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 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.

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.

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.

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.