Jonathan Hale

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 renal cryoablation: initial clinical series

OBJECTIVES To present the technique and short-term results of retroperitoneal laparoscopic renal cryoablation. METHODS Ten patients underwent laparoscopic renal cryoablation of 11 exophytic renal tumors ranging in size from 1.5 to 3 cm identified on computed tomography. Tumors were located at the upper (3), middle (5), or lower (3) pole of the kidney. Three patients had a solitary kidney. A 3-port retroperitoneal laparoscopic approach was used to create renal cryolesions. Puncture cryoablation was performed with a 4.8-mm cryoprobe. Real-time, endoscopic, steerable, color Doppler ultrasound was used to monitor the evolving cryolesion. All patients have completed a minimum follow-up of 3 months (mean 5.5, range 3 to 9). RESULTS Cryoablation was technically successful in all 10 patients (11 tumors). Under ultrasound guidance, the ice ball was intentionally created up to 1 cm beyond the tumor edge with the aim of achieving negative margins. Mean surgical time was 2.4 hours, cryoablation (double freeze-thaw) time 12.9 minutes, cryoprobe tip temperature -186 degrees C, and blood loss 75 mL. Systemic temperature remained unaltered. Hospital stay was less than 23 hours in 9 of 10 patients. Follow-up magnetic resonance imaging at 1 day and 1, 2, and 3 months identified the punched-out, nonenhancing, spontaneously resorbing, renal cryolesion. Follow-up biopsies of the cryoablated tumor site were negative for cancer in the 3 patients who have undergone the biopsy. CONCLUSIONS The initial series of laparoscopic renal cryoablation is presented. The retroperitoneoscopic approach, by avoiding the peritoneal cavity, minimizes the chances of the bowel coming in contact with the evolving cryolesion, and the potential sequelae thereof. Laparoscopic renal cryoablation is currently developmental and long-term data are awaited. Nevertheless, it is potentially an attractive addition to available nephron-sparing surgical techniques.

RENAL CRYOSURGERY: EXPERIMENTAL EVALUATION OF TREATMENT PARAMETERS

OBJECTIVES Cryosurgery represents a minimally invasive alternative for the management of small or equivocal lesions of the kidney. We evaluated the relationship between ultrasonographic appearance and intrarenal temperatures and the effect of renal artery occlusion on the efficacy of the freezing process in a canine model. METHODS Ten animals were treated with intraparenchymal cryoablative therapy with (n = 5) or without (n = 5) renal artery occlusion using a rapid freeze technique. Intrarenal temperatures were measured 1.0 cm away from the cryoprobe at various times during the freezing process. The distance from the cryoprobe to the ice ball as monitored by ultrasonography was also determined. The contralateral kidney was removed to facilitate studies of renal function and all animals were killed on day 28 for autopsy and histopathologic examination. RESULTS A target temperature of less than -20 degrees C was achieved 3.1 mm behind the ice ball in all animals tested. The ice ball stabilized at a radius of 16 mm with prolonged treatment, suggesting that multiple probes will be required to treat renal lesions greater than 2.5 cm in diameter. Renal artery occlusion did not significantly alter the freezing process and provided no practical advantage. Renal function remained stable (final serum creatinine level 1.5 mg/dL or less) in all but 1 animal in which an obstructive stricture of the ureteropelvic junction developed. Effective tissue ablation was confirmed at the treatment site in all instances. CONCLUSIONS Renal cryoablative therapy is a nephron-sparing modality that can be delivered in a safe, efficacious, and reproducible manner. The treatment parameters defined in this study should allow for intelligent patient selection and rational administration of renal cryotherapy.

Intraoperative Evaluation of Renal Cell Carcinoma: A Prospective Study of the Role of Ultrasonography and Histopathological Frozen Sections

PURPOSE Nephron sparing surgery is being performed increasingly for treatment of renal cell carcinoma, including in select patients with a normal contralateral kidney. The number of tumors in the involved kidney (single versus multiple) and presence or absence of perinephric fat involvement (pathological stage T1 to 2 versus T3A) are important prognostic factors. In a prospective study we evaluated the accuracy of intraoperative histopathological frozen section analysis of renal capsular biopsies for assessing local tumor stage, and the accuracy of intraoperative ultrasonography for assessing tumor focality. MATERIALS AND METHODS Intraoperative frozen section biopsies and ultrasonography were compared with information obtained from preoperative computerized tomography (CT), intraoperative inspection of the kidney by the surgeon and permanent histopathological specimens. RESULTS We evaluated 99 patients (102 kidneys) with localized sold renal masses undergoing either radical nephrectomy (48) or nephron sparing surgery (54). Final pathological analysis revealed 95 renal cell carcinomas (stage T3A in 24), 6 oncocytomas and 1 angiomyolipoma. Multiple tumors were detected in 18 of 102 kidneys overall. Frozen section analysis identified 87% of the stage T3A lesions with no false-positive results, compared to CT, which only identified 67%. Ultrasonography identified 14 of 18 multifocal tumors (78%) and was not more accurate than the combination of CT and intraoperative inspection. However, during nephron sparing surgery ultrasonography was useful to localize the intrarenal extent of tumors (17 cases). CONCLUSIONS Our results clarify the role of intraoperative ultrasonography and frozen section analysis in patients undergoing nephron sparing surgery for renal cell carcinoma. Frozen section analysis may be useful in select patients with small peripheral tumors who are under consideration for elective nephron sparing surgery.

The role of intraoperative ultrasonography during laparoscopic adrenalectomy

BACKGROUND The role of laparoscopic intraoperative ultrasonography (IOUS) in intraoperative decision making has grown rapidly in recent years. The purpose of this study was to evaluate its usefulness during laparoscopic adrenalectomy. METHODS Since 1995, laparoscopic ultrasonography has been used to evaluate the adrenal gland and surrounding organs in selective laparoscopic adrenalectomies. IOUS was performed in 19 of 114 laparoscopic adrenalectomies. RESULTS IOUS effected a change in management in 68% of these patients. IOUS displayed the location of the gland after a failed attempt at open resection; the adrenal vein, expediting control in four operations; no extraadrenal involvement by two large lesions (benign); vascular invasion in one tumor (carcinoma), prompting open resection; periadrenal invasion by one metastatic cancer and lymph node involvement in another; a 7 mm hyperaldosteronoma; no adenoma in two cases; bilateral hyperplasia; and a 14 cm cyst originating from the adrenal gland. IOUS facilitated partial adrenalectomy in two patients and revealed centrally located adenomas in two others requiring total adrenalectomy. CONCLUSIONS Laparoscopic IOUS during adrenal operation is valuable in selected cases. It is helpful to locate the gland and vein, confirm the presence or absence of abnormality, discern the resectability of large masses, and facilitate a partial adrenalectomy when desirable.

Prospective, blinded comparison of laparoscopic ultrasonography vs. contrast-enhanced computerized tomography for liver assessment in patients undergoing colorectal carcinoma surgery.

PURPOSE: To prospectively and blindly compare intraoperative laparoscopic ultrasonography to preoperative contrast-enhanced computerized tomography in detecting liver lesions in colorectal cancer patients. Additionally, we compared conventional (open) intraoperative ultrasonography with bimanual liver palpation to contrast-enhanced computerized tomography in a subset of patients. METHODS: From December 1995 to March 1998, 77 consecutive patients underwent curative (n=63) or palliative (n=14) resections for colorectal cancer. All patients undergoing curative resections were randomized to either laparoscopic (n=34) or conventional (n=29) surgery after informed consent. All patients underwent contrast-enhanced computerized tomography, diagnostic laparoscopy, and laparoscopic ultrasonography before resection. In those patients who had conventional procedures, intraoperative ultrasonography with bimanual liver palpation was also done. All laparoscopic ultrasonography and intraoperative ultrasonography evaluations were performed by one of two radiologists who were blinded to the CT results. All hepatic segments were scanned using a standardized method. The yield of each modality was calculated using the number of lesions identified by each imaging modality divided by the total number of lesions identified. RESULTS: In 43 of the 77 patients, both the laparoscopic ultrasonography and CT scan were negative for any liver lesions. In 34 patients, a total of 130 lesions were detected by laparoscopic ultrasonography, CT, or both. When compared with laparoscopic ultrasonography, intraoperative ultrasonography with bimanual liver palpation identified one additional metastatic lesion and no additional benign lesions. laparoscopic ultrasonography identified two patients with mets who had negative preoperative contrast-enhanced computerized tomography. CONCLUSIONS: Laparoscopic ultrasonography of the liver at the time of primary resection of colorectal cancer yields more lesions than preoperative contrast-enhanced computerized tomography and should be considered for routine use during laparoscopic oncologic colorectal surgery.

Intraoperative laparoscopic liver ultrasonography for staging of colorectal cancer

PURPOSE: This study was undertaken to evaluate the feasibility of intraoperative laparoscopic ultrasonography (ILUS) to completely scan all anatomic segments of the liver through a single port site during laparoscopic resection for colorectal cancer. METHODS: ILUS was performed in patients who were undergoing laparoscopic colorectal cancer surgery using the following approach: 1) presence of a radiologist in the operating room; 2) introduction of the probe through a single cannula site; 3) standardized sequence of four probe positions on liver surface; 4) identification of all major vascular/biliary hepatic structures as a guideline to scan all parenchymal segments of the liver. RESULTS: Twenty-two patients who were undergoing laparoscopic colorectal cancer surgery were prospectively enrolled. Computed tomography (CT) scan films were available for an immediate comparative analysis in the first 12 cases. Mean duration of the procedure was 10 (range, 5–15) minutes. All major vascular and biliary structures were identified in all patients. Sixteen focal abnormalities were identified by ILUS, and ten focal abnormalities were identified by CT scan in the same seven patients. In one patient, detection of a suspected metastasis not seen by preoperative CT scan led to conversion of the surgical procedure to a laparotomy. CONCLUSIONS: ILUS is a safe and expeditious technique that permits scanning of all anatomic liver parenchyma segments through a single cannula site. Because intraoperative palpation of the liver is not possible during laparoscopic colorectal cancer surgery, ILUS should probably be a standard component of the curative laparoscopic colorectal cancer operation.

CT findings of perforated rectal carcinoma presenting as Fournier’s gangrene in the emergency department

We report a case of a perforated rectal adenocarcinoma presenting as Fournier’s in the emergency department. CT findings in this case confirmed the clinical diagnosis, established the extent of disease, and suggested the presence of an underlying rectal neoplasm as the primary source of infection.

Ergebnisse einer prospektiven Doppelblindstudie zur Evaluierung von laparoskopischer Sonographie versus Computertomographie bei der Erfassung von Leberherden im Rahmen der Operation kolorektaler Karzinome

Ziel der Studie war es, in einer prospektiven Doppelblindstudie die Qualitat von laparoskopischer Sonographie (LS) und kontrastmittel-verstarkter Computertomographie (CT) bei der Entdeckung von Lebermetastasen kolorektaler Karzinome zu vergleichen. Alle LS-Untersuchungen erfolgten durch 2 Radiologen, die die CT-Ergebnisse nicht kannten. Bei 43 von 77 Patienten fanden sich keinerlei Lasionen in LS und CT. Bei 34 Patienten fanden sich 13o Leberherde in LS, CT oder beiden. Alle 53 Leberzysten waren durch LS nachweisbar, nur 40 im CT. Von 25 Leberhamangiomen wurden 19 in der LS, 12 im CT gesehen. Durch LS konnten 2 Patienten mit Lebermetastasen identifiziert werden, deren CT unauffallig war. Insgesamt waren von 130 Leberherden 123 (95%) bei der LS und 101 (78%) im CT sichtbar. Die LS der Leber ist zur Metastasensuche bei laparoskopischen kolorektalen Operationen geeignet.