Mechanical circular stapler device loaded with nonabsorbable titanium staples for ileo-prostate capsuloplasty following prostate capsule sparing cystectomy: initial experience in cadavers.

PURPOSE: Mechanical linear staplers have been safely used in urology with an acceptable 0% to 7.9% rate of stone formation in long-term follow-up. We sought to evaluate the feasibility of using mechanical circular stapler devices to perform ileocapsuloplasty following cystoadenomectomy in cadavers. MATERIAL AND METHOD: Three unfrozen cadavers were used in this study. The prostate was enucleated and removed along with the bladder, leaving an ample cavity wherein the 21-mm anvil could be easily accommodated. A 2-0 purse string suture was then placed at the prostate capsule rim and tightly tied around the anvil. Following this, the circular stapler device was introduced into the neobladder through its opened limb and the center rod of the stapler device was passed through an opening made at the most dependent portion of the pouch where another purse string suture was placed and tied around it. Finally, the center rod of the stapler was connected to the anvil and fired, thus completing the anastomosis. RESULTS: The procedure was feasible in all cases and 2 intact rings of prostatic capsule and bowel tissue were obtained, thus attesting the integrity of the anastomoses. Retrograde injection of methylene blue reassured that a watertight anastomosis was achieved whereas cystoscopic and macroscopic examination of the anastomotic site demonstrated a wide patent anastomosis in all cases. CONCLUSIONS: Use of mechanical circular stapler to perform ileocapsuloplasty in cadavers is feasible and has potential advantages such as decreased anastomotic time, diminished chances of urinary extravasations, and reduced degree of difficulty.

Complications in laparoscopic radical cystectomy. The South American experience with 59 cases.

OBJECTIVE: In this study, we have gathered the second largest series yet published on laparoscopic radical cystectomy in order to evaluate the incidence and cause of intra and postoperative complication, conversion to open surgery, and patient mortality. MATERIALS AND METHODS: From 1997 to 2005, 59 laparoscopic radical cystectomies were performed for the management of bladder cancer at 3 institutions in South America. Twenty nine patients received continent urinary diversion, including 25 orthotopic ileal neobladders and 4 Indiana pouches. Only one case of continent urinary diversion was performed completely intracorporeally. RESULTS: Mean operative time was 337 minutes (150-600). Estimated intraoperative blood loss was 488 mL (50-1500) and 12 patients (20%) required blood transfusion. All 7 (12%) intraoperative complications were vascular in nature, that is, 1 epigastric vessel injury, 2 injuries to the iliac vessels (1 artery and 1 vein), and 4 bleedings that occurred during the bladder pedicles control. Eighteen (30%) postoperative complications (not counting mortalities) occurred, including 3 urinary tract infections, 1 pneumonia, 1 wound infection, 5 ileus, 2 persistent chylous drainage, 3 urinary fistulas, and 3 (5%) postoperative complications that required surgical intervention (2 hernias - one in the port site and one in the extraction incision, and 1 bowel obstruction). One case (1.7%) was electively converted to open surgery due to a larger tumor that precluded proper posterior dissection. Two mortalities (3.3%) occurred in this series, one early mortality due to uncontrolled upper gastrointestinal bleeding and one late mortality following massive pulmonary embolism. CONCLUSIONS: Laparoscopic radical cystectomy is a safe operation with morbidity and mortality rates comparable to the open surgery.

Laparoscopic-assisted radical cystectomy with U-shaped orthotopic ileal neobladder constructed using nonabsorbable titanium staples.

INTRODUCTION: Recently, nonabsorbable staples have been safely used in a variety of urologic open and laparoscopic extirpative and reconstructive procedures. We report the surgical steps of our technique of U-shaped orthotopic ileal neobladder created with titanium staples. TECHNICAL CONSIDERATIONS: Using stay stitches, a 45 to 50-cm ileal segment is arranged in a U shape with two segments of approximately 20 cm and an afferent limb of 5 or 10 cm. An opening is made at the lowest point of the U-ileal segment on its antimesenteric border. The jaws of the 80 x 3.5-mm nonabsorbable mechanical stapler are accommodated within the bowel loop and fired twice, bringing together and detubularizing approximately 15 cm of each arm of the U. To complete the pouch detubularization, another small opening is made at the bottom of the chimney on its medial border. After this, a third nonabsorbable mechanical stapler had its jaws introduced through this opening and through the open end of the bowel segment on the right side and the stapler is fired, completing the U pouch. Subsequently, the open ends of the U segment and the opening made at the base of the afferent limb are closed with absorbable running sutures. CONCLUSIONS: Our technique is feasible and may represent an alternative to expand the spectrum of continent urinary reservoirs that could be expeditiously created with nonabsorbable staples. Continued surveillance is mandatory to determine the lithiasis-inducing potential of these titanium staples within the urinary tract.

Complications in laparoscopic radical cystectomy: The South American experience with 59 cases

OBJECTIVE: In this study, we have gathered the second largest series yet published on laparoscopic radical cystectomy in order to evaluate the incidence and cause of intra and postoperative complication, conversion to open surgery, and patient mortality. MATERIALS AND METHODS: From 1997 to 2005, 59 laparoscopic radical cystectomies were performed for the management of bladder cancer at 3 institutions in South America. Twenty nine patients received continent urinary diversion, including 25 orthotopic ileal neobladders and 4 Indiana pouches. Only one case of continent urinary diversion was performed completely intracorporeally. RESULTS: Mean operative time was 337 minutes (150-600). Estimated intraoperative blood loss was 488 mL (50-1500) and 12 patients (20 percent) required blood transfusion. All 7 (12 percent) intraoperative complications were vascular in nature, that is, 1 epigastric vessel injury, 2 injuries to the iliac vessels (1 artery and 1 vein), and 4 bleedings that occurred during the bladder pedicles control. Eighteen (30 percent) postoperative complications (not counting mortalities) occurred, including 3 urinary tract infections, 1 pneumonia, 1 wound infection, 5 ileus, 2 persistent chylous drainage, 3 urinary fistulas, and 3 (5 percent) postoperative complications that required surgical intervention (2 hernias - one in the port site and one in the extraction incision, and 1 bowel obstruction). One case (1.7 percent) was electively converted to open surgery due to a larger tumor that precluded proper posterior dissection. Two mortalities (3.3 percent) occurred in this series, one early mortality due to uncontrolled upper gastrointestinal bleeding and one late mortality following massive pulmonary embolism. CONCLUSIONS: Laparoscopic radical cystectomy is a safe operation with morbidity and mortality rates comparable to the open surgery.

Use of titanium knot placement device (TK-5) to secure dorsal vein complex during laparoscopic radical prostatectomy and cystoprostatectomy.

INTRODUCTION: We evaluated the feasibility and describe the surgical technique of using the Ti-Knot device TK-5 to secure the dorsal vein complex (DVC) during 20 consecutive cases of laparoscopic radical prostatectomy and cystoprostatectomy. TECHNICAL CONSIDERATIONS: Bloodless DVC ligation and transection was successfully achieved in 19 (95.03%) of 20 cases. In only 1 case, venous bleeding occurred after DVC transection. However, in this case, the two stitches used to ligate the DVC were tightly tied, and the bleeding probably occurred because the stitches were passed too superficially on the DVC. In another case, a third stitch had to be placed and tied with the aid of the Ti-Knot device because the second 2-0 Vicryl stitch placed at the DVC broke. In only 1 case did we experience some degree of trouble with the knotting process because one of the ends of the Vicryl suture slipped back into the abdominal cavity. The time to tie each suture with the Ti-Knot device, defined after the moment the needle was passed underneath the DVC to the moment the titanium knot was crimped and the Vicryl suture trimmed, was less than 1 minute (median 50 seconds, range 45 to 56) in all cases, except the case described above. No cases of the Ti-Knot device misfiring or malfunction occurred in this series. CONCLUSIONS: In our experience, the Ti-Knot titanium knot placement device proved to be safe and efficient during laparoscopic ligation and control of the DVC.

Laparoscopic radical cystectomy with intracorporeally constructed Y-shaped orthotopic ileal neobladder using nonabsorbable titanium staples exclusively.

Increasing evidence in published reports has suggested that titanium staples may be well tolerated inside the urinary tract. Recently, the Italian Group from Piedmont described an "easy, fast, and reliable" technique of a Y-shaped ileal neobladder that was created during open surgery with nonabsorbable mechanical staples. They observed an acceptable 6% rate of stone formation at a median follow-up of 20 months (range 8 to 47). We describe our initial experience with laparoscopic Y-shaped orthotopic ileal neobladder constructed entirely intracorporeally using titanium staples exclusively in an attempt to mitigate the time-consuming and skill-intensive task of freehand suturing required during laparoscopic creation of continent reservoirs.

Laparoscopic assisted radical cystoprostatectomy with Y-shaped orthotopic ileal neobladder constructed with non-absorbable titanium staples through a 5 cm Pfannensteil incision.

INTRODUCTION: We performed a laparoscopic radical cystoprostatectomy followed by constructing a Y-shaped reservoir extra-corporeally with titanium staples through a 5-cm muscle-splitting Pfannenstiel incision. SURGICAL TECHNIQUE: Upon completion of the extirpative part of the operation, the surgical specimen was entrapped and removed intact through a 5-cm Pfannenstiel incision. Through the extraction incision, the distal ileum was identified and a 40 cm segment isolated. With the aid of the laparoscope, the ureters were brought outside the abdominal cavity and freshened and spatulated for approximately 1.5-cm. Bilateral double J ureteral stents were then inserted up to the renal pelvis and the ureters were directly anastomosed to the open ends of the limbs of the neobladder. Following this, the isolated intestinal segment was arranged in a Y shape with two central segments of 14 cm and two limbs of 6 cm. The two central segments were brought together and detubularized, with two sequential firings of 80 x 3.5 mm and 60 x 3.5 mm non-absorbable mechanical stapler (Multifire GIA--US Surgical) inserted through an opening made at the lowest point of the neobladder on its anti-mesenteric border. The neobladder was reinserted inside the abdominal cavity and anastomosed to the urethra with intracorporeal laparoscopic free-hand suturing. CONCLUSION: Although this procedure is feasible and the preliminary results encouraging, continued surveillance is necessary to determine the lithiasis-inducing potential of these titanium staples within the urinary tract.

Transperitoneal versus retroperitoneal laparoscopic partial nephrectomy: patient selection and perioperative outcomes.

PURPOSE: We compared the results of transperitoneal (T) and retroperitoneal (R) approaches to laparoscopic partial nephrectomy (LPN) in regard to perioperative outcomes and technical considerations, thereby, identifying patient selection guidelines for each approach. MATERIALS AND METHODS: The choice of approach was dictated primarily by tumor location, that is TLPN for anterior or lateral lesions and RLPN for posterior or posterolateral lesions. The approaches differed primarily by the hilar control technique. During TLPN en bloc hilar control was achieved with a Satinsky clamp, while during RLPN individual vessel control was obtained with bulldog clamps. RESULTS: In a 3-year period 100 TLPNs and 63 RLPNs were performed for renal tumor. Of posterior tumors 77% were managed by RLPN, whereas 97% of anterior tumors were managed by TLPN. TLPN was associated with significantly larger tumors (3.2 vs 2.5 cm, p <0.001), more caliceal suture repairs (79% vs 57%, p = 0.004), longer ischemia time (31 vs 28 minutes, p = 0.04), longer operative time (3.5 vs 2.9 hours, p <0.001) and longer hospital stay (2.9 vs 2.2 days, p <0.01) than RLPN. Blood loss, perioperative complications, postoperative serum creatinine, analgesic requirements and histological outcomes were comparable between the groups. CONCLUSIONS: We perform TLPN for all anterior or lateral tumors as well as for large or deeply infiltrating posterior tumors that require substantive resection (heminephrectomy). The limited retroperitoneal space makes RLPN technically more challenging but provides superior access to posterior and particularly posteromedial lesions. When feasible, we prefer to perform laparoscopic partial nephrectomy by the transperitoneal approach because of its larger working area and superior instrument angles for intracorporeal renal reconstruction.

Laparoscopic assisted radical cystoprostatectomy with Y-shaped orthotopic ileal neobladder constructed with non-absorbable titanium staples through a 5 cm Pfannensteil incision

INTRODUCTION: We performed a laparoscopic radical cystoprostatectomy followed by constructing a Y-shaped reservoir extra-corporeally with titanium staples through a 5-cm muscle-splitting Pfannenstiel incision. SURGICAL TECHNIQUE: Upon completion of the extirpative part of the operation, the surgical specimen was entrapped and removed intact through a 5-cm Pfannenstiel incision. Through the extraction incision, the distal ileum was identified and a 40 cm segment isolated. With the aid of the laparoscope, the ureters were brought outside the abdominal cavity and freshened and spatulated for approximately 1.5-cm. Bilateral double J ureteral stents were then inserted up to the renal pelvis and the ureters were directly anastomosed to the open ends of the limbs of the neobladder. Following this, the isolated intestinal segment was arranged in a Y shape with two central segments of 14 cm and two limbs of 6 cm. The two central segments were brought together and detubularized, with two sequential firings of 80 x 3.5 mm and 60 x 3.5 mm non-absorbable mechanical stapler (Multifire GIA - US Surgical) inserted through an opening made at the lowest point of the neobladder on its anti-mesenteric border. The neobladder was reinserted inside the abdominal cavity and anastomosed to the urethra with intracorporeal laparoscopic free-hand suturing. CONCLUSION: Although this procedure is feasible and the preliminary results encouraging, continued surveillance is necessary to determine the lithiasis-inducing potential of these titanium staples within the urinary tract.

Stapleless laparoscopic assisted radical cystectomy with ileal neobladder in a male and with ileal loop in a female: initial report from Brazil.

INTRODUCTION: Here, we report our initial experience with laparoscopic assisted radical cystectomy without the use of surgical staples. CASES REPORT: A 70 year old male and a 55 year old female were diagnosed to have T2G3 transitional cell carcinoma of the bladder with negative metastatic work-out. Both patients were scheduled and agreed to a laparoscopic assisted radical cystectomy. In both cases, urinary diversion (orthotopic ileal Studer neobladder in the male and ileal conduit in the female) was performed extracorporeally following radical cystectomy. In both cases control of the bladder vascular pedicle was accomplished with a combination of metallic and hem-o-lock clips. The total surgical time was 6.5 hours in both cases. Estimated intra-operative blood loss was 500 cc and 350 cc respectively, however both patients required postoperative blood transfusions. No intraoperative complications occurred. In both cases, pathology revealed negative surgical margins. CONCLUSIONS: Extracorporeal creation of urinary diversion decrease the overall operative time. Laparoscopic pelvic lymphadenectomy can be performed following the extended template. The use of surgical clips instead of vascular Endo-GIA titanium staples to control the bladder vascular pedicles is feasible and safe in selected patients, thus reducing intraoperative surgical costs. Considerable experience with laparoscopic radical prostatectomy is necessary before one attempts laparoscopic radical cystectomy.

Impact of intraoperative heparin on laparoscopic donor nephrectomy.

PURPOSE: At many centers systemic heparinization is performed during laparoscopic donor nephrectomy because of concerns regarding graft thrombosis. However, no consensus exists in this regard. We evaluated the impact of intraoperative heparin on donor and recipient outcomes. MATERIALS AND METHODS: Between September 2000 and February 2003, 79 consecutive patients underwent laparoscopic live donor left nephrectomy at our institution. They were sequentially divided into 2 groups, that is group 1-the initial 40 patients who intraoperatively received 5,000 IU heparin intravenously and group 2-subsequent patients who did not receive heparin. The 2 groups were well matched demographically. Data were compared using the paired 2-tailed t test. RESULTS: The 2 donor groups were comparable in regard to mean blood loss (139 vs 179 cc, p = 0.59), intraoperative urine output (1.6 vs 1.6 l, p = 0.74), warm ischemia time (4 vs 4.2 minutes, p = 0.52), operative time (3.5 vs 3.5 hours, p = 0.97), and cold ischemia time (75 vs 82 minutes, p = 0.38). Complications occurred in 1 patient in group 1 (rhabdomyolysis induced acute renal failure) and in 2 in group 2 (chylous ascites and lumbar vein injury, respectively). No graft was lost due to vascular thrombosis in either group. Recipient immediate, early and delayed (6-month) graft function was comparable between the 2 groups. Acute rejection occurred in 5 recipients in group 1 and 1 in group 2. There was 1 recipient death per group at delayed followup. CONCLUSIONS: Routine use of heparin during laparoscopic donor nephrectomy is not necessary. Because of its potential for causing intraoperative or early postoperative hemorrhage, we no longer routinely administer intraoperative heparin during laparoscopic donor nephrectomy at our institution.

Stapleless laparoscopic assisted radical cystectomy with ileal neobladder in a male and with ileal loop in a female: initial report from Brazil

INTRODUCTION: Here, we report our initial experience with laparoscopic assisted radical cystectomy without the use of surgical staples. CASES REPORT: A 70 year old male and a 55 year old female were diagnosed to have T2G3 transitional cell carcinoma of the bladder with negative metastatic work-out. both patients were scheduled and agreed to a laparoscopic assisted radical cystectomy. In both cases, urinary diversion (orthotopic ileal Studer neobladder in the male and ileal conduit in the female) was performed extracorporeally following radical cystectomy. In both cases control of the bladder vascular pediclewas accomplished with a combination of metallic and hem-o-lock clips. The total surgical time was 6.5 hours in both cases. Estimated intra-operative blood loss was 500 cc and 350 cc respectively, however both patients required postoperative blood transfusions. No intraoperative complications occurred. In both cases, pathology revealed negative surgical margins. CONCLUSIONS: Extracorporeal creation of urinary diversion decrease the overall operative time. Laparoscopic pelvic lymphadenectomy can be performed following the extended template. The use of surgical clips instead of vascular Endo-GIA titanium staples to control the bladder vascular pedicles is feasible and safe in selected patients, thus reducing intraoperative surgical costs. Considerable experience with laparoscopic radical prostatectomy is necessary before one attempts laparoscopic radical cystectomy.

Laparoscopic live donor nephrectomy has equivalent early and late renal function outcomes compared with open donor nephrectomy.

OBJECTIVES: To assess the patterns of early functional recovery and long-term function in laparoscopic and open procured live donor nephrectomy (LDN) kidneys, highlighting the radionuclide scan as an additional tool for assessment, because of concerns regarding renal functional recovery after laparoscopic LDN. METHODS: We reviewed the donor and recipient records of 101 laparoscopic and 35 open LDNs performed between August 1997 and September 2001. Data were collected on demographic, immunologic, and intraoperative variables and ureteral/vascular complications. Delayed renal function recovery in recipients was evaluated by serum creatinine greater than 2.5 mg/dL on postoperative day 5, dialysis in first postoperative week, and two renographic criteria--the time to peak activity and the time to one-half peak activity on postoperative day 5. Long-term outcomes were evaluated by serum creatinine at 1, 3, 6, and 12 months and 2 and 3 years, creatinine clearance at 1 year, and patient and allograft survival. RESULTS: Donor and recipient age, sex, body mass index, and number of HLA mismatches did not differ between the two groups. The mean operating room time and blood loss were comparable. No differences were found in the early functional parameters (renography, creatinine at postoperative day 1 and 5, or dialysis in week 1) or long-term outcome (patient and graft survival, creatinine, and rejection at 1 year and patient and graft survival at 1, 2, and 3 years). CONCLUSIONS: Early recovery of graft function, longer term renal function, and 3-year patient and allograft survival are similar for live donor kidneys obtained by either a laparoscopic or an open surgical technique.

Dismembered percutaneous endopyeloplasty: a new procedure.

PURPOSE: We recently described a novel technique of percutaneous non-dismembered endopyeloplasty (Fenger type). Herein, we extend this transrenal technique further and report percutaneous dismembered endopyeloplasty (Anderson-Hynes type). MATERIALS AND METHODS: In five pigs with unilateral ureteropelvic junction (UPJ) obstruction created 3 to 6 weeks earlier, percutaneous dismembered endopyeloplasty was performed. Percutaneous transrenal access to the UPJ was obtained, and the UPJ was completely dismembered from within the renal pelvis through the solitary percutaneous tract. The dismembered proximal ureter was circumferentially mobilized, and in two animals, the UPJ segment was completely excised and removed. A spatulated end-to-end endopyeloplasty anastomosis (Anderson-Hynes) was created transrenally with 5 to 10 interrupted sutures using a novel nephroscopic suturing device (Sew-Right SR-5; LSI Solutions, Rochester, NY). In two animals, the entire percutaneous procedure was performed with CO2 insufflation instead of fluid irrigation. RESULTS: The technique was developed in three pigs. Subsequently, two pigs were treated and sacrificed at 2 and 5 weeks. All UPJs were dismembered successfully, and a precisely sutured mucosa-to-mucosa anastomosis was created. Intraoperative bleeding was negligible, and the operative time ranged from 3 to 5 hours, with the majority of the time dedicated to transrenal retroperitoneal dissection of the scarred, fibrotic UPJ. Carbon dioxide insufflation was efficacious because it minimized fluid extravasation and tissue edema and additionally enhanced visibility. Postoperative pyelograms revealed an adequately funneled UPJ, with good flow into the distal ureter. The two survival animals had minimal apparent morbidity from the procedure, and retrograde pyelograms at euthanasia revealed a patent anastomosis without extravasation. A 6F catheter easily crossed the reconstructed UPJ at autopsy in all animals. CONCLUSIONS: Dismembered percutaneous Anderson-Hynes endopyeloplasty is technically feasible and is promising. Further technical experience and additional functional outcome analysis in the survival model are necessary. With the technique described herein, we introduce the concept of percutaneous intrarenal reconstructive surgery (PIRS), wherein advanced intrarenal and retroperitoneal dissection with reconstruction can be performed endourologically, further broadening the horizons of conventional percutaneous techniques.

Complications of laparoscopic partial nephrectomy in 200 cases.

PURPOSE: We analyzed complications of the initial 200 cases treated with laparoscopic partial nephrectomy for a suspected renal tumor. MATERIALS AND METHODS: Since August 1999, 200 consecutive patients have undergone laparoscopic partial nephrectomy. Mean patient age was 61.6 years, mean body mass index was 29.9 and mean tumor size was 2.9 cm (range 1 to 10). There were 51 central tumors (25%) and 15 solitary kidneys (7.5%). A central tumor was defined as any tumor infiltrating up to the collecting system or renal sinus, during the excision of which entry into and repair of the collecting system was necessary. Mean estimated blood loss was 247 cc and mean operative time was 3.3 hours. Data on complications were obtained from a prospectively maintained computerized database and via telephone calls to patients and/or local referring physicians. RESULTS: A total of 66 patients (33%) had 1 or more complications, which were intraoperative in 11 (5.5%), postoperative in 24 (12%) and delayed in 31 (15.5%). Overall 30 patients (15%) had a non-urological complication and 36 (18%) had a urological complication, including hemorrhage in 19 (9.5%) and urine leakage in 9 (4.5%). Hemorrhage occurred intraoperatively in 7 cases (3.5%) and postoperatively in 4 (2%), while it was delayed in 8 (4%). Of patients with urine leakage none required reoperation, 6 (3%) required a Double-J stent (Medical Engineering Corp., New York, New York) only, 2 (1%) required a Double-J stent with computerized tomography guided drainage and 1 required no treatment. Open conversion was necessary in 2 patients (1%), reoperation was done in 4 (2%) and elective laparoscopic radical nephrectomy was performed in 1 (0.5%). CONCLUSIONS: Laparoscopic partial nephrectomy is an advanced procedure with potential for complications. It requires considerable experience with reconstructive laparoscopy.

Laparoscopic radical nephrectomy for large (greater than 7 cm, T2) renal tumors.

PURPOSE: Laparoscopic radical nephrectomy has emerged as a standard of care in appropriate candidates with clinical stage T1 renal tumors (7 cm or less). Herein we present our experience with laparoscopic radical nephrectomy for clinical stage T2 tumors (greater than 7 cm). MATERIALS AND METHODS: Patients undergoing laparoscopic radical nephrectomy between September 1997 and July 2003 were retrospectively subdivided into group LAPT1-166 with tumor size 7 cm and group LAPT2-65 with tumor size greater than 7 cm. Also, group LAPT2 was compared with a group of 34 contemporary, comparable patients undergoing open radical nephrectomy for tumor greater than 7 cm (group OPENT2). RESULTS: Compared with group LAPT1, group LAPT2 had younger patients, larger tumors and greater blood loss (100 vs 200 ml) (each p <0.001). Importantly operative time, analgesic requirements, hospital stay, and convalescence and complication rates were comparable. Group LAPT2 and group OPENT2 patients had similar sized tumors (9.2 and 9.9 cm, respectively) but shorter operative time (p = 0.03), lesser blood loss (p <0.001), shorter hospital stay (p <0.001) and more rapid convalescence (p = 0.02) occurred in LAPT2. CONCLUSIONS: Laparoscopic radical nephrectomy for stage T2 renal masses (greater than 7 cm) is feasible and efficacious. Laparoscopic nephrectomy offers the advantages of decreased blood loss, shorter hospital stay and more rapid recovery over open radical nephrectomy for comparable tumors greater than 7 cm. Although surgical outcomes are comparable with laparoscopic radical nephrectomy for smaller tumors (7 cm or less), adequate laparoscopic experience is necessary before performing radical nephrectomy for large T2 tumors.

Laparoscopic cytoreductive nephrectomy for metastatic renal cell carcinoma.

OBJECTIVE: To critically analyse the results of laparoscopic cytoreductive surgery for renal cell carcinoma (RCC), as phase III evidence supports cytoreductive nephrectomy before immunotherapy, and there is an overall shift towards minimally invasive renal surgery for this disease. PATIENTS AND METHODS: Since October 2000, 22 patients were treated by laparoscopic cytoreductive nephrectomy for metastatic RCC (group 1). All patients had radiological evidence of metastatic disease, with biopsy confirmation in 10. To put the results into perspective, 25 consecutive contemporary patients with large organ-confined nonmetastatic RCC (>7 cm, clinical stage T2) undergoing laparoscopic radical nephrectomy (group 2) were compared retrospectively. The baseline demographics were comparable between the groups. RESULTS: The mean tumour size was 8 cm in group 1 and 9.6 cm in group 2 (P = 0.07). Variables during and after surgery were comparable between the groups, with a mean operative duration of 3.1 vs 3.2 h (P = 0.82), blood loss of 285 vs 308 mL (P = 0.79), complications in two vs eight (P = 0.08), morphine sulphate equivalent requirements of 51.7 vs 44.1 mg (P = 0.1) and a median length of hospital stay of 1.7 vs 1.6 days (P = 0.68). In group 1 the median (range) time to immunotherapy was 35 (13-136) days. CONCLUSIONS: Laparoscopic cytoreductive nephrectomy is safe and effective in selected patients. Currently the procedure is offered to candidates eligible for immunotherapy and with tumours of < or = 15 cm, and no evidence of adjacent organ invasion or inferior vena caval thrombus. Significant perihilar adenopathy and numerous parasitic vessels can increase the complexity of the surgery. Adequate laparoscopic experience is necessary.

Laparoscopic nephron-sparing surgery for two or more ipsilateral renal tumors.

OBJECTIVES: To review our experience with laparoscopic nephron-sparing surgery in the management of two or more synchronous, ipsilateral renal masses. Minimally invasive nephron-sparing procedures are increasingly used for the treatment of select patients with a single, small renal tumor. METHODS: Since 1998, we have performed laparoscopic nephron-sparing surgery in 288 consecutive patients, including laparoscopic partial nephrectomy (n = 200) and renal cryotherapy (n = 88). Of these, 13 patients (4.5%) were treated for synchronous ipsilateral renal masses. RESULTS: A total of 27 renal tumors were treated in 13 patients. The patients were divided into four groups on the basis of the treatment. Group 1 (n = 3) underwent en-bloc laparoscopic partial nephrectomy encompassing both tumors; group 2 (n = 2) underwent individual laparoscopic partial nephrectomy of discrete masses during the same procedure; group 3 (n = 2) had one mass treated with partial nephrectomy and the other mass treated with cryotherapy; and group 4 (n = 6) had all tumors treated with cryotherapy. All cases were completed successfully without conversion to open surgery or laparoscopic nephrectomy. The mean overall operative time was 4.3 hours, and the mean blood loss was 169 mL. No intraoperative complications occurred. Three patients had postoperative complications, none requiring re-exploration. One patient in group 4 developed de novo tumors in the treated kidney, located distant from the cryoablated sites. CONCLUSIONS: Laparoscopic partial nephrectomy is an emerging, efficacious laparoscopic treatment option for select patients. Laparoscopic cryotherapy is a useful alternative or adjunct to partial nephrectomy. The judicious combination of these complementary techniques further extends the scope of minimally invasive nephron-sparing surgery.