy. The solitary complication in this study was an inferior vena caval tear during robotic right adrenalectomy, which was adequately repaired by sutures telerobotically in a remote manner. CONCLUSIONS To our knowledge we present the initial experience with remote telerobotic laparoscopic nephrectomy and adrenalectomy. Telepresent laparoscopic surgery is feasible.

Financial Analysis Of Open Versus Laparoscopic Radical Nephrectomy And Nephroureterectomy

PURPOSE Laparoscopic radical nephrectomy and nephroureterectomy are rapidly becoming established procedures in select patients with renal cell carcinoma and upper tract transitional cell carcinoma, respectively. We present a retrospective comparative analysis of laparoscopic versus open radical nephrectomy and nephroureterectomy from a financial standpoint. The effect of the learning curve on costs incurred was also evaluated. MATERIALS AND METHODS Detailed itemized cost data on 18 contemporary cases of open radical nephrectomy performed from September 1997 to July 1998 were compared with similar data on 20 initial laparoscopic cases performed from September 1997 to July 1998 and 15 more recent laparoscopic radical nephrectomy cases performed from August 1998 to July 1999. Financial data were also compared on 14 contemporary patients each who underwent open radical nephroureterectomy from June 1997 to December 1999, initial laparoscopic radical nephroureterectomy from June 1997 to December 1998 and more recent laparoscopic radical nephroureterectomy from January 1999 to October 2000. Yearly financial costs were adjusted for inflation by a 4% annual rate to reflect year 2000 data. RESULTS For radical nephrectomy mean operative time in the 18 open, 20 initial laparoscopic and 15 recent laparoscopic cases was 185.3, 205.7 and 147.3 minutes, respectively. Mean specimen weight was 555, 616 and 558 gm., and mean hospital stay was 132, 31 and 23 hours, respectively. Compared with open radical nephrectomy mean total costs associated with initial laparoscopy were 33% greater (p = 0.0003). Mean intraoperative costs were 102% greater and mean postoperative costs were 50% less. In contrast, the more recent laparoscopic cases were an overall mean of 12% less expensive than open surgery (p = 0.05). Mean intraoperative costs were only 33% greater and mean postoperative costs were 68% less. For radical nephroureterectomy mean operative time in the 14 open, 14 initial laparoscopic and 14 recent laparoscopic cases was 246, 196 and 195 minutes, respectively. Mean specimen weight was 442, 517 and 531 gm., and mean hospital stay was 142, 63 and 32 hours, respectively. Compared with open radical nephroureterectomy mean total costs associated with initial laparoscopic cases were 28% greater (p = 0.03). Mean intraoperative costs were 65% greater and mean postoperative costs were 27% less. In contrast, the more recent laparoscopic cases were an overall mean of 6% less expensive than open surgery (p = 0.63). Mean intraoperative costs were only 31% greater and mean postoperative costs were 62% less. CONCLUSIONS Initially in the learning curve laparoscopic radical nephrectomy and nephroureterectomy were 33% and 28% financially more expensive, respectively, than their open counterparts. However, with increased operator experience and efficiency resulting in more rapid operative time and decreased hospitalization laparoscopic radical nephrectomy and nephroureterectomy are currently 12% and 6% less expensive, respectively, than their open counterparts at our institution.

LAPAROSCOPIC MANAGEMENT OF CONGENITAL SEMINAL VESICLE CYSTS ASSOCIATED WITH IPSILATERAL RENAL AGENESIS

PURPOSE Congenital cysts of the seminal vesicles associated with ipsilateral renal abnormalities are rare. When they are symptomatic, open surgical excision has been the treatment of choice. We present our experience with laparoscopic management and provide a detailed literature review of this entity. MATERIALS AND METHODS Since 1985, 3 patients with symptomatic seminal vesicle cysts and ipsilateral renal agenesis have been treated at our center. Open surgical excision was performed in 1 patient and laparoscopic management was performed in the other 2. RESULTS Mean patient age was 35.7 years (range 30 to 42). Presenting symptoms were perineal pain in all 3 cases, dysuria in 2, irritable voiding in 2 and testicular pain in 1. Mean laparoscopic operative time was 195 minutes and mean estimated blood loss was 325 cc. Transabdominal or transrectal ultrasound was performed in 2 cases and computerized tomography was performed in all 3. CONCLUSIONS Seminal vesicle cysts associated with ipsilateral renal agenesis are rare but they should be considered in men with otherwise inexplicable irritable voiding symptoms, perineal discomfort or other genitourinary complaint of unclear etiology. Evaluation should include digital rectal examination, transrectal and transabdominal ultrasound, computerized tomography and cystoscopy. Laparoscopy provides excellent intraoperative access and visualization with minimal postoperative morbidity. It is likely to become the treatment of choice for this rare developmental anomaly.