We previously described the use of cold saline surface irrigation to achieve protective renal hypothermia in a laparoscopic partial nephrectomy porcine model. We now present our clinical application of this technique and characterization of the hypothermic effect during laparoscopic partial nephrectomy.
Seven patients underwent elective laparoscopic partial nephrectomy augmented with our hypothermia technique. Parenchymal temperature sensors were placed to confirm cooling efficacy and efficiency. After transperitoneal exposure of the kidney we performed temporary hilar vascular occlusion. Surface cooling with almost freezing normal saline was delivered with a laparoscopic suction/irrigation device. Tumor laparoscopic resection and renal reconstruction were completed. Outcome measures included intraoperative changes with hypothermia and postoperative estimated glomerular filtration rate changes.
All patients successfully underwent laparoscopic partial nephrectomy without complications or evidence of residual disease. A protective renal parenchymal temperature of less than 20C was achieved at a mean application time of 8.3 minutes. The hypothermic window of 15C to 25C was maintained an average of 30.4 minutes. In 2 cases cooling was repeated and 4 minutes were required to lower the temperature below 20C. The overall mean core body temperature decrease was 1.28C. At a mean followup of 22.4 months the median preoperative, immediate postoperative and final estimated glomerular filtration rate was 75, 65 and 71 ml/minute/1.73 m(2), respectively. There was no evidence of disease recurrence on followup imaging.
Our technique involving cold saline surface irrigation to achieve protective renal hypothermia is reproducible, and uses readily available laparoscopic instruments and equipment. This technique can be done simply and effectively, and may expand the use of laparoscopic partial nephrectomy.
" has also reported using the LANL technique in two cases of complete stag - horn stones [ Kijvikai , 2009 ] . These procedures were performed under renal hypothermia . This technique of renal cooling was duplicated from their previous report of the simple technique used in performing renal hypothermia during pure laparoscopic partial nephrectomy [ Kijvikai et al . 2010 ] . The mean cold ischemic time was 55 min , and the patients had a good renal function after surgery compared with the preop - erative level ."
[Show abstract][Hide abstract] ABSTRACT: To date, most cases of renal calculi have been managed with extracorporeal shockwave lithotripsy and endoscopic procedures. However, for complex renal stone conditions, these minimally invasive procedures may require multiple operative sessions. Open surgery is usually reserved as a salvage procedure, although it is invasive in nature. Laparoscopic treatment is well accepted in renal surgery. For stone disease, it can duplicate open surgical techniques such as pyelolithotomy, pyeloplasty, anatrophic nephrolithotomy, caliceal diverticulectomy and nephrectomy. Although the laparoscopic techniques for stone treatment are quite challenging, it is both feasible and safe. Laparoscopic treatment is a viable option for large renal stone treatment with an excellent stone-free rate, especially when patients require their stones to be treated within a single session. However, it is more invasive in nature than endourology procedures and so should be reserved as the last resort option for renal stone management in the modern endourology era.
Therapeutic Advances in Urology 02/2011; 3(1):13-8. DOI:10.1177/1756287211398254
[Show abstract][Hide abstract] ABSTRACT: Controlled tissue cooling, or hypothermia, has been used therapeutically for decades to mitigate the negative effects of traumatic, ischemic, and surgical insults. When applied systemically, moderate hypothermia can attenuate or prevent the extent of neurologic sequelae. Localized hypothermia, on the other hand, has the capacity to reduce tissue edema, suppress inflammation, and minimize the severity of peripheral nerve injury. Therapeutic hypothermia has been used in critical care, neurosurgery, ophthalmology, otolaryngology, cardiothoracic surgery and most recently in urology. Nerve injury during radical pelvic surgery can result in urinary incontinence or retention, impotence and bowel dysfunction. Localized hypothermia during radical prostatectomy has demonstrated improved recovery of urinary continence and erectile function, and similar benefits might be observed in other types of radical pelvic surgery.
[Show abstract][Hide abstract] ABSTRACT: We describe our multi-institutional experience using a laparoscopic clamp to induce selective regional ischemia during robot-assisted laparoscopic partial nephrectomy (RALPN) without hilar occlusion.
A retrospective review of Institutional Revew Board-approved databases of patients who underwent selective regional clamping during RALPN at four institutions was performed.
In 20 patients who were treated for elective indications, RALPN with parenchymal clamping was successful in 17 (85%). Mean age was 63 years (24-78 y). Median tumor diameter was 2.2 cm (1.1-7.2 cm). Mass location was polar in 13 (76%) and interpolar in 4 (24%). Median R.E.N.A.L. nephrometry score was 6 (4-10). Median overall operative time was 190 minutes (129-309 min), while selective clamp time was 26 minutes (19-52 min). Collecting system repair occurred in 8 (47%) patients. No patients needed a blood transfusion. There was no significant difference in preoperative (median 86 mL/min/1.73 m(2)) and immediate postoperative glomerular filtration rate (GFR) (median 78 mL/min/1.73 m(2), P=0.33) or with the most recent GFR (median 78 mL/min/1.73 m(2), P=0.54) at a mean follow-up of 6.1 months (1.2-11.9 mos). Final pathology determination revealed renal-cell carcinoma in 71% with no positive margins on frozen or final evaluation. In three additional patients who were undergoing RALPN, bleeding because of incomplete distal clamp compression necessitated subsequent central hilar clamping for the completion of the procedure.
In our preliminary multi-institutional experience, regional ischemia using a laparoscopic parenchymal clamp is feasible during RALPN for hemostasis. Careful preoperative selection of patients is needed to determine ideal patient and tumor characteristics. Further comparison studies are necessary to determine the true utility of this technique.
Journal of endourology / Endourological Society 09/2011; 25(9):1487-91. DOI:10.1089/end.2010.0667 · 1.71 Impact Factor
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