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At least 1,027 records · Page 57Linked to original sources

PubMed2000

Metastatic renal cell cancer after laparoscopic radical nephrectomy: long-term follow-up.

OBJECTIVE: To assess the risk of metastatic disease in longer-term follow-up of patients undergoing laparoscopic radical nephrectomy with morcellation for renal cell carcinoma (RCC). PATIENTS AND METHODS: We present the findings at follow-up at 13.5 to 70 months (mean 33.4 months) of 57 previously reported patients. Three, all of whom initially had clinical stage N0M0 disease, were found to have metastases. One, who had a clinical stage T3 grade III/IV tumor, developed an asymptomatic recurrence in the renal fossa with associated chest metastasis 14 months postoperatively. The second, who had a clinical stage T2 grade II/IV tumor, developed painful bony lesions and a chest metastasis 20 months postoperatively. The third patient, with a clinical stage T3 grade IV/IV tumor, was found to have a solitary port-side abdominal-wall recurrence with no other evidence of metastatic disease at 25 months. CONCLUSIONS: Longer-term follow-up has demonstrated a 5% (3/57) rate of metastases after laparoscopic radical nephrectomy. In two of these patients, the course was consistent with the natural history of RCC; however, the third had a port-site recurrence. Thus, it behooves us to be meticulous with our technique and to follow patients closely after laparoscopic nephrectomy. Several suggestions are made to reduce the likelihood of port-site recurrence.

Aged↗

PubMed2000

Simple nephrectomy: retroperitoneal approach.

Direct extraperitoneal surgery has become the preferred approach to laparoscopic nephrectomy since the introduction of the balloon dilation method. The lateral decubitus position provides good exposure, but the prone position is used at some centers to gain better exposure with the aid of gravity. The open conversion rate ranges from 0 to 16% and the complication rate from 5% to 45%, with most complications being minor. Retroperitoneal laparoscopic simple nephrectomy is definitely superior to open nephrectomy as judged by analgesic use and recovery time. The higher complication rate and lower efficiency can be taken care of by experience and proper case selection.

Catheterization↗

PubMed2000

Laparoscopic radical nephrectomy.

Although open nephrectomy is the standard of care for localized renal-cell carcinoma, the significant postoperative pain and lengthy convalescence have encouraged the use of laparoscopy, which can yield similar 2- to 5-year survival rates. Either a transperitoneal or a retroperitoneal approach may be used, and sometimes, they are combined. Generally, the technique is limited to tumors <10 cm, but larger tumors can be removed. Nitrous oxide is avoided as an anesthetic agent. The dissection follows accepted oncologic principles: in situ renal dissection within Gerota's fascia, early ligation of the renal vessels, and careful removal of the specimen to prevent tumor spillage. Dissection of the hilum is facilitated by a PEER retractor and an Endoholder. On average, patients having laparoscopic radical nephrectomy return to normal activities approximately 4.5 weeks sooner than those having open surgery, a fact not taken into account in cost analyses. Laparoscopic nephrectomy may offer a special benefit in patients with known metastatic disease, as interleukin-2 administration can be started a month earlier than after open surgery. There may also be immunologic benefits of minimally invasive v open surgery. The technique and instruments continue to evolve, and cost-effectiveness should continue to improve.

Biopsy↗

PubMed2000

Laparoscopic partial nephrectomy and wedge resection.

Partial nephrectomy is a more challenging operation than radical or simple nephrectomy, primarily because of the risk of complications such as bleeding. This problem is even more troublesome with minimally invasive approaches because of the dearth of effective hemostatic instruments and supplies. The location of the lesion determines whether a transperitoneal or a retroperitoneal route will be employed. Centrally located or anterior renal lesions generally are approached transperitoneally whereas peripheral lateral or posterior lesions are accessed by retroperitoneoscopy. The Harmonic Scalpel with slow cutting and high coagulation settings is useful for incising the renal capsule and parenchyma. The argon beam coagulator is helpful to stop any persistent bleeding. The few reported series of laparoscopic partial nephrectomy indicate considerably longer operative times than are needed for open surgery and hospitalization of upwards of 5 days, largely to monitor drainage and urine leakage. It is hoped that this advanced laparoscopic technique will become more user friendly with further developments in techniques and instrumentation to provide patients with the expected benefits of minimally invasive surgery.

Blood Loss, Surgical↗

PubMed2005

Laparoscopic right nephrectomy using a novel technique to excise an inferior vena-caval cuff in a porcine model.

BACKGROUND AND PURPOSE: Laparoscopic right nephrectomy has been performed using laparoscopic staplers to clamp and divide the renal vessels. In patients who have a tumor thrombus in the renal vein and in rightkidney donors, it is necessary to excise a cuff of the inferior vena cava (IVC) with the renal vein. We present a new technique for excising a cuff of the IVC and suturing it intracorporally using a new vascular clamp designed in our institution. MATERIALS AND METHODS: The vascular clamp was designed to be completely inserted into the peritoneal cavity through the hand-port incision. The renal vein with a cuff of the IVC was then excised, and the defect in the IVC was sutured with a vascular stitch intracorporally. This procedure was performed in the animal laboratory using a porcine model. RESULTS: A total of 20 hand-assisted right laparoscopic nephrectomies were performed. In the first five operations, the clamp dimensions and angles were modified until the ideal design was reached. In the next five operations, different suture materials and needle sizes were tried to find the best combination for the intracorporal IVC sutures. The first and second operations were not completed because of the difficulty in applying the initial version of the clamp to the IVC. In the 4th and 6th operations, bleeding occurred from the suture line: because of a missed stitch in the back wall of the IVC in one case and a needle stick to the IVC in the other case. The last 14 operations were successful without any bleeding or injuries. Suturing of the IVC was completed in 13 to 22 minutes. CONCLUSION: Right hand-assisted laparoscopic nephrectomy with excision of a cuff of the IVC using an intracorporal vascular clamp is safe and reproducible in a porcine model. In our hands, a learning curve of 10 cases was required.

Animals↗

PubMed2005

Third Prize: Comparison of radical nephrectomy, laparoscopic microwave thermotherapy, cryotherapy, and radiofrequency ablation for destruction of experimental VX-2 renal tumors in rabbits.

BACKGROUND AND PURPOSE: Currently available minimally invasive renal tumor-ablation procedures include cryotherapy, radiofrequency ablation, and microwave thermotherapy. In this study, we investigated the ability of these three approaches to destroy experimental renal tumors in rabbits. The mechanism of potential tumor metastasis was also explored. MATERIALS AND METHODS: The VX-2 tumor line is an aggressive rabbit epidermoid tumor with a high metastatic potential. An initial experiment comparing cooled-tip microwave thermotherapy with cryotherapy and radical nephrectomy for treatment of small VX-2 tumors revealed that all microwave-treated rabbits had local recurrence and that several also had diffuse intraperitoneal carcinomatosis. In view of these results, a second experiment was performed in which 45 New Zealand White rabbits were implanted laparoscopically with VX-2 xenografts underneath the kidney capsule and divided into five groups of 9 each. The test groups were microwave thermotherapy with a 3.5-mm cooled-tip probe, microwave thermotherapy with a 3.5-mm noncooled- tip probe, radiofrequency ablation with a 1.5-mm cooled-tip probe, radiofrequency ablation with a 1.5- mm non-cooled tip probe, and cryotherapy with a 2.3-mm cryoprobe. The control groups were five rabbits that were not treated, five rabbits with tumors that had the tumor pierced with a probe but were untreated, and five rabbits that underwent nephrectomy after piercing of the tumor. Treatment was initiated 5 days after tumor implantation. One month later, all animals were euthanized and autopsied. RESULTS: At 5 days after tumor implantation, laparoscopic inspection revealed no visible peritoneal metastases. At 1 month, in the cooled and non-cooled microwave-thermotherapy groups, carcinomatosis occurred in five and six of nine animals, respectively. In comparison, carcinomatosis was detected in two of nine animals in the cryotherapy group at autopsy. With respect to cooled and non-cooled radiofrequency ablation, carcinomatosis was observed in four of nine rabbits in each group. In the control groups, none of the animals with unpierced tumors exhibited carcinomatosis, while carcinomatosis was seen in two of the five rabbits with tumor violated by piercing and in three of the five rabbits that underwent immediate nephrectomy after piercing of the tumor. CONCLUSION: Carcinomatosis occurred most frequently in animals treated with microwave thermotherapy, followed by radiofrequency ablation, and lastly cryoablation. The simple act of piercing a highly aggressive tumor can result in local spread. More disconcerting, and less well understood, is why certain ablative modalities appear to increase the rate of intraperitoneal spread.

Animals↗

PubMed2005

Efficacy and safety of fast-track recovery strategy for patients undergoing laparoscopic nephrectomy.

BACKGROUND AND PURPOSE: Factors that adversely affect early recovery after major laparoscopic procedures include ileus, pain, nausea, emesis, and fatigue. The objective of this randomized controlled study was to evaluate the impact of a multimodal fast-track (FT) rehabilitation program on recovery and length of hospital stay after laparoscopic nephrectomy. PATIENTS AND METHODS: Thirty patients undergoing laparoscopic nephrectomy received either conventional care (control) or an FT recovery program. All patients received a standardized anesthetic technique and patient- controlled analgesia (morphine) for postoperative pain control. In the FT group, patients received premedication with rofecoxib and ranitidine, local anesthesia was administered at the ports and renal fosa during surgery, and postoperative non-opioid analgesic and gastrokinetic drugs were administered as part of an early enteral nutrition and mobilization program. During the postoperative period, pain and nausea were assessed at specific time intervals. In addition, recovery room and hospital discharge times, the need for rescue analgesics and antiemetics, patient satisfaction with pain management and quality of recovery, and side effects were recorded daily for 3 days after surgery. Patients were discharged home when they met previously defined discharge criteria. RESULTS: The FT group was discharged earlier from the recovery room (74+/-23 v 103+/-47 minutes) and the hospital (41+/-11 v 59+/-11 hours). Pain and nausea scores were consistently lower in the FT group during the first 48 hours after surgery. In addition, the requirement for antiemetic rescue therapy during the first 24 hours was reduced in the FT group (15% v 58%). The FT group also received less morphine during the first 2 postoperative days (14+/-16 v 40+/-24 mg). Finally, patient satisfaction with postoperative pain control was significantly higher in the FT group. CONCLUSIONS: A multimodal approach to minimizing postoperative side effects led to a reduced recovery room and hospital stay, as well as better pain control and patient satisfaction after laparoscopic nephrectomy.

Acetaminophen↗

PubMed2005

Comparison of a novel endoscope holder and traditional camera assistant for laparoscopic simple nephrectomy in a porcine model.

PURPOSE: To establish the feasibility of single-surgeon laparoscopy with application of a novel endoscope-holder device and to compare this technique with traditional assistant-driven laparoscopic camera control. MATERIALS AND METHODS: Bilateral simple nephrectomies were performed in six pigs. On one side, the operating surgeon employed the "scope holder" and performed the surgery without a laparoscopic assistant. On the contralateral side, an experienced camera operator was responsible for control of the laparoscopic field of vision in the traditional manner. The time required for hilar ligation and complete renal mobilization was documented. Pigs were sacrificed immediately after the procedure. RESULTS: The mean operative times for scope-holder and camera person-assisted nephrectomy were 20.7 minutes and 19.3 minutes, respectively. The time to hilar ligation in the scope-holder and camera-operator-assisted cohorts was 13 and 14.5 minutes, respectively. There were no significant differences in operative times or blood loss in the two groups. The operative surgeon perceived some increase in shoulder and neck pain with use of the scope holder. CONCLUSIONS: This novel device provides a means for the operative surgeon to safely perform a laparoscopic nephrectomy alone without significantly increasing operative time or morbidity.

Animals↗

PubMed2005

Laparoscopic partial nephrectomy.

In properly selected patients, partial nephrectomy yields oncologic efficacy similar to that of traditional radical nephrectomy. We have performed more than 415 laparoscopic radical nephrectomies over the 5-year period beginning in September 1999. All patients undergo a three-dimensional CT scan with 3-mm sections prior to the operation. We generally prefer the transperitoneal approach, although for posterior tumors, a retroperitoneal approach is preferred. The kidney is dissected using standard technique. Intraoperative hydration is given to maintain diuresis. Detailed real-time ultrasonographic delineation of the tumor is obtained to facilitate planning of the resection. We prefer en-bloc hilar clamping. The renal capsule is scored circumferentially with the "L" hook electrocautery. Parenchymal incision and tumor resection is performed using heavy reuseable scissors. The base of the resection defect is closed using a running 2-0 Vicryl on a CT-1 needle. The water-tightness of pelvicaliceal repair is tested by repeat gentle injection of indigo carmine through a ureteral catheter. Next, the parenchyma is closed with 1 Vicryl on a CTX needle placed over an oxidized cellulose bolster. The specimen is extracted within an entrapment bag. Initially, a surgeon should be highly selective, including patients with small, mostly exophytic, tumors. With increasing comfort and experience, the criteria can expand.

Hemostasis, Surgical↗

PubMed2005

Hand-assisted laparoscopic partial nephrectomy in the porcine model using gelatin matrix hemostatic sealant without hilar occlusion.

BACKGROUND AND PURPOSE: Gelatin matrix hemostatic sealant (GMHS) has been used for hemostasis during partial nephrectomy with hilar clamping. The objective of this study was to determine the ability of GMHS to achieve hemostasis without hilar clamping in the porcine model. MATERIALS AND METHODS: In this feasibility study, eight farm pigs underwent a left-hand-assisted laparoscopic partial nephrectomy (HALPN). The lower fourth of the kidney was removed with cold scissors, and GMHS was applied laparoscopically. Samples were collected for measurement of serum hemoglobin (Hb) and creatinine (Cr) prior to surgery and at 4 and 30 days after HALPN. The kidneys were harvested at 30 days, and retrograde pyelograms and pathologic analysis were performed. RESULTS: Application of GMHS achieved complete hemostasis in all eight animals. The mean estimated blood loss was 40 mL, and the operating time was short (mean 92.5 minutes). In three kidneys, a significant collecting system opening was noted but not repaired. At harvest, there were no hematomas, infections, or urine leaks in any animals. In one animal, a 2-cm contained fluid collection was identified. There was no difference in the preoperative and harvest Hb (9.63 v 9.21 g/dL; P = 0.49), but there was a slight increase in Cr (1.21 v 1.46 mg/dL; P = 0.01) possibly because of the decreased renal mass after partial nephrectomy. CONCLUSION: Even without hilar occlusion, GMHS was 100% safe and effective in controlling bleeding after HALPN in the porcine model. Avoidance of hilar occlusion may reduce the risk associated with warm renal ischemia and the extra dissection required to isolate the hilum in preparation for clamping.

Animals↗

PubMedDate not supplied

Early ligature of renal artery during radical laparoscopic transperitoneal nephrectomy: description of standard technique and direct access.

PURPOSE: We compared two techniques of early ligature of the renal artery during transperitoneal laparoscopic radical nephrectomy: a standard technique and a direct approach to the artery. PATIENTS AND METHODS: Of 100 patients undergoing transperitoneal laparoscopic radical nephrectomy at our institution, in the last 70, we used early renal-artery ligature. Of these, the standard technique after exposure of the vascular pedicle was used in 45 patients (group A), and ligature with a direct access to the renal artery was attempted in 25 patients (group B). RESULTS: No statistical differences were noted between the two groups in terms of age, lesion size, operative time, estimated blood loss, or intraoperative and postoperative complications. There were no recurrences of disease by CT evaluation in either group during follow-up (range 1-46 months). CONCLUSIONS: Transperitoneal laparoscopic radical nephrectomy with direct access to renal artery for early ligature is technically difficult but feasible and safe.

Adult↗

PubMed2005

Renal-tissue damage induced by laparoscopic partial nephrectomy using microwave tissue coagulator.

BACKGROUND AND PURPOSE: The microwave coagulator is a useful instrument that enables surgeons to perform partial nephrectomy without vascular clamping. The extent of postoperative thermal damage in surgically spared renal tissue has not been well examined. The present study was conducted to evaluate the tissue damage caused by microwave coagulation in laparoscopic partial nephrectomy (LPN) for small renal tumors. MATERIALS AND METHODS: Seven cases of LPN with a microwave tissue coagulator were entered in the present study. The median tumor diameter was 1.5 cm, and the median size of the resected specimen was 2.2 cm. Postoperative tissue damage was evaluated by contrast-enhanced CT 1 month after surgery. Surgically spared renal-tissue volume and functioning renal-tissue volume were estimated from the images by NIH Image 1.62 software. RESULTS: Postoperative CT revealed unenhanced renal tissue adjacent to the surgical margin. The median estimated volumes of surgically spared and functioning renal tissue were 96.1% (range 74.3%-99.8%) and 88.4% (range 68.0%-92.7%) of preoperative normal renal tissue, respectively. The percentile volume of functioning to surgically spared renal tissue ranged from 89.9% to 96.0% (median 92.8%). CONCLUSIONS: The microwave coagulator enables us to carry out partial nephrectomy without vascular clamping. Although 96% of normal renal tissue was surgically spared, 4% to 10% of this tissue was nonfunctioning as a result of microwave-induced thermal damage.

Aged↗

PubMed2005

Chylous ascites after laparoscopic donor nephrectomy.

Laparoscopic living-donor nephrectomy has decreased the disincentives to live renal donation with a risk of complications similar to that of open donor nephrectomy. We report a patient who developed chylous ascites after an otherwise-uneventful laparoscopic donor nephrectomy. On MEDLINE search, we could find only two other cases with similar complications. This condition has the potential to cause significant morbidity in the donor, which may reduce the advantages of the minimally invasive approach. We suggest that meticulous dissection of the renal hilum and clipping of lymphatic tissue around the renal vessels could prevent this untoward complication.

Chylous Ascites↗

PubMed2005

Health-related quality of life after retroperitoneoscopic and hand-assisted laparoscopic nephrectomy.

BACKGROUND AND PURPOSE: The assessment of postoperative recovery typically involves the use of measures that are open to bias. Whilst there has been some work done on the short-term postoperative recovery comparison for hand-assisted laparoscopic nephrectomy (HALN) and retroperitoneoscopic nephrectomy (RPN), to our knowledge, this is the first study to look at long-term health outcomes for these two procedures. This study sought objectively to compare long-term postoperative health-related quality of life (HRQoL) after retroperitoneoscopic and hand-assisted transperitoneal laparoscopic nephrectomy undertaken for renal pathology. This was achieved by both reviewing perioperative data from medical records and by using the SF-36 questionnaire postoperatively. PATIENTS AND METHODS: Patients who had undergone elective retroperitoneoscopic (N = 19) or transperitoneal HALN (N = 32) between 2001 and 2004 at our institution underwent objective HRQoL assessment via a validated telephone questionnaire (SF-36) and by review of postoperative data from the medical records. This survey was administered between 3 and 6 months after surgery. The data then underwent statistical analysis using the paired Student's t-test. RESULTS: Perioperative data showed no significant difference in the postoperative complication rate in the two groups. The HRQoL scores gathered from the SF-36 questionnaire gave mean scores of 67.4 and 68.5 for the HALN and RPN groups, respectively (100 represents maximum quality of life). This difference was not statistically significant. CONCLUSIONS: This is the first study to look at long-term (mean follow-up 6 months) health outcomes for patients undergoing RPN and HALN. The results show no greater long-term health benefit for one procedure over the other. This finding supports the data in the literature on the benefits of HALN over RPN in terms of a less protracted learning curve, greater technical ease, fewer intraoperative complications, and consequently reduced operating times with no loss of the long-term health benefit that is traditionally associated with the standard laparoscopic technique.

Female↗

PubMed2006

High body mass index in muscular patients and flank position are risk factors for rhabdomyolysis: case report after laparoscopic live-donor nephrectomy.

BACKGROUND AND PURPOSE: Rhabdomyolysis is well known after traumatic crush injuries or ischemia involving muscles. Postoperatively, it most likely is secondary to surgical positioning and patient muscle mass. We report a case after laparoscopic live-donor nephrectomy. CASE REPORT: A muscular 35-year-old man underwent elective left laparoscopic live-donor nephrectomy in a 70 degrees flank position with four ports. He was in the right-side lying position with hip flexion (flank position) for approximately 4 hours. A kidney bridge had been placed between the iliac crest and the rib cage. Postoperatively, the patient had light-pinkish urine and low urine output. There was marked induration of the buttocks and significant pedal and scrotal edema. With judicious use of alkalinization and diuretics, the patient did not require dialysis, and renal function returned to base level by postoperative day 20. The recipient of the kidney had a normal postoperative course. CONCLUSION: Rhabdomyolysis is a syndrome of muscle necrosis and release of intracellular components into the circulation. Acute renal failure secondary to myoglobinuria is a common complication. We currently use little flexion of the table during donor nephrectomy and bring the table to a neutral position immediately after kidney retrieval. Postoperatively, one needs a high index of suspicion for rhabdomyolysis to avoid or at least promptly recognize this rare but potentially serious condition after any operation lasting >or=4 hours.

Acute Kidney Injury↗

PubMed2005

Bilateral laparoscopic radical nephrectomy for renal tumors in patients with acquired cystic kidney disease.

PURPOSE: We describe our experience with simultaneous bilateral laparoscopic radical nephrectomy performed in patients with acquired cystic kidney disease (ACKD) and renal tumors. MATERIALS AND METHODS: Between June 2000 and September 2002, 10 patients with ACKD underwent simultaneous bilateral laparoscopic radical nephrectomy for renal lesions suspicious for carcinoma. The lesions were discovered during pretransplant evaluation in 9 patients and incidentally in 1 renal transplant recipient. A 3- or 4-port transperitoneal approach was used for each side to mobilize the kidney and secure the renal hilum. Both specimens were extracted through a midline supraumbilical incision. Operative time, blood loss, analgesic requirements, hospital stay, and convalescence and recurrence rates were determined. RESULTS: The mean age of the patients was 41.6 years (range, 29-47 years). Mean operative time was 6.5 hours (range, 4.5-9.7 hours) and mean estimated blood loss was 164 cc (range, 50-300 cc). There was one intraoperative complication-a clotted arteriovenous (AV) graft; and 2 postoperative complications-1 fluid overload and 1 adrenal insufficiency. The average length of hospital stay was 3.1 days (range, 2-4 days) and mean convalescence was 2.8 weeks (range, 1-6 weeks). All cancers were confined to the kidneys and there has been no recurrence during follow-up ranging from 6 to 26 months. CONCLUSION: Bilateral laparoscopic radical nephrectomy in end-stage renal disease patients is safe and feasible. The advantages of the laparoscopic approach include minimal intraoperative blood loss, shorter hospital stay, minimal postoperative pain, and a rapid return to normal activity. The laparoscopic technique offers an effective, minimally invasive therapeutic alternative to open surgery in high-risk end-stage renal disease patients.

Adult↗

PubMed1994

Laparoscopic nephrectomy and nephroureterectomy in the octogenarian with a renal tumor.

Renal cell carcinoma and transitional cell carcinoma of the kidney usually occur after the fifth or sixth decade. In the elderly patient, a curative open nephrectomy may not be considered because of concerns over concomitant operative morbidity. Recently, there has been rapid adaptation of laparoscopy as an alternative to established open urologic surgical procedures. We present our experience with laparoscopic nephrectomy and nephroureterectomy for renal tumors in the octogenarian patient. Laparoscopic nephrectomy, in the elderly patient, albeit a lengthy procedure, affords the patient minimal postoperative discomfort, early alimentation, and a quick return to regular activities.

Age Factors↗

PubMed2004

The rabbit nephrectomy model for training in laparoscopic surgery.

BACKGROUND: Laparoscopic surgical training is generally done with the teacher-student model using complex exercises. This study was performed to evaluate a new training model that emphasizes the repetition of simple procedures. METHODS: Laparoscopic surgery was performed in rabbits (n=200) using conventional instruments. Gynaecologists (n=10) and medical students (n=10) performed a series of exercises during 20 full days training. Nephrectomy was chosen to evaluate and score laparoscopic skills, i.e. duration of surgery and complication rate, since it mimics the surgical challenge and involves dissection of major vessels. Each surgeon performed 20 nephrectomies, alternating left and right sides. RESULTS: Duration of surgery and complications decreased with training. For duration of surgery, a two-phase exponential decay learning curve, with different decays for gynaecologists and students, was observed. Gynaecologists achieved shorter operating times than students for real and calculated times in the first procedure (P<0.0001 and P<0.0001) and for calculated time in the last procedure (P=0.001). Severe complications were more frequent in students than in gynaecologists (P=0.0003). CONCLUSION: The rabbit nephrectomy model is suitable for training in laparoscopic surgery. Since it implies the repetition of short and well-defined exercises, progression is easier to monitor and the necessity for continuous supervision is less, making training less expensive.

Animals↗