Laparoscopic nephrectomy: initial experience in Israel with 110 cases.
ABSTRACT Data during the last decade show that laparoscopic nephrectomy is becoming an accepted and advantageous minimally invasive alternative to the open procedure.
To evaluate the efficacy, safety and reproducibility of laparoscopic nephrectomy in a series of 110 consecutive procedures.
A total of 110 patients underwent laparoscopic nephrectomy in our institution during the last 3 years. Their data were entered into a database and analyzed, including age, gender, indications for surgery, operative time, blood loss, intraoperative complications, conversion rates, and postoperative complications (defined as complications occurring up to 1 month after surgery). Histologic results and outpatient follow-up were also recorded.
Mean age at surgery was 63 years (range 21-89 years). The indications for surgery included solid renal masses in 64 cases, non-functioning kidneys in 35, and collecting system or ureteral tumors in 11; and the procedures performed were radical nephrectomy, simple nephrectomy, or nephroureterectomy, respectively. The mean operative time was 125 minutes (range 70-310 minutes). Intraoperative complications were recorded in eight cases (7.3%), including vascular injuries of the renal artery in two, and of the renal vein, inferior vena cava and right adrenal vein in one case each. Injury of the large bowel and splenic hylus was recorded in one case and malfunction of the vascular endoGIA stapler leading to severe bleeding in one case. Nine cases were converted to open surgery (8.2%), four of them urgently due to intraoperative complications, while in another five cases conversions were elective following poor progression of the laparoscopic procedure. Comparison of the complication rate at follow-up between the initial 50 and the last 60 patients revealed no change. The conversion rate dropped significantly along the learning curve with 7 cases converted among the initial 50 patients, versus 2 in the last 60. There was no perioperative mortality. In two cases we recorded major postoperative complications, including pneumothorax treated by insertion of a thoracic drain and incarcerated inguinal hernia treated by surgery, while minor complications were seen in five patients. Histologic examination showed renal cell carcinoma pT1-T3a in 62 patients, oncocytoma in 5, transitional cell carcinoma T1G2-T3G3N1 in 10, renal sarcoma in 1, metastasis from lung tumor in 1, and end-stage kidney in the remainder. Negative margins were obtained in all cases.
Laparoscopic nephrectomy may be currently considered a routine, safe and effective procedure associated with minimal morbidity. The conversion rate seemed to drop significantly after 50 cases. In view of the inherent benefits for patients, in terms of reduced pain level, faster recovery and improved cosmetic results, the laparoscopic approach has become the standard approach for nephrectomy in our institution.
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ABSTRACT: To determine perioperative cellular immune responses to retroperitoneal laparoscopic radical nephrectomy by comparing them with those to open radical nephrectomy. Fifty-two patients with renal cell carcinoma were equally randomized into two groups: laparoscopic nephrectomy group (LN group) and open nephrectomy group (ON group) to compare differences in cellular immunofunction. The peripheral blood lymphocyte subpopulations (CD3, CD4, CD8, CD25, CD69, Fas/FasL) were detected with flow cytometry. All tests were performed before operation and at 1, 3, and 5 days after operation. All data were assessed by repeated measurement and variance analysis t test and chi(2) tests. CD3 and CD4 levels in the ON group decreased significantly 1 day and 3 days after operation but recovered on day 5; CD8 level (5 days after operation) in the ON group was significantly higher than that in the LN group. CD25 level (3 days after operation) in the LN group was significantly higher than that in the ON group. CD69 level 3 days after operation in the ON group was significantly higher than that in the LN group. In the ON group, CD69 increased markedly 3 days after operation. FasL level (in both the LN and ON groups) was higher than the normal reference; Fas and FasL in the ON group were higher than those in the LN group. The perioperative immune response is less obvious after a laparoscopic procedure compared with a conventional approach in patients with renal cell carcinoma.Journal of endourology / Endourological Society 10/2008; 22(9):2161-4. · 1.75 Impact Factor
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ABSTRACT: Laparoscopic surgery is widely accepted for managing renal disease. Thus, the system used to educate and train novice surgeons in laparoscopic surgery becomes important to reduce the risks of surgery during their training. A prospective study was carried out to determine the usefulness of using panoramic views during laparoscopic surgery. Between April 2004 and March 2007, four novice surgeons started learning laparoscopic radical nephrectomy: two carried out surgery without panoramic views and two used panoramic views. Operating time and blood loss for the initial 10 cases of each surgeon were compared. Panoramic views were obtained by interlacing each video frame of the video images electronically; the images were then processed and displayed during each step of laparoscopic surgery. Panoramic, real-time views could be obtained, and they served as navigation maps. The learning curve of surgeons using the panoramic views was shorter than that of surgeons who did not use panoramic views. Time to ligation of renal artery from port placement and the operating time was shorter (69.0 +/- 21.5 min vs 106.8 +/- 44.9 min, P = 0.0016, 212 +/- 42 min vs 254 +/- 46 min, P = 0.0489, respectively) and the estimated blood loss was less for the surgeons who used panoramic views (87 +/- 109 mL vs 334 +/- 268 mL, P = 0.0005). Panoramic views during laparoscopic surgery shortened operating time and reduced blood loss, indicating their usefulness in assisting novice surgeons to carry out procedures safely and accurately.International Journal of Urology 12/2008; 16(2):177-80. · 1.73 Impact Factor
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ABSTRACT: Despite worldwide availability of prenatal ultrasound, many patients are diagnosed in adult life with congenital anomalies such as ureteropelvic junction obstruction (UPJO), undescended testicle (UDT), ureterocele, hypospadias, vesicoureteral reflux (VUR) and primary obstructing megaureter (POM). The aim of this review was to describe these clinical conditions and their suggested management based on the available medical literature. Adult UPJO is not a rare condition; symptomatic patients should be treated rather than observed. Treatment options are nephrectomy for non-functioning kidneys and reconstructive surgery for functioning renal units. The adult UDT has low fertility potential and increased cancer risk; hence most of the data in the literature indicate performing an orchiectomy. Adult ureteroceles are usually related to single systems and they are intravesical and less obstructive. For symptomatic patients endoscopic incision showed high efficacy for symptom elimination with minimal side effects. Primary hypospadias correction in the adult patient is feasible, but success rates are low compared to the pediatric age group. Secondary correction, whether primary correction was performed in childhood or adulthood, is a challenging task with a high complication rate. Treatment decisions regarding adult patients with VUR are difficult to make as the available data are inconsistent; there is no strict evidence that reflux in an adult is directly related to renal growth impairment, ascending pyelonephritis, and/or embryo loss in a pregnant woman. In contrast to the pediatric age group, adult POM is usually a symptomatic condition and related to a high complication rate including infections, stone formation and renal failure. Spontaneous resolution is rare and hence active surgical management is advocated. Congenital urological anomalies identified in adulthood are not rare and pose a management challenge to the urologist. For most of the reviewed diseases, evidence-based management direction is difficult due to a lack of randomized trials and long-term follow up.Journal of pediatric urology 02/2008; 4(1):2-7. · 1.38 Impact Factor