Avi Beri

Laparoscopic partial nephrectomy for hilar tumors: technique and results.

BACKGROUND Laparoscopic partial nephrectomy for hilar tumors is a cutting edge procedure for which little data is available in the current literature. OBJECTIVE To describe our technique and results of laparoscopic partial nephrectomy for renal hilar tumors. DESIGN, SETTING, AND PARTICIPANTS Between April 2000 and September 2006, 94 partial laparoscopic nephrectomies were performed at our institution. A total of 18 (19.1%) patients had hilar tumors. A hilar tumor was defined as a lesion suspicious for renal cell carcinoma in contact with a major renal vessel on preoperative cross-sectional imaging. In 3 (16.7%) of the patients, the indication for nephron-sparing surgery was imperative. Mean tumor size was 3 cm (range, 2-4.5). Eight (44.4%) surgeries were performed with renal artery perfusion for cold ischemia; the remaining surgeries were performed under warm ischemia. INTERVENTION(S) After occluding the renal artery and controlling the renal vein by using separate rubber band tourniquets, we excised the tumor mass including delicate mobilization away from the blood vessels. Although we used to insert a ureteral stent at the beginning of our experience with laparoscopic partial nephrectomies, we no longer do so. All surgeries were performed by a single urologist (G.J.). MEASUREMENTS Operative time, ischemia time, blood loss, renal function using the Cockroft formula as well as renal scans, operative and post-operative complications, pathology parameters. RESULTS AND LIMITATIONS All surgeries were completed laparoscopically. Mean surgical time was 238 min (range, 150-420). Mean ischemia times were 42.5 min (range, 27-63) and 34.1 min (range, 24-56) for the cold and warm ischemia groups, respectively. Estimated intraoperative blood loss was 165 ml (range, 50-500). There were two (11%) entries into major vessels during tumor excision, namely a segmental renal artery in one patient and a segmental renal vein in another. Both of these occurrences were managed laparoscopically. One patient necessitated laparoscopic reexploration for urine extravasation in the immediate postoperative period. All postoperative nuclear scans (available in 12 of 18 patients) showed functional kidney moiety. Mean split renal function was 38.6% (range, 24-50) on the operated side. Histopathological examination confirmed renal cell carcinoma in 14 (77.8%) of the patients. One (7.1%) patient had a positive surgical margin on the surface that was adjacent to the renal artery. In a median follow-up of 26 mo (range, 1-59), no local recurrence or systemic progression occurred. CONCLUSION Laparoscopic partial nephrectomy for hilar tumors is a feasible and safe procedure in the hands of experienced laparoscopic surgeons. Oncological results seem excellent, but further follow-up is needed for accurate long-term assessment of this surgical approach.

Partial nephrectomy using renal artery perfusion for cold ischemia: functional and oncologic outcomes.

PURPOSE We present our series on the safety and long-term oncologic and functional outcomes of laparoscopic partial nephrectomy using renal artery perfusion for cold ischemia. PATIENTS AND METHODS Of 94 patients who underwent laparoscopic partial nephrectomy at our center between August 2000 and September 2006, 28 procedures were performed using cold ischemia and are included in this review. Mean age was 57.8 years (range 22-80 yrs). Mean tumor size was 2.67 cm (range 1.5-5 cm). Five patients had an imperative indication for partial nephrectomy. Eight tumors were hilar. Cold ischemia was achieved through renal artery catheterization followed by intraoperative artery clamping and perfusion with 4 degrees C lactated Ringer solution with mannitol. RESULTS Mean ischemia time was 40.8 min (range 25-101 min). Mean estimated blood loss was 241 mL (range 50-1000 mL). Three patients underwent conversion to open surgery, but their procedures were still completed under cold perfusion. Segmental artery penetration and venous penetration took place in one patient each. Two postoperative complications occurred, including pancreatitis and pulmonary embolism; none were related to the cold perfusion. Oncologic outcome revealed 100% disease-specific survival for 45 months median followup. Functional studies showed a mild decrease in renal creatinine clearance with improvement 1 month after surgery. Nuclear scans showed functional kidney moiety in all but one patient. CONCLUSION Intraoperative cold ischemia for laparoscopic partial nephrectomy using arterial perfusion is safe and feasible. It constitutes a viable alternative for complex tumors when ischemia time is expected to exceed 30 minutes. We provide proof of principle confirming the protective effect of cold perfusion to prevent parenchymal damage.

Practical hints for hemostasis in laparoscopic surgery

With the developments achieved in recent years in laparoscopic surgery, the field has acquired a host of new techniques to achieve haemostasis, allowing the surgeon to tackle complex procedures. These techniques include physical modalities (as simple as compression or suturing and as sophisticated as endovascular staples), thermal modalities (such as bipolar coagulation, laser or ultrasonic dissectors), and topical sealants (e.g. Fibrin glue or gelatine matrix). It is up to the laparoscopic surgeon to be familiar with all these different modalities and their proper use and limitations. It should also be kept in mind that the best approach to haemostasis in laparoscopy is prevention by thorough case preparation and meticulous dissection technique. We herein expose an overview of the available techniques to achieve haemostatic control in laparoscopic surgery in the emergency as well as the elective setting. Representative surgeries are used for illustrative purposes to describe special manoeuvres.

Do Urology Male Patients Prefer Same-Gender Urologist?

There are several studies on patients’ preference for same-gender physicians, especially female preference for same-gender gynecologists. Data regarding the preferences of urology patients, of whom the majority are males, are scarce. The objective of this study is to assess provider gender preference among urology patients. One hundred and nineteen consecutive men (mean age 57.6 years) who attended a urology clinic in one university-affiliated medical center were prospectively enrolled. A self-accomplished 26-item anonymous questionnaire was used to assess patients’ preferences in selecting their urologist. Of the 119 patients, 51 (42.8%) preferred a male urologist. Patients exhibited more same-gender preference for physical examination (38.3%), or urological surgery (35.3%), than for consultation (24.4%). Most patients (97%) preferred a same-gender urologist because they felt less embarrassed. Four patient characteristics were identified to be significantly associated with preference for a male urologist: religious status, country of origin, marital status, and a prior management by a male urologist. Of these, religious status was the most predictive parameter for choosing a male urologist. The three most important factors that affected actual selection, however, were professional skills (84.6%), clinical experience (72.4%), and medical knowledge (61%), rather than physician gender per se. Many male patients express gender bias regarding their preference for urologist. However, professional skills of the clinician are considered to be more important factors when it comes to actually making a choice.

MP10-10 CAN UROLOGISTS ACCURATELY STAGE AND GRADE UROTHELIAL CARCINOMA BY ASSESSING ENDOSCOPIC PHOTOGRAPHS OF TUMORS?

INTRODUCTION AND OBJECTIVES: Assessment of urothelial carcinoma (UC) during cystoscopy or TURBT has a significant impact on the urologist’s decision making: treatment with simple outpatient fulguration, the required depth of resection and the need of immediate post-surgical intravesical therapy all depend heavily on the urologist’s ability to accurately assess pre-biopsy tumor stage and grade. METHODS: Photographs of 50 UC were taken at the beginning of TURBT and were presented to 7 senior urologists separately, all blind to the pathological report. Each urologist was asked to rate the tumor as low grade and noninvasive (Ta low grade), high grade and noninvasive (Ta high grade) or invasive (T1 or more). Results were compared with the final pathological findings. RESULTS: The single urologist correctly predicted the tumor stage and grade in 63.5% of cases (222 of 350, average of 32 out of 50 accurate assessments). Of the 128 incorrect assessments 54 underestimated the UC and 74 overestimated it. After achieving consensus in each case it turned out that the final majority assessment was correct in 40 of 50 cases (80%). Sensitivity and specificity of the final results for the diagnosis of T1 or higher were 80% and 88.6% respectively. Sensitivity and specificity for TaLG were 83.3% and 80% respectively. Inter-rater reliability was calculated and showed fair agreement (kappa1⁄40.27). CONCLUSIONS: To our knowledge this is the first documented evaluation of urologists’ ability to assess UC stage and grade using endoscopic photographs. The single urologist can usually identify stage and grade of UC but accuracy increases when multiple senior urologists examine the photos and achieve consensus. When photos of UC exist, a team of senior urologists can make an excellent decision about the type and extent of surgical treatment and plan ahead post-surgical management of the patient.

PARTIAL NEPHRECTOMY USING RENAL ARTERY PERFUSION FOR COLD ISCHEMIA: FUNCTIONAL AND ONCOLOGICAL OUTCOMES

Purpose: We present our series on the safety and long-term oncologic and functional outcomes of laparoscopic partial nephrectomy using renal artery perfusion for cold ischemia. Patients and Methods: Of 94 patients who underwent laparoscopic partial nephrectomy at our center between August 2000 and September 2006, 28 procedures were performed using cold ischemia and are included in this review. Mean age was 57.8 years (range 22–80 yrs). Mean tumor size was 2.67 cm (range 1.5–5 cm). Five patients had an imperative indication for partial nephrectomy. Eight tumors were hilar. Cold ischemia was achieved through renal artery catheterization followed by intraoperative artery clamping and perfusion with 4°C lactated Ringer solution with mannitol. Results: Mean ischemia time was 40.8 min (range 25–101 min). Mean estimated blood loss was 241 mL (range 50–1000 mL). Three patients underwent conversion to open surgery, but their procedures were still completed under cold perfusion. Segmental artery penetration and ven...