Manuel Eisenberg

Zero Ischemia Anatomical Partial Nephrectomy: A Novel Approach

PURPOSE We present a novel concept of zero ischemia anatomical robotic and laparoscopic partial nephrectomy. MATERIALS AND METHODS Our technique primarily involves anatomical vascular microdissection and preemptive control of tumor specific, tertiary or higher order renal arterial branch(es) using neurosurgical aneurysm micro-bulldog clamps. In 58 consecutive patients the majority (70%) had anatomically complex tumors including central (67%), hilar (26%), completely intrarenal (23%), pT1b (18%) and solitary kidney (7%). Data were prospectively collected and analyzed from an institutional review board approved database. RESULTS Of 58 cases undergoing zero ischemia robotic (15) or laparoscopic (43) partial nephrectomy, 57 (98%) were completed without hilar clamping. Mean tumor size was 3.2 cm, mean ± SD R.E.N.A.L. score 7.0 ± 1.9, C-index 2.9 ± 2.4, operative time 4.4 hours, blood loss 206 cc and hospital stay 3.9 days. There were no intraoperative complications. Postoperative complications (22.8%) were low grade (Clavien grade 1 to 2) in 19.3% and high grade (Clavien grade 3 to 5) in 3.5%. All patients had negative cancer surgical margins (100%). Mean absolute and percent change in preoperative vs 4-month postoperative serum creatinine (0.2 mg/dl, 18%), estimated glomerular filtration rate (-11.4 ml/minute/1.73 m(2), 13%), and ipsilateral kidney function on radionuclide scanning at 6 months (-10%) correlated with mean percent kidney excised intraoperatively (18%). Although 21% of patients received a perioperative blood transfusion, no patient had acute or delayed renal hemorrhage, or lost a kidney. CONCLUSIONS The concept of zero ischemia robotic and laparoscopic partial nephrectomy is presented. This anatomical vascular microdissection of the artery first and then tumor allows even complex tumors to be excised without hilar clamping. Global surgical renal ischemia is unnecessary for the majority of patients undergoing robotic and laparoscopic partial nephrectomy at our institution.

Anatomic renal artery branch microdissection to facilitate zero-ischemia partial nephrectomy.

BACKGROUND Robot-assisted and laparoscopic partial nephrectomies (PNs) for medial tumors are technically challenging even with the hilum clamped and, until now, were impossible to perform with the hilum unclamped. OBJECTIVE Evaluate whether targeted vascular microdissection (VMD) of renal artery branches allows zero-ischemia PN to be performed even for challenging medial tumors. DESIGN, SETTING, AND PARTICIPANTS A prospective cohort evaluation of 44 patients with renal masses who underwent robot-assisted or laparoscopic zero-ischemia PN either with anatomic VMD (group 1; n=22) or without anatomic VMD (group 2; n=22) performed by a single surgeon from April 2010 to January 2011. INTERVENTION Zero-ischemia PN with VMD incorporates four maneuvers: (1) preoperative computed tomographic reconstruction of renal arterial branch anatomy, (2) anatomic dissection of targeted, tumor-specific tertiary or higher-order renal arterial branches, (3) neurosurgical aneurysm microsurgical bulldog clamp(s) for superselective tumor devascularization, and (4) transient, controlled reduction of blood pressure, if necessary. MEASUREMENTS Baseline, perioperative, and postoperative data were collected prospectively. RESULTS AND LIMITATIONS Group 1 tumors were larger (4.3 vs 2.6 cm; p=0.011), were more often hilar (41% vs 9%; p=0.09), were medial (59% and 23%; p=0.017), were closer to the hilum (1.46 vs 3.26 cm; p=0.0002), and had a lower C index score (2.1 vs 3.9; p=0.004) and higher RENAL nephrometry scores (7.7 vs 6.2; p=0.013). Despite greater complexity, no group 1 tumor required hilar clamping, and perioperative outcomes were similar to those of group 2: operating room time (4.7 and 4.1h), median blood loss (200 and 100ml), surgical margins for cancer (all negative), major complications (0% and 9%), and minor complications (18% and 14%). The median serum creatinine level was similar 2 mo postoperatively (1.2 and 1.3mg/dl). The study was limited by the relatively small sample size. CONCLUSIONS Anatomic targeted dissection and superselective control of tumor-specific renal arterial branches facilitate zero-ischemia PN. Even challenging medial and hilar tumors can be excised without hilar clamping. Global surgical renal ischemia has been eliminated for most patients undergoing PN at our institution.

Lymph Node Dissection Technique Is More Important Than Lymph Node Count in Identifying Nodal Metastases in Radical Cystectomy Patients: A Comparative Mapping Study

BACKGROUND The value of lymph node dissection (LND) in the treatment of bladder urothelial carcinoma is well established. However, standards for the quality of LND remain controversial. OBJECTIVE We compared the distribution of lymph node (LN) metastases in a two-institution cohort of patients undergoing radical cystectomy (RC) using a uniformly applied extended LND template. DESIGN, SETTING, AND PARTICIPANTS Patients undergoing RC at the University of Southern California (USC) Institute of Urology and at Oregon Health Sciences University (OHSU) were included if they met the following criteria: (1) no prior pelvic radiotherapy or LND; (2) lymphatic tissue submitted from all nine predesignated regions, including the paracaval and para-aortic LNs; (3) bladder primary; and (4) category M0 disease. The number and location of LN metastases were prospectively entered into corresponding databases. MEASUREMENTS LN maps were constructed and correlated with preoperative and pathologic characteristics. Kaplan-Meier curves were constructed to estimate overall survival (OS) and recurrence free survival (RFS) among LN-positive (LN+) patients. RESULTS AND LIMITATIONS Inclusion criteria were met by 646 patients (439 USC, 207 OHSU), and 23% had LN metastases at time of cystectomy. Although there was a difference in the median per-patient LN count between institutions, there were no significant interinstitutional differences in the incidence or distribution of positive LNs, which were found in 11% of patients with ≤pT2b and in 44% of patients with ≥pT3a tumors. Among LN+ patients, 41% had positive LNs above the common iliac bifurcation. Estimated 5-yr RFS and OS rates for LN+ patients were 45% and 33%, respectively, and did not differ significantly between institutions. CONCLUSIONS LN metastases in regions outside the boundaries of standard LND are common. Adherence to meticulous dissection technique within an extended template is likely more important than total LN count for achieving optimal oncologic outcomes.

Early Complications of Cystectomy After High Dose Pelvic Radiation

PURPOSE Radical cystectomy in patients with a history of pelvic radiation therapy is often a challenging and morbid procedure. We report early complication rates in patients undergoing cystectomy and urinary diversion after high dose pelvic radiation. MATERIALS AND METHODS From 1983 to 2008, 2,629 patients underwent cystectomy with urinary diversion at a single institution. Of these patients 148 received 60 Gy or greater pelvic radiation therapy before surgery. Patient medical records were retrospectively reviewed and any complication within 90 days of surgery was graded using the Clavien-Dindo system. RESULTS Median patient age was 74 years with a median American Society of Anesthesiologists score of 3. Patients received a median of 70 Gy pelvic radiation therapy a median of 2.3 years before surgery. Urinary diversions performed were ileal conduit in 65 patients (43.9%), continent cutaneous pouch in 35 (23.6%) and orthotopic neobladder in 48 (32.4%). A total of 335 early complications were identified. The highest grade complication was 0 in 23% of the patients, grade 1 in 12.2%, grade 2 in 32.4%, grade 3 in 18.9%, grade 4 in 7.4% and grade 5 in 6.1%. Age older than 65 years and American Society of Anesthesiologists score were statistically significant predictors of postoperative complications (p=0.0264 and p=0.0252, respectively). The type of urinary diversion did not significantly affect the grade distribution or number of early complications per patient (p=0.7444 and p=0.1807, respectively). CONCLUSIONS The early complication rate using a standardized reporting system in patients undergoing radical cystectomy after radiation therapy is higher than previously published in nonirradiated subjects. Age and American Society of Anesthesiologists score but not urinary diversion type were associated with early complications in this population.

Laparoendoscopic single-site nephrectomy in pediatric patients: initial clinical series of infants to adolescents.

OBJECTIVES To present our initial clinical series of laparoendoscopic single-site (LESS) nephrectomy using an umbilical incision in children ranging from infants to adolescents. Laparoscopic surgery in pediatric urology is increasingly being performed for many intra-abdominal ablative procedures, such as nephrectomy for poorly functioning kidneys. We have previously reported our initial experience with LESS surgery in the adult population. METHODS A total of 11 pediatric patients (age range 0.1-16.2 years, mean 5.7) underwent LESS nephrectomy using an umbilical incision. The perioperative clinical parameters were reviewed retrospectively. RESULTS The 11 LESS pediatric nephrectomies were technically successful without conversion to conventional laparoscopy or open surgery. An accessory port was used in 5 of the cases early in the clinical series. Of the 11 patients, 2 were infants, aged 39 days and 3.5 months. The mean operative time was 139 minutes (range 85-205), and the mean hospital stay was 1.5 days (range 1.0-2.1). Complications included delayed hydrocele formation in 2 male patients. CONCLUSIONS The results of our study have shown that LESS nephrectomy using a single umbilical incision in pediatric patients is technically feasible with good outcomes. Additional studies are needed to evaluate the expected benefits of this novel technique. Also, miniaturization of currently available equipment is needed to adapt to the small working spaces available in the pediatric patient.

Laparoendoscopic single-site surgery in urology.

Purpose of review To analyze the current literature regarding advances in laparoscopic single-site (LESS) surgery in urology. Recent findings Since its initial urologic description in 2007, there has been a surge of interest in LESS surgery. Published descriptions of LESS procedures now include virtually all extirpative and reconstructive urologic procedures. Novel instrumentation and techniques have been developed that offset many of the inherent increased technical demands with LESS surgery. Substantial clinical data have recently been reported that attest to the safety and efficacy of LESS surgery in select patients. Initial data have also been reported comparing morbidity outcomes with standard laparoscopy. Summary LESS is now an established technique within the field of minimally invasive urologic surgery. Further study is needed to determine the true benefits of the technique and the extent of its clinical application. Further refinements in technology will likely be needed before the widespread adoption of LESS.

Innovations in laparoscopic and robotic partial nephrectomy: a novel 'zero ischemia' technique.

Purpose of review To describe a novel ‘zero ischemia’ technique for laparoscopic and robotic partial nephrectomy. Recent findings Laparoscopic partial nephrectomy has been performed in 15 patients without the need for warm ischemia by utilizing pharmalogically induced hypotension. This consecutive series includes complex tumors in patients with multiple comorbidities. Herein we describe our current practice, initial results, and several practical considerations associated with the application of this novel technique. Summary Initial results with our ‘zero ischemia’ technique have been encouraging. Evaluation of long-term outcomes is ongoing.

Current status of laparoscopic partial nephrectomy.

Purpose of review As familiarity with laparoscopic partial nephrectomy (LPN) has grown, application has expanded into increasingly complex cases. In this review, we present a recent series describing use of LPN in specific clinical scenarios and describe common technical modifications commonly employed in each case. In addition, we discuss modifications to standardly performed maneuvers. Recent findings Partial nephrectomy was originally reserved for absolute indications and small peripheral masses. However, well tolerated utilization of LPN in larger and more complex tumors including those in hilar or central locations, in kidneys with multiple masses, and in patients with previous renal surgery have been described. Additionally, patients with comorbidities such as obesity, and anatomic variations including multiple renal vessels and solitary kidneys have also undergone LPN with success. Furthermore, modifications to standard techniques have helped improve perioperative characteristics, such as warm ischemia time, to levels comparable to open surgery. Although many of the LPN series are small, they represent the most recent novel applications of the technique. Summary LPN is a continuously evolving technique, and with case specific modifications can be safely performed in a wide range of clinical scenarios by sufficiently experienced hands.

Predicting survival after radical cystectomy: Validation of the SPARC score.

326 Background: The Survival Prediction After Radical Cystectomy (SPARC) score (Eisenberg et al, J Urol 2013) incorporates clinical and pathologic features to predict cancer specific survival (CSS) for urothelial carcinoma of the bladder. Validation of this model would improve its generalizability. Methods: Using the IRB-approved bladder cancer database at the University of Southern California (USC), we identified patients who underwent radical cystectomy (RC) for urothelial carcinoma of the bladder for curative intent from 1971-2009. Clinical factors (Charlson comorbidity index, ECOG performance status, hydronephrosis, adjuvant chemotherapy, smoking status) and pathologic factors (pathologic T stage, nodal status, multifocality, and lymphovascular invasion) included in the SPARC score were obtained. Patients were excluded if there were missing variables or if they underwent neoadjuvant chemotherapy. Associations between clinicopathologic factors and CSS were evaluated using Cox proportional hazards. Cali...

1979 INCIDENCE OF LYMPH NODE METASTASES ABOVE THE ILIAC BIFURCATION IN PATIENTS UNDERGOING RADICAL CYSTECTOMY WITH EXTENDED LYMPH NODE DISSECTION

NSAIDs, corticosteroids, finasteride, dutasteride, were not enrolled. On biopsy and on surgical specimens were evaluated changes in flogosis parameters (extensions,and grading according to score of Nickel) and density of Tcells, Bcells and macrophages (mean value of CD20, CD3, CD 68, CD8). RESULTS: Flogosis in the I group at baseline was: extensive (0%), multifocal(80%), focal (20%).The grading was: severe (20%), moderate (80%), mild (20%). After 6 months extension and grade of flogosis was reduced(100% focal;100% mild respectively)(p 0,05). The mean value of CD20, CD3, CD68,CD8, at baseline was of 14.8, 6.4, 5.9, 12.5: after 6 months the mean value was reduced (14.2,6,4.4,5 respectively)(p 0,05). In the subset IIB flogosis was extensive (0%), multifocal(46.1%), focal (53.9%);the grading was severe(7%),moderate(21%), mild(72%). The mean value of CD20, CD3, CD68, CD8 was respectively 40.6, 18.6, 6.7, 6. The subset IIA showed a reduction in the extension (focal 74%, multifocal 26%; extensive 0%),and in the grade of flogosis(mild 75%; moderate 20.8%; severe 4.1%)(p 0,05). Mean value of CD20, CD3,CD68, CD8 was 25.8, 12.7, 5.3, 4.1 respectively: analyzing the results we have a statistically significant reduction of Tcells, Bcells and macrophages(p 0,05). CONCLUSIONS: SeR LY Se may have an anti-inflammatory activity that might be of particular interest in BPH treatment.