Laparoscopic and robotic assisted adrenal surgery.

The aim of this paper is to review the current state of laparoscopic and robotic surgery in the mannagement of benign and malignant disease of the adrenal gland. Adrenal lesions can be adenomas, pheochromocytomas, myelolipomas, ganglioneuromas, adrenal cysts, hematomas, adrenal cortical carcinomas, metastases from other cancers, or other rare causes. Laparoscopic adrenalectomy (LA) has become the new standard of care for benign adrenal neoplasms and is being increasingly utilized for malignant disease. Robotic assistance offers unique advantages in visualizing and dissecting the adrenal gland, especially considering its challenging vasculature. Series of robotic adrenalectomy (RA) and LA show that techniques are both safe and effective compared to open. There is also growing evidence in using minimally invasive approaches in adrenal sparing-surgery. Success in these procedures depends on a firm understanding of adrenal anatomy and in careful patient selection. Both LA and RA are offer advantages to patients and are comparable in outcomes. RA offers the potential for increased visualization and faster learning curve which may allow for both faster, and more precise dissection, as well as increased utilization of minimally invasive techniques. While LA remains the standard of care, RA is an excellent option in high volume robotic centers from standpoints of outcomes, feasibility, and cost.

Hand assisted laparoscopic donor nephrectomy: a comparison with the open approach.

PURPOSE: Hand assisted laparoscopy combines aspects of open and laparoscopic surgery. A hand in the abdomen may facilitate laparoscopic live donor nephrectomy, allowing more urologists to participate. We report and compare our initial series of hand assisted laparoscopy donor nephrectomy with nephrectomy performed by standard open methods. MATERIALS AND METHODS: In the last 18 months 60 patients at 2 institutions underwent hand assisted laparoscopy donor nephrectomy. This cohort was compared to a contemporary group of 31 patients who underwent open donor nephrectomy via a flank incision at our 2 institutions. Demographic and outcome data were compared retrospectively in a nonrandomized fashion in the 2 groups. RESULTS: Demographic data on patient age, male-to-female ratio and body mass index were similar in the 2 groups. Operative time, transfusion rate, time to oral intake and complications were also similar. However, estimated blood loss, change in hematocrit preoperatively to postoperatively, hospitalization, parenteral and oral narcotic requirement, and donor convalescence were significantly less in the hand assisted laparoscopy versus open groups. In terms of allograft function, nadir creatinine, time to nadir creatinine, creatinine clearance at 6, 12, and 18 months, delayed graft function, episodes of acute rejection and ureteral stricture were similar in the groups. CONCLUSIONS: Hand assisted laparoscopy is safe, efficacious and reproducible for living related donor nephrectomy. Compared with the open technique hand assisted laparoscopy provides the donor with significantly decreased postoperative morbidity, while enabling excellent allograft function. Further randomized prospective studies are warranted.

Hand-assisted laparoscopic nephroureterectomy versus open nephroureterectomy for the treatment of transitional-cell carcinoma of the upper urinary tract.

BACKGROUND AND PURPOSE: For patients with upper tract transitional-cell carcinoma (TCC), nephroureterectomy with removal of a bladder cuff is the standard of care. Historically, it has been performed using two incisions or one large incision extending from the lateral flank to the symphysis pubis. We describe an alternative using endoscopic management of the bladder cuff combined with hand-assisted laparoscopic (HAL) nephroureterectomy. We compared our results using these minimally invasive advances with those of a contemporary open nephroureterectomy series. PATIENTS AND METHODS: Between May 1998 and June 1999, we performed 11 HAL nephroureterectomies with endoscopic management of the bladder cuff for the treatment of upper tract TCC. The results were compared with those in a contemporary series of 11 patients undergoing the traditional open operation at our institution. The patient age, male:female ratio, and ASA classification were similar in the two groups. Intraoperative measures considered were operative time, estimated blood loss, need for transfusion, complications, specimen weight and volume, pathologic stage and grade of the tumor, and the status of the surgical margins. Postoperative endpoints were time to sustained fluid intake; epidural, parenteral, and oral narcotic requirements; length of stay; and complications. Follow-up, specifically disease recurrence and overall survival, was recorded. RESULTS: The mean operative time was 291 minutes for HAL v 232 minutes for the open operation (P = NS). The average blood loss was 144 v 311 mL (P = 0.04), the mean specimen weight 368 v 392 g (P = NS), and the mean specimen volume was 630 v 693 cc (P = NS). No patient in the HAL group had a positive surgical margin, but one patient in the open surgery group did. The time to sustained fluid intake postoperatively averaged 1.4 v 2.3 days for the HAL and open groups, respectively (P = NS). The epidural narcotic requirement was 0 v 2.7 days (P < 0.001), the mean parenteral narcotic requirement was 45 v 44 mg of morphine sulfate equivalent (P = NS), and the oral narcotic requirement was 5.8 v 16 tablets (P < 0.04). The average length of stay was 4.6 days for the HAL group v 6.1 days for the open group (P = 0.04). In both groups, 7 of the 11 patients (63%) were without evidence of disease with a mean follow-up of 13 (HAL) and 17 (open) months. CONCLUSIONS: Hand-assisted laparoscopic nephroureterectomy with endoscopic management of the bladder cuff is an efficacious alternative to open surgery. The operative time, specimen weight and size, and risk of recurrence for the two procedures are similar. However, convalescence, as measured by pain medication requirements and length of stay, is significantly better with laparoscopy. Longer follow-up with larger numbers of patients is in progress.

Hand-assisted laparoscopic partial nephrectomy.

BACKGROUND AND PURPOSE: The indications for partial nephrectomy are expanding as newer and more complete data come forth. A partial nephrectomy has traditionally required a generous flank incision. We report our experience using hand-assisted laparoscopy (HAL) as a less-invasive approach to partial nephrectomies. PATIENTS AND METHODS: Between October 1999 and May 2000, we performed 11 HAL partial nephrectomies. The average age of the patients was 55.7 years, the average body mass index was 25.6, and the average ASA class was 2.2. The indications for partial nephrectomy were enhancing solid renal lesions (N = 9) and nonfunctioning renal moiety in a duplicated system (N = 2). In the majority of cases, access to the renal pedicle was obtained prior to the partial nephrectomy. However, in no case did the renal artery or vein require occlusion. Several excisional techniques were employed, but all relied heavily on the Harmonic Scalpel in conjunction with the argon beam coagulator. Different hemostatic agents were applied to the renal defect, including Surgicel, Avitene, and fibrin-soaked Gelfoam activated by thrombin. In several instances, pledget reinforced sutures were placed in the renal capsule to aid with hemostasis. RESULTS: The average operative time was 273 minutes, the estimated blood loss 319 mL, and the change in hematocrit 7.3 points. No patient required a transfusion, and there was one conversion to open. Postoperatively patients, required an average of 35.6 mg of morphine sulfate equivalent and 8.2 narcotic tablets, resumed oral intake in 1.7 days, and were discharged home in 3.3 days. There were no major complications and only two minor complications. Postoperatively, five lesions were found to be benign, four lesions were confirmed to be malignant, and two lesions were consistent with a nonfunctioning duplicated renal moiety. Specimen size averaged 180 cc, and the tumor diameter averaged 1.9 cm. There were no positive surgical margins. CONCLUSIONS: Hand-assisted laparoscopic partial nephrectomy is feasible and reproducible. The surgeon's hand in the operative field facilitates dissection, vascular control, hemostasis, and suturing. Further long-term and prospective studies are underway.

Hand-assisted laparoscopy in urology.

Hand-assisted laparoscopy (HAL) allows surgeons direct hand contact with the operative field, maximizing tactile feedback and minimizing surgical injury to the patient. Indications for HAL include radical, donor, and partial nephrectomies, nephroureterectomy, and, most recently, dismembered pyeloplasties. The advantages of HAL surgical techniques in comparative experience with standard laparoscopic technique are described.

Hand-assisted laparoscopic nephroureterectomy for the treatment of transitional cell carcinoma of the upper urinary tract.

OBJECTIVES: Nephroureterectomy with removal of the bladder cuff is the standard of care for patients with upper tract transitional cell carcinoma. Historically, it has been performed using two separate incisions or one large incision extending from the lateral flank to the symphysis pubis. We describe an alternative technique using endoscopic and hand-assisted laparoscopic techniques and present our experience. METHODS: During the past 18 months, 22 patients at two institutions underwent hand-assisted laparoscopic nephroureterectomy. In 19 patients, the distal ureter and bladder cuff were managed endoscopically. In 3 patients, the distal ureter and the bladder cuff were removed by an extravesical, laparoscopic technique. The intraoperative parameters assessed included operative time, estimated blood loss, specimen weight, surgical margin status, pathologic grade and stage, and acute complications. Postoperative endpoints included the time to sustained fluid intake, parenteral narcotic requirement (milliequivalents of morphine sulfate), oral narcotic requirement (number of tablets), length of stay, time until return to normal activity, and rate of tumor recurrence. RESULTS: The average age of our patient population was 65 years (range 42 to 86), 10 patients were men and 12 were women, and the average American Society of Anesthesiologists classification was 2.2. All but 2 patients had their specimens removed en bloc. No intraoperative complications occurred. The average operative time was 272 minutes (range 190 to 440), and the average blood loss was 180 mL (range 50 to 400); no patient required a transfusion. The mean specimen weight was 457 g (range 190 to 1420). All 22 patients had negative surgical margins. Postoperatively, the time to sustained fluid intake averaged 2.1 days (range 1 to 7), the mean parenteral narcotic requirement was 55 mEq (range 12 to 107.8) of morphine sulfate, the mean oral narcotic requirement was 5.8 tablets (range 1 to 14), and the average length of stay was 4.1 days (range 3 to 14). One patient developed thrombophlebitis of the right external jugular vein from a central line and required 2 weeks of intravenous antibiotics. The mean time to return to normal activity was 19 days; the mean follow-up was 13 months. Six patients had disease recurrence: four low-grade, low-stage bladder tumors and two metastatic tumors. All patients were alive at 18 months. CONCLUSIONS: Hand-assisted laparoscopic nephroureterectomy with endoscopic management of the bladder cuff is a viable and efficacious alternative to open nephroureterectomy. The technique allows the surgeon to perform an en bloc resection of the kidney, ureter, and bladder cuff without compromising oncologic principles. Patients benefit from a decrease in pain and hospital stay and quicker convalescence. Longer follow-up and comparative studies to standard open techniques are underway.

The detection of renal carcinoma cells in the peripheral blood with an enhanced reverse transcriptase-polymerase chain reaction assay for MN/CA9.

BACKGROUND: Using a reverse transcriptase-polymerase chain reaction (RT-PCR) assay, the authors previously determined the expression of MN/CA9 mRNA in renal cell carcinoma (RCC) and its absence in benign renal tissue. In the current study, the utility of an enhanced RT-PCR assay in the detection of renal carcinoma cells in the peripheral blood was assessed. METHODS: An enhanced MN/CA9 RT-PCR assay was applied to peripheral blood samples from a total of 96 patients. Forty-two patients had renal tumors, including 5 with benign renal lesions, 28 with localized RCC, and 9 with metastatic RCC. Fifty-four control patients without renal tumors were similarly tested. Pathologic staging for patients with localized cancer was T1N0M0 for 5, T2N0M0 for 9, and T3N0M0 for 14 patients. RESULTS: Cells expressing MN/CA9 were detected in 1 of 54 controls (1.8%) and in 18 of 37 cancer patients (49%). Thirteen of twenty eight patients (46%) with localized RCC and 5 of 9 (56%) with metastatic disease tested positive with the assay. No patient with a benign renal tumor exhibited MN/CA9 expression. All blood test results for patients with clear cell RCC were noted to be positive. No correlation was noted between MN/CA9 results and age, gender, or tumor grade. The differences in MN/CA9 results according to T classification were not statistically significant. CONCLUSIONS: The enhanced RT-PCR assay for MN/CA9 is a highly specific technique for detecting circulating renal carcinoma cells in the peripheral blood, and it may prove useful in the diagnosis and monitoring of RCC.

Ureteral tissue expansion for bladder augmentation: a long-term prospective controlled trial in a porcine model.

PURPOSE: We recently described a technique that iatrogenically produces segmental megaureter while preserving renal function. In our initial report in 5 of 8 pigs that underwent this procedure bladder augmentation with the expanded ureter was successful. Throughout the expansion and reconstructive process renal function was preserved and all 5 animals that underwent augmentation had increased bladder capacity at sacrifice 1 month postoperatively. In the present study we evaluated the long-term durability and performance of the ureteral segment used for augmentation. MATERIALS AND METHODS: We performed a prospective, controlled, double armed study in 8 pigs, including 4 control animals that underwent subtotal cystectomy only (group 1) and 4 animals that underwent subtotal cystectomy followed by bladder augmentation using the expanded ureteral segment (group 2). End point measurements included cystography, and measurement of bladder capacity, serum creatinine and random bladder residual urine volumes. All cystograms were performed using passive filling conditions at a standard filling pressure of 32 cm. water. RESULTS: Bladder capacity throughout the study revealed consistently higher volumes in group 2 than in group 1. In 3 of the 4 group 1 subjects vesicoureteral reflux developed compared to no reflux in group 2. Creatinine levels were elevated at sacrifice in 50% of the animals in group 1 compared to none in group 2. Random bladder residual urine was less than 150 cc in 3 of the 4 group 2 subjects. CONCLUSIONS: Serial cystograms in pigs after ureteral augmentation suggest that the tissue does not contract with time. Animals that underwent ureteral augmentation had significantly greater bladder capacity than controls. Random bladder residual urine volume remained low throughout the study period. Ureteral tissue expansion for bladder augmentation appears to be feasible and durable in this animal model. In addition, it may be protective against the deleterious effects associated with small capacity bladders.

Ureteral tissue expansion for bladder augmentation.

PURPOSE: Ureteral augmentation is an effective method of bladder reconstruction using the native urothelium of a megaureter. Clinically this procedure is contingent on the presence of an enlarged ureter. We have iatrogenically produced a segmental megaureter, while preserving renal function in a pig model. The urothelium of the enlarged ureter was then used for augmentation cystoplasty. MATERIALS AND METHODS: A tissue expander suitable for insertion into the lumen of the ureter was constructed. The tissue expander was passed antegrade through a flank incision of 8 pigs, and a separate nephrostomy tube was left in place. During the ensuing 1 to 4 weeks the pigs underwent daily dilation of the tissue expander without anesthesia. After dilation the pigs underwent ureteral augmentation of the bladder. The segment of expanded ureter was isolated from the native ureter, opened and anastomosed to the bladder. The continuity of the left ureter was restored by primary ureteroureterostomy. The animals underwent cystograms at 1 and 4 weeks and were sacrificed 4 weeks after augmentation. Tissue was harvested for gross and microscopic histology. RESULTS: Of the 8 pigs starting the protocol 5 underwent successful ureteral tissue expansion followed by bladder augmentation. Tissue expansion was performed from 1 to 4 weeks, and volumes of 150 to 1,000 cc were obtained. Two to 3 weeks of dilation was optimal to achieve ease of dilation, and no animal showed evidence of discomfort or failure to thrive. All 5 animals underwent successful ureteral augmentation with primary ureteroureterostomy. Tissue expansion volumes of approximately 250 cc were optimal for tissue management and ease of augmentation. Cystograms of all augmented animals showed increased bladder capacity with filling of the ureteral segment. Histological examination of the ureteral augmentation revealed preservation and regeneration of the urothelial mucosa. CONCLUSIONS: The use of a tissue expander in the lumen of the ureter is a novel method of generating urothelium for use in bladder augmentation. It may provide an alternative to bowel in patients who require bladder augmentation. Long-term studies are currently under way.

Expression of the tumor-associated gene MN: a potential biomarker for human renal cell carcinoma.

MN is a novel cell surface antigen originally detected in human HeLa cells. Although it is also expressed in normal gastric mucosa, this antigen was previously found to be expressed in cells with a malignant phenotype in certain tissues of the female genital tract (cervix and ovary). Using an oligonucleotide primer set specific for MN-complimentary DNA, we performed reverse transcription-PCR assays on RNAs extracted from human cell lines and tissues to evaluate whether this marker might be expressed at other sites. RNA libraries extracted from normal human heart, lung, kidney, prostate, peripheral blood, brain, placenta, and muscle were negative for MN expression. RNAs extracted from liver and pancreatic tissue were positive for MN expression. Three of six renal cancer cell lines tested revealed MN expression. In addition, 12 of 17 samples of human renal cell carcinoma tissue tested positive for MN, all 12 of which were clear cell adenocarcinomas. This survey identified a unique association of MN expression with renal cell cancers, especially those of the clear cell variety, suggesting that MN is a potential marker for the diagnosis, staging, and therapeutic monitoring of renal cell carcinoma in humans.