Sean P. Hedican

Meta-analysis of the complications of laparoscopic renal surgery : Comparison of procedures and techniques

PURPOSE We performed a meta-analysis of the literature to define the current expectations of complications during laparoscopic renal surgery. MATERIALS AND METHODS References were searched in the MEDLINE database from 1995 to 2004 using the terms complications and laparoscopic nephrectomy. Inclusion criteria were any series with greater than 20 cases, patient age older than 16 years and any complications listed for certain procedures, including laparoscopic radical nephrectomy, HA laparoscopic radical nephrectomy, LPN, HALPN, laparoscopic donor nephrectomy, HA laparoscopic donor nephrectomy, laparoscopic simple nephrectomy, laparoscopic nephroureterectomy and retroperitoneal laparoscopic nephrectomy. A data extraction form was created to categorize major or minor complications. A 5 member panel adhered to the strict criteria and extracted data from articles that met inclusion criteria. Data were entered into a spreadsheet and a meta-analysis was performed. RESULTS Initial review identified 73 of 405 references that were acceptable for retrieval and data extraction, of which 56 met inclusion criteria. The overall major and minor complication rates of laparoscopic renal surgery were 9.5% and 1.9%, respectively. There was a significant difference between the major complication rates of LPN and HALPN (21.0% vs 3.3%, p <0.05). CONCLUSIONS Our results show that patients who undergo laparoscopic renal surgery may have an overall major complication rate of 9.5%. The highest major complication rate is associated with technically challenging LPN (21%). There appears to be a significantly higher wound complication rate associated with HA surgery in comparison to that of standard laparoscopy (1.9% vs 0.2%, p <0.05).

Comparison of Percutaneous and Laparoscopic Cryoablation for the Treatment of Solid Renal Masses

OBJECTIVE The goal of this study was to compare the outcome, complications, and charges of percutaneous renal cryoablation and laparoscopic cryoablation of solid renal masses. MATERIALS AND METHODS A total of 30 percutaneous renal cryoablations (mean tumor size, 2.1 cm) in 30 patients (mean age, 67.0 years) and 60 laparoscopic renal cryoablations (mean tumor size, 2.5 cm) in 46 patients (mean age, 67.4 years) were compared. The size of the tumor, procedural complications, hospital charges, length of hospital stay, and tumor follow-up parameters were recorded. Monitoring after ablation was performed every 3 months using contrast-enhanced MRI or CT. RESULTS Both percutaneous cryoablation and laparoscopic cryoablation of solid renal masses had a high technical success rate (30/30 [100%] and 59/60 [98.3%]). There was no significant difference in the rate of residual disease (3/30 [10%] and 4/60 [6.7%], p = 0.68), and the secondary effectiveness rate is 100% for both groups to date. One renal mass treated using laparoscopic cryoablation had a local recurrence, but none of the masses treated using percutaneous cryoablation had a recurrence. The disease-specific survival is 100% in both groups with no significant difference in the mean follow-up time (14.5 vs 14.6 months, p = 1.0) or major complication rate (0/30 [0%] vs 3/60 [5.0%], p = 0.55). For the treatment of solid renal masses, percutaneous cryoablation was associated with 40% lower hospital charges (mean,

Comparison of Postoperative Pain, Convalescence, and Patient Satisfaction after Laparoscopic and Percutaneous Ablation of Small Renal Masses

14,175 vs

Cryoablation of small renal masses: assessment of the outcome at one institution

23,618, p < 0.00001) and a shorter hospital stay (mean +/- SD, 1.1 +/- 0.3 vs 2.4 +/- 2.1 days; p < 0.0001) than laparoscopic cryoablation. CONCLUSION Although certain tumors require laparoscopic intervention because of the location or size of the tumor, percutaneous renal cryoablation is safe and effective and is associated with lower charges when used for the treatment of small renal tumors.

Laparoscopic Cryoablation under Sonographic Guidance for the Treatment of Small Renal Tumors

PURPOSE To compare the convalescence and patient satisfaction between laparoscopic and percutaneous ablation for management of small renal masses. METHODS We performed a telephone survey comparing convalescence and operative satisfaction of patients who underwent laparoscopic and percutaneous ablation between October 2000 and June 2006 at our institution. A retrospective chart review was performed to compare perioperative and postoperative convalescence parameters. RESULTS A total of 93 patients underwent ablation of 103 small renal masses at our institution. Laparoscopic cryoablation was performed in 58 patients, percutaneous cryoablation in 20, and percutaneous radiofrequency ablation in 15 patients. Mean patient age was 66 years (range 24-86 years), median ASA (American society of Anesthesiologists) score was 3, and mean body mass index (BMI) was 30 kg/mm(2). There was no significant difference in the mean age, BMI, and median ASA scores between the groups. The mean diameter of the treated mass was slightly larger in the laparoscopic ablation group (2.6 cm) compared with masses in the percutaneous cryoablation (2.2 cm, P=0.027) and percutaneous radiofrequency ablation (2.2 cm, P=0.042) groups. All procedures were performed under general anesthesia. Compared with laparoscopic cryoablation, percutaneous cryoablation was associated with fewer probes used per lesion (P<0.04), shorter mean anesthesia time (P=0.001), shorter mean hospital stay (P=0.007), early return to nonstrenuous activity (P=0.007), and shorter time to complete recovery (P = 0.05). Similarly, compared with laparoscopic cryoablation, percutaneous radiofrequency ablation was associated shorter mean anesthesia time (P<0.001), early return to nonstrenuous activity (P=0.009), early return to strenuous activity (P=0.007), early return to strenuous activity (P=0.04), and early return to work (P=0.05). There was no difference in the percent of patients who had a preablation biopsy, the median opioid analgesic requirement, and patient satisfaction measured on a 0 to 5 scale between various groups. CONCLUSION Our study suggests that percutaneous ablation in carefully selected patients is associated with early convalescence compared with laparoscopic ablation.

Current Practice Patterns in the Use of Ablation Technology for the Management of Small Renal Masses at Academic Centers in the United States

To report our 5‐year experience with laparoscopic and percutaneous cryoablation (LCA and PCA) for managing small renal masses.

Early hypofractionated salvage radiotherapy for postprostatectomy biochemical recurrence

PURPOSE To evaluate the efficacy of ultrasound-guided laparoscopic cryoablation of small renal tumors. PATIENTS AND METHODS Eleven men and five women with solid renal tumors (mean size 2.6 cm) were treated using laparoscopically monitored cryoablation between October 2000 and October 2002. Nine tumors were left sided and seven right. Ten patients were treated retroperitoneoscopically and six transperitoneally. A double-freeze/active-thaw technique was utilized with two 10-minute freeze cycles. RESULTS The mean operating time was 188 minutes. There was one open conversion for failure to progress. The mean blood loss was 40 mL. Tumor biopsy demonstrated five renal-cell carcinomas, two oncocytomas, and lesions that either were benign or were not biopsied. The mean hospital stay was 1.9 days with a median stay of 1 day. With a mean follow-up of 9.6 months, all tumors remain nonenhancing and are stable or smaller than the original lesion. Two patients have died of unrelated causes and without evidence of disease. CONCLUSIONS This series of patients adds to the growing body of literature suggesting that cryoablation is a well-tolerated method for treating small renal tumors. Longer follow-up is required to fully define its place in the therapeutic armamentarium.

Hand-assisted laparoscopic renal surgery in the morbidly and profoundly obese.

OBJECTIVES To determine the current practice patterns in the use of ablation technology for the management of small renal masses at academic centers in the United States. METHODS An email survey was sent to 112 academic urologists subspecializing in minimally invasive management of renal cancer. The survey consisted of 13 questions and 4 clinical scenarios pertaining to the use of ablation technology. The responses were then tabulated and analyzed to determine practice trends. RESULTS The overall response rate was 62%. Ablation was offered by 93% of the academic urology centers and cryoablation was more frequently used (79%) than radiofrequency ablation (55%). Lack of sufficient efficacy data was the most prevalent reason (80%) for not offering ablation. The maximum size limit for offering ablation was 4 cm by 55% and 3 cm by 34% of the respondents. A collaborative approach using both radiologist and urologist was most commonly used (51%). Most urologists (68%) used both laparoscopic and percutaneous technique, depending on the tumor and adjacent organ location. Intraoperative ultrasound was universally used during the laparoscopic technique and was usually performed by the urologist (95%). Computed tomographic scan was the most frequently used imaging modality for percutaneous ablation (78%) and for surveillance of recurrent disease (81%). In a younger, healthy patient, most urologists recommend extirpative approach for the management of a small renal mass, whereas laparoscopic-assisted ablation was most commonly recommended for an elderly patient with comorbidities. CONCLUSIONS Our survey suggests that laparoscopic and percutaneous ablation is offered by the majority of academic centers for carefully selected patients.

Reduced bladder cancer recurrence rate with cardioprotective aspirin after intravesical bacille Calmette‐Guérin

Postprostatectomy adjuvant or salvage radiotherapy, when using standard fractionation, requires 6.5 to 8 weeks of treatment. The authors report on the safety and efficacy of an expedited radiotherapy course for salvage prostate radiotherapy.

Ablation of small renal masses: practice patterns at academic institutions in the United States.

BACKGROUND AND PURPOSE Obesity has been regarded as a relative contraindication to standard laparoscopic procedures. We evaluated the impact of morbid (body mass index [BMI] >30 kg/m2) and profound (BMI > 40 kg/m2) obesity on the results of hand-assisted laparoscopic renal surgery (HALRS). PATIENTS AND METHODS From September 1996 until October 2002, a total of 30 patients among 105 on whom HALRS was performed at our institution were morbidly obese, with a mean BMI of 35.8 kg/m2 (range 30.3-52.3 kg/m2). Eight patients were noted to have profound obesity, with a mean BMI of 44 kg/m2 (range 40.1-52.3 kg/m2). The HALRS procedures included radical nephrectomy in 23 patients, simple nephrectomy in 4, nephroureterectomy in 2, and partial nephrectomy in 1. At least one additional significant comorbidity was noted in 70% of these patients. We retrospectively evaluated the intraoperative and postoperative outcomes in this group of obese patients. RESULTS All procedures were performed successfully without the need for open conversion. The mean operative time was 262 minutes (range 125-361 minutes), and the mean estimated blood loss was 217 mL (range 50-600 mL). No transfusions or intraoperative complications occurred. The mean hospital stay was 4.1 days (range 2-13 days). There were 7 minor postoperative complications including ileus (N = 5), wound cellulitis (1), and urinary retention (1). No complications occurred in the profoundly obese patient subgroup. CONCLUSIONS Hand-assisted laparoscopic renal surgery is safe and effective in the morbidly and profoundly obese patient.