Search

Objectives: To study the feasibility and perioperative outcomes associated with a laparoscopic approach to completion nephrectomy in patients with locoregional disease recurrence after partial nephrectomy (PN) for renal cell carcinoma., Patients and Methods: We performed a retrospective review of patients who underwent PN between 2006 and 2016 and developed locoregional recurrence, defined by the presence of new disease within the original surgical bed. Those undergoing planned laparoscopic completion nephrectomy constituted the study cohort. Perioperative outcomes as well as clinical and pathologic parameters associated with ability to effectively perform laparoscopic completion nephrectomy were assessed., Results: Among 1259 patients who underwent PN during the study period, 45 cases (3.6%) of locoregional disease recurrence were observed. A laparoscopic approach to completion nephrectomy was attempted in 33 patients. Overall, 16 (48.5%) patients experienced a postoperative complication, 9 of whom (27.3%) had a major event (Clavien grade ≥3). Intraoperative open conversion was necessary in 12 (36%) patients. Higher R.E.N.A.L score of the original tumor (p < 0.001) and clinical evidence of synchronous metastatic relapse (p < 0.001) were associated with increased likelihood of open conversion. Blood loss (725 mL vs 175 mL, p < 0.001), operative time (280 minutes vs 160 minutes, p < 0.001), risk of major postoperative complication (58% vs 9.5%, p = 0.005), and hospital length of stay (4.5 days vs 2 days, p = 0.026) were significantly higher in individuals requiring open conversion., Conclusion: Laparoscopic completion nephrectomy for true locoregional recurrence is a technically demanding procedure associated with significant postoperative morbidity and a high rate of open conversion. Although feasible, careful patient selection may optimize surgical outcomes.

Background: There is no clear consensus as to the optimal method of entry in laparoscopic renal surgery and no reports have compared them in Urology. To analyze contemporary practice patterns in entry technique and port placement for laparoscopic kidney surgery., Methods: We identified 60 high volume urological laparoscopic centers. A purpose-built questionnaire was sent to surgeons. The survey included 22 questions regarding access techniques and port configuration during laparoscopic kidney surgery. Data on were collected and retrospectively analyzed. Concordance among port configurations was assessed using Cohen's Kappa statistics., Results: The survey was sent to 60 surgeons and completed by 32 of them. Surgical procedures included were laparoscopic radical nephrectomy (1177 LRN/year) and laparoscopic partial nephrectomy (1047 LPN/year). The transperitoneal route was preferred (85%). Hasson technique was used for the access in 55% of the cases. Patient lateral recumbent position is the most frequently used during the port placement (41%). Although there is a high variability in the port positioning among the surgeons, in more than 90% of cases it was found a specific concordance in triangulation of optics and operating trocars. There were no significant differences between port configuration in LRN and LPN. Limitations include retrospective design and limited sample., Conclusions: A standard port configuration has not been previously reported in urological literature. Our study suggests that the transperitoneal approach, the Hasson technique and a specific triangulation of optics and operating trocars have a significant concordance in some high volume laparoscopic urologic centers.

Introduction: Kidney cancer ranks among the top 10 most prevalent cancers in Western society, ∼90% of which are renal cell carcinomas. There has been a paradigm shift in the management of small renal masses with strong emphasis now placed on nephron-sparing surgery and increased utilization of laparoscopic approaches to partial nephrectomy. In this review, the current state of laparoscopic partial nephrectomy (LPN) is discussed., Evidence Acquisition: The PubMed database was queried using the MeSH terms "laparoscopy" and "nephrectomy," as well as the search term "partial." A search was performed filtering for "clinical trial," "review," "humans", and "English.", Evidence Synthesis: Articles that discussed intraoperative techniques, functional and oncologic outcomes, and a comparison between robot-assisted partial nephrectomy and LPN were synthesized., Conclusion: LPN reduces ischemia time, affords equivalent functional outcomes, oncologic outcomes, and equivalent complication rates compared with open partial nephrectomy. Future advances in laparoscopic technique and advancements in robotic technology offer potential to improve surgical and patient outcomes.

Objective: To determine the impact of skin-to-tumor (STT) distance on the risk for treatment failure following percutaneous cryoablation (PCA)., Methods: We retrospectively reviewed patients who underwent PCA with documented T1a recurrent renal cell carcinoma (RCC) at 2 academic centers between 2005 and 2015. Patient demographics, tumor characteristics, and perioperative and postoperative course variables were collected. Additionally, we measured the STT distance by averaging the distance from the skin to the center of the tumor at 0°, 45°, and 90° on preoperative computed tomography imaging., Results: We identified 86 patients with documented T1a RCC. The mean age at the time of surgery was 69 years (range: 37-91 years), and the mean tumor size was 2.7 cm (range: 1.0-4.0 cm). With a mean follow-up of 24 months (range: 3-63 months), 11 (12.8%) treatment failures occurred. Patients with treatment failure had significantly higher mean STT distance than those without: 11.0 cm (range: 6.3-20.1 cm) compared to 8.4 cm (range: 4.4-15.2 cm), respectively (P = .002). STT distance was an independent predictor of treatment failure (odds ratio: 1.32, 95% confidence interval: 1.04-1.69, P = .029). STT distance greater than 10 cm had a fourfold increased risk of tumor treatment failure (odds ratio: 4.43, 95% confidence interval: 1.19-16.39, P = .018). Tumor size, R.E.N.A.L. Nephrometry score, and number of cryoprobes placed were not associated with treatment failure., Conclusion: STT, an easily measured preoperative variable, may inform the risk of RCC treatment failure following PCA., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: We studied recurrence-free survival after partial vs radical nephrectomy for clinical stage T1 renal cell carcinoma in all patients and in those up staged to pathological stage T3a., Materials and Methods: We retrospectively reviewed the records of 1,250 patients who underwent partial or radical nephrectomy for clinically localized T1 renal cell carcinoma between 2006 and 2014. Recurrence-free survival was estimated using the Kaplan-Meier method and evaluated as a function of nephrectomy type with the log rank test and Cox models, adjusting for clinical, radiological and pathological characteristics., Results: A total of 86 recurrences (7%) were observed during a median followup of 37 months. No difference in recurrence-free survival between partial and radical nephrectomy was found among all clinical stage T1 renal cell carcinomas. T3a up staging was noted in 140 patients (11%) and recurrent disease was observed in 44 (31.4%) during a median followup of 38 months. Among up staged T3a cases partial nephrectomy was associated with shorter recurrence-free survival compared to radical nephrectomy on univariable analysis (recurrence HR 2.04, 95% CI 1.12-3.68, p = 0.019) and multivariable analysis (recurrence HR 5.39, 95% CI 1.94-14.9, p = 0.001)., Conclusions: In a subgroup of patients clinically staged T1 renal cell carcinoma will be pathologically up staged to T3a. Among these patients those who undergo partial nephrectomy appear to have inferior recurrence-free survival relative to those who undergo radical nephrectomy., (Copyright © 2017 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

A tumor-bearing right kidney was completely excised from an 85-year-old woman using a laparoscopic approach. A newly devised method for intra-abdominal organ entrapment and a recently developed laparoscopic tissue morcellator made it possible to deliver the 190 gm. kidney through an 11 mm. incision., (Copyright © 1991 American Urological Association, Inc. Published by Elsevier Inc. All rights reserved.)

Laparoscopic partial nephrectomy (LPN) compares favorably to traditional open nephron-sparing surgery (NSS) in terms of oncologic and surgical principles for kidney tumors. Studies have shown the modality to be feasible with similar oncologic efficacy and superior renal functional outcomes compared with laparoscopic radical nephrectomy (LRN) for tumors. The main advantages of LPN include marked improvements in estimated blood loss, decreased surgical site pain, shorter postoperative convalescence, better cosmesis, and nephron preservation. This review article evaluates the literature regarding LPN and discusses the main steps of the operation, the perioperative workup and management, surgical complications, and its role in the surgical management of kidney masses., (Copyright © 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Purpose: The clinical significance of a positive surgical margin after partial nephrectomy remains controversial. The association between positive margin and risk of disease recurrence in patients with clinically localized renal neoplasms undergoing partial nephrectomy was evaluated., Materials and Methods: A retrospective multi-institutional review of 1,240 patients undergoing partial nephrectomy for clinically localized renal cell carcinoma between 2006 and 2013 was performed. Recurrence-free survival was estimated using the Kaplan-Meier method and evaluated as a function of positive surgical margin with the log rank test and Cox models adjusting for tumor size, grade, histology, pathological stage, focality and laterality. The relationship between positive margin and risk of relapse was evaluated independently for pathological high risk (pT2-3a or Fuhrman grades III-IV) and low risk (pT1 and Fuhrman grades I-II) groups., Results: A positive surgical margin was encountered in 97 (7.8%) patients. Recurrence developed in 69 (5.6%) patients during a median followup of 33 months, including 37 (10.3%) with high risk disease (eg pT2-pT3a or Fuhrman grade III-IV). A positive margin was associated with an increased risk of relapse on multivariable analysis (HR 2.08, 95% CI 1.09-3.97, p=0.03) but not with site of recurrence. In a stratified analysis based on pathological features, a positive surgical margin was significantly associated with a higher risk of recurrence in cases considered high risk (HR 7.48, 95% CI 2.75-20.34, p <0.001) but not low risk (HR 0.62, 95% CI 0.08-4.75, p=0.647)., Conclusions: Positive surgical margins after partial nephrectomy increase the risk of disease recurrence, primarily in patients with adverse pathological features., (Copyright © 2016 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Background: The management of locally recurrent renal-cell carcinoma (RCC) following cryoablation remains a clinical dilemma. There is limited data regarding the management of locally recurrent disease in the setting of patients who have failed initial percutaneous cryoablation (PCA). We evaluate and report our experience with salvage PCA for local recurrence following renal cryoablation failure., Patients and Methods: We reviewed our experience with patients who underwent salvage PCA for local biopsy proven RCC recurrence following primary cryoablation procedures. Complications and oncologic outcomes were evaluated. Recurrence-free survival after primary and repeat cryoablation was plotted using the Kaplan-Meier curves., Results: A total 250 patients underwent primary cryoablation for RCC and 20 (8%) patients were identified who underwent repeat PCA for 21 locally recurrent tumors. The mean tumor size was 2.4 cm. Biopsy revealed clear cell in 14 patients, three papillary and four chromophobe RCC. All repeat cryoablation procedures were completed successfully, with no treatment failures on postprocedure imaging. There were no complications or deaths. With the median follow-up of 30 months (range 7-63), 3 (15%) patients experienced local recurrence. One patient had an enhancing lesion at 13 months following repeat PCA and underwent a third PCA. Two patients had recurrence at 6 and 35 months respectively and underwent successful laparoscopic partial nephrectomy. Local recurrence-free, metastasis-free and cancer-specific survival rates were 85%, 100%, and 100% respectively. Limitations include retrospective design and small number of patients., Conclusions: Repeat PCA after primary cryoablation failure is feasible, has a low complication rate, and acceptable short-term oncologic outcomes. Further studies with durable follow-up are required.

Purpose: A clinical dilemma surrounds the use of aspirin therapy during laparoscopic partial nephrectomy. Despite reduced cardiac morbidity with perioperative aspirin use, fear of bleeding related complications often prompts discontinuation of therapy before surgery. We evaluate perioperative outcomes among patients continuing aspirin and those in whom treatment is stopped preoperatively., Materials and Methods: A total of 430 consecutive cases of laparoscopic partial nephrectomy performed between January 2012 and October 2014 were reviewed. Patients on chronic aspirin therapy were stratified into on aspirin and off aspirin groups based on perioperative status of aspirin use. Primary end points evaluated included estimated intraoperative blood loss and incidence of bleeding related complications, major postoperative complications, and thromboembolic events. Secondary outcomes included operative time, transfusion rate, length of hospital stay, rehospitalization rate and surgical margin status., Results: Among 101 (23.4%) patients on chronic aspirin therapy, antiplatelet treatment was continued in 17 (16.8%). Bleeding developed in 1 patient in the on aspirin group postoperatively and required angioembolization. Conversely 1 myocardial infarction was observed in the off aspirin cohort. There was no significant difference in the incidence of major postoperative complications, intraoperative blood loss, transfusion rate, length of hospital stay and rehospitalization rate. Operative time was increased with continued aspirin use (181 vs 136 minutes, p=0.01)., Conclusions: Laparoscopic partial nephrectomy is safe and effective in patients on chronic antiplatelet therapy who require perioperative aspirin for cardioprotection. Larger, prospective studies are necessary to discern the true cardiovascular benefit derived from continued aspirin therapy as well as better characterize associated bleeding risk., (Copyright © 2016 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate whether elective off-clamp laparoscopic partial nephrectomy (LPN) affords long-term renal functional benefit compared with the on-clamp approach., Patients and Methods: This is a retrospective review of patients who underwent elective LPN between 2006 and 2011. Patients were followed longitudinally for up to 5 years. In all, 315 patients with radiographic evidence of a solitary renal mass and normal-appearing contralateral kidney underwent elective LPN; 209 were performed on-clamp vs 106 off-clamp. One patient who required conversion from LPN to open PN was excluded from the study. Additionally, four patients in the on-clamp cohort who underwent subsequent radical nephrectomy for local-regional recurrence were excluded from longitudinal functional evaluation after their procedure. The primary objective was to evaluate differences in postoperative estimated glomerular filtration rate (eGFR) between hilar clamping groups. Subgroup analyses were performed for patients with clamp times >30 min and those with baseline renal insufficiency (eGFR <60 mL/min/1.73m(2) ). Risk of developing worsened or new-onset renal insufficiency was also compared., Results: The mean preoperative eGFR was similar between the on-clamp and off-clamp cohorts (80.7 vs 84.1 mL/min/1.73m(2) , P > 0.05). Univariable and multivariable analyses did not show significant differences in postoperative eGFR between both groups among all-comers, those with clamp times >30 min, and patients with baseline renal insufficiency. Risk of chronic kidney disease was not diminished by the off-clamp approach with up to 5 years of follow-up., Conclusions: Progressive recovery of renal function after hilar clamping in the elective setting eclipses short-term functional benefit achieved with off-clamp LPN by 6 months; there was no significant difference in eGFR or the percentage incidence of chronic kidney disease between the on-clamp and off-clamp cohorts with up to 5 years follow-up. As such, eliminating transient ischaemia during elective LPN does not confer clinical benefit., (© 2015 The Authors BJU International © 2015 BJU International Published by John Wiley & Sons Ltd.)

Background and Purpose: Increased body mass index (BMI) has been shown to have inferior perioperative outcomes in patients undergoing laparoscopic partial nephrectomy (LPN). The aim of this study was to determine the differences in perioperative outcomes for patients undergoing LPN in normal, overweight, and obese persons using established BMI risk categories., Methods: A retrospective review of 488 patients undergoing LPN was performed stratifying patients according to BMI of <25 kg/m(2), 25 to 30 kg/m(2), and >30 kg/m(2). The analysis of variance test, chi-square analysis, and bivariate regression models were used to compare comorbidities and perioperative outcomes among the groups., Results: One hundred and eighty nine of 369 patients were identified as being obese. Obese patients were found to have a significantly higher American Society of Anesthesiologists class (2.4 vs 2.1) than normal weight patients (P=0.03). No significant differences were demonstrated in estimated blood loss, operative time, transfusion requirement, or rate of conversion between the groups. In addition, there was no significant difference in cardiovascular, pulmonary, thromboembolic, or infectious complications between the groups. Obesity was significantly associated with bleeding necessitating angioembolization (P=0.033)., Conclusion: LPN demonstrates equivalent perioperative outcomes in normal, overweight, and obese patients. The minimally invasive approach achieves equivalent outcomes in patients undergoing major abdominal surgery although further studies of alternate procedures are needed to validate our findings.

Objective: To compare the efficacy and safety of local anesthesia with conscious sedation (LACS) with general anesthesia (GA) in patients undergoing percutaneous renal cryoablation (PRC) for renal cortical neoplasms., Methods: We performed a retrospective review of patients undergoing PRC between 2003 and 2013. Patient demographics, tumor characteristics, and perioperative and postoperative follow-up data were recorded and analyzed. We compared 3 principal outcomes across the GA and LACS groups: anesthesia-related outcomes, treatment failure, and complications., Results: A total of 235 patients with available data were included. Of these, 82 underwent PRC under GA and 153 patients under LACS. The 2 groups were similar with regard to age, gender, body mass index, American Society of Anesthesiologists score, tumor features, preoperative serum creatinine level, and hematocrit value. The GA and LACS groups had a similar percentage of patients with biopsy-proven renal cell carcinoma (68.5% and 64.2%, respectively; P = .62). The mean follow-up time for GA and LACS was 37 and 21 months, respectively (P <.0001). The mean procedure time for GA was significantly longer compared with LACS (133 vs 102 minutes; P <.001), and the mean hospital stay was shorter under LACS (1.08 vs 1.95 days; P <.0001). There was no difference in immediate failure (0% and 1.9%; P = .051) or recurrences (11% and 3.9%, respectively; P = .051) between GA and LACS groups. There was no difference in intraoperative and postoperative treatment-related complications between the 2 groups., Conclusion: PRC for small renal masses under LACS is effective and safe. PRC with LACS has the advantage of decreased procedure time and a shorter hospital stay., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objectives: To present our experience demonstrating the feasibility of off-clamp laparoscopic partial nephrectomy (LPN) for hilar tumors and evaluate intermediate oncologic and renal functional outcomes., Patients and Methods: A retrospective review of LPN cases in nine patients was performed. Hilar lesions were defined as renal cortical tumors in direct physical contact with the renal artery, vein, or both as identified on preoperative imaging and confirmed intraoperatively. Although the renal hilum vasculature was isolated for possible clamping if needed, tumor extirpation was performed off-clamp, eliminating warm ischemia time (WIT). The clinicopathologic parameters, perioperative course, complications, and long-term oncologic and renal functional outcomes were analyzed., Results: Nine patients underwent off-clamp LPN for complex hilar tumors. The mean age was 60.5 years, mean American Society of Anesthesiologists physical classification (ASA) score was 2, and mean BMI was 27.7 kg/m(2). The mean tumor size and volume were 3.2 cm and 35.8 cm(3), respectively. A greater proportion of the tumors (55.6%) were endophytic and mostly of clear cell histology (78%). The mean operative time was 131 minutes, estimated blood loss 250 cc, need for transfusion 0%, and complication rates 22%. No positive margins were present intraoperatively or on final pathology. After a median follow-up of 42.8 months, there was no evidence of clinical or radiographic recurrence in any patient. There was no change in the mean estimated glomerular filtration rate preoperatively and at a median follow-up of 32 months (97.2 mL/minute vs 81.3 mL/minute; p=0.052)., Conclusion: Complex renal hilar tumors can be successfully managed with laparoscopic nephron-sparing surgery with elimination of WIT with preservation of perioperative, renal functional, and oncologic outcomes.

Objective: To present our experience with laparoscopic partial nephrectomy (LPN) for hilar tumors and evaluate intermediate oncologic and renal functional outcomes., Materials and Methods: A retrospective review of LPN cases performed in 488 patients was performed. Hilar lesions were defined as renal cortical tumors in direct physical contact with the renal artery, vein, or both, as identified on preoperative imaging and confirmed intraoperatively. The clinicopathologic parameters, perioperative course, complications, and oncologic and 6-month renal functional outcomes were analyzed., Results: A total of 488 patients underwent LPN, of which 43 were hilar. The mean tumor size for hilar and nonhilar tumors was 3.6 cm and 3.1 cm, respectively. The mean operative time was shorter for hilar as compared with nonhilar tumors (129.1 minutes vs 141.8 minutes). Mean estimated blood loss was greater in LPN for hilar tumors (311.65 mL vs 298.4 mL). There were no statistically significant differences noted in any of the perioperative parameters investigated despite a higher nephrometry complexity score in the hilar group. Change in estimated glomerular filtration rate at 6 months showed a decrease of 10.9 mL/min and 8.8 mL/min for hilar and nonhilar tumors, respectively (P = NS). There was 1 recurrence detected in the hilar group, with a median follow-up of 41.6 months., Conclusion: In the hands of an experienced laparoscopist, LPN can safely be performed for hilar tumors, with preservation of perioperative outcomes and durable renal functional and oncologic outcomes., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objectives: There is lack of consensus in the Urology community regarding surveillance after laparoscopic partial nephrectomy (LPN), particularly for patients with stage I tumors. The purpose of this article is to characterize the rate of recurrence after partial nephrectomy in a low risk cohort., Methods: Data were collected on all laparoscopic partial nephrectomies performed at a single institution from January 2006 through May 2011. Patients without at least 1 year of follow-up information were excluded from examination. Patients were stratified based on the pathologic tumor stage at the time of partial nephrectomy. Patients with stage I (a and b) tumors were then examined for recurrence., Results: A total of 639 patients underwent LPN during the time period. Of this, 360 patients had stage T1 renal cell carcinoma (RCC) (302 with pT1a and 58 with pT1b) and met research criteria. There were 8 recurrences (2.2%) within this cohort ( Table 1 ). All of the tumors were of clear cell histology and none had Furhman grade 1 histology. Only one of these patients had a positive margin at the time of partial nephrectomy and all patients had negative biopsy of the tumor resection bed. A majority of the recurrences occurred locally in the ipsilateral kidney or retroperitoneum. Most of the recurrences occurred within 1-2 years postoperatively., Conclusions: Approximately 2% of patients who underwent LPN for RCC with resultant low risk, stage I tumor pathology developed metastasis. There were no recurrences in nonclear cell pathologies and no recurrences with Furhman grade 1 or tumors smaller than 3 cm.

Objective: To present outcomes of a randomized, patient-blinded controlled trial on Pfannenstiel laparoendoscopic single-site (LESS) vs conventional multiport laparoscopic live donor nephrectomy., Patients and Methods: Patients presenting as left kidney donors between January 2009 and November 2011 were randomized to LESS donor nephrectomy (LESS-DN: n = 15) or conventional laparoscopic donor nephrectomy (LDN: n = 14). Patients were blinded to the surgical approach preoperatively and attempts to continue patient blinding postoperatively were made by applying dressings consistent with multiple conventional laparoscopic incisions for all patients. De-identified data related to the operation, peri-operative course and postoperative follow-up were prospectively collected and compared between the two groups with an intention-to-treat analysis., Results: There were no significant differences between the groups when comparing operating time, estimated blood loss (EBL), i.v. fluid administration, renal allograft warm ischaemia time (WIT), length of hospital stay (LOS) and total inpatient analgesic requirements. Quantitative pain assessment was not significantly different on postoperative day (POD) #0, however, it was significantly lower in the LESS-DN group, beginning on POD #1 (P < 0.05). The changes in haematocrit and serum creatinine in the two groups were not significantly different, and there were no blood transfusions in either group, nor was there a decline in estimated glomerular filtration rate to <60 mL/min per 1.73 m² of body surface area in any patients. Two patients in the LESS-DN group were converted to conventional LDN, both because of failure to progress effectively. All allografts were functional at the time of transplantation and revascularization, with no cases of hyperacute rejection., Conclusions: Peri-operative variables including EBL, WIT and LOS were equivalent when comparing Pfannenstiel LESS-DN with conventional LDN. Patient-reported visual analogue pain scale scores were significantly lower in the LESS-DN group beginning on the first postoperative day., (© 2013 The Authors. BJU International © 2013 BJU International.)

Purpose of Review: An off-clamp, or zero-ischemia, approach to laparoscopic partial nephrectomy has been a proposed means of preserving global renal function by preventing ischemia to normal renal parenchyma. However, for clinical stage T1b tumors this provides a unique challenge as the large size of these tumors further complicates an already difficult procedure. This review provides an overview of outcomes for laparoscopic partial nephrectomies performed with or without hilar clamping for clinical stage T1b tumors., Recent Findings: There is a paucity of data for laparoscopic partial nephrectomies for this larger tumor size. The feasibility of performing laparoscopic partial nephrectomy for renal tumors 4-7 cm in size has clearly been demonstrated. Not unexpectedly, using an off-clamp technique during laparoscopic partial nephrectomy has variably shown increased intraoperative blood loss when compared to hilar controlled procedures. This does not, however, seem to translate into increased risk of transfusion or loss of visualization leading to compromise in oncologic outcomes. Lastly, some data suggest improved short-term and long-term preservation of renal function as estimated by estimated glomerular filtration rate., Summary: With accumulating data pointing to the long-term health benefits of nephron sparing surgery over radical nephrectomy and its oncologic equivalency confirmed, there is an increased push to perform partial nephrectomy for larger tumors. As demonstrated in the setting of a solitary kidney, every minute of warm ischemia counts and ischemia is an important modifiable variable that impacts renal function. As such, off-clamp dissection has potential advantages. The reviewed data show that foregoing hilar clamping for T1b tumors is not only feasible, but is likely beneficial with respect to renal function and does not appear to carry an increased risk of transfusion despite increased blood loss.

Objective: To evaluate perioperative and 6-month renal functional outcomes of patients undergoing off-clamp vs complete hilar control laparoscopic partial nephrectomy (LPN)., Patients and Methods: A retrospective review of 489 patients undergoing LPN was completed. Preoperative imaging assessed tumour characteristics. Patient demographics, perioperative parameters, and postoperative outcomes were documented. Multivariable regression analysis was used to assess factors contributing to changes in postoperative renal function between off-clamp and clamped LPN., Results: In all, 289 LPNs were performed on-clamp and 150 were performed off-clamp. Tumours in the on-clamp group were larger than those in the off-clamp group (mean [range] 3.3 [0.5-13.5] vs 2.7 [0.4-9] cm, P = 0.003). Univariable analysis comparing off-clamp to on-clamp cohorts showed that estimated glomerular filtration rate (eGFR) was better preserved in the off-clamp cohort at 6 months (-5.8% vs -11.4%, P = 0.046). Multivariable analysis of the groups showed that estimate blood loss (P = 0.015) and warm ischaemia time (WIT, P < 0.001) were the only significant predictors of decreased eGFR in the postoperative period. Difference in eGFR at 6 months was not significant when WIT was limited to 30 min. The complication rate was greater in the clamped cohort (10% vs 20%, P = 0.012). There was no difference in transfusion rate or positive margin status., Conclusions: LPN without hilar clamping is feasible, safe and associated with less renal injury as assessed by postoperative GFR in select patients. With experience, it can be applied to complex renal lesions., (© 2012 THE AUTHORS. BJU INTERNATIONAL © 2012 BJU INTERNATIONAL.)

Purpose: The R.E.N.A.L. nephrometry is a standardized scoring system that quantifies the complexity of kidney tumors. We evaluated our experience with laparoscopic cryoablation and determined the ability of nephrometry to predict complications., Materials and Methods: We reviewed the records of all patients who underwent laparoscopic cryoablation from July 2005 to February 2010 at 3 institutions. The composite R.E.N.A.L. score was determined using preoperative imaging, and tumors were categorized as low (4-6), moderate (7-9) or high complexity (10-12). Perioperative data were analyzed to determine the presence of complications. The distribution of surgical complications and tumor categories was compared using the chi-square and Student's t test. Logistic regression was used to analyze the association between nephrometry score and postoperative complications., Results: A total of 210 patients underwent laparoscopic cryoablation, 77 of whom had available preoperative imaging. Mean patient age was 64.5 years and mean tumor size was 2.6 cm (range 1 to 4.5). Mean nephrometry score was 6.1 (range 4 to 12). Of the tumors 47 (61%) were categorized as low, 23 (30%) as moderate and 7 (9%) as high complexity lesions. Overall there were 15 (19.5%) complications, including 7 (9.5%) major and 8 (10%) minor complications. There was a significant difference in complication rates among the low (47 patients, 0%), moderate (23 patients, 35%) and high complexity (7 patients, 100%) groups, respectively (p <0.001). On multivariate analysis nephrometry score was independently associated with a higher risk of postoperative complications (OR 2.23, 95% CI 1.05-2.11, p = 0.008)., Conclusions: In a multi-institutional cohort of patients undergoing laparoscopic cryoablation, the R.E.N.A.L. nephrometry score is independently associated with the occurrence of complications. Therefore, nephrometry can be used to successfully stratify patients in terms of anticipated risk of complications which, in turn, may help with surgical decision making., (Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Background and Purpose: Surgical management of a renal neoplasm in a solitary kidney is a balance between oncologic control and preservation of renal function. We analyzed patients with a renal mass in a solitary kidney undergoing nephron-sparing procedures to determine perioperative, oncologic, and renal functional outcomes., Patients and Methods: A multicenter study was performed from 12 institutions. All patients with a functional or anatomic solitary kidney who underwent nephron-sparing surgery for one or more renal masses were included. Tumor size, complications, and recurrence rates were recorded. Renal function was assessed with serum creatinine level and estimated glomerular filtration rate., Results: Ninety-eight patients underwent 105 ablations, and 100 patients underwent partial nephrectomy (PN). Preoperative estimated glomerular filtration rate (eGFR) was similar between the groups. Tumors managed with PN were significantly larger than those managed with ablation (P<0.001). Ablations were associated with a lower overall complication rate (9.5% vs 24%, P=0.01) and higher local recurrence rate (6.7% vs 3%, P=0.04). Eighty-four patients had a preoperative eGFR ≥60 mL/min/1.73 m(2). Among these patients, 19 (23%) fell below this threshold after 3 months and 15 (18%) at 12 months. Postoperatively, there was no significant difference in eGFR between the groups., Conclusions: Extirpation and ablation are both reasonable options for treatment. Ablation is more minimally invasive, albeit with higher recurrence rates compared with PN. Postoperative renal function is similar in both groups and is not affected by surgical approach.

Unlabelled: Study Type--Therapy (case series). Level of Evidence 4. What's known on the subject? And what does the study add? Minimizing renal ischemia and reperfusion injury is an area of active investigation and is particularly significant in cases of laparoscopic renal surgery where the kidney experiences warm ischemia. Reports of partial clamping, early unclamping, and off-clamp laparoscopic partial nephrectomy have demonstrated potential technical modifications that can offer a protective role in preserving renal function. We investigated off-clamp laparoscopic partial nephrectomy for tumours with varying clinical stage to determine feasibility, perioperative outcomes, and renal functional changes when compared to a contemporary cohort of standard laparoscopic partial nephrectomy with complete hilar clamping performed by a single surgeon., Objective: • To compare the operative outcomes and oncological efficacy of off-clamp (OC) laparoscopic partial nephrectomy (LPN) vs complete hilar control (HC) LPN for stage T1a-T2 renal cell carcinoma., Methods: • Retrospective review of all LPNs between June 2006 and March 2010 was performed, stratifying 390 patients by clinical T stage (cT1a = 313, cT1b = 62, cT2 = 15). • Perioperative and postoperative parameters were analysed comparing patients who underwent OC LPN (n= 126) with those who had HC LPN (n= 264) collectively and within each clinical stage cohort., Results: • There was no significant difference in the proportion of OC LPN for cT1a tumours compared with cT1b and cT2, P= 0.21. • OC vs HC LPN patients had a greater estimated blood loss (EBL) but with no significant difference in perioperative blood transfusion rates. • When compared by clinical stage, EBL was greater only for clinical stage T1a disease (P= 0.02) but not cT1b (P= 0.91) or cT2 (P= 0.42) tumours. • There was no difference in the operative time or length of hospitalization between OC and HC LPN by stage: cT1a (P= 0.77 and P= 0.17), cT1b (P= 0.77 and P= 0.07) and cT2 (P= 0.42 and P= 0.66), respectively. • In our series, one case (0.3%) of HC LPN had a positive margin on final pathology, one case was converted to open partial nephrectomy (0.3%), and two cases of OC LPN (1.6%) were intraoperatively converted to HC LPN., Conclusions: • OC LPN is a feasible surgical option for patients with cT1-T2 renal cell carcinoma that completely avoids renal ischaemic injury with the benefits of minimally invasive surgery. • LPN can be performed OC in patients with larger, more complex renal tumours without compromising the operative time, blood loss requiring transfusions, length of hospitalization, complication rates, or positive surgical margin rates compared with HC LPN., (© 2011 THE AUTHORS. BJU INTERNATIONAL © 2011 BJU INTERNATIONAL.)

LaparoEndoscopic Single-Site (LESS) nephroureterectomy is a recent iteration of laparoscopic renal surgery whereby the minimally-invasive approach of laparoscopy has been condensed to a single operative access site in efforts to minimize convalescence and improve cosmesis. To date, LESS nephroureterectomy has been reported successful for both adult and pediatric patient populations, most commonly for treatment of upper tract urothelial carcinoma in adults. For the treatment of upper tract urothelial carcinomas, comparative oncologic effectiveness of LESS compared to conventional laparoscopy or open surgery is pending further investigation. Overall, LESS nephroureterectomy has proven its role as a feasible and safe option of minimally-invasive surgery, minimizing the number and length of the surgical incisions used.

Purpose: This study aimed to evaluate the need for intraoperative ultrasound (IOUS) and recommendation for surgical approach in the resection of renal tumors through a survey of practicing urologists, with correlation to tumor imaging features and urologist practice pattern., Materials and Methods: An institutional review board-approved retrospective review, compliant with the Health Insurance Portability and Accountability Act, of 44 renal tumors that underwent laparoscopic partial nephrectomy at the study institution was performed. The numeric component of the RENAL nephrometry score (radius [diameter], % exophytic, nearness [to collecting system/renal sinus], location) was calculated for each case using preoperative computed tomography/magnetic resonance imaging. Five anonymized images of each tumor were presented to 4 academic urologists with varying practice patterns. Reviewers independently scored each case for its need for IOUS, for recommendation of a surgical technique, and for the difficulty of the proposed surgery., Results: The RENAL scores were as follows: RENAL 1 (low complexity, score 4-6; n = 19); RENAL 2 (moderate complexity, score 7-9; n = 23); RENAL 3 (high complexity, score 10-12; n = 2). The only RENAL score component significantly influencing need for IOUS was percentage exophytic (P = 0.00002). There was an inverse relationship between normalized and averaged need for IOUS and percentage exophytic (P < 0.0001). The predominant influence for recommendation of surgical method was the reviewer him/herself, with each reviewer's recommendations closely matching his/her practice pattern. Size and percentage exophytic represented the only tumor features significantly (P = 0.03) influencing surgical recommendation., Conclusions: There was a significant difference in the perceived need for IOUS and surgical recommendation when 4 academic urologists reviewed a series of renal masses requiring resection. Percentage exophytic correlated inversely with need for IOUS. Urologist's practice pattern and tumor size and percentage exophytic were most predictive of surgical recommendation.

Objectives: To report the first large multi-institutional experience, including clinical and renal functional outcomes after treatment of iatrogenic vascular lesions (eg, renal artery pseudoaneurysm, arteriovenous fistula). These lesions are uncommon after minimally invasive partial nephrectomy (MIPN) but can be associated with significant morbidity., Methods: A retrospective review of MIPN was performed at 4 centers. Patients developing pseudoaneurysm or arteriovenous fistula in the postoperative period were identified. The demographic, disease, and perioperative details and data regarding the presentation and treatment of vascular lesions were collected., Results: Of the 998 patients undergoing MIPN, 20 (2.0%) presented with iatrogenic vascular lesions (17 with pseudoaneurysm and 3 with arteriovenous fistula). The mean age was 55.9 years, the tumor size was 2.6 cm, and the body mass index was 30.8 kg/m(2). Twelve patients (60%) had >50% endophytic tumors, 7 patients (35%) had undergone collecting system repair, and the mean warm ischemia time was 26 minutes. All patients presented with gross hematuria at a mean of 14.5 days postoperatively. The diagnosis was made using urgent computed tomography scan in all cases. Selective embolization was performed in 16 patients; 2 required no intervention and had spontaneous resolution, and 2 had negative angiography findings. Four patients required transfusion during rehospitalization. Although 4 patients had categorical worsening of the glomerular filtration rate after MIPN, all patients had stable function acutely after angioembolization, and 3 patients had categorical glomerular filtration rate improvement through a mean follow-up of 20 months. No patients had recurrent hemorrhagic events., Conclusions: Iatrogenic vascular lesions occur in ∼2% of MIPN cases. Although a subset of patients will have resolution with observation only, most require angioembolization, with excellent clinical and renal function outcomes., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objectives: • To determine the frequency of delayed postoperative haemorrhage requiring selective angioembolization (SAE) after laparoscopic partial nephrectomy (LPN). • To describe the clinical presentation and characterize the angiographic findings encountered in this setting., Patients and Methods: • Prospective data from 640 LPNs performed between August 1993 and May 2009 were retrospectively analyzed, from which patients with delayed postoperative haemorrhage (defined as 'gross haematuria ≥ 7 days postoperatively that persists for more than 24 h') and requiring SAE were identified. • Clinicopathological, preoperative and perioperative factors were reviewed. • Selective catheterization and angiography of the renal artery was performed for persistent gross haematuria and for haemodynamic instability associated with a significant drop in haematocrit level. • Arteries feeding the bleeding site were identified and embolized with endovascular coils., Results: • Patients presented with delayed haemorrhage between 7 and 30 days after surgery. SAE was required in 13 patients (2%) for delayed postoperative bleeding. • Of the 640 LPNs, 68 (10.6%) were performed without hilar occlusion ('off-clamp') of whom one (1.5%) had a delayed haemorrhage, which was successfully embolized. • For patients with and without delayed haemorrhage after LPN, the mean tumour size was 2.7 cm and 3.3 cm (P= 0.31), the mean warm ischaemia time was 28.2 min and 14.3 min (P < 0.001), and the mean estimated blood loss 403.8 mL and 308.2 mL (P= 0.26), respectively. • Percutaneous angiography showed renal artery pseudoaneurysm in 10 patients and arterial contrast extravasation in three patients, two of whom also had an arteriovenous fistula. • Following embolization, creatinine levels remained stable in all patients., Conclusions: • Clinically significant delayed postoperative bleeding after LPN occurs in a small percentage of patients. • Angiography will accurately make the diagnosis of RAP or AVF and SAE is safe and effective procedure that allows for preservation of renal function., (© 2010 THE AUTHORS. BJU INTERNATIONAL © 2010 BJU INTERNATIONAL.)

Laparoscopic live donor nephrectomy is a safe, minimally invasive alternative to the customary open approach. During the past two decades, laparoscopic renal surgery has increased the availability of renal allograft specimens for transplantation. Specifically, the laparoscopic approach has minimized postoperative pain and duration of recovery, making it a more attractive option for potential altruistic organ donors. Here we detail the techniques, challenges, and troubleshooting approaches necessary for this technically challenging, yet valuable operation.

Objectives: To identify risk factors associated with hemorrhage during laparoscopic partial nephrectomy (LPN), and to determine the impact of hemorrhage on hospital course., Methods: We retrospectively analyzed prospective data from 335 LPNs to identify clinicopathologic factors associated with hemorrhagic complications (blood loss requiring ≥ 1 U transfusion) and extended length of hospitalization (≥ 3 days). We excluded patients with a coagulopathy or perioperative vascular injuries., Results: We identified 23 patients (7%) undergoing LPN with hemorrhagic complications (group 1 and 312 patients (93%) without complications (group 2). Mean age was 64.1 ± 14.4 vs 57.6 ± 12.7(P = .006), American Society of Anesthesiologists (ASA) score ≥ 3 seen in 61% vs 37% (P = .02), mean tumor size (cm) was 2.90 ± 2.02 vs 2.59 ± 1.15 (P = .93), mean total operative time (min) was 250.1 ± 116.1 vs 191.8 ± 69.2 (P = 0.006), and mean hospital stay (days) was 4.7 ± 3.4 vs 3.1 ± 3.0 (P = .0002), for groups 1 and 2, respectively. Hypertension, diabetes mellitus, chronic renal insufficiency, obesity, smoking, and coronary artery disease-congestive heart failure were present in group 1 vs group 2: 39.1% vs 31.4% (P = .4), 17.4% vs 8% (P = .12), 8.7% vs 1.9% (P = .09), 4.3% vs 3.5% (P = .57), 17.4% vs 5.4% (P = .04), and 8.7% vs 2.2% (P = .11), respectively. On multivariate analysis, smoking (P < .0437) and ASA score ≥ 3 (P < .0233) were associated with hemorrhagic complications. Hemorrhagic complications were 3.5 times more likely in smokers than nonsmokers (95% confidence interval, 1.0-11.7), and 2.9 times more likely with an ASA class ≥ 3. Only age (P < .0002) and operative time (P < .0001) were associated with longer hospitalization., Conclusions: High ASA scores and smoking are risk factors for hemorrhagic complications during LPN. Hemorrhagic complications did not significantly affect hospitalization length., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objectives: To compare laparoendoscopic single-site (LESS) Pfannenstiel donor nephrectomy with a contemporary series of standard laparoscopic (SL) donor nephrectomies., Methods: The initial 6 LESS donor nephrectomies were compared with a case-matched 6 SL donor nephrectomies within the same time period (June 2008 till March 2009). Patient characteristics (sex, age, body mass index, graft volume, and vascular anatomy), perioperative data (operative time, warm ischemia time [WIT], and estimated blood loss), and postoperative information (complications, length of stay, visual analog scale [VAS], and total morphine requirements) were collected prospectively and analyzed retrospectively., Results: In the LESS group, there were no conversions to SL or open. There was no significant difference between the two groups in terms of baseline characteristics (age, body mass index, allograft volume). However, SL group included more right-sided patients (three compared with one) and more venous anomalies (retrorenal veins in two patients and multiple veins in another). There was no significant difference between SL and LESS in terms of operative time (117 vs. 142 minutes), WIT (5 minutes in both groups), estimated blood loss (150 vs. 100 mL), median length of stay (2 days in both), and total morphine equivalents (42 vs. 83 mg). None of the patients received transfusions perioperatively. A patient in the SL group developed a wound infection requiring packing and antibiotics. There were no perioperative complications in the LESS group. Although VAS scores were lower in the LESS versus SL group at each of post-operative day (POD) #2 (1.5 vs. 4) and discharge (0 vs. 2), this did not reach statistical significance., Conclusions: In this small retrospective series, SL was associated with more complex renal anatomy. However, there was no difference between the two groups in terms of WIT, narcotic requirements, and VAS scores. Therefore, the advantages of LESS may only be cosmesis. To verify these results, both procedures need to be compared prospectively in a randomized fashion.

Context: The gained expertise in the surgical technique of partial nephrectomy (PN) with excellent oncologic outcome and reduced morbidity has contributed to more frequent use of PN in many centres of reference, and the recent evidence favouring PN over radical nephrectomy (RN) in the prevention of chronic kidney disease and possibly linking it to a better overall survival (OS) will constitute a strong argument for wider use of PN., Objective: To objectively analyse the advantages of PN over RN and to evaluate the risk-benefit ratio of expanding the indications of PN T1b renal cortical tumours., Evidence Acquisition: Literature searches on English-language publications were performed using the National Library of Medicine database. The queries included the keywords partial nephrectomy and nephron sparing surgery. Eight hundred four references were scrutinised, and 175 publications were identified and reviewed. Sixty-nine articles were selected for this review. These references formed the basis for this analysis and were selected based on their relevance and the importance of their content., Evidence Synthesis: The use of PN has been steadily increasing, particularly in tertiary care centres. This trend is now strengthened by evidence supporting the role of PN in reducing the risk of chronic kidney disease in patients with renal masses < or =4 cm. A wider use of PN for larger tumours, granted technical feasibility, is supported by the preliminary evidence, suggesting an OS advantage favouring PN over RN. However, the potential for selection bias and residual confounding factors may contribute to the observed difference. In the carefully selected patients with tumours >4 cm, PN obtained equivalent oncologic outcome to that achieved after RN. Although higher morbidity rates were seen after PN, the complication type and severity were not prohibitive., Conclusions: The available evidence supports elective PN as the standard surgical treatment for renal cortical tumours < or =4 cm. For larger tumours, PN has demonstrated feasibility and oncologic safety in the carefully selected patient population studied., (Copyright 2009 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Objective: To assess patient compliance with preoperative instructions and to determine causes and factors of noncompliance, as noncompliance might affect surgical outcome and has potential medicolegal implications., Patients and Methods: One surgeon counselled 101 consecutive patients before undergoing laparoscopic renal surgery. Deliberate discussions instructed patients to bring their radiograph films on the day of surgery and complete a preoperative bowel preparation. Noncompliance was defined as failure to bring films and/or complete bowel preparation. Patient demographics, socio-economic and clinical variables were analysed, and reasons for failure to comply with instructions were also recorded., Results: Twenty-four of the 101 (24%) patients were not compliant, 13 with films only, seven with bowel preparation only, and four with both sets of instructions. Univariate analysis showed that language and race were factors for noncompliance. Multivariate analysis showed that non-Caucasians had 17 times the risk of noncompliance (P < 0.001); long distance from home to the site of care had five times the risk of noncompliance (P = 0.041), and each day between the initial consultation and the date of surgery had 1.05 times the risk of noncompliance (P < 0.001). The most common reason given by patients for noncompliance was that they were never given the preoperative instructions., Conclusions: Noncompliance with preoperative surgical instructions is a significant issue and is increased in non-Caucasian patients, those travelling long distances, and those whose surgery date is long after their preoperative consultation. A systems-based approach is needed to address this significant issue.

Objectives: To describe laparoendoscopic single site (LESS) donor nephrectomy procedure through a Pfannenstiel incision. Laparoscopic donor nephrectomy has become the standard approach in harvesting kidneys from live donors. This is usually performed through 3 ports placed in a triangular manner in addition to the Pfannenstiel incision where the kidney is removed., Methods: Through a 5 cm Pfannenstiel incision, three 5 mm ports were placed in a triangular manner. A 5 mm flexible-tip laparoscope was used to perform laparoscopic donor nephrectomy. Before ligating the renal hilum, the superior midline trocar was exchanged for a 12-mm trocar to allow for an Endo-GIA stapler. After the kidney was placed in the entrapment sac, the anterior rectus fascia between the 2 midline ports was incised and the kidney was removed. After closure of the fascial defects, the Pfannenstiel incision was closed in a subcuticular manner., Results: LESS Pfannenstiel donor nephrectomy was successfully performed in 6 patients without standard laparoscopic or open conversion. No additional needlescopic instruments were used. The median age was 46 years with median body mass index of 28.3 kg/m(2). The median operative time was 142 minutes with a median warm ischemia time of 5 minutes. Median hospital stay was 2 days and the median pain score at discharge was 0. None of the patients received transfusions perioperatively and none had peri-operative complications., Conclusions: LESS Pfannenstiel donor nephrectomy offers the benefits of improved cosmesis over the standard laparoscopic donor nephrectomy. Prospective randomized trials are needed to compare the postoperative pain levels in between these 2 techniques., (2010. Published by Elsevier Inc.)

Purpose: We present oncological outcomes at a followup of 10 years or greater after laparoscopic radical nephrectomy for cancer., Materials and Methods: Between February 1994 and March 1999 a total of 73 laparoscopic radical nephrectomies were performed by 2 surgeons for pathologically confirmed renal cell carcinoma. Data were obtained from patient charts, radiographic reports, telephone followup and a check of the Social Security Death Index., Results: Mean followup was 11.2 years (range 10 to 15). Each patient completed a minimum 10-year followup. Mean patient age at surgery was 60 years. Mean tumor size on computerized tomography was 5 cm (range 1.7 to 13). Pathological stage was pT1a in 41% of cases, pT1b in 30%, pT2 in 15%, pT3a in 10%, pT3b in 3% and pT4 in 1%. High grade tumors (Fuhrman 3 or greater) were present in 18 cases (28%). A positive surgical margin occurred in 1 case. Actual 10-year overall, cancer specific and recurrence-free survival rates were 65%, 92% and 86%, respectively. Overall, cancer specific and recurrence-free survival rates at 12 years were 35%, 78% and 77%, respectively. At a mean of 67 months 10 patients (14%) had metastatic disease, of whom 8 (11%) died., Conclusions: Long-term oncological outcomes after laparoscopic radical nephrectomy for renal cell carcinoma are excellent and appear comparable to those of open surgery.

Objective: To evaluate whether a period of surveillance before laparoscopic partial nephrectomy (LPN) affects the pathological and clinical outcomes of patients with a small renal mass, as although the standard treatment for an enhancing renal mass remains surgical extirpation, surveillance of small renal masses has become a potential option in appropriately selected patients., Patients and Methods: The clinical and pathological data of 32 patients who had LPN for a small clinical stage T1a renal mass after a surveillance period of >or=3 months was analysed and compared with those from a matched group of patients who had immediate LPN., Results: The mean interval between diagnosis and LPN in the surveillance group was 15.8 months. The mean tumour size at presentation was 1.97 cm in the surveillance group with a growth rate of 0.56 cm/year. The proportion of patients upstaged from cT1 to pT3a was no different between the groups. There was no difference between the groups in warm ischaemia time, blood loss, operating room time, complications and length of stay after LPN. At the last follow-up (mean 60 months) there were no local recurrences or distant metastases., Conclusion: Baseline size does not appear to predict tumour malignant potential, and growth rates of malignant and benign tumours were similar in the two groups. A delay in surgery of >1 year was not associated with added surgical morbidity, nor did it preclude patients from undergoing definitive surgery via a minimally invasive approach with an equally effective early oncological outcome.

Objectives: To assess the perioperative outcomes in patients >75 years old to better define the role of laparoscopic renal surgery in this expanding segment of the U.S. population. The outcomes of elderly patients undergoing laparoscopic renal procedures are less well defined than those of younger patients., Methods: We retrospectively reviewed the records of 115 patients >75 years old who had undergone laparoscopic renal surgery. The clinical and pathologic features and complication rates were analyzed. The patients were substratified according to the type of laparoscopic procedure performed and extreme age (>80 years)., Results: The mean age of our 115 patients was 79.9 years (range 75-91). The median estimated blood loss was 200 mL (interquartile range 100-387). The transfusion rate was 9.6%. The median length of stay was 4 days (interquartile range 3-5). The overall complication rate for the entire cohort was 22.6% and was 13.7% in those >80 years. The number of patients who experienced a complication was 22 (19.1%). Patients with a Charlson comorbidity index >2 were more likely to experience a perioperative complication than were patients with a Charlson comorbidity index <1 (35% vs 16%; P = .034)., Conclusions: Our data support the safety and feasibility of laparoscopic renal procedures in elderly patients. Furthermore, this safety extends to patients of advanced age (>80 years). The overall complication rates and other perioperative parameters appear to be comparable to those in published studies; however, patients with a Charlson comorbidity index >2 are at a greater risk of complications in the perioperative period.

Objectives: To assess the perioperative outcomes of elective laparoscopic partial nephrectomy to treat renal tumors in patients with tumor burdens > 4 cm compared with those with tumor burdens of < or = 4 cm., Methods: A retrospective review of medical records was performed for all patients who had undergone laparoscopic partial nephrectomy for renal tumors from January 2000 to March 2005. The preoperative risk factors (ie, sex, age, American Society for Anesthesiologists score), perioperative course (ie, operative time, estimated blood loss, warm ischemia time, intraoperative and postoperative complications, transfusion rate, intraoperative biopsy of surgical margins, length of hospitalization), and pathologic outcomes (ie, tumor stage, type, and grade) were collected and compared between the patients in the 2 cohorts., Results: Patients with larger tumors had significantly more complications (37.0% vs 21.8%, P = .039) and a significantly longer hospitalization (4.1 vs 3.0 days, P = .026). For those with malignant tumors > 4 cm compared with those with malignant tumors of < or = 4 cm, the complication rate was 33.3% and 11.6% (P = 0.006) and the length of hospitalization was 4.5 and 3.2 days (P = .055), respectively. No other differences were noted between the 2 groups stratified by tumor size., Conclusions: Laparoscopic partial nephrectomy is an oncologically feasible option for tumor burdens > 4 cm in the greatest dimension to provide a nephron-sparing option for patients in whom individually selected lesions can be isolated.

Purpose: There are limited data on the indications for open conversion during laparoscopic surgery. The frequency of conversion for various procedures is poorly quantified and the degree to which this changes with time is not well understood. Risk factors for conversion are not defined. We addressed these issues in a large series of laparoscopic operations., Materials and Methods: We reviewed our database of 2,128 laparoscopic operations performed between 1993 and 2005, including radical nephrectomy in 549 patients, simple nephrectomy in 186, partial nephrectomy in 347, donor nephrectomy in 553, pyeloplasty in 301, nephroureterectomy in 106 and retroperitoneal lymph node dissection in 86. Open conversions were identified and the frequency of conversion for the total cohort and specific procedures was determined. Trends in conversion with time were assessed and indications analyzed. Clinicopathological features between patients requiring conversion and those who did not were compared., Results: We identified 68 patients (3.3%) who underwent conversion to open surgery (group 1) and 2,011 (96.7%) who did not (group 2). The frequency of conversion was greatest during nephroureterectomy (8.49%), followed by simple nephrectomy (5.91%), retroperitoneal lymph node dissection (4.65%), partial nephrectomy (4.32%), radical nephrectomy (2.91%), donor nephrectomy (2.53%) and pyeloplasty (0.33%). The absolute number of conversions and conversions/cases performed per year decreased significantly with time, reaching a nadir of less than 1% per year. Conversion was inversely related to case volume and cumulative experience. Indications included vascular injury in 38.5% of cases, concern with margins in 13.5%, bowel injury in 13.5%, failure to progress in 11.5%, adhesions in 9.6%, diaphragmatic injury in 1.9% and other in 11.5%. The distribution of indications remained similar with time. There were no differences in patient age, gender, surgical history, American Society of Anesthesiologists score or tumor stage between groups 1 and 2. In groups 1 and 2 mean operative time was 304 vs 219 minutes and estimated blood loss was 904 vs 255 cc (each p <0.0001)., Conclusions: The rate of conversion during laparoscopic surgery is not uniform across procedures and it is important for patient counseling. The most common indication for conversion is vascular injury. Importantly the frequency of conversion is dynamic and likely related to case volume and cumulative experience.

Objectives: The aim of this study was to compare the perioperative outcomes of open (OPN) and laparoscopic (LPN) partial nephrectomy in obese and non-obese patients., Methods: We analyzed records for a cohort of 56 patients (28 obese and 28 non-obese) who underwent OPN, as well as 112 (56 obese and 56 non-obese) who underwent LPN., Results: Obese patients undergoing OPN had increased operative time (285.9 +/- 69.7 versus 195.2 +/- 59.8 minutes), blood loss (484.5 +/- 272.1 versus 391.7 +/- 308.6 mL), clamp time (44.4 +/- 12.8 versus 28.2 +/- 10.5 minutes), intraoperative complications (14.3% versus 1.8%), postoperative complications (35.7% versus 17.9%), and hospital stay (6.4 +/- 2.8 versus 3.2 +/- 2.2 days) than those undergoing LPN. Comparison of obese versus non-obese patients who underwent LPN revealed similar perioperative outcomes, with the exception of a greater blood loss in the obese patient cohort (391.7 +/- 308.6 versus 280.9 +/- 202.1 mL). Finally, in comparing perioperative data among non-obese patients who underwent OPN versus LPN, those who underwent LPN were found to have improved operative times (248.9 +/- 45.0 versus 181.1 +/- 62.4 minutes), less blood loss (412.4 +/- 274.6 versus 280.9 +/- 202.1 mL), fewer intraoperative complications (21.4% versus 1.8%), and shorter length of hospital stay (6.3 +/- 2.8 versus 3.2 +/- 1.6 days)., Conclusions: Laparoscopic partial nephrectomy has significantly better perioperative outcomes than open partial nephrectomy in both the obese and non-obese populations.

Objectives: To present our experience performing laparoscopic partial nephrectomy (LPN) for hilar renal tumors and demonstrate the feasibility and short-term oncologic efficacy., Methods: The patients who had undergone LPN for excision of a hilar tumor, defined as a renal tumor that came in direct contact with the renal artery and/or vein, were identified. The clinicopathologic parameters, perioperative course, complications, and oncologic outcomes were analyzed., Results: A total of 18 patients with a hilar renal mass (4.4%) underwent elective LPN. The mean tumor size was 3.24 cm (range 1.3 to 8), and the mean preoperative creatinine was 1.04 mg/dL (range 0.6 to 1.8). The mean operating room and warm ischemia time was 173 minutes (range 93 to 337) and 29.4 minutes (range 17 to 50), respectively. The pelvicaliceal system was entered and repaired in 10 patients (55.6%), and the median estimated blood loss was 394.4 mL (range 100 to 1500). The mean hospital stay was 3 days (range 2 to 5). Histopathologic examination confirmed renal cell carcinoma in 13 patients (72.2%). The surgical margins and frozen sections of the tumor base were negative in all cases. The tumor stage was pT1 in 11 patients (85%), pT2 in 1 patient (7.7%), and pT4 in 1 patient (7.7%). The mean postoperative creatinine was 1.2 mg/dL (range 0.6 to 2.3). Postoperative transfusion was required in 4 patients (22.2%), including 1 patient who required intraoperative transfusion (5.5%) and 1 who required angioembolization (5.5%). During a mean follow-up of 12.3 months (range 0.2 to 66), no patient had evidence of local recurrence or metastatic disease., Conclusions: Experienced laparoscopic surgeons can safely perform LPN for hilar renal tumors. The short-term oncologic results have been promising; however, long-term follow-up is necessary.

Objectives: To address the incidence of local recurrence and port site metastasis in patients who underwent laparoscopic radical nephroureterectomy (RNU) for upper tract transitional cell carcinoma (TCC)., Methods: Between August 1993 and February 2006 116 laparoscopic RNU were performed in 115 patients at our institution. A traditional open excision, a laparoscopic stapler resection or a different approach was used for the management of the distal ureter in 76, 27, and 11 cases, respectively. Clinical follow-up as well as perioperative and pathologic data were retrospectively collected., Results: Perioperative and pathologic data were available in all 116 cases. Clinical outcomes were available in 107 patients with a mean follow-up of 30.5 months (range 1 to 148). Six patients (5.6%) had a local recurrence develop, including 1 patient with port site metastasis (0.9%) at an average of 5.7 months. In 2 of these patients, violation of the ipsilateral urinary tract was noted perioperatively., Conclusions: We report, in this large single-center series of laparoscopic RNU, a low incidence of local recurrence. Our results confirm that a laparoscopic approach to upper tract TCC does not result in a clinically significant increased risk of tumor spillage provided that principles of oncologic surgery are followed.

Purpose: To evaluate the safety and oncologic efficacy of extravesical laparoscopic stapling of the distal ureter and bladder cuff during nephroureterectomy for pelvicaliceal transitional-cell carcinoma (TCC)., Patients and Methods: Patients with primary pelvicaliceal TCC and no history of TCC of the bladder or ureter who underwent extravesical laparoscopic control of the bladder cuff were compared with a similar group of patients submitted to the open transvesical approach. Operative results and oncologic outcomes were compared., Results: Operative time, estimate blood loss, length of hospital stay, rate of positive margins, and postoperative complications were not statistically different in the two groups of patients. With an average of almost 4 years of follow-up, the laparoscopic approach to the bladder cuff was associated with an increase in the overall rate of recurrence and a shorter recurrence-free survival, although these differences were not statistically significant. Rates of local and bladder recurrence and distant metastases were similar., Conclusions: Laparoscopic stapling of the bladder cuff has oncologic efficacy and outcomes similar to those of the open transvesical approach. However, the laparoscopic procedure may carry a higher risk of recurrence and a shorter recurrence-free interval than the open transvesical approach.

Purpose: Laparoscopic partial nephrectomy is an increasingly performed, minimally invasive alternative to open partial nephrectomy. We compared early postoperative outcomes in 1,800 patients undergoing open partial nephrectomy by experienced surgeons with the initial experience with laparoscopic partial nephrectomy in patients with a single renal tumor 7 cm or less., Materials and Methods: Data on 1,800 consecutive open or laparoscopic partial nephrectomies were collected prospectively or retrospectively in tumor registries at 3 large referral centers. Demographic, intraoperative, postoperative and followup data were compared between the 2 groups., Results: Compared to the laparoscopic partial nephrectomy group of 771 patients the 1,028 undergoing open partial nephrectomy were a higher risk group with a greater percent presenting symptomatically with decreased performance status, impaired renal function and tumor in a solitary functioning kidney (p<0.0001). More tumors in the open partial nephrectomy group were more than 4 cm and centrally located and more proved to be malignant (p<0.0001 and 0.0003, respectively). Based on multivariate analysis laparoscopic partial nephrectomy was associated with shorter operative time (p<0.0001), decreased operative blood loss (p<0.0001) and shorter hospital stay (p<0.0001). The chance of intraoperative complications was comparable in the 2 groups. However, laparoscopic partial nephrectomy was associated with longer ischemia time (p<0.0001), more postoperative complications, particularly urological (p<0.0001), and an increased number of subsequent procedures (p<0.0001). Renal functional outcomes were similar 3 months after laparoscopic and open partial nephrectomy with 97.9% and 99.6% of renal units retaining function, respectively. Three-year cancer specific survival for patients with a single cT1N0M0 renal cell carcinoma was 99.3% and 99.2% after laparoscopic and open partial nephrectomy, respectively., Conclusions: Early experience with laparoscopic partial nephrectomy is promising. Laparoscopic partial nephrectomy offered the advantages of less operative time, decreased operative blood loss and a shorter hospital stay. When applied to patients with a single renal tumor 7 cm or less, laparoscopic partial nephrectomy was associated with additional postoperative morbidity compared to open partial nephrectomy. However, equivalent functional and early oncological outcomes were achieved.