Tom Deklaj

Laparoscopic partial nephrectomy: a single-center evolving experience.

OBJECTIVES To review our laparoscopic partial nephrectomy (LPN) experience, examine the evolution of technique, and compare the outcomes between the early and recent experience. The indications and surgical technique of LPN continuously evolve. METHODS Data for 184 patients who underwent LPN for a tumor between October 2002 and August 2008 was retrieved from a prospective database. Surgical and functional outcomes for the entire cohort were analyzed and the first 50 (group 1) and most recent 50 (group 2) cases were compared. RESULTS The groups were similar in terms of baseline renal function, body mass index, and comorbidities. The mean tumor size and the proportion of central tumors in groups 1 and 2 were 2.4 vs 3 cm and 12% vs 52%, respectively (P <.003). In group 2 we stopped the use of ureteral catheters and bolster renorrhaphy, and routinely clamped the renal hilum. Mean warm ischemia time in groups 1 and 2 (30 and 27 minute, respectively, P = .3) and the complication rate were similar. Overall, patients with tumors >4 cm had more complications (P = .042). In group 2 the estimated blood loss and hospital stay decreased (243 vs 140 mL, P = .01, 1.4 vs 2.5 days, P <.001). Overall 78% of the tumors were malignant and the positive margin rate was 3%. With a median follow-up of 18 months, no local or distant tumor recurrences were observed. CONCLUSIONS With growing experience and technical modifications, LPN is now performed for patients with larger and more central tumors. Longer follow-up is necessary to evaluate oncologic outcomes.

Laparoscopic Partial Nephrectomy for Tumors Larger Than 4 cm: A Comparative Study

PURPOSE To compare the perioperative and functional outcomes of patients with clinical T(1a) and T(1b) renal tumors after laparoscopic partial nephrectomy (LPN). PATIENTS AND METHODS Data of 184 patients who underwent LPN were retrieved from a prospective, Institutional Review Board-approved database. The patients were stratified for analysis into groups: 149 (81%) patients with clinical stage T(1a) (group 1) and 35 (19%) patients with clinical stage T(1b) (group 2). Perioperative and postoperative outcomes were compared. RESULTS No significant differences between groups 1 and 2 in warm ischemia time, estimated blood loss, operative time, conversion rate, intraoperative complication rate, and hospital stay were observed. The incidence of postoperative complications in group 2, however, was twice that of group 1 (25.7% vs 12%) (P = 0.04). Clinical staging correlated with the pathologic staging in 96% of the patients in group 1 and in only 71% in group 2 (P < 0.001). Upstaging to pT(2) or pT(3) occurred in 29% of the patients in group 2. High-grade tumors were more prevalent in group 2 (36% vs 12%) (P = 0.001). The number of patients with positive margin was higher in group 2, but the difference was not statistically significant. The mean decline in estimated creatinine clearance (median follow-up 18 months) was significantly higher in group 2. CONCLUSIONS LPN in patients with tumors >4 cm, while safe and feasible in experienced hands, is associated with a higher postoperative complication rate, as well as a higher rate of pathologic upstaging. Such data should be discussed when counseling patients with larger tumors for LPN.

Laparoscopic Radical Versus Laparoscopic Partial Nephrectomy for Clinical T1bN0M0 Renal Tumors: Comparison of Perioperative, Pathological, and Functional Outcomes

AIM To compare outcomes in patients treated with laparoscopic partial nephrectomy (LPN) and laparoscopic radical nephrectomy (LRN) for clinical T1bN0M0 renal masses. MATERIALS AND METHODS Between 2002 and 2008, 33 and 52 consecutive patients who underwent LPN and LRN, respectively, for clinical stage T1bN0M0 tumors were retrospectively identified from a prospectively maintained database of 450 patients undergoing laparoscopic renal surgery. Perioperative, pathological, and postoperative outcomes were compared. RESULTS The two groups of patients were similar in age, sex, and body-mass index. Mean radiographic tumor size was smaller (4.8 vs. 5.2 cm, p = 0.04) in the LPN group. Mean operative time (228 vs. 175 minutes, p < 0.0001) and mean estimated blood loss (233 vs. 112 mL, p = 0.003) were higher in the LPN group. Intraoperative complication rates of 15.2% versus 5.7% (p = 0.28) and postoperative complication rates of 24.2% versus 13.5% (p = 0.20) were observed in the LPN and LRN groups, respectively. Overall median follow-up was 15 and 21 months for the LPN and LRN cohorts, respectively. A 12.5% and 29.3% decline in estimated glomerular filtration rate was observed (p = 0.002), and 30.3% compared with 55.7% of patients developed an estimated creatinine clearance (eCrCl) < 60 mL/minutes after treatment (p = 0.04) for LPN and LRN, respectively. There were no differences in pathological stage distribution between the two groups. In the LPN group there were no local or systemic recurrences, and one positive surgical margin was observed. One patient developed metastatic disease in the LRN group. CONCLUSIONS LPN for T1b renal tumors provides superior intermediate-term preservation of renal function compared with LRN. Continued follow-up of these patients is required to evaluate oncological outcomes.

Laparoscopic Partial Nephrectomy: Predictors of Prolonged Warm Ischemia

PURPOSE The kidney is often exposed to warm ischemia during laparoscopic partial nephrectomy. Warm ischemia time is associated with acute and possible long-term renal damage, particularly beyond a 30-minute threshold. We evaluated patient and tumor characteristics that might predict prolonged warm ischemia time. MATERIALS AND METHODS A prospective institutional database was searched for patients who underwent laparoscopic partial nephrectomy with renal vessel clamping. Warm ischemia time was treated as a continuous and a categorical (more or less than 30 minutes) variable. The association between warm ischemia time, and preoperative and surgical parameters was evaluated using linear and logistic regression analysis. The latter analysis was used to develop and internally validate a preoperative nomogram to predict warm ischemia time longer than 30 minutes. RESULTS On multivariate linear regression analysis tumor size (coefficient 1.6, 95% CI 0.7-2.6, p = 0.001), body mass index (coefficient 0.3, 95% CI 0.1-0.5, p = 0.005) and central tumor location (coefficient 3.7, 95% CI 0.5-7, p = 0.02) were independent predictors of longer warm ischemia time. Patients with 2 or more of certain risk factors, including body mass index greater than 30 kg/m(2), tumor greater than 4 cm and a centrally located tumor, were 5 times more likely to have warm ischemia time greater than 30 minutes than patients without the risk factors (p = 0.002). A nomogram incorporating predictors of longer warm ischemia time showed 75.4% accuracy. CONCLUSIONS Greater tumor size, central tumor location and higher body mass index are associated with longer warm ischemia time. By incorporating these 3 risk factors into a nomogram prolonged warm ischemia time (greater than 30 minutes) can be accurately predicted preoperatively.

Laparoscopic Nephron-Sparing Surgery in the Management of Angiomyolipoma: A Single Center Experience

BACKGROUND AND PURPOSE Angioembolization is often the first-line treatment for patients with renal angiomyolipoma (AML). Regrowth and repeated hemorrhage after embolization, however, remain a concern. Laparoscopic partial nephrectomy (LPN) is the definitive, minimally invasive treatment alternative. We compared the outcomes of LPN in patients who had a diagnosis of AML with patients with other renal tumors. PATIENTS AND METHODS From a prospective LPN database, we identified patients with a final pathologic diagnosis of AML (group 1). The ability of preoperative imaging to predict AML final pathology results was studied. Surgical and postoperative outcomes in group 1 were compared with the outcomes of the rest of our LPN cohort (group 2). RESULTS Of 184 LPNs that were performed between 2002 and 2008, 14 (7.6%) patients and 15 renal units had a diagnosis of AML. Two patients underwent concomitant LPN and radiofrequency ablation (RFA) for multiple AML lesions. In group 1, only 33% of the patients had a preoperative diagnosis of AML. There were no significant differences in tumor size, age, preoperative estimated creatinine clearance, body mass index, and comorbidities between the groups. The mean estimated blood loss in groups 1 and 2 was 214 mL and 178 mL, respectively (P = 0.5). The complication rates were similar between the groups. With a median follow-up of 15 months, no AML recurrences or bleeding was observed in group 1. CONCLUSIONS The results of LPN or RFA, when appropriate, in AML patients are comparable to the results of LPN for other renal tumors. The preoperative imaging studies were a poor predictor of AML in patients who were undergoing LPN.

Laparoscopic partial nephrectomy for technically challenging tumours

Study Type – Therapy (case series)
Level of Evidence 4

Localized T1a Renal Lesions in the Elderly: Outcomes of Laparoscopic Renal Surgery

OBJECTIVE The objective of this study was to compare the outcomes of patients >or=70 years of age undergoing laparoscopic partial nephrectomy (LPN), laparoscopic radical nephrectomy (LRN), and laparoscopic ablative techniques (LAT) for small renal masses. METHODS From a prospectively maintained database we identified 19 (LRN), 28 (LPN), and 19 (LAT) patients aged >or=70 who underwent surgery for cT1aN0M0 lesions. Perioperative, surgical, and functional outcomes were compared. RESULTS The three groups were similar in age, race, body mass index, and estimated creatinine clearance. In the LRN group, mean tumor diameter was larger (3.3 vs. 2.4 cm [LPN] and 2.7 cm [LAT]; p = 0.0005) and there was a higher percentage of central tumors (73.7% vs. 25.0% and 5.3%; p < 0.0005) when compared with the LPN and LAT groups, respectively. Although intraoperative and postoperative complication rates were similar, mean estimated blood loss and operative time were highest in the LPN group (p < 0.05). Moreover, 42.1%, 39.3%, and 42.1% of patients had preoperative stage 3 chronic kidney disease in the LRN, LPN, and LAT groups, respectively. Patients who underwent LRN had a lower follow-up estimated creatinine clearance (43.4 vs. 61.4 mL/min [LPN] and 59.2 [LAT]; p < 0.01) and a higher likelihood of developing stage 3 chronic kidney disease after treatment (100% vs. 25.0% [LPN] vs. 18.2 [LAT]; p < 0.0005). CONCLUSIONS Impaired renal function is common in elderly patients presenting with renal masses. LPN and LAT provide superior preservation of renal function when compared with LRN in this population. In appropriately selected patients >or=70 years of age presenting with T1a renal lesions, laparoscopic nephron-sparing approaches should be considered.

Predicting Collecting System Transection at Laparoscopic Partial Nephrectomy: Analysis of Tumor Parameters

OBJECTIVE Repair of renal collecting system (CS) during laparoscopic partial nephrectomy (LPN) requires advanced skills and nevertheless prolongs renal ischemia time. We assessed tumor parameters that may predict CS transection and thus improve preoperative planning. METHODS Data were prospectively collected for 184 consecutive LPN cases performed at our institution between 2002 and 2008 by a single senior surgeon. Twelve patients were excluded because of open conversion and seven because of missing data. Among the rest (n = 165), CS was transected in 115 (61%). Tumor parameters (radiographic appearance-solid vs. cystic, size, polar location, and depth) were evaluated with univariate and multivariate logistic regression analysis. Classification and Regression Tree analysis was applied to define the optimal cutoff for tumor size. RESULTS In univariate analysis, tumor size (odds ratio [OR] 2.8, 95% confidence interval [CI] 1.8, 4.3; p < 0.0001) and tumor appearance (solid: OR 2.1, 95% CI 1.1, 4.3) achieved statistical significance, while tumor depth (endophytic: OR 3.1, 95% CI 0.8, 11.0; p = 0.08) trended toward significance. In multivariate analysis, size (p < 0.0001) and solid tumor appearance (p = 0.006) were independent predictors. In Classification and Regression Tree analysis, 2.5 cm was found to be the optimal cutoff for the tumor size. CONCLUSIONS The odds of CS transection during LPN triple with each additional centimeter in tumor size, are 10-fold higher for tumors >2.5 cm, and are almost twice higher for solid tumors, compared with cystic. These findings may be useful in LPN planning.