Hand-assisted laparoscopic partial nephrectomy without formal collecting system closure: perioperative outcomes in 104 consecutive patients.
ABSTRACT Laparoscopic partial nephrectomy (LPN) paralleling open techniques, particularly closure of the collecting system, can be technically challenging for the novice laparoscopist. We describe operative results and complications of a single surgeon, retrospectively reviewed series using a simplified method of hand assistance and a fibrin glue patch for hemostasis without formal collecting system closure.
We identified 104 consecutive patients between September 2003 and January 2009 who underwent hand-assisted laparoscopic partial nephrectomy (HALPN). Our technique involves routine hilar clamping after isolation of the tumor and mobilization of the kidney. After resection of the mass, a fibrin glue patch is placed within the surgical defect and secured with bolstering sutures. No attempt is made to suture the collecting system, nor are ureteral catheters placed when the collecting system is entered during resection of the tumor.
Mean tumor size was 2.8 cm (median 2.5 cm, range 0.7-7.0 cm). With hilar clamping, warm ischemia time averaged 24.5 minutes (range 11-39 min). Estimated blood loss averaged 220 mL (range 50-1500 mL), and five (4.8%) patients received transfusions either intraoperatively or postoperatively. Urine leak occurred in 1.9% (n=2) of patients overall and 4.3% (2/47) of patients with documented collecting system entry. Both urine leaks resolved with conservative management only.
HALPN without formal collecting system closure is a safe and effective technique with similar urine leak and transfusion rates compared with other series. This technique may allow more urologists to perform minimally invasive partial nephrectomy or to do so with potentially shorter ischemia times.
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ABSTRACT: Recently, our institution refined a technique for robot-assisted renorrhaphy utilizing sliding Weck Hem-O-Lock clips, which are tightened by the surgeon seated at the console and locked into place with a LapraTy clip. In addition to the relative ease of implementation, we believe that our technique also provides a superior strength of closure over other commonly used techniques. An in vivo porcine model was used to compare a sliding-clip technique against an assistant-placed LapraTy-only closure, and a surgeon-placed simple suture closure. A force gauge was used to record the maximum tension that could be applied during each closure method before the suture ripped through the renal parenchyma, thus illustrating the relative strength of each closure. The simple suture closure performed relatively poorly, ripping through parenchyma at a mean force of 11.3 N. The LapraTy-only method allowed a maximum applicable mean force of 16.7 N. The sliding Weck clip with a LapraTy bolster provided the tightest closure, allowing for a mean force of 32.7 N before ripping through parenchyma. Statistical analysis reveals that a sliding-clip technique provides a significantly tighter closure than both of the other tested methods. A sliding-clip technique allows for more tension to be safely applied to the closure of a partial nephrectomy defect than other commonly used methods. We believe that this is primarily attributable to the larger footprint of the Hem-O-Lock clip, which allows for the tension to be distributed over a greater surface area. The LapraTy then ensures the security of the closure by holding the Weck clip in place. Further studies are necessary to determine if this increased tension translates into appreciably better hemostasis.Journal of endourology / Endourological Society 02/2010; 24(4):605-8. DOI:10.1089/end.2009.0244 · 1.75 Impact Factor
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ABSTRACT: INTRODUCTION: Robotic assisted laparoscopic partial nephrectomy (RALPN) and laparoscopic partial nephrectomy (LPN) have become standard for the surgical management of small renal masses (SRM). However, no studies have evaluated the short-term outcomes or cost of RALPN as compared to hand assisted laparoscopic partial nephrectomy (HALPN) in a standardized fashion. METHODS: A retrospective review of all patients who underwent HALPN or RALPN from 2006 to 2010 were assessed for patient age, Body Mass Index (BMI), American Society of Anesthesiologists (ASA) score, radiographic tumor size, nephrometry (R.E.N.A.L.) scores, operative and room times, hospital length of stay (LOS), estimated blood loss (EBL), requirement of hilar vessel clamping, warm ischemia time (WIT), pre and post procedural creatinine and hemoglobin levels, and complications. Total costs of the procedures were estimated based on operating room component (operative staff time, anesthesia, and supply) and hospital stay cost (room and board, pharmacy). A robotic premium cost, estimated based on the yearly overall cost of the daVinci S surgical system divided by the annual number of cases, was included in the RALPN cost. Cost figures were obtained from hospital administration and applied to the mean HALPN and RALPN patient. RESULTS: 47 patients underwent HALPN since 2005 and 21 patients underwent RALPN since 2008. ASA, BMI, EBL, tumor size, nephrometry score, positive margin rate, change in creatinine, change in hemoglobin, morphine equivalents used and complication rate were all similar in both groups (p > 0.05). Room time and operative time were significantly shorter for the HALPN cohort (p=0.001) whereas LOS was significantly shorter in the RALPN cohort (p=0.019). Despite the shorter LOS, RALPN was associated with a $1165 increased cost, mainly due to increased operating room time and premium cost of the robot. CONCLUSIONS: While early in our experience, RALPN offered no significant advantage in short-term outcomes over HALPN and was associated with a increased cost of over $1,150.Journal of endourology / Endourological Society 08/2012; 27(2). DOI:10.1089/end.2012.0210 · 1.75 Impact Factor