The Impact of Gender on Tumour Stage in In-House Complications and Choice of Urinary Diversion: Results of the Austrian Cystectomy Registry.

INTRODUCTION AND OBJECTIVES: Bladder cancer is characterized by gender-dependent disparities. To further address this issue, we analysed a prospective, multicentre cystectomy registry. METHODS: An online database was developed that included patient demographics, intra/perioperative data, surgical data and in-house complications. RESULTS: Four hundred fifty-eight patients (112 [24.5%] women and 346 [75.5%] men) were analysed. Men and women were comparable regarding age (mean 68 years), body mass index (mean 26.5) and the mean Charlson score (4.8). Women had more advanced tumour-stages (pT3/pT4; women: 57.1%; men: 48.1%). The rate of incontinent urinary diversion was higher in women (83.1%) than in men (60.2%) and in a multivariate analysis, the strongest predictors were M+ status (OR 11.2), female gender (OR 6.9) and age (OR 6.5). Women had a higher intraoperative blood transfusion rate. The overall rate of in-house complications was similar in both genders (men: 32.0%, women: 32.6%). Severe (Clavien-Dindo grade >2) medical (women: 6.3%; men: 5.2%) and surgical (women: 21.5%; men: 14.4%) in-house complications, however, were more frequent in women. CONCLUSIONS: This multicentre registry demonstrates several gender-related differences in patients undergoing radical cystectomy. The higher transfusion rate, the rare use of orthotopic bladder substitutes and the higher in-house complication rate underline the higher complexity of this procedure in women.

Partial nephrectomy using renal artery perfusion for cold ischemia: functional and oncologic outcomes.

PURPOSE: We present our series on the safety and long-term oncologic and functional outcomes of laparoscopic partial nephrectomy using renal artery perfusion for cold ischemia. PATIENTS AND METHODS: Of 94 patients who underwent laparoscopic partial nephrectomy at our center between August 2000 and September 2006, 28 procedures were performed using cold ischemia and are included in this review. Mean age was 57.8 years (range 22-80 yrs). Mean tumor size was 2.67 cm (range 1.5-5 cm). Five patients had an imperative indication for partial nephrectomy. Eight tumors were hilar. Cold ischemia was achieved through renal artery catheterization followed by intraoperative artery clamping and perfusion with 4 degrees C lactated Ringer solution with mannitol. RESULTS: Mean ischemia time was 40.8 min (range 25-101 min). Mean estimated blood loss was 241 mL (range 50-1000 mL). Three patients underwent conversion to open surgery, but their procedures were still completed under cold perfusion. Segmental artery penetration and venous penetration took place in one patient each. Two postoperative complications occurred, including pancreatitis and pulmonary embolism; none were related to the cold perfusion. Oncologic outcome revealed 100% disease-specific survival for 45 months median followup. Functional studies showed a mild decrease in renal creatinine clearance with improvement 1 month after surgery. Nuclear scans showed functional kidney moiety in all but one patient. CONCLUSION: Intraoperative cold ischemia for laparoscopic partial nephrectomy using arterial perfusion is safe and feasible. It constitutes a viable alternative for complex tumors when ischemia time is expected to exceed 30 minutes. We provide proof of principle confirming the protective effect of cold perfusion to prevent parenchymal damage.

Laparoscopic partial nephrectomy for hilar tumors: technique and results.

BACKGROUND: Laparoscopic partial nephrectomy for hilar tumors is a cutting edge procedure for which little data is available in the current literature. OBJECTIVE: To describe our technique and results of laparoscopic partial nephrectomy for renal hilar tumors. DESIGN, SETTING, AND PARTICIPANTS: Between April 2000 and September 2006, 94 partial laparoscopic nephrectomies were performed at our institution. A total of 18 (19.1%) patients had hilar tumors. A hilar tumor was defined as a lesion suspicious for renal cell carcinoma in contact with a major renal vessel on preoperative cross-sectional imaging. In 3 (16.7%) of the patients, the indication for nephron-sparing surgery was imperative. Mean tumor size was 3 cm (range, 2-4.5). Eight (44.4%) surgeries were performed with renal artery perfusion for cold ischemia; the remaining surgeries were performed under warm ischemia. INTERVENTION(S): After occluding the renal artery and controlling the renal vein by using separate rubber band tourniquets, we excised the tumor mass including delicate mobilization away from the blood vessels. Although we used to insert a ureteral stent at the beginning of our experience with laparoscopic partial nephrectomies, we no longer do so. All surgeries were performed by a single urologist (G.J.). MEASUREMENTS: Operative time, ischemia time, blood loss, renal function using the Cockroft formula as well as renal scans, operative and post-operative complications, pathology parameters. RESULTS AND LIMITATIONS: All surgeries were completed laparoscopically. Mean surgical time was 238 min (range, 150-420). Mean ischemia times were 42.5 min (range, 27-63) and 34.1 min (range, 24-56) for the cold and warm ischemia groups, respectively. Estimated intraoperative blood loss was 165 ml (range, 50-500). There were two (11%) entries into major vessels during tumor excision, namely a segmental renal artery in one patient and a segmental renal vein in another. Both of these occurrences were managed laparoscopically. One patient necessitated laparoscopic reexploration for urine extravasation in the immediate postoperative period. All postoperative nuclear scans (available in 12 of 18 patients) showed functional kidney moiety. Mean split renal function was 38.6% (range, 24-50) on the operated side. Histopathological examination confirmed renal cell carcinoma in 14 (77.8%) of the patients. One (7.1%) patient had a positive surgical margin on the surface that was adjacent to the renal artery. In a median follow-up of 26 mo (range, 1-59), no local recurrence or systemic progression occurred. CONCLUSION: Laparoscopic partial nephrectomy for hilar tumors is a feasible and safe procedure in the hands of experienced laparoscopic surgeons. Oncological results seem excellent, but further follow-up is needed for accurate long-term assessment of this surgical approach.

Laparoscopic radioisotope-guided sentinel lymph node dissection in staging of prostate cancer.

OBJECTIVES: To present our experience in laparoscopic sentinel lymph node (SLN) dissection in staging of clinically localized prostate cancer. METHODS: From November 2001 to January 2005 laparoscopic SLN dissection was performed in 140 patients with clinically localized prostate cancer preceding radical prostatectomy. Mean preoperative prostate-specific antigen (PSA) level was 8.26 ng/ml (SD 9.46). At 24 h before surgery, 2 ml 99mTc-labeled human albumin (2 ml/200 MBq) colloid was injected into the prostate gland under transrectal ultrasound guidance. Prostatic SLNs were detected by preoperative planar scintigraphy and intraoperative scanning with a specially designed laparoscopic gamma probe. The detected nodes were dissected and evaluated on frozen section. In case of positive frozen section extended lymph node dissection was performed. RESULTS: SLN was identified on both or one pelvic sidewall in 96 (68.1%) and 36 (25.7%) of the patients, respectively. SLNs were undetectable in 8 (5.7%) cases. In 48.2% (135 of 280) of the pelvic sidewalls, SLNs were exclusively outside the obturator fossa. Final histopathologic examination revealed SLN metastases in 19 (13.5%) patients; 71.4% (20 of 28) of the detected metastases were outside the current standard of lymph node dissection limited to the obturator fossa. Mean tumor size was 2.3 mm (SD 1.7). CONCLUSIONS: Our data confirm the reliability of laparoscopic SLN dissection in staging of prostate cancer. Significant numbers of detected metastases were outside of the routinely sampled obturator fossa. Small metastasis size makes them undetectable by currently available preoperative imaging modalities.

Laparoscopic extended pelvic lymph node dissection for prostate cancer: description of the surgical technique and initial results.

OBJECTIVE: In patients with prostate cancer, extended pelvic lymph node dissection (ePLND) yields a higher number of lymph node metastases (LNM) than standard pelvic lymph node dissection (PLND) of the obturator fossa only. We describe our laparoscopic technique of extended lymph node dissection and provide the number and locations of positive lymph nodes from our experience. METHODS: In a total of 35 selected patients with clinically localized prostate cancer, laparoscopic ePLND was performed prior to laparoscopic radical prostatectomy. The template included the genitofemoral nerve up to the bifurcation of the common iliac artery and down to the epigastric artery. In the "split and roll" technique the internal and external iliac arteries including the bifurcation and the external iliac vein were completely mobilized. After freeing the obturator nerve, the entire lymph node package was released from the pelvic side wall. RESULTS: Mean operative time was 90min/patient. The complications were two temporary and reversible neurapraxias (ischiatic nerve and obturator nerve), one deep vein thrombosis, and two lymphoceles. One lymphocele healed conservatively; the second was marsupialized laparoscopically. Eleven (31.4%) patients had lymph node metastases; their mean prostate-specific antigen (PSA) level was 20.3+/-7.0 ng/ml (range: 5.2-39.7 ng/ml) and their median Gleason sum in biopsy was 7 (range: 6-8). Mean size of the LNM was 3.1+/-1.0 mm (range: 0.2-8). In 5 of the 11 patients with LNM these were detected exclusively outside the obturator fossa. LNM were in the obturator fossa only in two (one bilateral), around the external iliac artery only in two, around the internal iliac artery only in two, and around the external iliac artery and internal iliac only in one patient. CONCLUSIONS: Laparoscopic ePLND can be combined with laparoscopic radical prostatectomy. Standardization of the technique facilitates surgery to a great extent. e-PLND detects LNM in a significant number of patients. The majority of LNM are outside the obturator fossa. The transperitoneal approach allows a wide exposure and is the most important factor to enable successful ePLND.

Nephron-sparing surgery for renal tumours: acceleration and facilitation of the laparoscopic technique.

OBJECTIVE: Present our surgical technique for and experience with laparoscopic partial nephrectomy (LPN) for renal tumours during warm ischaemia. METHODS: Twenty-five patients underwent LPN during warm ischaemia via a transperitoneal four-trocar approach. Mean tumour size was 26.2+/-7.3mm (range: 11-39 mm). Sixteen tumours were exophytic, 7 endophytic, and 2 central. The renal vessels were secured by an umbilical tape and occluded by a self-made Rumel tourniquet. Tumours were excised with a cold Endo-shear. The interstitial tissue and collecting system was closed using a running suture secured by two resorbable clips. Parenchymal edges were approximated using a running suture over a haemostatic bolster. The threads were secured by non-resorbable clips. During follow-up, renal function was evaluated by determination of serum creatinine, (99m)Tc-mercaptoacetyltriglycine scintigraphy, and parenchymal transit time. RESULTS: Mean ischaemia time was 28.9+/-5.2 min (range: 19-40 min) and the mean blood loss was 177.4+/-285.5 ml (range: 50-1500 ml). No intraoperative complications occurred and no patient needed conversion to open surgery. Surgical margins were negative in all patients. One postoperative surgical-related perirenal haematoma occurred, which was treated conservatively (no transfusions required). None of the patients had a urinary leak. During a mean follow-up of 6.2 mo (range: 1-15 mo), none of the patients had local or port-site recurrence or distant metastasis. Parenchymal transit time was increased in 1 of 10 investigated patients (ischaemia time: 26 min), indicating ischaemic parenchymal damage. CONCLUSION: Our technical refinements for LPN during warm ischaemia have widened indications to more complex tumours. The use of clips rather than knot tying made the procedure easier and faster and allowed completion of the suturing during an acceptable warm ischaemia time. The self-made Rumel tourniquet is safe and efficient for vessel control and occlusion. These improvements increase feasibility so that LPN can be used by more laparoscopic urologic surgeons.

Long-term functional outcome of renal units after laparoscopic nephron-sparing surgery under cold ischemia.

BACKGROUND AND PURPOSE: Renal-artery occlusion is used to control bleeding during laparoscopic nephronsparing surgery, but there are worries about ischemic damage. We compared the functional outcomes of kidneys treated under warm and cold ischemia. PATIENTS AND METHODS: Twelve patients treated with warm ischemia and 14 treated with cold ischemia had renal function investigation 3 to 6 months postoperatively. Four and ten patients, respectively, also had preoperative studies. RESULTS: In patients treated with warm ischemia, two kidneys had evidence of possible damage, but the kidney with the longest ischemia (56 minutes) was normal. Among patients treated with cold ischemia, function was lost in one case. Parenchymal transit time was prolonged in five patients, but in four cases, this probably was attributable to performance of a contrast-enhanced CT scan the same day. In the fifth patient, an ischemic injury is possible. CONCLUSION: The parenchymal transit time is a good indicator of ischemic damage. Nephron-sparing surgery can lead to damage even if the ischemia time is short and cold ischemia is used. More data are needed on the factors determining such injury.

Detection of pelvic lymph node metastases in patients with clinically localized prostate cancer: comparison of [18F]fluorocholine positron emission tomography-computerized tomography and laparoscopic radioisotope guided sentinel lymph node dissection.

PURPOSE: Accurate detection of lymph node metastases in prostate cancer has important implications for prognosis and approach to treatment. We investigated whether preoperative [18F]fluorocholine combined in-line positron emission tomography-computerized tomography and intraoperative laparoscopic radioisotope guided sentinel pelvic lymph node dissection can detect pelvic lymph node metastases in patients with clinically localized prostate cancer as reliably as extended pelvic lymph node dissection. MATERIALS AND METHODS: A total of 20 patients (mean age 63.9 +/- 6.7 years, range 52 to 75) with clinically localized prostate cancer, prostate specific antigen greater than 10 ng/ml, and/or a Gleason score sum of 7 or greater and negative bone scan were enrolled in the study. [18F]fluorocholine combined in-line positron emission tomography-computerized tomography was performed before surgery. Sentinel pelvic lymph node dissection preceded extended pelvic lymph node dissection including the area of the obturator fossa, external iliac artery/vein and internal iliac artery/vein up to the bifurcation of the common iliac artery. Laparoscopic radical prostatectomy was performed afterward. RESULTS: In 10 of the 20 patients (50%) lymph node metastases were detected, and were exclusively found outside the obturator fossa in 62%. These metastases would not have been identified with standard lymph node dissection of the obturator fossa only. [18F]fluorocholine combined in-line positron emission tomography-computerized tomography was true positive in 1, false-positive in 2, false-negative in 9 and true negative in 8 patients. The largest lymph node metastasis not seen with [18F]fluorocholine combined in-line positron emission tomography-computerized tomography was 8 mm. Laparoscopic sentinel guided lymph node dissection revealed lymph node metastases in 8 of 10 patients. In the other 2 patients sentinel lymph node dissection was not conclusive. In 1 patient normal nodal tissue was completely replaced by cancer and, therefore, there was no tracer uptake in the involved pelvic sidewall/node, and the other patient had no tracer activity at all in the involved pelvic sidewall. Extended pelvic lymph node dissection missed 1 lymph node metastasis (2 mm diameter near pudendal artery) which was detected by sentinel pelvic lymph node dissection only. CONCLUSIONS: Extended pelvic lymph node dissection reveals a higher number of lymph node metastases as described for obturator fossa dissection only. [18F]fluorocholine combined in-line positron emission tomography-computerized tomography is not useful in searching for occult lymph node metastases in clinically localized prostate cancer. Sentinel guided pelvic lymph node dissection allows the detection of even small lymph node metastases. The accuracy of sentinel pelvic lymph node dissection is comparable to that of extended pelvic lymph node dissection when the limitations of the method are taken into consideration.

Treatment of radiation-induced hemorrhagic cystitis with laparoscopic cystoprostatectomy.

Hemorrhagic cystitis can occur 6 months to 10 years after pelvic irradiation. Various palliative treatment alternatives may be unsuccessful in the management of severe hemorrhagic cystitis, so that in rare cases radical surgery will be the last resort.A 77-year-old man with persistent bleeding due to hemorrhagic cystitis after radiotherapy for prostate cancer was initially treated with conservative measures. All of these treatment methods were unsuccessful. His condition deteriorated and became life-threatening. As a last resort, laparoscopic cystoprostatectomy and mini-laparotomy ileal conduit diversion were successfully performed with no intraoperative or postoperative complications. To our knowledge, this is the first report on laparoscopic cystoprostatectomy for a patient with previous radiotherapy to the pelvis.

Detection of early lymph node metastases in prostate cancer by laparoscopic radioisotope guided sentinel lymph node dissection.

PURPOSE: Radioisotope guided sentinel lymph node (SLN) dissection (SLND) for prostate cancer has been shown to increase the sensitivity of detecting early metastases in open pelvic lymph node dissection. We developed a technique that allows SLND to be performed by laparoscopy in conjunction with laparoscopic radical prostatectomy. MATERIALS AND METHODS: In 71 consecutive patients SLND was performed by 1 surgeon preceding laparoscopic radical prostatectomy. Mean preoperative prostate specific antigen was 8.88 ng/ml (range 2.1 to 25.4). At 24 hours prior to surgery 3 ml (200 MBq) Tc labeled human albumin colloid were injected into the prostate gland under transrectal ultrasound guidance. An especially designed laparoscopic gamma probe was used to measure radioactivity during surgery. SLNs were identified and removed. If frozen section analysis showed metastases, extended pelvic lymph node dissection was performed. RESULTS: Radioactivity was detected on 2, 1 and no sides in 50 (70.4%), 19 (26.7%) and 2 patients (2.8%), respectively. In 81 of the 142 pelvic side walls (54.7%) SLNs were exclusively outside of the obturator fossa. Histopathological examination showed metastases to SLNs in 9 patients (12.9%). Eight of the 11 detected metastases (72.7%) were outside of the obturator fossa. Lymph node metastases were exclusively found in Tc marked lymph nodes. Mean tumor size was 1.7 mm (range 0.2 to 3.9). CONCLUSIONS: SLND is feasible by laparoscopy. It detects micrometastases outside of the obturator fossa in a significant number of patients. We noted that the transperitoneal approach allowing wide exposure and a gamma probe with a 90-degree lateral energy window is the most important factor to enable successful laparoscopic SLND.

Role of laparoscopy in management of renal stones: single-center experience and review of literature.

BACKGROUND AND PURPOSE: Laparoscopy can be an alternative modality in the management of renal stones. We present our experience with laparoscopic renal stone surgery. PATIENTS AND METHODS: Eighteen patients (4 males, 14 females) with mean age of 51 years (range 18-86 years) underwent 19 laparoscopic procedures. The mean stone number and size, excluding five patients who had nephrectomy/heminephrectomy, were 1.9 (range 1-5) and 1.3 cm (range 0.5-4.5 cm), respectively. Three patients with ureteropelvic junction obstruction underwent pyeloplasty and concomitant pyelolithotomy. Three patients with upper-pole caliceal-diverticular stones had nephrolithotomy and fulguration of the diverticular mucosa. Three patients with stones and hydrocalix with scarred cortex had partial nephrectomy, two under cold and one under warm ischemia. Five patients, including one with a horseshoe kidney (who had one procedure on each kidney), had pyelolithotomy as an alternative to percutaneous nephrolithotomy. Patients with stones in a nonfunctioning kidney underwent nephrectomy (three patients) or heminephrectomy (one patient). RESULTS: All procedures were completed laparoscopically. The operative time was variable depending on the complexity of the procedures, from 115 minutes for Fengerplasty to 315 minutes for partial nephrectomy under cold ischemia (mean 178 minutes). The estimated blood loss was 53.2 mL (range 20-120 ml), and none of the patients received a blood transfusion. Complete stone clearance was achieved in 93% of the procedures. The mean hospital stay was 10.5 days (range 5-35 days). Three patients needed temporary pigtail-catheter drainage for obstruction after pyelolithotomy. One patient with a solitary kidney and infected staghorn calculus had prolonged urinary leak, which stopped with conservative management. One nephrectomy for nephrocutaneous fistula was complicated by a late colonic perforation necessitating colostomy. CONCLUSION: Laparoscopic surgery is effective for complex renal stones and allows for adjunctive procedures. It can also be an alternative to percutaneous nephrolithotomy. It complements other minimally invasive procedures, and a need for open stone surgery should be rare in the future.

Laparoscopic adrenal surgery for recurrent tumours in patients with hereditary phaeochromocytoma.

OBJECTIVE: To report our experience with Laparoscopic Partial Adrenalectomy (LPA) for recurrent tumours in patients with hereditary phaeochromocytoma. PATIENTS AND METHODS: Five patients with hereditary phaeochromocytoma (4 with von Hippel-Lindau disease and 1 with Multiple Endocrine Neoplasia 2B), who had undergone adrenal surgery previously, presented with recurrent adrenal tumours. One patient was pregnant at 20 weeks of gestation. All patients underwent hormonal evaluation, genetic screening and imaging with CT or MRI, metaiodobenzylguanidine (MIBG) scintigraphy. RESULTS: Of the 7 attempted LPA in five patients, five procedures (71%) were successfully completed and total adrenalectomy was needed on two occasions. The adrenal vein could be spared in all patients except one. There were no intra-operative complications. The adrenal function was adequate in all patients without need for steroid supplementation except one patient who lost both adrenals eventually. There was no correlation between the preservation of adrenal vein and adrenocortical function. CONCLUSION: Laparoscopic partial adrenalectomy is feasible, safe and effective in recurrent phaeochromocytoma, despite previous adrenal surgery and is technically easier if the previous approach had been laparoscopic as well. Patients with hereditary phaeochromocytoma are prone for recurrent tumours and may need repeated surgical procedures. Hence, minimally invasive approach is ideal for these patients.

Laparoscopic nephron sparing surgery: evolution in a decade.

OBJECTIVE: To present our experience with laparoscopic nephron sparing surgery (NSS) over a decade. METHODS: Seventy-eight patients underwent NSS since 1994. Two techniques were used-partial nephrectomy without ischemia (group 1) in 29 patients, and with ischemia (group 2) which was in cold or warm ischemia in 24 and 25 patients respectively. The mean tumour size was 1.97 and 2.2 cm in groups 1 and 2 respectively. Renal reconstruction evolved in our hands during this period. We changed many technical details and now we depend more on clips for securing the sutures rather than free hand knotting. RESULTS: The mean operative time was 162 and 216 minutes in groups 1 and 2 respectively. Mean ischemia time for patients with cold and warm ischemia was 44.9 and 33.8 minutes respectively. 3 patients in group 2 were converted to open surgery. Mean blood loss was 254 and 212 ml for group 1 and 2 respectively with two major bleedings in group 2. Minor intra-operative complication occurred in 3 patients, and major and minor postoperative complication in 15 patients. At a mean follow-up of 23.9 and 12.2 months for groups 1 and 2 respectively there was no recurrence. CONCLUSION: Warm and cold ischemia have widened the indications for laparoscopic NSS to more complex tumours and allow renal reconstruction with acceptable complication rate.

Prospective, randomized controlled study: transperitoneal laparoscopic versus retroperitoneoscopic radical nephrectomy.

OBJECTIVES: To evaluate the transperitoneal and retroperitoneal approaches for endoscopic radical nephrectomy in a prospective randomized manner to assess the possible differences in the outcome related to patients' morbidity and technical difficulty for the surgeon. METHODS: A total of 40 patients with Stage cT1-T2 were randomized into two equal groups: laparoscopic radical nephrectomy (LRN) and retroperitoneoscopic radical nephrectomy (RRN). The patient demographics and tumor characteristics were comparable. Two surgeons with differing experience performed an equal number of procedures in both treatment arms. The outcome was compared, and the technical difficulty for the surgeon and assistant was assessed with the European scoring system. RESULTS: All procedures were completed without a need for conversion. No statistically significant differences were found between the two approaches in terms of the number and size of the trocars used, length of incision, specimen weight, pathologic stage, operative time, need for additional procedures such as adrenalectomy and/or lymph node sampling, estimated blood loss, need for blood transfusions, analgesic requirement, length of hospital stay, or the incidence of minor or major complications. All patients in the LRN group resumed oral intake on postoperative day 1, but only 75% did so in the RRN group. The technical difficulty score for either the surgeon or the assistant did not differ significantly between the two groups. Both approaches allowed complete tumor excision. The robotic assistance system (AESOP) was more difficult with RRN compared with LRN. CONCLUSIONS: This first prospective randomized study comparing LRN and RRN did not find any real difference between the two approaches in relation to patient morbidity or the technical difficulty for the surgeon.

Laparoscopic partial adrenalectomy for recurrent pheochromocytoma in a boy with Von Hippel-Lindau disease.

We describe a case of a boy with Von Hippel-Lindau disease who presented with recurrent right adrenal pheochromocytoma 4.5 years after laparoscopic bilateral partial adrenalectomy. The boy had a second laparoscopic adrenal-sparing removal of the tumor. By this technique, not only the recurrent tumor was successfully removed but also the unaffected adrenal cortex could be preserved for the second time. To our knowledge, this is the first published case of its type.

Laparoscopic partial nephrectomy in cold ischemia: renal artery perfusion.

PURPOSE: Laparoscopic partial nephrectomy represents a feasible option for patients with small renal masses. We describe our initial experience with laparoscopic partial nephrectomy in cold ischemia achieved by renal artery perfusion. MATERIALS AND METHODS: From November 2001 to March 2003 laparoscopic partial nephrectomy in cold ischemia was performed in 15 patients with renal cell carcinoma. Cold ischemia was achieved by continuous perfusion of Ringers lactate at 4C through the renal artery, which was clamped. Tumor excision was performed in a bloodless field with biopsy taken from the tumor bed. The collecting system was repaired if needed. Renal reconstruction was performed by suturing over hemostatic bolsters. RESULTS: All procedures were successfully completed laparoscopically by our new technique. Mean operative time was 185 minutes (range 135 to 220). Mean ischemia time was 40 minutes (range 27 to 101). Estimated mean intraoperative blood loss was 160 ml (range 30 to 650). Entry to the collecting system in 6 patients was repaired intraoperatively. Additional vascular repair was done in 2 patients. There were no significant postoperative complications. Postoperative followup in 8 patients showed that the renal parenchyma was not damaged by the ischemic period. CONCLUSIONS: Our initial experience of incorporating cold ischemia via arterial perfusion into laparoscopic partial nephrectomy shows the feasibility and safety of the technique. We believe that this approach has the potential to make laparoscopic partial nephrectomy for renal cell carcinoma safe and reliable.