Rodrigo Frota

Minimally Invasive Nephron Sparing Management for Renal Tumors in Solitary Kidneys

PURPOSE We present a large series of minimally invasive nephron sparing surgery outcomes in solitary kidneys with a focus on treatment selection criteria, and oncological and functional outcomes. MATERIALS AND METHODS Of 1,019 patients who underwent minimally invasive nephron sparing surgery since September 1997 at our institution 36, 36 and 29 underwent laparoscopic partial nephrectomy, cryoablation and radio frequency ablation, respectively, for tumors in a solitary kidney. Data, including patient and tumor characteristics, surgery details, complications, and postoperative renal function and intermediate term oncological outcomes in each patient, were obtained by telephone contact or from charts. The 3 groups were compared for perioperative, functional and oncological outcomes. RESULTS On multivariate analysis tumor size, aspect and remnant kidney status were independent predictors of treatment selection. Cancer specific and overall survival at 2 years was 100% and 91.2% for laparoscopic partial nephrectomy, 88.5% and 88.5% for cryoablation, and 83.9% and 83.9% for radio frequency ablation, respectively. Disease-free survival was significantly better for laparoscopic partial nephrectomy than for cryoablation and radio frequency ablation (100% vs 69.6% and 33.2%, respectively, p <0.0001). The mean estimated glomerular filtration rate change for laparoscopic partial nephrectomy, cryoablation and radio frequency ablation of 17, 3 and 7 ml per minute per 1.73 m(2) reflected a 26%, 6% and 13% decrease from baseline, respectively, which was statistically significant (p = 0.0016). CONCLUSIONS Laparoscopic partial nephrectomy and probe ablative procedures can be safely and efficiently done for renal tumor in patients with a solitary kidney. Intermediate term oncological outcomes are superior for laparoscopic partial nephrectomy despite somewhat poorer renal function outcomes than those of cryoablation and radio frequency ablation.

Risk factor analysis of postoperative complications in laparoscopic partial nephrectomy.

PURPOSE We evaluate our experience with laparoscopic partial nephrectomy to determine risk factors for postoperative complications. MATERIALS AND METHODS A prospectively maintained database of 507 laparoscopic partial nephrectomy procedures since September 1999 was retrospectively analyzed with emphasis on postoperative complications. Severity of complications was graded using a 5-tiered scale based on National Cancer Institute Common Toxicity Criteria Version 2.0 reporting criteria. Complication rates were compared between 1999 to 2002 and 2003 to 2006. Multivariate analysis of baseline and perioperative variables was performed to identify risk factors associated with postoperative complications for the 2 eras. RESULTS After 507 laparoscopic partial nephrectomy procedures 93 patients (19.7%) had 107 complications, including 49 urological (9.7%) and 58 nonurological (11.4%). Of the complications, 20.6% were grade I, 45% were grade II, 30% were grade III, 4.7% were grade IV and none were grade V. On multivariate analysis, presence of a solitary kidney (1999 to 2002 p = 0.0115, 2003 to 2006 p = 0.0045), increased warm ischemia time (1999 to 2002 p = 0.0399, 2003 to 2006 p = 0.0066) and increased estimated blood loss (1999 to 2002 p = 0.0224, 2003 to 2006 p = 0.0293) were significant predictors of overall postoperative complications for the 2 eras. Compared to the 1999 to 2002 era, the 2003 to 2006 era witnessed a dramatic increase in number of total laparoscopic partial nephrectomy procedures (100% increase) and complex tumors (132% increase), yet overall (p = 0.001), urological (p = 0.03) and nonurological (p = 0.02) complications decreased significantly. CONCLUSIONS Prolonged warm ischemia, increased intraoperative blood loss and solitary kidney status increase the likelihood of postoperative complications after laparoscopic partial nephrectomy. With experience the incidence of complications has decreased significantly despite a significant increase in tumor and procedural complexity.

Comparison of radical prostatectomy techniques: open, laparoscopic and robotic assisted

INTRODUCTION To review the current status of laparoscopic radical prostatectomy (LRP) and robotic assisted radical prostatectomy (RALP) in relation to radical retropubic prostatectomy (RRP) in the management of localized prostate cancer. MATERIALS AND METHODS Between 1982 and 2007 published literature was reviewed using the National Library of Medicine database and the following key words: retropubic, laparoscopic, robotic, robot-assisted, and radical prostatectomy. Special emphasis was given to the technical and cost considerations as well as operative, functional and oncologic outcomes. In particular, reports with pioneering work that have contributed to the evolution of the technique, presenting comparative outcomes and with large series encompassing intermediate/long term follow-up, were taken into account. RESULTS After intermediate term follow-up, LRP and RALP achieved similar oncologic and functional results compared to RRP. However, LRP and RALP were associated with decreased blood loss, faster convalescence and better cosmetics when compared to RRP. The RALP technique is undoubtedly more expensive. CONCLUSIONS The oncologic and functional outcomes for LRP and RALP are similar to RRP after intermediate term follow-up. Long term follow-up and adequately designed studies will determine the inherent advantages and disadvantages of the individual techniques in the management of localized prostate cancer.

Laparoscopic Partial Nephrectomy versus Laparoscopic Cryoablation for Multiple Ipsilateral Renal Tumors

BACKGROUND Management of multiple ipsilateral renal tumors is a dilemma in clinical practice. The effects of minimally invasive nephron-sparing procedures in this group of patients have not been assessed. OBJECTIVE To evaluate the technical feasibility and outcomes of laparoscopic partial nephrectomy (LPN) and laparoscopic cryoablation (LCA) for multiple ipsilateral renal tumors. DESIGN, SETTING, AND PARTICIPANTS Between September 1999 and December 2006, 27 patients were treated with minimally invasive nephron sparing surgery (LPN or LCA) for synchronous multiple ipsilateral renal tumors in a single operating session at our institution. Fourteen patients with 28 tumors underwent LPN, and 13 patients with 31 tumors underwent LCA as the sole treatment modality. INTERVENTION Medical records were retrospectively reviewed and data were collected. MEASUREMENTS Demographic, intraoperative, postoperative, and intermediate-term follow-up data were compared between the two groups. RESULTS AND LIMITATIONS Patients in the LPN group had fewer tumors (2 vs. 2.4, p=0.04) and larger dominant tumor size (3.6 vs. 2.5 cm, p=0.005) in the affected kidney and lower preoperative serum creatinine levels (1 vs. 1.4 mg/dl, p=0.02). Compared to the LCA group, patients in the LPN group had greater estimated blood loss (200 vs. 125 ml, p=0.02) and longer hospital stays (90 vs. 52.3h, p=0.02). There were no open conversions, and no kidneys were lost. Complication rate, renal functional outcomes, and intermediate-term cancer-specific survival rates were similar between the two groups. CONCLUSIONS Both LPN and LCA are viable options for patients with multiple ipsilateral renal tumors in select patients. Renal functional outcomes, complication rates, and intermediate-term survival rates are comparable between the two groups in this small series.

The effect of prostate weight on the outcomes of laparoscopic radical prostatectomy

Associate Editor

Simultaneous laparoscopic nephroureterectomy and cystectomy: a preliminary report

PURPOSE Patients with muscle-invasive bladder cancer and concomitant upper urinary tract tumors may be candidates for simultaneous cystectomy and nephroureterectomy. Other clinical conditions such as dialysis-dependent end-stage renal disease and non-functioning kidney are also indications for simultaneous removal of the bladder and kidney. In the present study, we report our laparoscopic experience with simultaneous laparoscopic radical cystectomy (LRC) and nephroureterectomy. MATERIALS AND METHODS Between August 2000 and June 2007, 8 patients underwent simultaneous laparoscopic radical nephroureterectomy (LNU) (unilateral-6, bilateral-2) and radical cystectomy at our institution. Demographic data, pathologic features, surgical technique and outcomes were retrospectively analyzed. RESULTS The laparoscopic approach was technically successful in all 8 cases (7 males and 1 female) without the need for open conversion. Median total operative time, including LNU, LRC, pelvic lymphadenectomy and urinary diversion, was 9 hours (range 8-12). Median estimated blood loss and hospital stay were 755 mL (range 300-2000) and 7.5 days (range 4-90), respectively. There were no intraoperative complications but only 1 major and 2 minor postoperative complications. The overall and cancer specific survival rates were 37.5% and 87.5% respectively at a median follow-up of 9 months (range 1-45). CONCLUSIONS Laparoscopic nephroureterectomy with concomitant cystectomy is technically feasible. Greater number of patients with a longer follow-up is required to confirm our results.

Feasibility of Laparoscopic Partial Nephrectomy After Previous Ipsilateral Renal Procedures

OBJECTIVES Previous renal surgery has been considered a relative contraindication to laparoscopic partial nephrectomy (LPN) because of perirenal surgical adhesions. We present our experience with LPN in patients with previous ipsilateral renal surgery. METHODS Of 679 patients undergoing LPN for a renal mass from September 1999 to November 2006, 25 (3.7%) had undergone previous ipsilateral open or percutaneous renal procedures. The LPN technique included hilar clamping, cold tumor excision, and sutured renal reconstruction. The perioperative outcomes were retrospectively analyzed from a prospectively maintained database. RESULTS Previous renal surgery included open surgery in 12 patients (nephro/pyelolithotomy in 8, pyeloplasty in 2, and partial nephrectomy in 2) and percutaneous surgery in 13 (percutaneous nephrolithotomy in 9 and renal biopsy in 4). The mean interval from previous surgery was 6.6 years (range 0.3-34). LPN (16 transperitoneal and 9 retroperitoneal) was successful in all patients. The mean tumor size was 2.5 cm (range 1-5.6), the warm ischemia time was 35.8 minutes (range 22-57), and the estimated blood loss was 215 mL (range 25-600). The mean operative time was 3 hours (range 1.5-4.5), and the hospital stay was 3.1 days (range 1-7.6). Histopathologic examination confirmed renal cell carcinoma in 19 patients (76%). No open conversions were needed, and no kidneys were lost. No intraoperative complications and 3 postoperative complications (12%) developed, including blood transfusion in 1, nausea and epistaxis in 1, and compartment syndrome requiring fasciotomy in 1 patient. CONCLUSIONS The results of our study have shown that, in select patients, LPN is feasible after previous ipsilateral renal surgery. However, it can be technically challenging, and adequate previous experience with LPN is necessary.

Laparoscopic partial cystectomy for urachal and bladder cancer

PURPOSE To report our initial experiences with laparoscopic partial cystectomy for urachal and bladder malignancy. MATERIALS AND METHODS Between March 2002 and October 2004, laparoscopic partial cystectomy was performed in 6 cases at 3 institutions; 3 cases were urachal adenocarcinomas and the remaining 3 cases were bladder transitional cell carcinomas. All patients were male, with a median age of 55 years (45–72 years). Gross hematuria was the presenting symptom in all patients, and diagnosis was established with trans-urethral resection bladder tumor in 2 patients and by means of cystoscopic biopsy in the remaining 4 patients. Laparoscopic partial cystectomy was performed using the transperitoneal approach under cystoscopic guidance. In each case, the surgical specimen was removed intact entrapped in an impermeable bag. One patient with para-ureteral diverticulum transitional cell carcinoma required concomitant ureteral reimplantation. RESULTS All six procedures were completed laparoscopically without open conversion. The median operating time was 110 minutes (90–220) with a median estimated blood loss of 70 mL (50–100). Frozen section evaluations of bladder margins were routinely obtained and were negative for cancer in all cases. The median hospital stay was 2.5 days (2–4) and the duration of catheterization was 7 days. There were no intraoperative or postoperative complications. Final histopathology confirmed urachal adenocarcinoma in 3 cases and bladder transitional cell carcinoma in 3 cases. At a median follow-up of 28.5 months (range: 26 to 44 months), there was no evidence of recurrent disease as evidenced by radiologic or cystoscopic evaluation. CONCLUSIONS Laparoscopic partial cystectomy in carefully selected patients with urachal and bladder cancer is feasible and safe, offering a promising and minimally invasive alternative for these patients.

Are prostate needle biopsies predictive of the laterality of significant cancer and positive surgical margins

To determine whether data obtained from preoperative prostate needle biopsy can predict the laterality of significant cancer and positive surgical margins on final‐specimen pathology after laparoscopic radical prostatectomy (LRP).

The use of an endoscopic stapler vs suture ligature for dorsal vein control in laparoscopic prostatectomy : operative outcomes

To identify differences in operative outcome between methods of controlling the dorsal vein complex during laparoscopic prostatectomy, i.e. suture ligature or stapling with an endoscopic stapler (Endopath ETS Flex 45 linear stapler; Ethicon, Cincinnati, OH, USA).