Vol. 169, No.4, Supplement, Saturday, April 26, 2003 THE JOURNAL OF UROLOGY® 21 RESULTS: Laparoscopic partial nephrectomy with hypothermia was performed in 7 patients (8 renal units). Identification of the hilar vessels followed by clamping and cooling allowed meticulous dissection and removal of the renal tumor in a bloodless field. Suture closure of the collecting system was also performed. Complications consisted of a single post-operative stroke, and one transient urine leak which sealed spontaneously following stent placement. Surgical margins were negative in each patient. CONCLUSIONS: This video illustrates a novel surgical technique which allows laparoscopic partial nephrectomy to be meticulously performed in a bloodless field. Some previously reported techniques for laparoscopic partial nephrectomy do not provide optimal conditions for resection. Laparoscopic partial nephrectomy of intraparenchymal lesions without vascular control risks significant bleeding. Hemorrhage may obscure vision of the surgical field compromising the margin status. Performing partial nephrectomy with warm ischemia requires significantfacility with intracorporeal suturing, and time pressure constraints may compromise margin status and risk renal deterioration. Our new techniquerecreates the advantagesof the open procedure while maintaining a minimally invasive approach. Source of Funding: None. V79 NON-EXOPHYTIC RENAL CELL CANCER; A DIFFICULT CASE FOR RETROPERITONEAL LAPAROSCOPIC PARTIAL NEPHRECTOMY -SUCCESSFUL ASSISTANCE WITH POWER DOPPLER ULTRASONOGRAPHY- Hidenori Zakoji", Kazuhiko Shiiki, Yasuhisa Furuya, Takayuki Tsuchida, Isao Araki, Yoshio Takihana, Nobuaki Tanabe, Masayuki Takeda, Yamanashi, Japan INTRODUCTION AND OBJECTIVE: Laparoscopic partial nephrectomy for non-exophytic renal tumor is challenging procedure because of difficulty in detecting tumor. We report a male case of non-exophytic renal cancer for which identification with endoscope was difficult, but he successfully underwent retroperitoneal laparoscopic partial nephrectomy assisted by intraoperative ultrasonography. METHODS: Using retroperitoneal laparoscopic technique, the kidney was identified and separated from perirenal fat to explore the tumor. Only slightly protrudingarea of renal surface was seen, but could not be comfirmedendoscopically. Sonographical monitoring in IOMHz frequency was performed to evaluate location and size of the tumor. Power Doppler ultrasound was very helpful in recognizing tumor and its blood flow. Laparoscopic partial nephrectomy could be performed using microwave tissue coagulator and argon beam coagulator for hemostasis. RESULTS: Operative time was 202 minutes. Blood loss was lOamI. There were no complications during 9-day-hospital stay. Pathological diagnosis was renal cell carcinoma, and the surgical margin was negative. CONCLUSIONS: Intraoperative ultrasonography is very helpful for laparoscopic partial nephrectomy, even in non-exophytic renal tumors. Source of Funding: None. V80 LAPAROSCOPIC RADICAL NEPHRECTOMY FOR CANCER WITH LEVEL I RENAL VEIN THROMBUS Anup P Romani", CLEVELAND, OH INTRODUCTION AND OBJECTIVE: Renal cell carcinoma(RCC) is associated with thrombus extending into the venous system in 5-10% cases. In patients with organ-confined disease, open radical nephrectomy with concomitant thrombectomy is considered the treatment of choice. Laparoscopic radical nephrectomy is rapidly becoming a standard of care for a majority of patients with Tl- T2 cancers. With growing experience, we have applied laparoscopy to select patients with T3b RCC with level I renal vein thrombus. METHODS: We present a video of a 82 year old patient with a pre-operative diagnosis of renal cancer with renal vein thrombus who underwent laparoscopic radical nephrectomy at our institution. The tumor size was 5 cms. Laparoscopy was carried out by a 4-port transperitoneal approach. The renal vein was secured with an endo -GIA stapler proximal to the thrombus. To date we have performed laparoscopic radical nephrectomy in 16 patients having cancer with a renal vein thrombus. These data are also presented. RESULTS: The total operative time was ISO minutes. The blood loss was 150cc. Intra-operative urine output was 775cc. The specimen weight was 867 grams. There were no complications. The patient was ambulating and on oral liquids by 24 hours. At 2 month follow up there was no local recurrence or metastasis. For the 16 cases done to date, the mean blood loss was 363cc, mean operative time was 3.2 hours, mean follow up was 14.5 months and 3 patients had recurrence of tumor. CONCLUSIONS: Laparoscopic radical nephrectomy is feasible and safe in patients with renal cell carcinoma with level I thrombus. With growing experience, laparoscopy may potentially be applied to more extensive venous involvement in the future. Source of Funding: None. V8l LAPAROSCOPIC RADICAL NEPHRECTOMY WITH VENA CAVAL AND RIGHT ATRIAL THROMBECTOMY UTILIZING DEEP HYPOTHERMIC CIRCULATORY ARREST- THE VIDEO Anoop M Meraney*, Mihir Desai, Gyung Tak Sung, Anup Ramani, Sidney Abbreu, Hiroaki Harasaki, Manabu Sato, Jihad Kaouk, lnderbir Gill, cleveland, OH INTRODUCTION AND OBJECTIVE: In patients with renal cel1cancer with level 3 or 4 tumor thrombi, conventional treatment comprises surgical exploration through a median sternotomy and large midline or chevron abdominal incision, for performance of radical nephrectomy followed by inferior vena cava and right atrial thrombectomy under deep hypothermic circulatory arrest. Recently, advances in minimally invasive surgery have enabled the application of these techniques for the performance of technically advanced surgical procedures. This video demonstrates laparoscopic radical nephrectomy and minimally invasive level 4 thrombectomy utilizing deep hypothermic circulatory arrest in the calf model. METHODS: The procedure was performed in 6 male calves weighing 70-80 kg. Initially, the neck vessels were cannulated for subsequent cardiopulmonary bypass. Next, a laparoscopic team performed right radical nephrectomy and exposed the intra abdominal inferior vena cava (IVC). Simultaneously, thoracoscopic access to the right atrium was obtained by a second group of laparoscopic surgeons. Subsequently, cardio-pulmonary bypass, cardiac arrest under deep hypothermic conditions, and complete exsanguination were performed. A level 4 coagulum thrombus was created by needle injection. Combined laparoscopic and thoracoscopic IVC and right atrial thrombectomy were performed in a bloodless field. An angioscope was employed to visually confirm complete thrombus clearance. Laparoscopic and thoracoscopic techniques were then utilized for suture repair of the IVC and right atrium. Cardiopulmonary bypass was re-established, and the animal was gradually re-warmed. Once sinus rhythm was re-established at normal body temperature, the animal was weaned off the pump. RESULTS: Average operative time was 494.5 mins (range, 355 to 705 mins), average time to achieve core cooling was 63.5 mins (range, 50 to 120 mins), and average time to rewarm the animal was 101.8 mins (range, 70 to 130 mins). Following ciculatory arrest, the average blood volume drained into the bypass pump was 2633.3 cc (range, 1400 to 3200 cc). The average estimated blood loss was 350 cc (range, 200 to 750 cc). CONCLUSIONS: Laparoscopic radical nephrectomy with IVC and right atrial thrombectomy is feasible in the calf model. The technique can be performed utilizing minimally invasive techniques exclusively. Source of Funding: None. V82 PERCUTANEOUS RENAL CRYOABLATION William B Shingleton», Patrick E Sewell, Jackson, MS INTRODUCTION AND OBJECTIVE: Renal tumor cryoablation can be performed via a percutaneous approach with minimal morbidity and technical success. This videotape will demonstrate the technique utilizing magnetic resonance image (MRI) guidance. METHODS: A 75 year old male with a biopsy proven renal cell carcinoma measuring 4.5 ern in diameter underwent percutaneous cryoablation. The image guidance system was an interventional MRI unit and the cryoablation instrument was the Galil Medical Cryohit System.® RESULTS: This videotape illustrated the complete procedure required for percutaneous renal cryoablation. CONCLUSIONS: Renal cryoablation can be successfully performed percutaneously with MRI guidance. There is minimal morbidity associated with this procedure. This treatment technique will require continued follow-up to assess the durability of response. Source of Funding: None. Adrenal, Kidney, Ureteral Surgery (II) Moderated Poster Saturday, April 26, 2003 3:30-5:30 PM 84 LAPAROSCOPIC AND OPEN PARTIAL NEPHRECTOMY IN 200 CASES lnderbir S Gill, Cleveland, OH; Surena F Matin", Houston, TX; Mihir M Desai, Andrew Steinberg, Jihad H Kaouk, Edward Mascha, Julie Thorton, Brenda Strzempkawski, Mahmoud Sherief, Andrew C Novick, Cleveland, OH INTRODUCTION AND OBJECTIVE: We compare the perioperative outcomes after laparoscopic and contemporary open nephron sparing surgery (NSS) for patients with a solitary renal tumor -:57 em.
Transcript
Vol. 169, No.4, Supplement, Saturday, April 26, 2003 THE JOURNAL OF UROLOGY® 21
RESULTS: Laparoscopic partial nephrectomy with hypothermia wasperformed in 7 patients (8 renal units). Identification of the hilar vessels followedby clamping and cooling allowed meticulous dissection and removal of the renaltumor in a bloodless field. Suture closure of the collecting system was alsoperformed. Complications consisted of a single post-operative stroke, and onetransient urine leak which sealed spontaneously following stent placement.Surgical margins were negative in each patient.
CONCLUSIONS: This video illustrates a novel surgical technique which allowslaparoscopic partial nephrectomy to be meticulously performed in a bloodless field.Some previously reported techniques for laparoscopic partial nephrectomy do notprovide optimal conditions for resection. Laparoscopic partial nephrectomy ofintraparenchymal lesions without vascular control risks significant bleeding.Hemorrhage may obscure vision of the surgical field compromisingthe margin status.Performing partial nephrectomy with warm ischemia requires significantfacility withintracorporeal suturing, and time pressure constraints may compromise margin statusand risk renal deterioration. Our new technique recreates the advantages of the openprocedure while maintaininga minimally invasive approach.
Source of Funding: None.
V79NON-EXOPHYTIC RENAL CELL CANCER; A DIFFICULTCASE FOR RETROPERITONEAL LAPAROSCOPIC PARTIALNEPHRECTOMY -SUCCESSFUL ASSISTANCE WITH POWERDOPPLER ULTRASONOGRAPHY- Hidenori Zakoji", KazuhikoShiiki, Yasuhisa Furuya, Takayuki Tsuchida, Isao Araki, Yoshio Takihana,Nobuaki Tanabe, Masayuki Takeda, Yamanashi, Japan
INTRODUCTION AND OBJECTIVE: Laparoscopic partial nephrectomy fornon-exophytic renal tumor is challenging procedure because of difficulty indetecting tumor. We report a male case of non-exophytic renal cancer for whichidentification with endoscope was difficult, but he successfully underwentretroperitoneal laparoscopic partial nephrectomy assisted by intraoperativeultrasonography.
METHODS: Using retroperitoneal laparoscopic technique, the kidney wasidentified and separated from perirenal fat to explore the tumor. Only slightlyprotrudingarea of renal surface was seen, but could not be comfirmedendoscopically.Sonographical monitoring in IOMHz frequency was performed to evaluate locationand size of the tumor.Power Doppler ultrasoundwas very helpful in recognizingtumorand its blood flow. Laparoscopic partial nephrectomy could be performed usingmicrowave tissue coagulator and argon beam coagulator for hemostasis.
RESULTS: Operative time was 202 minutes. Blood loss was lOamI. Therewere no complications during 9-day-hospital stay. Pathological diagnosis was renalcell carcinoma, and the surgical margin was negative.
CONCLUSIONS: Intraoperative ultrasonography is very helpful forlaparoscopic partial nephrectomy, even in non-exophytic renal tumors.
Source of Funding: None.
V80LAPAROSCOPIC RADICAL NEPHRECTOMY FOR CANCERWITH LEVEL I RENAL VEIN THROMBUS Anup P Romani",CLEVELAND, OH
INTRODUCTION AND OBJECTIVE: Renal cell carcinoma(RCC) isassociated with thrombus extending into the venous system in 5-10% cases. Inpatients with organ-confined disease, open radical nephrectomy with concomitantthrombectomy is considered the treatment of choice. Laparoscopic radicalnephrectomy is rapidly becoming a standard of care for a majority of patients withTl-T2 cancers. With growing experience, we have applied laparoscopy to selectpatients with T3b RCC with level I renal vein thrombus.
METHODS: We present a video of a 82 year old patient with a pre-operativediagnosis of renal cancer with renal vein thrombus who underwent laparoscopicradical nephrectomy at our institution. The tumor size was 5 cms. Laparoscopy wascarried out by a 4-port transperitoneal approach. The renal vein was secured withan endo -GIA stapler proximal to the thrombus. To date we have performedlaparoscopic radical nephrectomy in 16 patients having cancer with a renal veinthrombus. These data are also presented.
RESULTS: The total operative time was ISO minutes. The blood loss was150cc. Intra-operative urine output was 775cc. The specimen weight was 867grams. There were no complications. The patient was ambulating and on oralliquids by 24 hours. At 2 month follow up there was no local recurrence ormetastasis. For the 16 cases done to date, the mean blood loss was 363cc, meanoperative time was 3.2 hours, mean follow up was 14.5 months and 3 patients hadrecurrence of tumor.
CONCLUSIONS: Laparoscopic radical nephrectomy is feasible and safe inpatients with renal cell carcinoma with level I thrombus. With growing experience,laparoscopy may potentially be applied to more extensive venous involvement inthe future.
Source of Funding: None.
V8lLAPAROSCOPIC RADICAL NEPHRECTOMY WITH VENACAVAL AND RIGHT ATRIAL THROMBECTOMY UTILIZINGDEEP HYPOTHERMIC CIRCULATORY ARREST- THE VIDEOAnoop M Meraney*, Mihir Desai, Gyung Tak Sung, Anup Ramani, Sidney Abbreu,Hiroaki Harasaki, Manabu Sato, Jihad Kaouk, lnderbir Gill, cleveland, OH
INTRODUCTION AND OBJECTIVE: In patients with renal cel1cancer withlevel 3 or 4 tumor thrombi, conventional treatment comprises surgical explorationthrough a median sternotomy and large midline or chevron abdominal incision, forperformance of radical nephrectomy followed by inferior vena cava and right atrialthrombectomy under deep hypothermic circulatory arrest. Recently, advances inminimally invasive surgery have enabled the application of these techniques for theperformance of technically advanced surgical procedures. This video demonstrateslaparoscopic radical nephrectomy and minimally invasive level 4 thrombectomyutilizing deep hypothermic circulatory arrest in the calf model.
METHODS: The procedure was performed in 6 male calves weighing 70-80kg. Initially, the neck vessels were cannulated for subsequent cardiopulmonarybypass. Next, a laparoscopic team performed right radical nephrectomy andexposed the intra abdominal inferior vena cava (IVC). Simultaneously,thoracoscopic access to the right atrium was obtained by a second group oflaparoscopic surgeons. Subsequently, cardio-pulmonary bypass, cardiac arrestunder deep hypothermic conditions, and complete exsanguination were performed.A level 4 coagulum thrombus was created by needle injection. Combinedlaparoscopic and thoracoscopic IVC and right atrial thrombectomy were performedin a bloodless field. An angioscope was employed to visually confirm completethrombus clearance. Laparoscopic and thoracoscopic techniques were then utilizedfor suture repair of the IVC and right atrium. Cardiopulmonary bypass wasre-established, and the animal was gradually re-warmed. Once sinus rhythm wasre-established at normal body temperature, the animal was weaned off the pump.
RESULTS: Average operative time was 494.5 mins (range, 355 to 705 mins),average time to achieve core cooling was 63.5 mins (range, 50 to 120 mins), andaverage time to rewarm the animal was 101.8 mins (range, 70 to 130 mins).Following ciculatory arrest, the average blood volume drained into the bypasspump was 2633.3 cc (range, 1400 to 3200 cc). The average estimated blood losswas 350 cc (range, 200 to 750 cc).
CONCLUSIONS: Laparoscopic radical nephrectomy with IVC and right atrialthrombectomy is feasible in the calf model. The technique can be performedutilizing minimally invasive techniques exclusively.
Source of Funding: None.
V82PERCUTANEOUS RENAL CRYOABLATION William BShingleton», Patrick E Sewell, Jackson, MS
INTRODUCTION AND OBJECTIVE: Renal tumor cryoablation can beperformed via a percutaneous approach with minimal morbidity and technicalsuccess. This videotape will demonstrate the technique utilizing magneticresonance image (MRI) guidance.
METHODS: A 75 year old male with a biopsy proven renal cell carcinomameasuring 4.5 ern in diameter underwent percutaneous cryoablation. The imageguidance system was an interventional MRI unit and the cryoablation instrumentwas the Galil Medical Cryohit System.®
RESULTS: This videotape illustrated the complete procedure required forpercutaneous renal cryoablation.
CONCLUSIONS: Renal cryoablation can be successfully performedpercutaneously with MRI guidance. There is minimal morbidity associated withthis procedure. This treatment technique will require continued follow-up to assessthe durability of response.
Source of Funding: None.
Adrenal, Kidney, Ureteral Surgery (II)Moderated Poster
Saturday, April 26, 2003 3:30-5:30 PM
84LAPAROSCOPIC AND OPEN PARTIAL NEPHRECTOMY IN 200CASES lnderbir S Gill, Cleveland, OH; Surena F Matin", Houston, TX; MihirM Desai, Andrew Steinberg, Jihad H Kaouk, Edward Mascha, Julie Thorton,Brenda Strzempkawski, Mahmoud Sherief, Andrew C Novick, Cleveland, OH
INTRODUCTION AND OBJECTIVE: We compare the perioperativeoutcomes after laparoscopic and contemporary open nephron sparing surgery(NSS) for patients with a solitary renal tumor -:57 em.
22 THE JOURNAL OF UROLOGY® Vol. 169, No.4, Supplement, Saturday, April 26, 2003
assisted techniques facilitate the procedure in select cases while maintaining thebenefits of minimally invasive surgery. Herein, we report our experience withhand-assisted laparoscopic partial nephrectomy.
METHODS: Between October 1999 and September 2002, we performed 44hand-assisted partial nephrectomies. Forty-two cases were performed for anenhancing or partially enhancing renal mass. Two cases were performed for aduplicated, non-functioning renal moiety. All cases were performed via anintraperitoneal approach.
RESULTS: The mean operative time was 202 +/- 58 min. Estimated bloodloss was 267 +/- 345 mL and 2 patients (4.5%) required blood transfusions. Onepatient required conversion to open partial nephrectomy. There were no majorcomplications. Post-operative endpoints included mean IV narcotic usage (29.7 +/16.9 mEq), PO narcotic usage (7.8 +/- 5.8 tabs), time to PO intake (38.6 +/- 42.3hrs), and length of hospitalization (3.1 +/- 1.2 days). Pathologic data is representedin the table below.
CONCLUSIONS: Hand-assisted laparoscopic partial nephrectomy istechnically feasible and reproducible. The surgeon's hand is of significant benefitin dissection, vascular control, hemostasis and suturing. Facilitation by handassistance may make laparoscopic nephron-sparing surgery a more widelyavailable minimally invasive alternative to open surgery.
Pathologic Data (N=44)
Source of Funding: None.
METHODS: 200 consecutive patients underwent laparoscopic (N=100) oropen (N= 100) NSS for a sporadic single renal tumor $7 em. Both surgicalapproaches were similar, including transient hilar control, tumor excision in abloodless field, pelvicalyceal repair, suture-ligation of intrarenal vessels, and renalparenchymal reconstruction. Demographic, intraoperative, postoperative, andshort-term follow-up data were retrospectively compared between the 2 groups.
RESULTS: Comparing laparoscopic versus open groups, median tumor size was2.&m and 3.3cm (P=0.005), surgicaltime was 3 vs. 3.9 hrs. (P<0.001), blood loss was125 vs. 250 ml (P <0.001), pelvicalyceal repair was done in 63.9% vs. 73.4% of cases(P=0.20), and mean warm ischemiatime was 27.8 vs. 17.5min. (P<0.001), respectively.In the laparoscopic and open groups,mediananalgesic requirement was 20.2 vs.252.5mgmorphinesulfateequivalents (P <0.001), hospitalstay was 2 vs. 5 days (P<0.001), andconvalescence 4 vs.6 weeks(P<0.00I). Postoperative serumcreatinine (1.1vs. 1.2mg/dL,P =0.65) was similar. No kidneywas lost due to warm ischemic injury. Medianwidthofmarginswas 4 mm for bothapproaches (P=0.11). Laparoscopic NSS was associated witha higherrateof intraoperative complications (5 vs.0, P=O.02).No significant difference inthe overall incidence of complications was found,but renal/urologic complications weremore commonin the laparoscopic group (11% vs. 2%, P=O.OI).
CONCLUSIONS: The laparoscopic approach is associated with higher urologiccomplications than the open approach but there is an equivalent overall incidence ofpostoperativecomplications.Laparoscopic NSS is emerging as an equally efficaciousminimally invasive nephron-sparing operation with respect to renal functionaloutcomes, in the setting of less blood loss, reduced postoperativenarcoticusage, earlierhospital discharge, and a faster convalescence. Continued efforts are required todevelop laparoscopicrenal hypothermiatechniquesand to decrease the warm ischemiatime while increasing the amount of intrarenal suturing.
85LAPAROSCOPIC NEPHRON SPARING SURGERY: EVOLVINGTECHNIQUE AND CONTEMPORARY EXPERIENCE RamakrishnaVenkatesh*, Jamil Rehman, Richard Vanlangendonk, Adam Kibei, Robert SFigenshau, St. Louis, MO; Chandru P Sundaram, Indianapolis, IN; Ralph VClayman, Orange, CA; Jaime Londman, St. Louis, MO
INTRODUCTION AND OBJECTIVE: Several techniques of laparoscopicnephron sparing surgery (LNSS) have been described. We report our recentexperience with the surgery.
METHODS: We reviewed the data of 31 patients who underwent LNSSbetween February 2000 and September 2002. Hemostasis was achieved with acombination of bipolar energy, argon beam coagulation, collagen, oxidizedcellulose and fibrin glue. In sixteen patients we used a monopolar radiofrequencydevice (Tissue Link Floating Ball) to aid partial nephrectomy. Laparoscopicultrasonography was used to assess the tumor extent and the resection margin wasevaluated by frozen section, in each case. Transperitoneal approach was performedin 22 cases and retroperitoneal approach in 9 cases.
RESULTS: The patients mean age was 58 years (range=38-81), theaverage ASA score was 2 (range= 1-4), and the mean BMI was 26 (range= 1833). The mean size of the renal masses was 2.1 em (range = 1-4 em). Allprocedures were successfully completed laparoscopically. Mean operative timewas 218 minutes (70-352) and the average blood loss was 370mL (503000mL), with 5 (16%) patients requiring blood transfusion. Mean ischemiatime was 19 minutes (range= 10-32) during 7 procedures that required renalvascular clamping. Renal vascular clamping was not required in 70% ofexophytic lesions. Midrenal tumors accounted for 56% of the masses.Collecting system closure was performed in 5 (16%) patients. The meanhospital stay was 2.6 days (range=2-5). Mean analgesic requirement was 26mg MS04 equivalents (range=7-110). Post-operative complications includedtwo urinomas (6.5%), two asymptomatic pneumothoraces (6.5%), an ileus(3%), a myocardial infarction (3%) and a renal arterial aneurysm (3%).Histopathological examination revealed renal cell carcinoma in 20(65%),oncocytoma in 4(13%), benign lesions in 5(16%) and angiomyolipoma in 2(6%) patients. There was one positive surgical margin; no tumor recurrence hasbeen observed with a mean follow up of 8 months (range = 1-31).
CONCLUSIONS: The technique for LNSS should be tailored to the individualpatient depending upon the size and location of the tumor. Control of the renal hilarvasculature was not required for the majority of exophytic masses. Renal vascularclamping was required for the majority of tumors located in the midrenal regionnear the renal hilum.
Source of Funding: None.
86LAPAROSCOPIC PARTIAL NEPHRECTOMY IS FEASIBLE:WILL HAND-ASSISTANCE MAKE IT THE STANDARD OFCARE? Ravi Munver*, R Ernest Sosa, Joseph J Del Pizzo, New York, NY
INTRODUCTION AND OBJECTIVE: Conventional laparoscopic nephronsparing surgery is not performed at many medical centers as it is a technicallydifficult procedure even in the hands of advanced laparoscopic surgeons. Hand-
*Presenting author.
87LAPAROSCOPIC PARTIAL NEPHRECTOMY: UNIQUEAPPLICATIONS Andrew P Steinberg*, Sidney C Abreu, Anup Ramani,Mihir Desai, Jihad Kaouk, Inderbir S Gill, Cleveland, OR
INTRODUCTION AND OBJECTIVE: Laparoscopic partial nephrectomy(LPN) is feasible, efficacious and currently the minimally invasive nephron sparingprocedure of choice at the Cleveland Clinic for select peripheral tumors. It is nowalso being applied to renal tumors in more complicated circumstances such asrenovascular disease, 2 tumors, coexisting adrenal pathology or horseshoe kidney.
METHODS: We retrospectively reviewed the charts of 185 patients who haveundergone LPN at the Cleveland Clinic. Data from 13 patients with atypicalsituations were extracted.
RESULTS: see TableCONCLUSIONS; Laparoscopic partial nephrectomy is an advanced
laparoscopic technique which has emerged as an efficacious treatment option forselect patients with renal tumors at our institution. It is now being appliedsuccessfully, with increasing frequency to more advanced cases, unique, initialexamples of which are demonstrated herein.
88GELATINE-MATRIX-THROMBIN TISSUE SEALANT(FLOSEAL)AS A TOOL FOR EFFECTIVE HEMOSTASIS INOPEN AND LAPAROSCOPIC PARTIAL NEPHRECTOMIESFrank Richter*, Maximilian Tiillmann, Ingolf Turk, Serdar Deger, DietmarSchnorr, Stafan A Loening, Berlin, Germany
INTRODUCTION AND OBJECTIVE: Long-term follow-up studies havedemonstrated that effective local tumor control and long-term tumor-freeprogression rates can be achieved by nephron sparing surgery. However,
Vol. 169, No.4, Supplement, Saturday, April 26, 2003 THE JOURNAL OF UROLOGY® 23
92LAPAROSCOPIC TRANSPERITONEAL ADRENALECTOMY:10 YEAR EXPERIENCE Andrea Cestariv, Piera Bellinzoni, AntoniaCentemero, Matteo Riva, Vincenzo Dell'acqua, Giorgio Guazzoni. PatrizioRigatti, Milan, Italy
INTRODUCTION AND OBJECTIVE: Laparoscopic adrenalectomy hasactually become the technique of choice for removal of benign adrenal lesions.Various laparoscopic techniques and approaches have been reported, with a
91INCIDENCE OF MULTIPLE ALDOSTERONE-PRODUCINGADENOMAS ~LAPAROSCOPIC TOTAL VERSUS PARTIALADRENALECTOMY Shigeto Ishidoyas, Akihiro Ito, Makoto Satoh,Kiyohide Sakai, Seiichi Saito, Yutaka Chiba, Fumitoshi Sato, Sadayoshi Ito,Kiminobu Sasano, Yoichi Arai, Sendai, Japan
INTRODUCTION AND OBJECTIVE: Laparoscopic surgery has become astandard method for adrenal operation. Primary aldosteronism is known to beoccasionally characterized as multiple adenomas. Laparoscopic totaladrenalectomy versus enucleation of aldosterone-producing adenoma (APA) stillremains controversial (J Urol, 153:1775, 1995). We performed both the differentoperations and compare retrospectively the results of these operations.
METHODS:A total of 78 patientswith primary aldosteronism underwent surgeryin our single institution. Unilaterallaparoscopictotal adrenalectomy was performed50patients (50 adrenals).Singlepathologistexamined the number of APAs. A total of 28patients (33 adrenals, including 5 bilateral cases) underwent laparoscopic partialadrenalectomy or enucleation.Postoperativemedian follow-up was 49 months.
RESULTS: Laparoscopic total adrenalectomy was successfully performed andimproved hypertension, suppressed plasma rennin activity, and high plasmaaldosterone concentration in alISO patients. Fifteen patients demonstrated multipleAPAs (30%). Among 28 patients with partial adrenalectomy or enucleation, twopatients still suffer from hypertension with high plasma aldosterone concentration.
CONCLUSIONS: Primary aldosteronism is highly associated with multipleAPAs. Laparoscopic total adrenalectomy is effective and appropriate comparedwith partial adrenalectomy or enucleation.
Source of Funding: None.
90ADRENALECTOMY FOR PHEOCHROMOCYTOMA IN USCASES:LAPAROSCOPY VS OPEN SURGERY Anoop Meraney*,Anup P Ramani, Jihad Kaouk, Sidney Abreu, Andrew Steinberg, Mihir Desai,Brenda Strzempkowski, Emmanuel Bravo, Cleveland, OH
INTRODUCTION AND OBJECTIVE: Laparoscopic adrenalectomy is the preferredsurgical approach for mostadrenal tumors. However, therehavebeensubstantial concernsabout potential hemodynamic instability during laparoscopic excision ofpheochromocytomas. We presentour experience with laparoscopic adrenalectomy in 60patients and retrospectively compareit to 55 undergoing open adrenalectomy.
METHODS: From January 1997 to April 2002, 60 patients underwentlaparoscopic adrenalectomy for pheochromocytoma at our institution. These datawere retrospectively compared to 55 patients who underwent open adrenalectomyfor pheochromocytoma from January 1991 to December 2000. Preoperative,intraoperative, immediate postoperative and follow up levels of 5 differentcatecholamines were measured in all patients in the laparoscopic group, to assessintraoperative catecholamine fluxes. No laparoscopic case was converted to open.Comparison of the two groups was done by the Chi square and Wilcoxon rank sumtest with a p value< 0.05 considered significant.
RESULTS: Mean age in the laparoscopic group was 52 years and in the opengroup was 50 years. SEE TABLE
CONCLUSIONS: Laparoscopic adrenalectomy is a safe, feasible and effectiveapproach for patients with pheochromocytoma. Compared to open surgery, itresults in decreased hospital stay, decreased morbidity and more rapidconvalescence. In our institution laparoscopic approach is the preferred techniquefor excision of a pheochromocytoma.
ADRENAlECTOMY FOR PHEOCHROMOCYTOMA: LAPAROSCOPY VSOPEN
LAPAROSCOPIC(n=60) OPEN (n=55)BMITumor slze(cms)Surgical t1me(mlns)Blood loss(cc)lntrlIop max.SBP(mmhg)Intraop max DBp(mmhg)Hospital stay(hrs)MS04 equlvqlent(mg)Follow up (months)Coovalasence(days)
89DECREASE IN BLOOD LOSS IN PATIENTS WHO UNDERWENT TISSUELINK DISSECTING SEALER 3.0™ DEVICEASSISTED PARTIAL NEPHRECTOMY FOR SUSPECTEDRENAL CELL CARCINOMA: A NEW SURGICAL TECHNIQUEMutahar Ahmed*, Cristian Andrade, Newark, NJ; Ihor Sawczuk,Hackensack, NJ
INTRODUCTION AND OBJECTIVE: We report our initial experiencewith the TissueLink Dissecting Sealer 3.0™ device assisted partialnephrectomy for suspected renal cell carcinoma and compare our results withthe use conventional method of electrocatutery in partial nephrectomies.Nephron-sparing surgery(NSS) has recently been acknowledged as a treatmentmodality for selected renal tumors. Since the 1950s, improvements achieved insurgical technique have lead to greater use of NSS with acceptable rates ofpost-operative morbidity. Use of advanced hemostatic techniques has lead toadequate hemostasis with acceptable amounts of blood loss. By couplingradiofrequency with a low-volume saline irrigation, the Tissuel.ink'P" devicepre-coagulates renal parenchyma minimizing loss of blood. The coupling ofradio-frequency and fluid conduction also avoid tissue charring or desiccationmaking dissection easier.
METHODS: The charts of 18 consecutive patients, in a six month period, whounderwent open nephron-sparing surgery for suspected renal cell carcinoma werereviewed. The primary surgeon in each case was the same.
RESULTS: The mean tumor size excised was 3.6 cm (range 2-6.0cm) in thegroup who underwent NSS with the new technique while mean tumor size removedwas 4.0 (range 1.5-8cm) for the conventional group. The mean operative blood losswas statistically lower than the conventional electrocautery group (155ml versus232ml, p<0.05). Operative time did not differ statistically between the TissueLinkDS3.0 assisted NSS group and the conventional method group (2.2 hours versus2.4 hours, respectively). There was no difference in mean hospital stay between thetwo groups. No operative complications are reported. Hilar vessels were clampedin 4 patients who underwent the new technique (mean clamp time 8.3 minutes) andin 6 patients who underwent the conventional technique (mean clamp time 7.3minutes). Intra-operative frozen section showed margins were negative in allpatients. One patient died on the 4th post-operative day of a myocardial infarctionin the conventional method group. There was no clinically significant differencebetween preoperative and postoperative creatinine levels (0.95mg/dl and 1.06mgldl, respectively) in the patients who underwent NSS assisted by the TissueLinkDS3.0 device.
CONCLUSIONS: Tissue Link DS3.0 assisted partial nephrectomy is apromising new technique for excising renal masses while providing adequatehemostasis.
Source of Funding: None.
hemostasis is a major issue and the lack of effective means of hemostasishas limited a wider use of the laparoscopic approach to nephron sparingsurgery.
METHODS: Between January 2001 and August 2002, a total of 36 patientswith renal cell carcinomas were treated by partial nephrectomies using atwo-component tissue sealant (FloSeal, Baxter Inc.). The median age was 55.2years (range 34-71 years). Follow-up time was 1-18 months (median 5.5months). The tumor diameter ranged from 2- 5 cm (median 2.9 cm). Seventeencases were performed by open retroperitoneal surgery - nineteen cases wereperformed laparoscopically using a trans peritoneal approach. The twocomponent tissue sealant (consisting of a gelatine matrix granula-componentand a thrombin component) was applied after resection of the tumor and beforeperfusion of the kidney. The following parameters were recorded: (I) Timeuntil complete hemostasis was achieved. (2) Decrease in postoperativehemoglobin level. (3) Postoperative bleeding. (4) Presence or absence of aperirenal hematoma 24 hrs. and 10 days postoperatively.
RESULTS: (I) After application of the tissue sealant for 1-2 minutes to themoist resection site, the hemostasis was immediate in all cases. When reperfusionof the kidney was established, hemostasis was maintained. (2) The decrease inpostoperative hemoglobin level ranged from 0.3 to 1.2 points (median 0.8 points).None of the patients required blood transfusions. (3) There were no cases ofpostoperative bleeding. (4) An ultrasound examination 24 hours and 10 dayspostoperatively demonstrated the absence of a significant perirenal hematoma.(5)Comparing open versus laparoscopic partial nephrectomies with respect tointraoperative blood loss, decrease in hemoglobin, postoperative hematomaformation and overall complication rate did not reveal a statistically significantdifference
CONCLUSIONS: The two-component tissue sealant FloSeal providedimmediate and durable hemostasis in open and laparoscopically performed partialnephrectomies. The tissue sealant may provide a tool to expand the possibilities oflaparoscopic nephron sparing surgery.
Source of Funding: None.
24 THE JOURNAL OF UROLOGY® Vol. 169, No.4, Supplement, Saturday, April 26, 2003
transperitoneal or retroperitoneal route. We present our ten years experience withtransperitoneal laparoscopic adrenalectomy.
METHODS: Between October 1992 and May 2002, 195 laparoscopicapproaches to the adrenal gland have been performed, namely 170 unilateraladrenalectomy (73 right, 97 left - 58 Conn's disease, 39 Cushing's Disease, 35Pheocrhomocytoma, 30 non functioning adenomas and 8 malignancy), 17 bilateraladrenalectomy and 8 cases of conservative surgery. The patients were placed in a60-degree flank position with the bed flexed to increase the surgical field; the firststep of the intervention was the early ligation of the adrenal vein, as a land markto correctly dissect the adrenal gland.
RESULTS: The laparoscopic procedure was succesfully completed in allbut 5 cases which were converted into open surgery (1 for duodenal injuryduring pneumoperitoneum induction with open access and 2 duringprocedures for malignancy). Mean operative time was 152 min. in the unilateralgroup, 235 min in the bilateral group and 84 min in the conservativegroup. Delayed complications included 3 cases of hemoperitoneum whichwere drained surgically, 3 cases of severe blood loss which were treated withblood transfusions, 2 cases of wound infection. Patients were able to ambulateon the morning of the first postoperative day and were discharged respectively2.7, 5 and 1.5 days after surgery in the unilateral, bilateral and conservativegroup.
CONCLUSIONS: Laparoscopic transperitoneal adrenalectomy is a safe andeffective, minimally invasive approach for patients with benign functioning or nonfunctioning adrenal masses. This technique has low morbidity, minimalpostoperative analgesic requirements, short hospital stay.
Source of Funding: None.
93THE TREATMENT OF SOLID RENAL MASSES: 5 YEARSREVIEW OF OUR TREATMENT PATTERN Sharam Gholami",Hugo Bermudez, Hugues Widmer, Declan Cahill, Xavier Cathelineau, HerveBaumert, Bertrand Guillonneau, Guy Vallancien, Paris, France
INTRODUCTION AND OBJECTIVE: Previous reports have demonstratedadvantages of laparoscopic (lap.) treatment of renal masses compared toconventional open surgery. We review our 5 years single center experience intreatment of solid renal masses to evaluate our patterns of treatment and lessons wehave learned.
METHODS: From March 1997 to August 2002,284 patients were treatedfor solid renal masses. We retrospectively reviewed our database of patients todetermine the details of the clinical history and treatment. 288 tumors weretreated for suspected renal carcinoma consisting of 48 open radicalnephrectomies (ORN), 162 lap. radical nephrectomies (LRN), 36 open partialnephrectomies (OPN) and 42 lap. partial nephrectomies (LPN) were performed.4 patients had 2 tumors that were treated on separate occasions. Prospectivelycollected data on staging, operative details and post-operative course wereanalyzed.
RESULTS: Malignancy was diagnosed in 261 (90.6%) cases. Operativedetails listed in table below. In general, tumors less than 5 em were removedby LPN and tumors between 5 and 9 ern were treated with LRN. ORN wasreserved for tumors greater than 9 em, renal vein or vena cava invasion andcontraindications for laparoscopic. All tumors were removed intact forpathological analysis. In large tumors requiring a long incision for specimenremoval, we favored an open approach for nephrectomy. During the first twoyears, OPN were initially performed for larger (>3cm) masses and deepparenchymal tumors, but with greater surgeon experience with intracorporealsuturing, the majority of these tumors were performed laparoscopically in years4 and 5.
CONCLUSIONS: At our institution, laparoscopic surgery has replaced opensurgery for tumor less than 9 cm. Small to medium sized renal masses areapproached laparoscopically with partial nephrectomy. Tumors greater than 5 ernare treated with laparoscopic nephrectomy and open surgery is done if the tumoris greater than 9 cm or has a large venous thrombus.
Summary of thetreatment of therenal masses.
95LONG TERM STUDY OF THE EFFICACY OF ACUCISEENDOPYELOTOMY FOR PRIMARY AND SECONDARY UPJOBSTRUCTION IN ADULTS Sameer K Sharma*, Boris V Klopukh,Thomas M Turk, Maywood, IL
INTRODUCTION AND OBJECTIVE: Since its introduction, retrogradeendopyelotomy with the Acucise catheter has become a popular treatment forprimary and secondary UPJ obstruction. Published series have shown success ratesapproaching 80%. We present our long-term experience with Acuciseendopyelotomy for the treatment of primary and secondary UPJ obstruction.
METHODS: We performed a single institution, retrospective review of allpatients that underwent Acucise endopyelotomy between January 1992, and May2002. Presenting symptoms, age, sex, diagnostic imaging, operative time, hospitalstay, stent duration, type of stent, complications, folJow-up studies, length offollow-up, need for reoperation, and success was recorded. Success was defined ascomplete resolution of symptoms and a non-obstructed renal scan. A minimalfollow-up of one year was required to include a patient in the review.
RESULTS: We identified 80 patients (62 primary UPJO, 18 secondary UPJO)who underwent Acucise endopyelotomy for UPJ obstruction. 54 of the 62 patientswith primary UPJ obstruction and 14 of the 18 patients with secondary UPJobstruction had sufficient follow-up for analysis. Average age was 45 years andaverage follow-up was 6.1 years (range 0.7 - 10.1 years). Mean operative time was46 minutes. Mean hospitalization was 1.7 days and mean stent duration was 47days. Our success rate for primary UPJ obstruction was 54% (29/54) and forsecondary UPJ obstruction was 50% (7/14). There was no difference in our successrate between the first 27 and second 27 patients (52% vs. 55% respectively) whounderwent Acucise endopyelotomy for primary UPJ obstruction. There was also nodifference found if the patient had been stented prepoperatively. For primary UPJobstruction our complication rate was 15% with hemorrhage in 2 cases (4%). Forsecondary UPJ obstruction our complication rate was 14% with one hemorrhageand one urinoma.
CONCLUSIONS: Our long-term experience with Acucise endopyelotomy forprimary and secondary UPJ obstruction demonstrates success rates of 54% and
94PATHOLOGIC CORRELATION BETWEEN URETEROPELVICJUNCTION OBSTRUCTION AND CROSSING VESSELS Peter APinto", Rachel Bluebond-Langner, Bruce Track, Thomas W Jarrett, Louis RKavoussi, Baltimore, MD
INTRODUCTION AND OBJECTIVE: The natural history and etiology ofureteropelvic junction (UPJ) obstruction is not well defined. The significance ofcrossing vessels in patients with UPJ obstruction continues to be debated. In aneffort to assess the implication of crossing vessels we examine the pathology of theUPJ in patients with and without crossing vessels.
METHODS: 95 pathological specimens were examined from our series of 155laparoscopic pyeloplasties for primary UPJ obstruction. The presence or absence ofcrossing vessels was documented intraoperatively. Five histologic categories wereidentified including, normal ureteral tissue, chronic inflammation, fibrosis, smoothmuscle hypertrophy and smooth muscle atrophy.
RESULTS: Crossing vessels were observed in 98 of 155 patients. Of the 95pathologic specimens sent 65 had crossing vessels and 30 did not. Results arediagramed in Table 1. When evaluating for pathologic findings, patients with acrossing vessel had a statistically significant decrease in observed histologicchanges (p<0.0003). Patients with a crossing vessel are 7.7 times less likely tohave intrinsic ureteral pathology (C.r. 2.1 - 27.8).
CONCLUSIONS: In our series the most common histologic observation in thegroup with crossing vessels was a lack of change in the UPJ tissue while in thegroup without crossing vessels chronic inflammation was the predominanthistology. We would argue that the intermittent extrinsic mechanical pressurecaused by the crossing vessel does not induce a change in the ureteral tissueappreciated by histology. As such, this would explain the lower success seen withendoincision when compared to pyeloplasty, since a full thickness cut in the uretermay not routinely cause relocation or geometric rearrangement of the UPJ. Giventhe absence of pathology in the ureter, structural change to the UPJ achieved bypyeloplasty may provide a more definitive solution for patients presenting with UPJobstruction and a concomitant crossing vessel.
Table 1:Comparison of UPJ pathology Inpatients withandwithoutcrossing vessels
Source of Funding: O. Orandaliano et al., MCP-1 and EOF renal expressionand urine excretion in human congenital obstructive nephropathy, KidneyInternational, vol:58, 182-192,2000.
RESULTS: Short-term data showed an overall high recovery rate of theinvolved renal units and the time to treatment has been the most importantprognostic factor to determine renal recovery: immediate (intraoperative or within3 days from ureteral injury), early (within 15 days) and delayed (after 15 days)reparative procedures obtained a recovery rate of 93.5%, 92.3% and 71.4%respectively. Long-term data, observed in the selected 14 patients, have showed inthe table.
CONCLUSIONS: In long-term follow-up, only immediate treatment isassociated with restoration of normal renal function, blood pressure and EOFIMCPI ratio. In the early anddelayed groups, in spite of resolved obstruction, alongwith hypertension and reduction of EOFIMCPI ratio, a deterioration of renalfunction was observed in 31% of renal units. In the future, the clinical applicationof the EOFIMCPl ratio should provide a prognostic factor of restored renalfunction in obstrncted kidneys.
LClng-tenn data cbl8flledInUte selected 14patIents.
99to·YEAR EXPERIENCE WITH THE PERCUTANEOUSSCLEROTHERAPY OF SIMPLE RENAL CYSTS VladimirNovotny", Sven Oehlschldger, Andreas Manseck; Manfred Wirth, Dresden,Germany
INTRODUCTION AND OBJECTIVE: Simple renal cysts are a commonfinding in 1/3 of a population. They are usually asymptomatic requiring notreatment. However, in some patients with pain or obstruction of the pelvicalicealsystem, surgical intervention should be considered. The percutaneous sclerotherapyas a simple and minimally invasive treatment was first performed in 1939.Introduction of ultrasound into urology has lead to more professional routine withultrasound-guided percutaneous sclerotherapy. In this study, the efficacy of thesclerotherapy in the treatment of the symptomatic single renal cysts has beenevaluated.
METHODS: In the past 10 years, between October 1992 and September 2002,37 patients underwent 46 ultrasound guided percutaneous sclerotherapy of
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98PERCUTANEOUS MANAGEMENT OF CALCULI WITHINHORSESHOE KIDNEYS Ganesb V Raj, Yeh H Tan*, Brian K Auge,Steven A Terranova, Alon Z Weizer, Durham, NC; John Denstedt, JamesWatterson, Darren Beiko, London, ON, Canada;Dean G Assimos, WinstonSalem, NC; Glenn M Preminger, Durham, NC
INTRODUCTION AND OBJECTIVE: Percutaneous nephrolithotomy (PNL)management of calculi within horseshoe kidneys (HSK) can be challenging due tothe altered anatomic relationship in the retroperitoneum. We therefore performed amulti-institutional review to assess the safety and efficacy PNL in HSK.
METHODS: Of 37 patients identified with calculi in HSK from threeinstitutions, 24 (65%) underwent PNL as primary treatment. Mean age was 48.4years and 75% were male. Three patients had staghorn calculi and the mean stonesize as measured by computed digitized stone surface area was 448 mm2• Meanfollow-up was 5.8 months. Stone composition, stone-free rates, complication rates,and the need for secondary intervention were evaluated.
RESULTS: Renal access was obtained through an upper pole calyx in 63%, alower pole calyx in 25% and a middle calyx in 4%. After primary or second lookprocedures, 21/24patients (87.5%) were rendered stone free. Flexible nephroscopywas used in 84% of cases. Minor complications occurred in 4 (16.7%) whereas 3patients (12.5%) experienced major complications including significant bleedingnecessitating early cessation, nephropleural fistula and pneumothorax. No deathsoccurred as a result of treatment. Stone analysis was available for 21 (87.5%).Calcium stones predominated (87.5%) followed by uric acid (9.5%) and struvite(4.8%).
CONCLUSIONS: PNL for renal calculi in patients with HSK is technicallychallenging and usually requires upper pole access and flexible nephroscopy due tothe altered anatomic relationships of the fused renal units. The high stone free ratecombined with a relatively low incidence of major complications suggests thatpercutaneous nephrolithotomy is an effective means of stone management for thiscomplex patient population.
Source of Funding: .None.
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50% respectively. These success rates are significantly less than those previouslyreported. We believe additional studies with long follow-up on the efficacy ofAcucise endopyelotomy are needed to confirm our results at other institutions.Comparison with other minimally invasive approaches to endopyelotomy andpyeloplasty are also required.
Source of Funding: None.
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Source of Funding: None.
96ENDOPYELOTOMY: DETERMINING THE DURABILITY OFENDOUROLOGIC INTERVENTION Justin M Albani", Stevan BStreem, Cleveland, OH
INTRODUCTION AND OBJECTIVE: This study was done to criticallyevaluate the durability of endourologic intervention for the treatment ofureteropelvic junction obstruction (UPJO), and to further establish guidelines forpostoperative surveillance.
METHODS: Since 1989, 150 patients underwent endourologic managementfor UPJO. Of these, 127 (53 men, 74 women), age 13-79 (mean 40.4) years wereavailable for evaluation and constitute the study group. Endourologic managementconsisted of cautery wire balloon endopyelotomy (n = 25), percutaneousendopyelotomy (n = 67), and ureteroscopic holmium laser endopyelotomy (n =35). Success was defined as both symptomatic relief and radiographic (IVP,diuretic renogram, or both) resolution at latest follow-up. Statistical analysis wasperformed to develop a Kaplan-Meier Curve to determine 're-stenosis freesurvival.
RESULTS: Follow-up ranged from 1-128 (mean 22) months. Kaplan-MeierEstimates of time to re-stenosis (failure) after endourologic intervention werecalculated with the following probabilities of failure: 6 months, 11.9%; 12 months,21.6%; 18 months, 24%; 24 months, 26.7%; 30 months, 31.7%, 36 months, 36.7%;42 months, 36.7%; 48 months, 36.7%.
CONCLUSIONS: The long-term success of 63.3% in this large series issomewhat lower than what is reported in the literature. This likely is a result oflonger follow-up. The novel finding specifically evaluated here is that while mostfailures become evident within the first 12 months, failures can develop as late as3 years after intervention. As such, patients should be followed at least that long toensure a durable result.
91LONG-TERM FOLLOW·UP OF IATROGENIC URETERALINJURIES: A 30·YEAR EXPERIENCE IN TREATING 246INJURIES MicheleBattaglia, PasqualeDitonno", VitoMancini, GiuseppeGrandaliano, Paola Pontrelli, Vincenzo Stellacci, Silvano Palazzo, PasqualeMartino, Francesco P Selvaggi, Bari, Italy
INTRODUCTION AND OBJECTIVE: Ureteric iatrogenic injuries are apotential complication of open or endoscopic surgical procedures. Theprincipal aim of the treatment is to restore, as soon as possible, the ureteralcontinuity to prevent the impairment of the kidney. Although a promptprocedure resolves the obstruction, long-term data on function of disobstructedrenal units are lacking. We report our long-term data from 246 ureteral injuriesoperated in the last 30 years.
METHODS: From June 1972 to June 2002, we studied retrospectively 197patients (146 F and 51 M, PM ratio 2.8:1) with 246 lesions of the ureters (49bilateral cases). The median age was 48.5 years (range 17 months-80 years).Follow-up protocol included renal function tests, urineculture, IVP at 3, 6, 12 and24 months. From our database 14 patients, for a total of 18 ureters, with aminumum follow-up of 4 years (median follow-up: 14.4 years, range 48-299) wereselected. The repairing surgery included 3 endoscopic stentings, 8ureteroneocystostomy with psoas-hitch, 2 transureteroureterostomy and 1 ilealconduit. In this group, we also tested MA03 renal scan and overnight urine BOFIMCP-I ratio as newly molecular marker of renal damage.
26 TIlE JOURNAL OF UROLOGY@ VoL 169, No.4, Supplement, Saturday, April 26, 2003
symptomatic single renal cysts. The average age was 61,4 (31 to 81) years.Indication for the treatment was pain syndrome in 33 cases and pelvicalicealobstruction in 9 cases. The percutaneous punctures were performed in localanaesthesia with temporary insertion of a percutaneous nephrostomy tube,followed by polidocanol instillation. 4 patient underwent repeated sclerotherapythrough the nephrostomy tube without previous puncture 24 to 48 hours after thefirst sclerotisation. Sonographical evaluation of the cysts has been done pre-andpost-surgically.
RESULTS: All punctures were performed without complications. The averagediameter of the cysts was 9,16 (4,4 to 15) em. A mean regression in the diameterof the cysts of 84,8% (100 to 60%) was achieved. Cytology of aspirated fluid wasnegative in all cases.
CONCLUSIONS: The ultrasound guided percutaneous sclerotherapy ofsymptomatic single renal cysts in local anaesthesia is well tolerated, minimallyinvasive treatment which can also be performed in high-risk patients. According toour results, this technique should be considered as the treatment of choice in thecase of symptomatic single renal cysts.
INTRODUCTIONAND OBJECTIVE: The natural history of simple renal cysthad been studied in our institute. We previously reported that the prevalence ofrenal cysts increased with age and showed a remarkable difference in incidence bysex (J Urol, 167:21-23,2(02). Several reports showed significant associationbetween renal cysts and hypertension. We examined risk factors for renal cyst ina large population-based health survey.
METHODS: We collected data on 17,914 individuals who participated in amultiphasic health screening program at our institute in 2000. An ultrasound wasused for the diagnosis of renal cyst. Logistic analysis was used to examine the riskfactors for renal cyst, including sex, age, serum creatinine, hypertension,hypercholesterolemia, diabetes mellitus, and habitation of smoking.
RESULTS: The prevalence of renal cysts was 9.9%, ranging from 3.8% inthirties to 18.5% in sixties. They were detected in 13.0% of men and 5.8% ofwomen. Mean serum creatinine was 0.83mgldl in individuals with cyst and0.76mgfdl without cyst. Hypertension was defined as systolic blood pressure>140mmHg, diastolic blood pressure >90mmHg, or the current use ofantihypertensive medication. Multivariate logistic regression analysis showed thatage (p<O.OOOl), sex (p<O.OOOI), serum creatinie (p<O.OOOI), and hypertension(p==0.0047) were significant risk factors for renal cyst. Other factors were notsignificant in this study.
CONCLUSIONS: The risk factors for renal cyst are considered to beold age,gender of male, renal dysfunction and hypertension.
Source of Funding: None.
101THE RELEVANCE OF DIURETIC RENOGRAPHY FORDIAGNOSIS OF URETEROPELVIC JUNCTION OBSTRUC·TION Eduard Dobry", Dagmar Miska, lmke Lange. Urs E Studer.Hansjorg Danuser, Berne. Switzerland
INTRODUCTION AND OBJECTIVE: Diagnosis of ureteropelvic junctionobstruction (UPJO) is based upon the patient history, urography, retrogradepyelography and diuretic renography. The necessity for and diagnostic value ofdiuretic renography have rarely been investigated. We therefore analyzed patientswith UPJO retrospectively as to the diagnostic value of diuretic renography in thepreoperative workup.
METHODS: In a series of 170 consecutive patients with UPJO 119 patientshad a diuretic renography with both split renal function and diuresis renographyindex. Diuretic renography was performed using I131-Hippuran and analyzedusing the method of O'Reilly. Diuretic renography was considered obstructivewhen split renal function on the side of UPJO was ,.,;;40% andlor the secretion indexjudged as at least "partial obstructive". UPJO was diagnosed, without using thedata of the diuretic renal scan, by typical urography and retrograde pyelographyfindings and clinical symptoms such as intermittent, permanent or acute flank painor obstructive pyelonephritis.
RESULTS: Diuretic renography indicated a functional obstruction in 73 ofthe 119 patients (61%). Of these 73 patients 44% had both parameters positive,split renal function with ,.,;;40% and an obstructive diuresis index. In 16% onlythe split renal function with :;;;40% was positive and in 40% only theobstructive diuresis index was positive. Diuretic renography was consideredpositive, as defined above, in 59% of patients with intermittent flank pain, in100% of the patients with permanent flank pain, in 80% of the patients withacute flank pain, and in 85% of the patients with obstructive pyelonephritis asthe initial clinical symptom.
*Presenting author.
CONCLUSIONS: The diagnostic value of the diuretic renography in UPJO issmall. In patients with typical urography, retrograde pyelography and typicalclinical symptoms confirmation of the UPJO by diuretic renography is high, butusually unnecessary as an indication for surgery. In the diagnostic difficult groupof patients with intermittent flank pain, the diuretic renography is positive andhelpful in only 60%. Therefore a negative diuretic renal scan in these cases doesnot allow exclusion of UPJO.
Source of Funding: None.
102URETERAL RECONSTRUCTION WITH SMALL INTESTINESUBMUCOSAGRAFT AND A COLLAGEN INHIBITOR DavidADuchene», Devin B Johnson. LucasJacomides, Dallas. TX.; Kenneth Ogan,Atlanta. GA; Cheryl A Napper. Margaret S Pearle. Jeffrey A Cadeddu,Dallas. TX.
INTRODUCTION AND OBJECTIVE: Ureteral stricture presents acomplex management problem. Small intestine submucosa (SIS) has been usedsuccessfully as an onlay graft in ureteral repair, but tubularized segmentinterposition of SIS has been unsuccessful. Our objective was to evaluatewhether a type-I collagen inhibitor, halofuginone, would prevent strictureformation in a tubularized SIS interposition graft to provide a durable ureteralrepair.
METIlODS: Twelve domestic female pigs underwent either laparoscopicureteral incision followed by a SIS onlay graft (N=5), or ureteral excision followedby a SIS tubularized interposition graft (N==7). Animals were grouped as control,receiving no halofuginone (N=3), low-dose (0.2 mglkglday) halofuginone(N=5),or high dose (0.4 mglkglday) halofuginone (N=4). AUanimals had ureteral stemsfor 2 weeks after surgery and were survived for 6 to 9 weeks. An intravenousurogram (IVU) was performed in all animals prior to sacrifice. Kidneys wereharvested for gross and histological examination.
RESULTS: One onlay graft animal died of an unrelated systemic illness. Theremaining 4 SIS ureteral onlay animals had grossly normal kidneys, including Icontrol, 2 low-dose, and 1 high-dose animal. The IVU was normal in the control,showed delayed excretion with mild hydroureteronephrosis in the low-doseanimals, and was normal in the high-dose pig. Pathology revealed inflammation,mild fibrosis, and scant epithelium resembling transitional epithelium at the graftsite. All 7 ureteral tubularized interposition graft kidneys grossly demonstratedeither severe hydroureteronephrosls (N==5) or renal atrophy (N=2). All hadcomplete obstruction (no uptake or excretion) on IVU. Pathology revealedcomplete obliteration of the ureteral lumen with an extensive surroundinginflammatory and fibrotic reaction.
CONCLUSIONS: An onlay graft technique with SIS appears to have partialsuccess in the porcine model of ureteral injury. Halofuginone, a type-I collageninhibitor, did not demonstrate a significant beneficial effect. Ureteral tubularizedinterpositions with SIS are unsuccessful and not improved by the use ofhalofuginone.
Source of Funding: Southwestern Center for Minimally Invasive Surgery.
103IMPACT OF TRAINING IN PERCUTANEOUS RENAL ACCESSON SUBSEQUENT UROLOGIC PRACTICE Courtney Lee", ManojMonga, Minneapolis, MN
INTRODUCTION AND OBJECTIVE: The technique of percutaneous renalaccess is not taught in many urologic residency training programs. Percutaneousrenal access has been an integral component of our residency training program forthe last twenty years. The objective of this study is to evaluate the impact ofresidency training in percutaneous renal access.
METIlODS: Surveys were mailed to residents who graduated from 1981-2001.Surveys evaluated the level of training in percutaneous access during residency andcurrent practice patterns with regards to percutaneous renal surgery.
RESULTS: Responses were received from 33 of the 48 surveys mailed (69%).Current practice patterns with regards to performance of percutaneous renalsurgery and obtaining percutaneous renal access are summarized in Table I. Nosignificant differences were seen in current practice patterns based on the numberof cases performed during residency. Urologists trained in percutaneous accesswere more likely (50%) to consider upper tract transitional cell cancer as anindication for percutaneous renal surgery than those not trained in access (0%).Theprimary reasons stated not to perform their own access included that the radiologisthas better equipment (67%) or skills (50%), obtaining access takes extra time(50%) with inadequate reimbursement (17%), the urologist feels (s)he does nothave adequate skills (39%) or efforts have been impeded by hospital politics(28%). Concerns of increased liability or increased radiation exposure were notsignificant considerations.
CONCLUSIONS: Only a minority of residents trained in percutaneous renalaccess continue to utilize those skills after residency. Efforts to improve the
Vol. 169, No.4, Supplement, Saturday, April 26, 2003 THE JOURNALOF UROLOGY@ 27
imaging equipment in endourological suites and efforts to provide educationalopportunities to improveand refresh skills in percutaneousrenal access may helpto increase the urologist's involvementin this important technique.
Current Practice Patterns in Percutaneous Access andRanllSurgery
Infections/Inflammation of the GenitourinaryTract: Prostate, Urethra &Genitalia
Moderated PosterSaturday, April 26, 2003 3:30-5:30PM
104LEVOFLOXACIN TREATMENT FOR CHRONIC PRO·STATITIS/CHRONIC PELVIC PAIN SYNDROME(CP/CPPS) INMEN: A RANDOMIZED PLACEBO CONTROLLED MULTI·CENTER TRIAL J Curtis Nickels, Joe Downey, Janet Clark, and TheCanadian Prostatitis Research Group, Kingston, ON, Canada
INTRODUCTION AND OBJECTIVE: Uncontrolled studies have supportedthe use of antibiotics in CP/CPPS. We undertook a Canadian multicenterrandomized placebocontrolled trial to evaluate the safety and efficacyof 6 weeksof levofloxacin therapycompared to placebo in CP/CPPS.
METHODS: Menwith an NIH diagnosisof CP/CPPS(specifically no infectionlocalizedto prostate)were randomized to levofloxacin (500mg/day)or placebofor6 weeks in 8 Canadian centers. The study was powered to show a significanttreatmenteffect with 100randomizedpatients.Patients were assessedat baseline,3 weeks,6 weeks and 12 weeks with the NIH Chronic ProstatitisSymptomIndex(CPSI) and a patient directed SubjectiveGlobal Assessment(SGA).
RESULTS: 65 men(average age56.2years,range36 to78;duration of symptoms,6.9 years, range0.6 to 32)wererandomized (36 to levofloxacin; 29 to placebo) andallwereevaluable in an intention to treatanalysis. Bothgroupsexperienced progressiveimprovement in symptoms, withthe levofloxacin groupshowing a greaterdecrease insymptom scoreandhighernumbers of responders thanplacebo. Therewasa significantdecrease in CPSIin the levofloxacin groupcompared to theplacebo groupat 3 weeks(4.5 vs 0.6;p=O.02). Therewasa numerical, but not statistically significant increasedresponder rate in the levofloxacin groupcompared to theplacebogroupmeasured bypercentage of patients witha 25%and50% respectively in CPSI.Morepatients in thelevofloxacin groupwereratedas responders witha 6 pointdecrease in CPSIand SGAcompared to theplacebogroup; the difference wasstatistically significant at 3 weeks.Data is presented in the table.No patients withdrew because of adverse events. Onepatient withdrew before the 6 week assessment. Adverse events (all mild) werereported in 17%of the levofloxacin groupand 24%of theplacebo group.
CONCLUSIONS: This small pilot controlled study showed that six weeks oflevofloxacin therapyresultedin early and significantimprovement in symptomsinmendiagnosedwith CPPS. Improvementcontinuedduringand after treatmentbutwas not significantly different from placebo. The clinical ramifications of thesefindings needs to be addressed.
P=Placebo T=Levofloxacin Treatmenl"p<O.05
Source of Funding: Janssen-Ortho Canada.
106ALFUZOSIN TREATMENT FOR CHRONIC PROSTATITIS/CHRONIC PELVIC PAIN SYNDROME (CP/CPPS): A PROSPEC·TIVE RANDOMIZED PLACEBO CONTROLLED STUDY AareMehik*, Oulu, Finland; Peeter Alas, Oulainen; Finland; J Curtis Nickel,Kingston, ON, Canada; Ari Sarpola; Pekka Hellstrom. Oulu, Finland
INTRODUCTION AND OBJECTIVE: Alpha-blockers have been suggestedfor the treatment of CP/CPPS. We undertook a prospective, placebo-controlledstudy to examine the long term efficacy of alfuzosin, compared to placebo andstandard therapy, in CP/CPPS.
METHODS: 120 consecutive men diagnosed with CP/CPPS wereprospectivelyscreenedand randomizedto alfuzosin5 mg bid, placeboand control(standard)therapy(exceptalphablockers)groups.70 subjectsagreed to participatein the study. Patients were treatedfor 6 monthsand then followedup for a further6 months.The changefrom baselinein the total and domainscoresof the validatedFinnish version of the NIH-Chronic Prostatitis Symptom Index (CPSI) was theprimary outcome parameterfor this study.
RESULTS: Datafrom61 patients wereavailable forevaluation (19in alfuzosin, 16inplacebo and26 in controVstandard groups). At theendof 6 months of active therapy, thealfuzosin grouphada significant decrease in totalCPSIscorecompared to theplacebo andcontroVstandard groups (9.9, 3.8 and4.3 decrease in CPSIrespectively; p=;O.OI). Therewasa significant improvement in painscorein thealfuzosin group at 6 months comparedtotheplacebo andcontroVstandardgroups (p=0.01),butnotinthevoiding orquality oflifescorebetween the3 groups. 65%of thepatients in thealfuzosin group hada greater than33%improvement in themeanNIH-CPSI totalscorecompared to 24%and 32%of theplacebo andcontroVstandard groups respectively (p=0.02). At 12months (6 months afteralfuzosinlplacebo discontinued), thesymptom scores in all domains of theCPSIshoweddeterioration compared tooriginal baseline in thealfuzosin and placebo groups but notthecontroVstandard group(CPSI score was3.5,0.1and5.6points below baseline respectively.MildGI symptoms and a decrease in ejaculate volume was noted by I and 4 patientsrespectively in the alfuzosin group. No patients dropped out of the study because of anadverse event
CONCLUSIONS: 6 months of alfuzosin therapy for CP/CPPS is safe, welltolerated and results in modest but significant improvement in the NIH-CPSI,particularly the pain domain, compared to placebo and standard/traditionaltreatment.The beneficialeffect is only apparentafterseveralmonthsof therapyanddisappears when treatment is discontinued.
Source of Funding: ProstatitisFoundation,NIH-NIDDK.
METIlODS: Men(n=;488) enrolledin the NIHChronic Prostatitis Cohort(CPC)Study from seven clinical centers (6 U.S., I Canada) reported baseline screeningsymptoms using the NIH Chronic Prostatitis Symptom Index (CPS!). The CPSIprovides standardized scoresfor QOL, average pain intensity, and urinary symptomsseverityrating. In addition, a demographic profile, including age and partner(livingwithanother) stalUS, a comprehensive history, physical examination andfurtherqualityof lifeassessements (including affective distress scorefromSF 12)wereobtained fromeach participant. Regression modeling of QOL, adjusted for age, partner status,urological symptoms, and centerto centervariability, was utilized to characterize theassociations withpainand affective distress.
RESULTS: Urinary scores, affective distress, and pain scores were significantpredictors of QOL for CP/CPPS patients. HigherQOL scores indicate more severeimpairment (median =; 8.0; range0 to 12).In particular, forevery1 pointincrease inurinary scores(range0 to 10),therewasa corresponding increase inQOLscoreof0.11points(p =;0.0012); forevery1pointincrease in painscores(range0 to 21), therewasa corresponding increase in QOL scoreof 0.42 points(p < 0.0001); and for every 1pointdecrease in affective distress (range 1 to 6; lowerscores indicate more severeimpairment), the QOL score increased by 0.38 points(p < 0.0001). Age and Partnerstatusdid not significantly contribute to changesin QOL scores.
CONCLUSIONS: The present study shows that psychological factors,especially related to pain, are important in understanding QOL in CP/CPPS,independentof age and urinary status. As pain increases,QOL decreases.Furtherdata relating psychological factors to pain in CP/CPPS are needed to understandhow pain symptoms affect QOL and may be integral in developing empiricallyguided pain managementtreatment.
105PAIN AND AFFECTIVE DISTRESS AS PREDICTORS OFQUALITY OF LIFE IN CHRONIC PROSTATITIS/CHRONICPELVIC PAIN SYNDROME (CP/CPPS) Dean A Tripp», J CurtisNickel, Kingston, ON,Canada; RichardJ Landis, JillS Knauss, Philadelphia,PA; and the CPCRN, Bethesda, MD
INTRODUCTION AND OBJECTIVE: To examine how affective distress,pain intensity, and partner status impact Quality of Life (QOL) in CP/CPPS,adjustedfor age and urologicalsymptoms. Thesefactorswere also usedto examinetheir uniquecontributions to pain intensity.
107TOTAL PROSTATE-SPECIFIC ANTIGEN IS ELEVATED ANDSTATISTICALLY, BUT NOT CLINICALLY SIGNIFICANT INPATIENTS WITH CHRONIC PELVIC PAIN SYNDROME/PROSTATITIS RobertB Nadler", AnthonyJ Schaeffer, Chicago, IL; JillS Knauss, Kathleen J Propert, RichardLandis, Philadelphia, CA; StephenDMikolajczyk, San Diego, CA; Richard B Alexander, Baltimore, MD
INTRODUCTION AND OBJECTIVE: To determine if PSA or Percent FreePSA could be used as a marker for Chronic Pelvic Pain Syndrome (CPPS)/Prostatitis, and whether PSA and Percent Free PSA values were in the rangeassociated with prostate cancer.
