Advanced Urology Laparoscopic Course 2014

ADVANCED LAPAROSCOPIC AND ROBOTIC UROLOGY SKILLS FORUM
BULLDOGS VS ENBLOC CLAMPING AND MINIMIZING WARM

ISCHEMIA
Christopher French MD FRCSC
Genitourinary Oncology/ EndoUrology
Eastern Heath, Memorial University of Newfoundland
June 2014
HILAR MANAGEMENT:
CLAMP TIME!!!
CLAMPLESS
EVIDENCE
TECHNIQUES
RISKS
Points of Discussion
Contents
Introduction 49
Indications and Contraindications 49
Surgical Technique 50
Comparison of Open and Laparoscopic Partial
Nephrectomy 53
Complications of Laparoscopic Partial Nephrectomy 53
Current Issues and Future Directions 54
Renal Hilar Clamping 54
Laparoscopic Renal Hypothermia 55
Hemostatic Aids 55
Conclusions 56
References 56
Introduction
With widespread use of modern imaging techniques,
renal tumors are commonly diagnosed incidentally.
These tumors are often small with favorable biological
behavior, including a slow growth rate and a low inci-
dence of local recurrence and metastasis. Moreover,
small incidentally detected renal tumors have a 22%
40% chance of being benign on final pathological
analysis [1]. With strong evidence supporting ne-
phron-sparing surgery (NSS) for renal tumors less
than 4 cm and the evolution of minimally invasive
surgical technique, there has been a trend away from
radical nephrectomy in the management of small renal
tumors.
In the past decade, several minimally invasive ther-
apy options for NSS have been developed in an at-
tempt to minimize operative morbidity while achiev-
ing comparable oncological outcomes and preserving
renal function. These minimally invasive procedures
comprise tumor excision (laparoscopic partial ne-
phrectomy), which aims to duplicate the established
technique of open partial nephrectomy and probe-ab-
lative strategies (cryotherapy and radiofrequency abla-
tion). In this chapter, we discuss the current status of
laparoscopic partial nephrectomy.
Compared to radical nephrectomy, laparoscopic
partial nephrectomy is a considerably more techni-
cally challenging procedure. Issues of renal hypother-
mia, renal parenchymal hemostasis, pelvicaliceal re-
construction, and parenchymal renorrhaphy by pure
laparoscopic techniques pose unique challenges to the
surgeon. Nonetheless, ongoing advances in laparo-
scopic techniques and operator skills have allowed the
development of a reliable technique of laparoscopic
partial nephrectomy, which aims to replicate the es-
tablished procedure of open partial nephrectomy [2].
As such, laparoscopic partial nephrectomy is emerging
as an attractive minimally invasive nephron-sparing
option at select institutions. The worldwide experience
with laparoscopic partial nephrectomy is summarized
in Table 1 [39].
Indications and Contraindications
Initially, laparoscopic partial nephrectomy was re-
served for the select patient with a favorably located,
small, peripheral, superficial, and exophytic tumor
[1012]. With experience, we have carefully expanded
the indications to select patients with more complex
tumors: tumor invading deeply into the parenchyma
up to the collecting system or renal sinus [13], upper
pole tumors requiring concomitant adrenalectomy
[14], completely intrarenal tumor, tumor abutting the
renal hilum, tumor in a solitary kidney, or a tumor
substantial enough to require heminephrectomy [15].
Although there is growing evidence supporting elec-
tive partial nephrectomy for select tumors 47 cm in
size [16], laparoscopic partial nephrectomy for these
complex tumors is most often utilized in the setting of
compromised or threatened global nephron mass
wherein nephron preservation is an important con-
3.1 Laparoscopic Partial Nephrectomy
Antonio Finelli, Inderbir S. Gill
a 3.1 Laparoscopic Partial Nephrectomy 51
Fig. 1. Retroperitoneal
laparoscopic partial
nephrectomy. Because
of the limited working
space, the renal vein and
artery were initially iso-
lated and controlled
with laparoscopic bull-
dog clamps. A Satinsky
clamp is now routinely
used. Adapted from [2]
Fig. 2. Transperitoneal
nephrectomy. A laparo-
scopic Satinsky clamp is
used to clamp the hilum
en bloc. Adapted from
[2]
a 3.1 Laparoscopic Partial Nephrectomy 51
Fig. 1. Retroperitoneal
nephrectomy. Because
of the limited working
space, the renal vein and
artery were initially iso-
lated and controlled
with laparoscopic bull-
dog clamps. A Satinsky
clamp is now routinely
used. Adapted from [2]
Fig. 2. Transperitoneal
nephrectomy. A laparo-
scopic Satinsky clamp is
used to clamp the hilum
en bloc. Adapted from
[2]
CLAMP TIME
Less than 30 minutes !!!!!
But there is no safe time
Setup, parenchymal and deep sutures ready and prepared
Early unclamping
Artery only vs Hilum
Tumors >4cm, central location and BMI >30 assoc with longer clamp times
Vessels dissected and ready, clamped only if needed ?
Partial arterial clamping
Kidney Cancer
Is Renal Warm Ischemia over 30 Minutes during
Laparoscopic Partial Nephrectomy Possible?
One-Year Results of a Prospective Study
Francesco Porpiglia
a,
*, Julien Renard
a
, Michele Billia
a
, Francesca Musso
a
,
Alessandro Volpe
a
, Rodolfo Burruni
a
, Carlo Terrone
a
, Loredana Colla
b
,
Giorgina Piccoli
b
, Valerio Podio
c
, Roberto Mario Scarpa
a
a
Department of Urology, University of Turin, San Luigi Hospital, Orbassano Torino, Italy
b
Department of Nephrology, University of Turin, San Giovanni Battista Hospital, Torino, Italy
c
Department of Radiology and Nuclear Medicin, University of Turin, San Luigi Hospital, Orbassano, Torino, Italy
e ur op e an ur ol og y 5 2 ( 2 0 0 7 ) 1 1 7 0 1 1 7 8
avai l abl e at www. sci encedi r ect . com
j our nal homepage: www. eur opeanur ol ogy. com
Article info
Article history:
Accepted April 5, 2007
Published online ahead of
print on April 11, 2007
Keywords:
Laparoscopy
Partial nephrectomy
Renal function
Warm ischemia
Abstract
Objective: To evaluate renal damage and impairment of renal function
1 yr after laparoscopic partial nephrectomy (LPN) with warm ischemia
>30 min.
Methods: From July 2004 to June 2005, 18 patients underwent LPN with
warm ischemia time >30 min. Kidney damage markers (daily protei-
nuria and tubular enzymes) and renal function (serum creatinine, cysta-
tin C, and creatinine clearances) were assessed on postoperative days 1
and 5 and at 12 mo. Glomerular ltration rate (GFR) was evaluated before
surgery and at 3 mo. Renal scintigraphy was performed before the
procedure, at 5 d and at 3 and 12 mo postoperatively. Statistical analysis
was performed using the Student t test and logistic regression analysis.
Results: In terms of kidney damage and renal function markers, the
statistical analysis demonstrated that at 1 yr there was complete return
to the normal range and no statistical difference between the values at
the various time points. The GFR was not signicantly different before
and 3 mo after surgery. In terms of scintigraphy of the operated kidney,
the values were 48.35 3.82%(4050%) before the procedure, 36.88 8.42
(1650%) on postoperative day 5 ( p = 0.0001), 40.56 8.96 (2050%) at
3 mo ( p = 0.003), and 42.8 7.2% (2050%) 1 yr after surgery ( p = 0.001).
Conclusion: Our results demonstrate that kidney damage occurs during
LPN when warm ischemia is >30 min. This damage is only partially
reversible and efforts should be made to keep warm ischemia within
30 min.
#2007 European Association of Urology. Published by Elsevier B.V. All rights reserved.
* Corresponding author. Department of Urology, San Luigi Hospital, Regione Gonzole 10,
10043, Orbassano, Torino, Italy. Tel. +39 011 9026558; Fax: +39 011 9026244.
E-mail address: porpiglia@libero.it (F. Porpiglia).
0302-2838/$ see back matter #2007 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.eururo.2007.04.024
Kidney Cancer
Francesco Porpiglia
a,
*, Julien Renard
a
, Michele Billia
a
, Francesca Musso
a
,
Alessandro Volpe
a
, Rodolfo Burruni
a
, Carlo Terrone
a
, Loredana Colla
b
,
Giorgina Piccoli
b
, Valerio Podio
c
a
a
b
c
Article info
Article history:
Keywords:
Laparoscopy
Partial nephrectomy
Renal function
Warm ischemia
Abstract
>30 min.
30 min.
Kidney Cancer
Francesco Porpiglia
a,
*, Julien Renard
a
, Michele Billia
a
, Francesca Musso
a
,
Alessandro Volpe
a
, Rodolfo Burruni
a
, Carlo Terrone
a
, Loredana Colla
b
,
Giorgina Piccoli
b
, Valerio Podio
c
a
a
b
c
Article info
Article history:
Keywords:
Laparoscopy
Partial nephrectomy
Renal function
Warm ischemia
Abstract
>30 min.
30 min.
WARM ISCHEMIA
18 patients
Lap Partial with
warm ischemia >30min
serum creatinine, whereas creatinine clearance
showed a paradoxical increase.
The GFR (evaluated by nuclear medicine using
51
Cr-EDTA) was not significantly different before
and 3 mo after the procedure: mean GFR was
91.60 22.68 ml/min/1.73 m
2
preoperatively and
79.12 13.69 ml/min/1.73 m
2
3 mo after surgery
( p = ns) (Table 5).
As far as the contribution of the operated kidney
to the overall renal function (evaluated by renal
scintigraphy with
99m
Tc-MAG3) is concerned, the
preoperative value was 48.35 3.82% (range: 40
50%), 36.88 8.42%(range: 1650%) on postoperative
day 5 ( p = 0.0001), 40.56 8.96% (range: 2050%) at
3 mo ( p = 0.003), and 42.8 7.2% (range: 2050%) 1 yr
after surgery ( p = 0.001) (Table 5). One year after
surgery, there is still a significant difference com-
pared to the preoperative values, although it is
evident that after an initial drop there is a trend
toward a progressive recovery (Fig. 2). However, it is
important to point out that the number of patients
included in this study could affect the statistical
power.
At the 1-yr follow-up, no patient had developed
new morbidities.
As far as the logistic regression model is con-
cerned, the statistical analysis demonstrated that
the loss of function in the operated kidney (eval-
uated by radionuclide scintigraphy) is not influ-
enced by lesion size at pathology, patient age, and
presence of comorbidities, but it is influenced
significantly ( p < 0.05) by the maximum thickness
of resected healthy parenchyma and duration of
warm ischemia.
The loss of renal function is maximal between 32
and 42 min of warm ischemia time, as shown by the
drop of the curve in Fig. 3. Between 42 and 60 min,
the curve flattens out, demonstrating a minor
further loss of function when the warm ischemia
time is in this range.
4. Discussion
Althoughconsidereda challenging technique, LPNis
gaining wide acceptance worldwide, especially in
urologic departments where advanced laparoscopy
is carried out [26]. To perform an accurate surgery, it
is essential to resect the lesion and to obtain
hemostasis in a short warm ischemia time to avoid
kidney damage [3,27].
According to Rocca Rossetti [10], warm ischemia
in open surgery can be classified as follows:
(1) <10 minharmless; (2) up to 30 mingenerally
reversible lesions; (3) >30 minrisk of irreversible
parenchymal lesions increasing rapidly with the
ischemic time; and(4) >60 minirreversible lesions.
Regarding the site of kidney damage, the same
author states that nephrons react differently to
ischemia; glomeruli tolerate the ischemia better
than tubular epithelia, whereas proximal convo-
luted tubules are more sensitive to ischemic damage
[10]. More recently, other authors suggested that
warm ischemia determines a reduction in medul-
lary blood flow causing hypoxic injury to the tubular
structures in this region [9]. Furthermore, it seems
that the degree of damage is proportional to the
warm ischemia time. The higher sensitivity of the
proximal tubuli to ischemia is due to a low capacity
of the cells to generate adenosine triphosphate
(ATP), whereas the remaining tubular cells are
protected by the persistence of ATP. When warm
ischemia is prolonged, the cells from the distal
Fig. 2 Contribution of operated kidney to the overall renal
function at the various time points (radionuclide renal
scintigraphy with
99m
Tc-mercaptoacetyltriglycine).
POD = postoperative day.
Fig. 3 Logistic regression model. Full orange
curve = evolution of kidney damage over time; it is evident
that between 32 and 42 min there is a major drop,
corresponding to the phase in which parenchymal
damage is maximum. The starting point of the critical
phase of warm ischemia is at the 32-min time mark. The
interrupted curves correspond to the confidence intervals.
e ur op e an ur ol og y 5 2 ( 2 0 0 7 ) 1 1 7 0 1 1 7 8 1175
IS THERE A SAFE WARM ISCHEMIA
TIME?
Kidney Cancer
Comparison of Warm Ischemia Versus No Ischemia During Partial
Nephrectomy on a Solitary Kidney
R. Houston Thompson
a,
*, Brian R. Lane
b
, Christine M. Lohse
a
, Bradley C. Leibovich
a
,
Amr Fergany
b
, Igor Frank
a
, Inderbir S. Gill
c
, Steven C. Campbell
b
, Michael L. Blute
a
a
Mayo Medical School and Mayo Clinic, Rochester, MN, USA
b
Glickman Urological Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
c
Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
E UR OP E AN UR OL OGY XXX ( 2 0 1 0 ) XXX XXX
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Article info
Article history:
Accepted May 31, 2010
print on
Keywords:
Ischemia
Kidney neoplasms
Postoperative complications
Nephrectomy
Warm ischemia
Abstract
Background: The safe duration of warmischemia during partial nephrectomy (PN)
remains controversial.
Objective: To compare the short- and long-term renal effects of warm ischemia
versus no ischemia in patients with a solitary kidney.
Design, setting, and participants: Using the Cleveland Clinic and Mayo Clinic
databases, we identied 458 patients who underwent open (n = 411) or laparo-
scopic (n = 47) PN for a renal mass in a solitary kidney between 1990 and 2008.
Patients treated with cold ischemia were excluded.
Measurements: Associations of ischemia type (none vs warm) with short- and
long-term renal function were evaluated using logistic or Cox regression models.
Results and limitations: No ischemia was used in 96 patients (21%), while 362
patients (79%) had a median of 21 min (range: 455) of warm ischemia. Patients
treated with warm ischemia had a signicantly higher preoperative glomerular
ltration rate (GFR; median: 61 ml/min per 1.73 m
2
vs 54 ml/min per 1.73 m
2
;
p < 0.001) and larger tumors (median: 3.4 cm vs 2.5 cm; p < 0.001) compared
with patients treated with no ischemia. Warm ischemia patients were signicantly
more likely to develop acute renal failure (odds ratio [OR]: 2.1; p = 0.044) and a GFR
<15 ml/min per 1.73 m
2
in the postoperative period (OR: 4.2; p = 0.007) compared
with patients who did not have hilar clamping. Among the 297 patients with a
preoperative GFR 30 ml/min per 1.73 m
2
, patients with warm ischemia were
signicantlymorelikelytodevelopnew-onset stageIVchronickidneydisease(hazard
ratio: 2.3; p = 0.028) during a mean follow-up of 3.3 yr. Similar results were obtained
adjusting for preoperative GFR, tumor size, and type of PNina multivariable analysis.
Limitations include surgeon selection bias when determining type of ischemia.
Conclusions: Warm ischemia during PN is associated with adverse renal conse-
quences. Although selection bias is present, PN without ischemia should be used
when technically feasible in patients with a solitary kidney.
# 2010 Published by Elsevier B.V. on behalf of European Association of Urology.
* Corresponding author. Department of Urology, Mayo Clinic, 200 First Street SW, Rochester,
MN 55905, USA. Tel. +507 284 3981; Fax: +507 284 4951.
E-mail address: Thompson.robert@mayo.edu (R.H. Thompson).
EURURO 3489 16
Please cite this article in press as: Thompson RH, et al. Comparison of Warm Ischemia Versus No Ischemia During Partial
Nephrectomy on a Solitary Kidney. Eur Urol (2010), doi:10.1016/j.eururo.2010.05.048
0302-2838/$ see back matter #2010 Published by Elsevier B.V. on behalf of European Association of Urology. doi:10.1016/j.eururo.2010.05.048
1.73 m
2
and 30 d of GFR follow-up, 47 (16%) developed
new-onset stage IV chronic kidney disease during follow-up.
Within this subset, mean follow-up for patients treated
without ischemia was 5.3 yr (median: 4.2; range: 0.218.2)
and 2.7 yr (median: 1.6; range: 0.119.0) for patients treated
withwarmischemia. MedianGFR(change frompreoperative
GFR) at last follow-up for patients treated with no ischemia
andwarmischemia was 54.3(0.9) and48.2(12.7) ml/min
per 1.73 m
2
, respectively. Patients treated with warm
ischemia were significantly more likely to develop new-
onset stage IV chronic kidney disease (HR: 2.3; 95% CI, 1.1
4.9; p = 0.028) compared with patients treated with no
ischemiaduringfollow-up(Fig. 1). Adjustingfor preoperative
GFR, tumor size, and type of PN in a multivariable analysis,
patients treated with warmischemia remained at significant
risk of new-onset stage IV chronic kidney disease (HR: 2.6;
95% CI, 1.15.8; p = 0.022). When these analyses were
repeated on the subset of patients treated with open PN
only, warm ischemia remained significantly associated with
these end points after multivariable adjustment for preoper-
ative GFR and tumor size (Table 2, Fig. 2).
4. Discussion
In this report, we update our previous collaboration
evaluating renal functional outcomes in patients with a
solitary kidney treated with PN. In these updated results, we
include nearly twice as many patients (458 vs 259 treated
with no ischemia or warmischemia), we better assess renal
function with GFR (as opposed to serum creatinine alone),
and we include patients treated with both open and
laparoscopic approaches compared with our prior analysis
[3]. Our data suggest that warm ischemia during PN is
associated with an increased risk of ARF in the postopera-
tive period and increased risk of new-onset stage IV chronic
kidney disease during follow-up when compared with
patients managed without hilar clamping. Although we did
not observe an increased risk of dialysis (either temporary
or permanent) for patients treated with warm ischemia, it
should be noted that renal function decline in a graded
fashion increases the risk of cardiovascular morbidity,
hospitalization, and death from any cause [2]. For tumors
amenable to enucleation, these observations support the
use of no ischemia or regional compression during PN,
especially in the setting of a solitary kidney.
The renal cortex is exquisitely sensitive to warm
ischemia, as metabolic activities are predominantly aerobic.
Immediately following renal arterial occlusion, adenosine
triphosphates begin to break down into monophosphate
nucleotides, providing energy for structural and functional
cellular integrity [11,12]. As energy sources become rapidly
depleted in an anaerobic environment, cellular membrane
transport mechanisms fail, and an influx of salt and water
results in cellular edema and death [11]. Although the
maximal safe duration of warm ischemia is controversial,
our groups individually [7,8] and in collaboration [3] have
observed that warm ischemia should be limited to 20 min
whenever feasiblea notion that was recently supported by
an international collaborative review of the literature [5].
However, the current analysis does not address the
maximum time during which interruption of renal blood
flow is best tolerated. Rather, we chose to focus on a group
of patients for whom the surgeon decided that cold
ischemia was not needed (ie, the tumor was sufficiently
exophytic or small enough that the surgeon determined
that the maximum duration of warm ischemia would be
<2030 min). During the study time period, standard
practice at both Mayo Clinic and Cleveland Clinic was to
use hypothermic conditions for complex tumors where
>2030 min of ischemia was anticipated. Thus, patients
who received cold ischemia were excluded from this
analysis. Although selection bias still exists among our
cohort of patients, our results suggest that for tumors
amenable to no ischemia, lack of hilar clamping may reduce
the risk of ARF and chronic kidney disease.
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Fig. 1 Evaluation of new-onset stage IV chronic kidney disease among
297 patients treated with no ischemia and warm ischemia during partial
nephrectomy in the setting of a solitary kidney.
GFR = glomerular filtration rate.
Fig. 2 Evaluation of new-onset stage IV chronic kidney disease among
266 patients treated with no ischemia and warm ischemia during open
partial nephrectomy (laparoscopic cases excluded) in the setting of a
solitary kidney.
GFR = glomerular filtration rate.
E UR OP E A N UR OL OGY XXX ( 2 0 1 0 ) XXX XXX 4
EURURO 3489 16
Kidney Cancer
Comparison of Warm Ischemia Versus No Ischemia During Partial
Nephrectomy on a Solitary Kidney
R. Houston Thompson
a,
*, Brian R. Lane
b
, Christine M. Lohse
a
, Bradley C. Leibovich
a
,
Amr Fergany
b
, Igor Frank
a
, Inderbir S. Gill
c
, Steven C. Campbell
b
, Michael L. Blute
a
a
Mayo Medical School and Mayo Clinic, Rochester, MN, USA
b
Glickman Urological Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
c
Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
E UR OP E AN UR OL OGY XXX ( 2 0 1 0 ) XXX XXX
1
2
3
4
5
6
7
8
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Article info
Article history:
Accepted May 31, 2010
print on
Keywords:
Ischemia
Kidney neoplasms
Postoperative complications
Nephrectomy
Warm ischemia
Abstract
Background: The safe duration of warmischemia during partial nephrectomy (PN)
remains controversial.
Objective: To compare the short- and long-term renal effects of warm ischemia
versus no ischemia in patients with a solitary kidney.
Design, setting, and participants: Using the Cleveland Clinic and Mayo Clinic
databases, we identied 458 patients who underwent open (n = 411) or laparo-
scopic (n = 47) PN for a renal mass in a solitary kidney between 1990 and 2008.
Patients treated with cold ischemia were excluded.
Measurements: Associations of ischemia type (none vs warm) with short- and
long-term renal function were evaluated using logistic or Cox regression models.
Results and limitations: No ischemia was used in 96 patients (21%), while 362
patients (79%) had a median of 21 min (range: 455) of warm ischemia. Patients
treated with warm ischemia had a signicantly higher preoperative glomerular
ltration rate (GFR; median: 61 ml/min per 1.73 m
2
vs 54 ml/min per 1.73 m
2
;
p < 0.001) and larger tumors (median: 3.4 cm vs 2.5 cm; p < 0.001) compared
with patients treated with no ischemia. Warm ischemia patients were signicantly
more likely to develop acute renal failure (odds ratio [OR]: 2.1; p = 0.044) and a GFR
<15 ml/min per 1.73 m
2
in the postoperative period (OR: 4.2; p = 0.007) compared
with patients who did not have hilar clamping. Among the 297 patients with a
preoperative GFR 30 ml/min per 1.73 m
2
, patients with warm ischemia were
signicantlymorelikelytodevelopnew-onset stageIVchronickidneydisease(hazard
ratio: 2.3; p = 0.028) during a mean follow-up of 3.3 yr. Similar results were obtained
adjusting for preoperative GFR, tumor size, and type of PNina multivariable analysis.
Limitations include surgeon selection bias when determining type of ischemia.
Conclusions: Warm ischemia during PN is associated with adverse renal conse-
quences. Although selection bias is present, PN without ischemia should be used
when technically feasible in patients with a solitary kidney.
# 2010 Published by Elsevier B.V. on behalf of European Association of Urology.
* Corresponding author. Department of Urology, Mayo Clinic, 200 First Street SW, Rochester,
MN 55905, USA. Tel. +507 284 3981; Fax: +507 284 4951.
E-mail address: Thompson.robert@mayo.edu (R.H. Thompson).
EURURO 3489 16
0302-2838/$ see back matter #2010 Published by Elsevier B.V. on behalf of European Association of Urology. doi:10.1016/j.eururo.2010.05.048
Interruption of renal blood flow via pedicle clamping is
often necessary during PN, especially for complex tumors
with deep parenchymal invasion. Vascular clamping aids in
hemostasis and allows precise surgical closure of the
collecting system and parenchymal defect. However, pre-
dominately exophytic tumors without deep parenchymal
invasioncanbeamenabletoenucleationwithout theneedfor
hilar clamping. The theoretical concern of hemorrhage or
urine leak fromlack of visualization was not observed in the
current analysis. Infact, patients treatedwithwarmischemia
were more likely to have intraoperative hemorrhage (5% vs
2%) and develop a postoperative urine leak (5% vs 1%)
compared with patients treated without hilar clamping,
although these differences were not statistically significant.
Nevertheless, our results support that the use of no ischemia
whentechnicallyfeasibleinproperlychosenpatients will not
invite an excess risk of hemorrhage or urine leak. It is,
however, important to point out that the majority of renal
tumors are not amenable to no ischemia. For these patients,
we advocate warm ischemia only if ischemia time is
anticipated to be <20 min [3,5,7,8]. For laparoscopic cases,
an early unclamping technique was recently reported to
significantly reduce ischemia time [13], and robotic assist-
ance may further reduce clamping times [14]. In addition, a
novel selective vascular occlusion delivered via angiographic
techniques was recently observed to hold promise [15].
However, for patients with complex tumors, where ischemic
timesareanticipatedtobe>2030 min, strongconsideration
shouldbe givento hypothermic conditions withice slush[5].
This study is not without limitations. The data were
collected in a retrospective fashion, and our results are
limited to the inherent biases associated with this approach.
Additionally, there is a significant selection bias when
comparing patients treated with no ischemia and warm
ischemia. Patients treated with no ischemia were likely to
have more exophytic and smaller tumors that were at a
reduced risk of complications. However, patients treated
with warm ischemia were, for the most part, thought to
have tumors that were amenable to <2030 min of
ischemia. Coupled with the fact that patients treated with
no ischemia had reduced baseline renal function, our results
support the use of no ischemia when technically feasible,
especially in the setting of a solitary kidney. We do not
submit that clamping should be avoided at all costs but
rather support the use of no clamping in select patients with
a tumor that is amenable to manual compression.
5. Conclusions
Warm ischemia during PN is associated with an increased
risk of ARF and chronic kidney disease. Although selection
biases likely contributed to these results, PN with no
ischemia should be used when technically feasible in
patients with a solitary kidney. Other measures to protect
against ischemic injury, including hypothermia and phar-
macologic manipulations, should be studied in an effort to
improve renal functional outcomes in this challenging
patient population, many of whom require an ischemic
interval to facilitate optimal PN.
Author contributions: R. Houston Thompson had full access to all the
data in the study and takes responsibility for the integrity of the data and
the accuracy of the data analysis.
Study concept and design: Thompson, Lane, Campbell, Blute.
Acquisition of data: Thompson, Lane, Lohse.
Analysis and interpretation of data: Thompson, Lane, Campbell, Blute,
Lohse.
Drafting of the manuscript: Thompson, Lane.
Critical revision of the manuscript for important intellectual content:
Thompson, Lane, Campbell, Blute, Fergany, Gill, Leibovich.
Statistical analysis: Lohse.
Obtaining funding: None.
Administrative, technical, or material support: None.
Supervision: Campbell, Blute.
Other (specify): None.
Financial disclosures: I certify that all conicts of interest, including
specic nancial interests andrelationships andafliations relevant tothe
subject matter or materials discussed inthe manuscript (eg, employment/
afliation, grants or funding, consultancies, honoraria, stock ownership or
options, expert testimony, royalties, or patents led, received, or pending),
are the following: None.
Funding/Support and role of the sponsor: None.
Acknowledgment statement: The authors acknowledge the late Dr
AndrewC. Novick, who operated on a majority of the patients included in
this study.
References
[1] Thompson RH, Kaag M, Vickers A, et al. Contemporary use of partial
nephrectomy at a tertiary care center in the United States. J Urol
2009;181:9937.
[2] Go AS, Chertow GM, Fan D, McCulloch CE, Hsu CY. Chronic kidney
disease and the risks of death, cardiovascular events, and hospitali-
zation. N Engl J Med 2004;351:1296305.
[3] Thompson RH, Frank I, Lohse CM, et al. The impact of ischemia time
during open nephron sparing surgery on solitary kidneys: a multi-
institutional study. J Urol 2007;177:4716.
[4] Godoy G, Ramanathan V, Kanofsky JA, et al. Effect of warmischemia
time during laparoscopic partial nephrectomy on early postopera-
tive glomerular ltration rate. J Urol 2009;181:243843, discussion
24435.
[5] Becker F, Van Poppel H, Hakenberg OW, et al. Assessing the impact
of ischaemia time during partial nephrectomy. Eur Urol 2009;56:
62534.
[6] La Rochelle J, Shuch B, Riggs S, et al. Functional and oncological
outcomes of partial nephrectomy of solitary kidneys. J Urol 2009;
181:203742, discussion 2043.
[7] Thompson RH, Leibovich BC, Lohse CM, Zincke H, Blute ML. Com-
plications of contemporary open nephron sparing surgery: a single
institution experience. J Urol 2005;174:8558.
[8] Lane BR, Babineau DC, Poggio ED, et al. Factors predicting renal
functional outcome after partial nephrectomy. J Urol 2008;180:
23638, discussion 23689.
[9] RichstoneL, Kavoussi LR. Re:Theimpact of ischemiatime duringopen
nephron sparing surgery on solitary kidneys: a multi-institutional
study: R.H. Thompson, I. Frank, C.M. Lohse, I.R. Saad, A. Fergany, H.
Zincke, B.C. Leibovich, M. L. Blute, and A. C. Novick. J Urol 2007;
178:1119, author reply 111920.
[10] Levey AS, Bosch JP, Lewis JB, Greene T, Rogers N, Roth D, Modica-
tion of Diet in Renal Disease Study Group. A more accurate method
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E UR OP E A N UR OL OGY XXX ( 2 0 1 0 ) XXX XXX 5
EURURO 3489 16
WHAT ARE YOUR OPTIONS FOR HILAR
MANAGEMENT:
BULLDOGS
12.5 Port lap Bulldog
No need for extra port
Less leaks
always tag with vessel
loop
Less Handcufng
5
1
/1
Fixed applicator for temporary endoscopic vascular clips
Shaft length: 34 cm
Diameter: 12.5 mm
PL531R
CLIP APPLICATORS AND REMOVERS
ATRAUMATIC ENDO VESSEL CLIPS (for temporary occlusion)
Articulating applicator for temporary endoscopic vascular clips
Shaft length: 34 cm
Diameter: 12.5 mm
PL530R
1
/1
Cat. No. Closing force Jaw length Jaw shape
PL544S 350 g 25 mm short/straight
PL545S 450 g 45 mm long/straight
PL548S 350 g 25 mm short/curved
PL549S 450 g 45 mm long/curved
VASCULAR BULLDOG CLIP AND APPLIERS
MANAGEMENT:
BULLDOGS
12.5 Port lap Bulldog
No need for extra port
Less leaks
always tag with vessel loop,
stitch ext
Less Handcufng
Less chance of over
tightening
MANAGEMENT:
SATINSKI
Straight or slight curve easier to use in in
port.
Flex port available for others
Sometimes in the way
Leaks
Extra post
4
Vascular Clamps for Temporary Occlusion
PM171R*
Satinsky Atraumatic Clamp, 38mm jaw,
5mm, 31cm PM711R PM973R
PM177R*
Satinsky Atraumatic Clamp, 51 mm jaw,
1/2
PM173R
Crafoord Endo-vascular Clamp, short jaw,
1/2
Order by component
De Bakey Atraumatic Clamp, straight,
50mm Jaw, 10mm, 22cm PM712R PM992R
1/2
PM175R*
De Bakey Atraumatic Clamp, curved,
1/2
PM176R*
De Bakey Atraumatic Clamp, S-shaped,
1/2
COMPONENTS
COMPLETE JAW INSERT INSULATED STANDARD OPTIONAL
INSTRUMENT OUTER TUBES HANDLE HANDLES
Optional Handles for Customizing Instruments - Interchangeable for 5mm and 10mm instruments
PO958R (Non-Ratchet) PO959R (Ratchet) PM950R (Non-Ratchet) PM951R (Ratchet)
PM954R (Ratchet) PM955R (Non-Ratchet) PM957R (Ratchet)
with lock
Instruments may be ordered COMPLETE or assembled from COMPONENTS ordered separately
*For use with 12.5mm flexible Trocars
MANAGEMENT:
SATINSKI
Faster than bulldogs
More likely to incompletely clamp
Less precise
Fall off, knock off
incomplete force at the tip
Complex vasculature, less effective
4
Vascular Clamps for Temporary Occlusion
PM171R*
Satinsky Atraumatic Clamp, 38mm jaw,
PM177R*
Satinsky Atraumatic Clamp, 51 mm jaw,
1/2
PM173R
Crafoord Endo-vascular Clamp, short jaw,
1/2
Order by component
De Bakey Atraumatic Clamp, straight,
50mm Jaw, 10mm, 22cm PM712R PM992R
1/2
PM175R*
De Bakey Atraumatic Clamp, curved,
1/2
PM176R*
De Bakey Atraumatic Clamp, S-shaped,
1/2
COMPONENTS
COMPLETE JAW INSERT INSULATED STANDARD OPTIONAL
INSTRUMENT OUTER TUBES HANDLE HANDLES
Optional Handles for Customizing Instruments - Interchangeable for 5mm and 10mm instruments
PO958R (Non-Ratchet) PO959R (Ratchet) PM950R (Non-Ratchet) PM951R (Ratchet)
PM954R (Ratchet) PM955R (Non-Ratchet) PM957R (Ratchet)
with lock
Instruments may be ordered COMPLETE or assembled from COMPONENTS ordered separately
*For use with 12.5mm flexible Trocars
MANAGEMENT:
UNCLAMPED
Unclamping is a viable option
Based on surgeon experience
Hilum ready during dissection
Can minimize clamp time risk!
Thus longer dissection without
ischemia
WHAT ARE YOUR OPTIONS FOR
HILAR MANAGEMENT
COMPLICATIONS
Vascular Injuries Are
Underreported
Excluded from case series
Complications from Lap Partial
are decreasing with time in large
series.
Planning for NSS Planning for NSS
(Part 2: (Part 2: You can do it to You can do it to ) )
Complications Complications
Hemorrhage Hemorrhage
Renal inIarction / loss Renal inIarction / loss
Urinary leak or Iistula Urinary leak or Iistula
Abscess Abscess
Rates Rates
Lap Lap PNx PNx - - 9 9
Open Open PNx PNx - - 6.3 6.3
RFA RFA - - 6 6
Lap Lap RNx RNx - - 3.4 3.4
Open Open RNx RNx - - 1.3 1.3
Partial Nephrectomy Planning: Partial Nephrectomy Planning:
Everybody Everybody s doing it, you can to s doing it, you can to
Brian R. Herts, MD Brian R. Herts, MD
Associate ProIessor oI Radiology Associate ProIessor oI Radiology
Head, Abdominal Imaging, Imaging Institute & Head, Abdominal Imaging, Imaging Institute &
StaII, The StaII, The Glickman Glickman Urological and Kidney Inst. Urological and Kidney Inst.
Cleveland Clinic Cleveland Clinic
CLAMPING FORCE:
Urologists are not routinely
clamping vessels.
What can we learn from vascular
surgery?
Cardiovascular Surgery, Vol. 7, No. 4, pp. 457463, 1999
! 1999 The International Society for Cardiovascular Surgery. Published by Elsevier Science Ltd
All rights reserved. Printed in Great Britain
09672109/99 $20.00 0.00
www.elsevier.com/locate/cardiosur
PII: S0967-2109(98)00154-9
The effect of increasing clamping forces on
endothelial and arterial wall damage:
an experimental study in the sheep
A. I. Margovsky, A. J. Chambers and R. S. A. Lord
Surgical Professorial Unit, St Vincents Hospital, University of NSW, Sydney, Australia
Purpose: This study aimed to relate the level of physical force applied to the arterial wall by
atraumatic clamps to the degree of endothelial and wall damage. Methods: Sixteen sheep
carotid and femoral arteries were each demarcated into four segments 1 cm apart (total 64
segments). Each segment was clamped for 15 min with a standard angled DeBakey vascular
clamp. Four levels of force were generated by closing the clamp at three, four, ve and six
notches of closure. The extent of endothelial injury was assessed by using a dedicated com-
puter assisted image acquisition program to measure the area stained by Evans blue dye.
The extent of damage to the layers of the arterial wall was analyzed and compared by scanning
electron microscopy and light microscopy. Results: For femoral arteries, the area of endothelial
injury was considerably less for three notch (3.76 0.28 newtons) and four notch (5.68
0.29 newtons) closure compared with that for ve notch (6.19 0.31 newtons) and six notch
(6.61 0.16 Newtons) closure (p 0.01). For carotid arteries, three notch (5.68
0.28 newtons) closure caused less damage than did four notch (7.98 0.29 newtons), ve
notch (9.17 0.40 newtons) and six notch (9.57 0.64 newtons) closure (P 0.02). Scan-
ning electron microscopy conrmed the extent and depth of arterial injury corresponded
directly to the forces generated by the vascular clamps. Conclusions: The closing forces gener-
ated by arterial clamps correlated positively with the extent of artery wall injury. Vascular
clamps should be applied at the minimum level of force that will arrest blood ow. ! 1999
The International Society for Cardiovascular Surgery. Published by Elsevier Science Ltd. All
rights reserved
Keywords: arterial wall, endothelial wall, sheep, vascular clamp
Introduction
Clamps are used to arrest ow and to control bleed-
ing from arteries [1], but they may also cause moder-
ate to severe damage to the vessel wall [24], which
could jeopardize an otherwise successful vascular
reconstruction. Some of these complications, such as
creation of a ap, dissection, through-and-through
injury and arterio-venous stulae follow relatively
gross instrumentation. Other effects, including intra-
Correspondence to: Professor Reginald S. A. Lord, Surgical Prof-
essorial Unit, Level 17, OBrien Building, St Vincents Hospital, Vic-
toria Street, Darlinghurst, NSW 2010, Australia
CARDIOVASCULAR SURGERY JUNE 1999 VOL 7 NO 4 457
vascular thrombosis and later stricture formation [5,
6], reect more subtle injuries including endothelial
disruption [7].
Previous reports described some of the features of
clamp design and the effects of different clamps on
the vessel wall. These studies concentrated parti-
cularly on relating available vascular atraumatic
clamps in terms of their occlusive ability and holding
capacity to the effect on the vessel wall [13, 5, 8
11]. In some of these reports, the arteries studied
were relatively small, such as rat and rabbit aortas,
and femoral arteries [5, 1214]. In other studies,
canine arteries were employed [2, 3, 8, 9, 11].
Despite the differences in arterial diameters, wall
thickness, lamellar units and other morphological
09672109/99 $20.00 0.00
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rights reserved
Introduction
disruption [7].
Vascular clampsendothelium and artery wall interactions: an experimental study in the sheep: A. I. Margovsky et al.
characteristics, these studies consistently uncovered
endothelial damage and other cellular injuries. The
pressures generated by different types of clamps were
occasionally measured [3, 4, 10, 13], but no previous
studies graded the pressures applied to the vessel
wall to the subsequent injury, nor have previous
studies investigated clamp-related injuries in relation
to differences in artery diameter.
Investigators have generally used histological
examination and scanning electron microscopy to
determine vessel wall damage [1, 2, 5, 8, 9, 11, 12,
15]. Other methods for measuring the extent of
injury include the assessment of functional ability
[14], vasomotor responses [12] and local platelet
uptake [4]. In vivo staining with Evans blue has also
proved useful for dening the extent of endothelial
disruption [3, 8], especially when a computer-
assisted program was employed to calculate the dam-
aged areas [16].
This study aimed to investigate the correlation
between the forces generated by commonly used vas-
cular clamps and the ensuing endothelial and artery
wall damage. The carotid and femoral arteries of the
sheep were studied in vivo to achieve a reproducible
animal model.
Materials and methods
Experimental protocol
Sheep were studied, as the carotid and femoral
arteries are of similar calibre to those in man. The
carotid and femoral arteries of four adult sheep
weighing between 40 and 50 kg were used. A total
of 16 arteries were subjected to varying clamp forces
and the extent of endothelial damage was assessed
by Evans blue staining, histological examination and
scanning electron microscopy.
Anesthaesia was induced using intravenous Nem-
butal (15 mg/kg) and maintained using oxygen with
1.52.5% Halothane. An intravenous line provided
uid replacement with normal saline through an
external jugular vein. Systemic blood pressure was
monitored through a catheter in the deep femoral
artery and mean blood pressure was maintained
between 90 and 100 mmHg.
Both carotid arteries were exposed via a midline
neck incision. The femoral arteries were exposed
through groin incisions. An aliquot of 150 IU/kg of
sodium Heparin was administered intravenously
5 min before the rst set of clamps was applied to
the carotid arteries.
Four identical angled DeBakey arterial clamps
(Downs Surgical, UK) were placed on the middle
section of each exposed artery at 1-cm intervals, avo-
iding any branches and surrounding tissues, and
commencing at the distal end to avoid clamping a
collapsed vessel (Figure 1). The jaws of each clamp
Figure 1 Diagram showing four angled DeBakey vascular clamps applied
to the artery with forces generated at (a) three notch, (b) four notch, (c)
ve notch and (d) six notch, respectively. t thickness of clamped artery
is proportional to the force applied
were placed at right angles to the long axis of the
vessel, with the vessel held 1 cm from the tip of the
clamp. The four clamps were closed to three, four,
ve and six notches, respectively, and left in place
for 15 min.
After the last clamp was removed, a 0.5% solution
of Evans blue dye (up to a total volume of 3 ml/kg)
was administered intravenously and allowed to circu-
late for 30 min [16]. All carotid and femoral arteries
were then removed, opened longitudinally and
pinned at. The areas of blue staining were exam-
ined under a dissecting microscope at 7 magni-
cation. A video camera (KP-M1E, HitachiDenshi,
Japan) connected to the viewing post of the micro-
scope was used to acquire images. The images were
transferred to a computer (Apple Macintosh, using
Image Scion, version 1.51, National Institutes of
Health, USA), which calculated the area of blue
staining in each vessel using appropriate calibration.
At the end of each experiment, the animals were
humanely killed. Half of the samples were then xed
in glutaraldehyde and prepared for scanning electron
microscopy (Stereoscan S150, Cambridge Instru-
ment CO, UK). The rest of the arterial specimens
subjected to clamping were xed in 10% buffered
formalin. The morphological changes were studied
after staining the parafn sections with haematoxylin
and eosin.
Clamping force and pressure measurements
Before the clamps were applied, the closing force for
each notch of the DeBakey angled vascular clamps
employed in this experiment was pre-measured by an
electronic loading-cell device with 0.1 N resolution
CLAMPING FORCE:
Excessive clamping force can injure the
renal artery.
Ratcheting forces on satinski can be over
applied more than bulldogs, active vs
passive force
Minimal force should only be applied
There can be a lot of surgeon tension, dont
let that translate to a vascular injury
Lump of coal to diamond in sphincter
syndrome
09672109/99 $20.00 0.00
PII: S0967-2109(98)00154-9
rights reserved
Introduction
disruption [7].
09672109/99 $20.00 0.00
PII: S0967-2109(98)00154-9
rights reserved
Introduction
disruption [7].
using the following procedure (Figure 2) where: A
electronic load-cell measured force to 0.1 N resol-
ution; and B electronic digital callipers measured
distance to 0.01 mm resolution.
For a given notch setting D refers to the displace-
ment of the application point of the callipers. The
force from the load cell (A) was correlated with the
gap between the jaws of the arterial clamp (C) as
measured by the gauge (B). The procedure was
repeated for a range of gaps with the displacement
determined by the screw thread (E).
At any notch setting, ve different loads were
applied giving a load in newtons (N)/deection
(t mm) ratio for that notch setting. The measure-
ments were repeated three times for each notch set-
ting giving a family of curves. Using a statistical
curve tting software package (Microsoft Excel 4.0)
one empirical function was derived to obtain the gap
thickness (deection) in terms of the two variables:
No (the notch settings) and F (force). The family of
curves was then replotted using this derived math-
ematical function to ensure agreement with the orig-
inal experimental data (Figure 3).
The external diameters of the arteries and the
thickness of the clamped arteries were measured
using callipers. These measurements were used to
calculate the average forces generated by the clamps,
using the equation:
F
t (5.9957 1.4688 No)
0.4163 0.0172 No
where: F force applied (newtons); t clamped
thickness (mm); No notch number.
The areas subjected to clamp application were cal-
culated using the equation:
A D (mm) 3 mm,
where: A area of the clamped artery; D external
Figure 2 Diagram showing setup for electronic loading-cell measure-
ments of forces generated by clamps (explanation in text)
Figure 3 Diagram showing computer-analysed correlations between the
clamped thickness and forces generated by DeBakey vascular clamp
diameter of clamped artery; 3 mm width of the
angled DeBakey vascular clamp.
To calculate the specic compressive pressure (P)
immediately under the clamp face, the estimated
clamping force was divided by the compressed area,
which is related to the area of the clamp face as fol-
lows:
P F/A,
where: P pressure (newtons/mm
2
); F force
(newtons); A area of the clamped artery (mm
2
).
All the surgical and technical procedures were per-
formed at the Department of Biomedical Engineer-
ing of the University of NSW, with approval from
the local Animal Care and Ethics Committee
(ACEC). The data were analysed using the Wil-
coxon signed-rank non-parametric statistical test.
Values are shown as mean s.d.
Results
Clamping force and pressure measurements
The mean external diameters were 7.2 0.8 mm for
carotid arteries and 5.3 0.7 mm for femoral
arteries.
The clamping forces generated by the standard
angled DeBakey vascular clamps were calculated for
carotid and femoral arteries in relation to the thick-
ness of the vessel clamped (Table 1). The mean area
(mean s.d.) subject to clamp application in the
carotid arteries was 67.86 7.5 mm
2
for carotid
arteries and 49.95 6.5 mm
2
for the femoral
arteries.
The results of the specic compressive pressures
were expressed as mean s.d. (Table 2). Other vari-
ables, including systemic blood pressure and vessel
elasticity, were not included in the calculations
because all measurements were performed under
Figure 5 Scanning electron microscopy images at the sites of clamps application: a, b, c, d femoral artery (original magnication 25); e, f, g, h
carotid artery (original magnication 25); a, e three notch; b, f four notch; c, g ve notch and d, h six notch
In mild injuries, light microscopy analysis did not
identify any signicant endothelial injury and the
internal elastic lamina was intact. However, vacuoliz-
ation of some smooth muscle cells in deep medial
areas was observed in some specimens (Figure 6A).
In moderate injuries, vacuolization of smooth
muscle cells in the media was consistently detected.
The internal elastic lamina was partially disrupted in
ssures and the adjacent endothelial cells showed
denite signs of injury within the ssure zone with-
out extensive desquamation of the cells around the
clamped site (Figure 6B).
In severe injuries, the cell response was different
compared with moderate injury, including complete
desquamation of the endothelial cells in the zone of
clamp application. Vacuolization of smooth muscle
cells in the supercial and deeper part of media was
apparent. Continuity of the internal elastic lamina
was broken in the ssure zone, with the ssure usu-
ally extending through the medial layer to form a
cavity often lled with thrombus (Figure 6C).
Discussion
Numerous reports conrm that vascular clamps can
damage the vessel wall [1, 3, 57, 12, 1719]. Most
of these studies evaluated different vascular clamps
in a general way with relatively few analysing the
effects of specic features of clamp design. Clamp
geometry, closing force, weight and holding ability
are known to inuence the extent of trauma. The
architecture of the jaw face [3, 8, 10], the type of
vessel [15] and the duration of clamping are also
important. In the present study, the extent of endo-
CLAMPING FORCE:
Excessive clamping force can injure
the renal artery.
Ratcheting forces on satinki can be
over applied more than bulldogs,
design.
Minimal force should only be applied
There can be a lot of surgeon
tension, dont let that translate to a
vascular injury
09672109/99 $20.00 0.00
PII: S0967-2109(98)00154-9
rights reserved
Introduction
disruption [7].
09672109/99 $20.00 0.00
PII: S0967-2109(98)00154-9
rights reserved
Introduction
disruption [7].
Figure 6 Light microscopy showing damage of the sheep carotid artery upon clamp application (original magnication 100). (A) Mild damage, (B)
moderate damage, (C) severe damage
thelial disruption has been directly correlated with
increasing forces of clamp application, with the study
design limiting the effect of other variables including
the duration of clamping [16].
A sheep model was used in this investigation
because ovine carotid and femoral arteries are com-
parable in size to those in man. Standard angled
DeBakey clamps were chosen because these clamps
are commonly used in human vascular procedures.
These clamps are similar to other serrated clamps
that, in general, have proved to be most reliable and
resistant to slipping. A further reason for using the
DeBakey clamp in our study was that the DeBakey
clamp ranked as average among other vascular
atraumatic clamps [2].
The force needed to occlude a vessel is determined
by four variables: vessel diameter, blood pressure,
vessel elasticity and blade contact area. The closing
pressure of clamps used to occlude small calibre ves-
sels has been estimated [13], but the precise relation-
ship between the forces generated by the clamp, the
actual closing pressures, and the subsequent arterial
wall injuries have not been quantied.
Berlin and Berlin [10] established that com-
pression forces of 50 to 75 g are needed to arrest
ow in a vessel under 300 mm pressure. Most of the
widely used vascular clamps examined, however,
required 200 to 1000 g or even greater force to
engage the latches [10].
Harvey and Gough [8] demonstrated that when a
clamp was applied with sufcient force to occlude a
vessel, the damage was considerably less than when
the clamp was fully closed [8] and Pabst et al. [20]
conrmed that excessive clamping forces caused sev-
ere endothelial damage.
In the present experiment, the forces generated at
three-notch clamping induced a signicantly smaller
area of endothelial disruption than forces generated
at four, ve and six notches. The area of damage
reached a maximum level at ve notches, beyond
which there was no further signicant change. The
results indicate that damage to endothelium depends
on the closing pressure of the specic clamp within
a limited range, but increases in pressure beyond this
have no additional effect on the endothelium. This
observation may relate to blood vessels being viscoel-
astic and thus sharing some of the characteristics of
viscous liquids, namely, continuous deformation
after a force is applied.
Scanning electron microscopy demonstrated a
direct relationship between vascular compressive
forces and arterial wall damage. Higher magni-
cation revealed deposition of platelets on the surface
proportional to the endothelial lesions, but there was
little evidence of thrombogenesis, perhaps because
of the brief duration of clamp application.
The minimal endothelial damage produced by
forces generated at three-notch clamping suggests
that effective occlusion of arteries 4.58 mm external
diameter can be performed safely at this level of
clamp closure. However, the amount of damage
caused will be additionally inuenced by vessel size,
systemic blood pressure, clamp jaw geometry,
arterial wall elasticity and the duration of clamp
application.
Evans blue dye injected intravenously stains dam-
aged endothelial cells, and this property has proved
reliable in outlining the areas of clamp application
[12]. The authors rened the use of Evans blue
staining by a new method of computer-assisted
analysis to achieve precise calculation of the dam-
aged surface. Using this and other technology the
OTHER MEANS OF CONTROL
Vessel loop tourniquet
Pre made on the bench
Less Clamping force ??
Operator dependant
OTHER MEANS OF CLAMPING
Temporary Hemolocs on the artery
Non red vascular stapler
Not ideal, clamping force uncontrolled
You are really doing a nephrectomy !!!
high risk of injury
Aberant Vessels
Arterial anatomy
Arterial anatomy
Venous anatomy Venous anatomy
Circumaortic leIt renal vein Retroaortic leIt renal vein
Tumor position Tumor position
Four renal segments, based on vascular territories Four renal segments, based on vascular territories
apical
anterior
basilar
posterior
CASE STUDY
53 yo man presents with the above CT after an emergency visit
for central abdominal pain.
Pain settled, US normal except solid left renal mass
CASE STUDY
Mass is considered for biopsy but you decide that it wont change
your management.
Its 3.3cm solid enhancing, well circumscribed, 70% exophytic
lateral mid polar, without nodes. CT chest normal.
Hilum shows a single artery and vein
Management?
CASE STUDY
Lap Left partial
Clamp? Clampless?
Technique.
You go with Satinski.
Blood loss100 cc, clamp time 13min
Surgery goes well, you pat yourself on the back
(a hero in your own mind), Beers taste good that evening.
CASE STUDY
Day 2 he develops Nausea and an ileus.
You think he should be going home. Bloodwork.
CBC, Lytes BUN Cr, LFTs and LDH
Hb 134 Cr 140 (84 preop) AST 1.5Xnormal LDH 2Xnormal
You order a Renogram to avoid dye
CASE STUDY
HILAR MANAGEMENT
The current standards of Bulldogs or Satinky are not without aws
Satinski can slip off or incompletely occlude but can be quick and require less meticulous hilar dissection
Bulldogs require the vessels dissected clean which can lead to inadvertent injury or bleeding
Dissection of the renal artery or atheroclerotic embolic events can occur and are underreported.
Renal artery stenosis has been reported associated with hypertension post arterial clamping
Excessive force of vessel loops can injure vessels.
All methods of control need careful application of force to the minimal requirement
Unexpected bleeding due to an unrecognized arterial unclamped branch should NOT mean more pressure on
the clamp
Incomplete occlusion of the artery with an occluded vein can lead to infarction from venous congestion,
hemorrhage or poor visibility and poor renal defect closure
USE THE TECHNIQUE THAT YOU ARE
COMFORTABLE WITH
TREAT THE VESSELS WITH CARE WHEN
CLAMPING
BULLDOGS ARE ARGUABLY LESS RISKY DUE TO
THE PASSIVE FORCE
SATINSKI REQUIRES AN EXTRA PORT PLACED
CAREFULLY OUT OF THE WAY, BUT ARE QUICK
VESSEL LOOPS ARE AN ALTERNATIVE
CLAMPLESS IS THE ONLY TECHNIQUE WITHOUT
ISCHEMIA
CLAMP TIME IS CRITICAL WITH PRECISE SURGERY
CLAMPLESS ALLOWS SLOWER NON ISCHEMIC
MICRO DISSECTION, APPEARS TO BE ON THE RISE.
Conclusion
ABERRANT ANATOMY?
CLAMP ARTERY ONLY TO AVOID VENOUS
CONGESTION.
SEGMENTAL ARTERY ONLY, WITHOUT VEIN
IF BLEEDING WHEN CLAMPED, DO NOT
CRANK RATCHET EXCESSIVELY, ITS PROB AN
ACCESSORY VESSEL.
TAG ALL BULLDOGS, ITS NO FUN LOOKING
FOR ONE THAT HAS FALLEN OFF
DO YOU NEED MORE THAN ONE TOOL FOR
HILAR CONTROL.
EFFECTIVE USE OF BULLDOGS OR SATINSKI,
VESSEL LOOPS OR HAND PORT
Conclusion
ADVANCED LAPAROSCOPIC AND ROBOTIC UROLOGY SKILLS
FORUM
ENUCLEATION VS. EXCISION: MAINTAINING TUMOUR MARGINS
Christopher French MD FRCSC
Genitourinary Oncology/ Endourology
Eastern Heath, Memorial University of Newfoundland
June 2014
STANDARD PARTIAL
NEPHRECTOMY VS ENUCLEATION
thickness of 1 mm (range: 0.381.6) laying beyond
the tumor pseudocapsule with signs of chronic
inflammation [21]. This precious microscopic layer
of renal parenchyma allows the presence of negative
surgical margins also in patients with tumors
extending beyond the pseudocapsule (Fig. 1).
Taking into account the minimum thickness of
the safety margin in the most recent NSS series, it is
probable that in a significant percentage of cases the
margin that resulted was 1 mm, substantially
similar to the one reported by Minervini et al after
simple enucleation [10,11,1316,21]. Therefore, sim-
ple enucleation can be considered a safe technique,
in perfect harmony with the EAU guidelines, which
only recommend the presence of a minimal tumor-
free surgical margin of healthy tissue in order to
reduce the risk for local relapse [1].
Nevertheless, the study by Minervini et al raises
new questions that will probably be solved in the
future.
From the surgical point of view, simple enuclea-
tion is performed through an incision of the renal
parenchyma at 12 mm from the neoplasia and
through the blunt development of a space between
the tumor pseudocapsule and the normal renal
tissue, without any visible healthy parenchyma
surrounding the tumor [1]. Starting from this
assumption, how can we explain the presence of a
1-mm margin of kidney parenchyma around the
pseudocapsule? Is it possible to think that the
thickness of the healthy tissue surrounding the
tumor is larger where the pseudocapsule is infil-
trated by the tumor?
Waiting for further studies confirming Minervini
et als results [21], we believe it is only possible to
formulate hypotheses. For example, the presence of
chronic inflammation in the healthy tissue around
the tumor could justify a stronger adhesion to the
pseudocapsule, causing its involuntary removal
during simple enucleation. This inflammation could
be a direct consequence of the compression of the
tumor on the healthy parenchyma or of a neoplastic
infiltration of the pseudocapsule. To further inves-
tigate this aspect, it could be useful to explore the
correlations between the thickness of the tissue
surrounding the neoplasia and the tumor size or the
extension of the pseudocapsular infiltration.
Even though the scientific attention is mostly
focused on the parenchymal side of the tumor, the
study by Minervini et al [21] highlights the impor-
tance of the risk of infiltration also on the adipose
slope of the tumor. Although less frequent than the
parenchymal infiltration, from the oncologic point
of view, the involvement of the perirenal fat has an
Fig. 1 (a) Traditional partial nephrectomy with excision of an adequate additional margin of peritumor renal parenchyma
(410 mm); (b) minimal partial nephrectomy with excision of a 1-mm safety margin.
STANDARD PARTIAL
NEPHRECTOMY
As pioneered by Novick (open)
Objectives are for complete tumour removal
While preserving the largest part of healthy parenchyma
Generally tumours less than 4cm
requires closure/repair of calyces, central vessels
Minimize vascular compromise of healthy remainder of kidney and
Minimize warm ischemia
STANDARD PARTIAL
NEPHRECTOMY
Pros
Wide excision gives pathologist rim of healthy tissue
This healthy rim should benet the patient
Similar to open technique
Less ambiguous pathology reports
Our Traditional Training and comfort zone
Less anxiety re Patient and Surgeon for follow up
STANDARD PARTIAL
NEPHRECTOMY
Cons
Can be more complicated
Leaks, AVF, bleeding risks
More difcult Lap Repair of defect
longer warm ischemia ?
No true surgical planes
All factors that compromise the healthy remainder of kidney
SIMPLE TUMOUR ENUCLEATION
Terminology
Super Selective Microdissection
Minimal partial nephrectomy
What is the Margin of safety?
MARGIN OF SAFETY
UROPEAN UROLOGY 55(2009) 1315-1320
presence of adjacent nodular areas, the percentage
of tumor deepened into the kidney, and the
relationships with the urinary collecting system.
Currently, the impact of these factors on the
thickness of the safety margins surrounding the
resected tumor during partial nephrectomy has
been scarcely addressed.
The further emerging information is that the
thickness of the parenchyma surrounding the tumor
does not influence the long term progression-free
survival in patients with negative surgical margins
[16]. This informationhas beenacknowledgedby the
most recent version of the European Association of
Urology (EAU) guidelines recommending the pre-
sence of a minimal tumor-free surgical margin of
healthy renal parenchyma surrounding the resected
tumor in order to reduce the risk of local relapse or
progression, without specifying the exact minimum
thickness to be taken [1].
In this scenario, simple enucleation has found a
growing number of supporters as NSS for small RCC.
This surgical technique consists of the incision of
the renal parenchyma within a few millimeters
from the tumor and the blunt dissection of a plan
between the pseudocapsule of the tumor and the
normal renal tissue without the inclusion in the
removed tissue of any visible normal renal par-
enchyma.
Even though the simple enucleation might be
correctly used in patients with bilateral kidney
tumors and/or with solitary kidneys preserving
most parenchyma possible, its use in patients with
single tumors and contralateral normal kidney is
more controversial considering the higher risk of
local recurrences, particularly in patients with
neoplastic infiltration of the tumor pseudocapsule
[7,12,17].
Despite this skepticism, literature data show that
simple enucleation provides oncologic results simi-
lar to the conventional NSS. In a series of 232
patients who had undergone simple enucleation for
4 cm RCC, Carini et al reported 5-yr and 10-yr
cancer-specific survival rates of 96.7% and 94.7%,
respectively. Moreover, the authors observed no
case of positive surgical margins or recurrence at the
initial site of the tumor after a mean follow-up of
76 mo [18]. The absence of positive surgical margins
should let us hypothesize the absence of neoplastic
infiltration beyond the tumor pseudocapsule. This
theory is inconflict with literature data, reporting an
infiltration of the tumor pseudocapsule in percen-
tages ranging between 15% and 100% [17,19,20].
In the current issue of European Urology, Minervini
et al report the results of anaccurate histopathologic
analysis on 90 consecutive patients who had under-
gone simple enucleation for T1a RCC between 2006
and 2007 [21]. The prospective design of the study
and the pathologic methodology allowed the
authors to obtain a set of original morphological
data on the status of tumor pseudocapsule and
surgical margins in patients who had undergone
simple enucleation. The thickness of tumor pseu-
docapsule ranged between 0.04 mm and 0.79 mm. A
neoplastic pseudocapsule infiltration was reported
in 33% of cases. In detail, the parenchymal side of
the pseudocapsule was involved in 26.6% of cases,
while the extrarenal adipose side was infiltrated in
6.6% of cases. The pseudocapsule infiltration was
more frequent in patients with larger tumors, higher
nuclear grading, or coagulative tumor necrosis.
Similar to most partial nephrectomy series, 14% of
patients showed a neoplastic infiltration beyond the
pseudocapsule toward the renal parenchyma.
How is it possible to find and explain negative
surgical margins in this group of patients after a
simple enucleation?
The most original data from Minervini et al
consist of the description of a tissue with a median
Table 1 Summary of the most recent data from the literature: analysis of the mean, minimum, and maximum values of
the safety margin of healthy tissue around the tumor during partial nephrectomy
Study Cases Safety margin Indications
Mean value, mm Range, mm
Piper et al [10] 67 4.5 112 A safety margin <1 mm is sufcient.
Sutherland et al [11] 41 2.5 0.57 A minimum safety margin (25 mm) is sufcient.
Castilla et al [16] 69 3.5 0.59.5 The extension of the safety margin is not related
to disease progression in patients with negative
surgical margins.
Berdjis et al [13] 121 5 123 No correlations between safety margins and disease
progression/local relapse.
Timsit et al [14] 61 Cortical: 7 410 Tumor localization and its more or less intraparenchymatous
penetration sometimes render difcult a safety margin of 1 cm. Bottom: 2 05
Li et al [15] 115 Cortical: 4.5 46 A <5-mm safety margin is sufcient.
Bottom: 2.2 06
e ur op e a n ur o l og y 5 5 ( 2 0 0 9 ) 1 3 1 5 1 3 2 0 1316
Pros
Debatable, but any margin in a T1a renal mass is safe.
Surgical plane allowing blunt dissection
Deep margin resection avoids larger vessels
Avoids calyx
Less complex closure
less risk of delayed complications since less calyx entry
less normal parenchyma removed.
Less risk of ischemic normal tissue
less bleeding
Amenable to clamp less technique
Cons
Requires very clear visibility
Easy to enter tumour capsule
Cystic masses can be very difcult
Multifocality 10%
requires communication with pathologist
Irregular borders/inammatory tumours
more extensive fat dissection off tumour
Not for T2 or high grade tumours
Unclamped Hand-Assisted Laparoscopic Partial Nephrectomy for
Predominantly Endophytic Renal Tumors
Jason D. Engel,
1
Stephen B. Williams
2
Urology Journal Vol 10 No1 Winter 2013
769 Vol. 10 | No. 1 | Winter 2013 | UROLOGY JOURNAL
Unclamped Hand-Assisted Laparoscopic Partial Nephectomy | Engel and Williams
lows the inherent pyramidal anatomy to a single artery at its
base. This artery is pinched oII between the thumb and index
fnger, allowing Ior immediate removal oI the tumor Ior thor-
ough pathologic examination Ior tumor type and adequacy
of margins. As long as the plane has not been forced in any
way, hemostasis, even at this point, is generally excellent
with only a Iew points oI bleeding at the base oI the deIect.
A single fnger can generally be gently placed in the deIect to
hold pressure. II cortical bleeding occurs as well, this is eas-
ily managed by manual compression of the defect. Bleeding
is compressed Ior a Iull ten minutes, which occurs during
pathologic analysis of the specimen.
In the setting of negative margins, no further resection is per-
formed. If there is a positive margin, or if there is clinical
suspicion oI inadequate resection despite negative margins,
careIul inspection oI the deIect can be perIormed with little
blood loss to guide further resection. Nephrectomy is per-
Iormed where there are multiIocal positive margins or where
deeper resection is not safe or feasible. Bulldog clamps may
be applied at this point if a more aggressive standard laparos-
copy or open partial nephrectomy is deemed feasible.
AIter checking Ior collecting system leaks with a retrograde
Figure 1. Computed tomography scan revealing a 2.2 cm enhancing lesion in the anterior mid-pole and a 1.6 cm enhancing
lesion in the postero-medial lower pole.
Figure 2. The lesion before and after enucleation with use of the fnger fracture technique.
NEPHRON SPARING
CARINI ET AL 2009
40 E U R O P E A N U R O L O G I C A L R E V I E W
Renal Cell Carcinoma
Between January 2000 and June 2008, 269 patients had kidney
surgery for pathologically confirmed pT1a RCC of whom 240 (89.2%)
had NSS and 29 (10.8%) had RN. The number of NSS performed in our
department for clinically T1a tumours has increased over time due to
increasing surgical experience and better understanding of the
technique. The ratio between NSS and RN has changed from 3:1 in the
period between January 1986 and December 1999 to 9:1 in the period
January 2000 to June 2008 (see Figure 2).
Several papers have shown that NSS can be safely performed using a
laparoscopic approach and could represent a viable alternative to open
NSS with the goal of decreasing post-operative pain and speeding up
the return to normal activities. Laparoscopic partial nephrectomy (LPN)
has been shown to have intermediate oncological outcomes similar to
those of open NSS.
13
A recent multi-institutional survey from 17
centres in the US and Europe, with 855 laparoscopic cases, using LPN
for tumours <4cm showed an overall incidence of positive margins of
2.4%. This demonstrated that the oncological efficacy of LPN is
comparable to that of open partial nephrectomy.
14
A recent comparison of the intra-operative, post-operative and
oncological data of 771 LPN and 1,028 open NSS procedures collected
from three large referral centres in the US concluded that equivalent
functional and early oncological outcomes can be achieved with these two
approaches.
15
Warm ischaemia time should always be limited to 2030
minutes, and these rules should also apply for LPN. Rocca-Rossetti et al.
16
studied 30 kidneys removed after 1560 minutes of warm ischaemia.
Ultra-thin sections, using light and electron microscopy, showed distinct
changes appearing mainly in the proximal tubules after ~20 minutes with
rapidly increasing signs of cellular degeneration at 30 minutes.
Independent of the preferred approach, the adoption of a conservative
strategy for treating renal masses 4cm may reduce the incidence of
RN for pathologically diagnosed benign lesions. In our department,
during the period January 2000 to June 2008, 295 patients had NSS
for tumours 4cm and of those 14.9% were diagnosed as benign
lesions. The incidence of benign lesion was even higher in the paper
by Frank et al., who evaluated 2,770 patients who had RN or NSS for
sporadic, unilateral, non-metastatic, solid renal masses and found that
23% of renal tumours <4cm were benign.
17
Nephron-sparing Surgery for Intracapsular
Renal Tumours >4cm
NSS is widening its horizons to expand its indications to tumours >4cm,
supported by the concept, reported by several recent papers, that
multifocality is not directly related to a tumours greatest dimension.
1821
Lang et al. reported an incidence of multifocality for tumours 4cm and
7cm of 12.9 and 10.9%, respectively, showing no significant
correlation between multifocality and tumour size.
20
DiMarco et al.
retrospectively reviewed the pathological features associated with
multifocality in a series of 2,373 patients treated by RN.
21
The incidence
of multifocality in the pT1a and pT1b RCCs (clear cell and papillary cell
subtypes, taken together) was 6.4 and 2.2%, respectively.
A possible explanation for these findings can be found in an excellent
retrospective review on 1,970 RCCs from the Mayo Clinic.
17
The authors
found that each 1cm increase in tumour size was associated with a 17%
increase in the odds of clear cell compared with papillary RCC. For smaller
tumours (<4cm), the incidence of clear cell and papillary cell subtype was
66.3 and 30.6%, respectively. For tumours 47cm in size, the incidence
of clear cell subtype increased to 82.7% and of papillary subtypes
decreased to 14.1%.
17
The papillary histological subtype is the most
accredited risk factor for multifocality along with peri-nephric invasion
(pT3a). The indications for elective open NSS should be expanded to
include all intracapsular renal tumours regardless of tumour size.
A few studies published to date have specifically evaluated the role of
open NSS for the treatment of RCC up to 7cm in greatest dimension (see
Table 1) and have shown that these tumours behave in a more aggressive
way than pT1a, yielding a poorer prognosis. Cancer-specific survival is not
related to the type of surgical procedure used (NSS versus RN).
12,2227
Figure 1: Evaluation of Incidence Distribution of Nephron-sparing
Surgery and Radical Nephrectomy, January 2000 to June 2008
0
140
RN
NSS
120
110
80
60
40
47
33
29
61
49
102
87
115
28
52
20
20002001 20022003 20042005 20062007 2008
Figure 2: Evaluation of Incidence Distribution of Nephron-sparing
Surgery and Radical Nephrectomy in Relation to Tumour Stage*,
January 2000 to June 2008
0
300
RN
NSS
250
29
240
55
51
20
11
200
150
100
50
pT1a pT1b pT2
NSS = nephron-sparing surgery; RN = radical nephrectomy.
*pT1a, pT1b and pT2 renal cell carcinoma.
NSS = nephron-sparing surgery; RN = radical nephrectomy.
Laparoscopic partial nephrectomy has
been shown to have intermediate
oncological outcomes similar to those
of open nephron-sparing surgery.
Minervini_subbed.qxp 16/3/09 12:00 pm Page 40
LAPAROSCOPY IS NOT OPEN
SURGERY
Unique surgical environment
C02 15mm, brief rises to 20 are felt to be safe
Venous pressure 8-15mm
High Magnication and visibility
Specic surgical techniques, sliding clip repair, no knots
hemostatic agents developed along side lap implementation
Surgical tactile feedback maintained
Should laparoscopy emulate what we do open?
NEPHRON SPARING
MARGINS AND STAGE
CARINI ET AL 2009
surgery by comparing the results of PN versus RN in
contemporary series of renal tumors >4 cm. Patard
et al compared the specific survivals of two groups of
T1T2 tumors treated either by PN (n = 379) or by RN
(n = 1075) [5]. In patients treated by PN, the cancer
deathrate was higher for tumors >4 cmcomparedto
tumors 4 cm(6.2%vs. 2.2%, respectively). However,
in the population of tumors >4 cm, disease-specific
survival was not significantly different whether
treated by PN or RN (6.2% vs. 9%, p = 0.8). Moreover,
local and distant recurrence rates were comparable
for larger and smaller tumors (3.6%and 7.1%vs. 2.3%
and 15.6%, p = 0.5). Likewise, the group from the
Mayo Clinic compared 60 patients with T1b tumors
treated by PN to 534 patients with identical tumors
treated by RN [6]. Their study included control
groups of T1a tumors for each procedure. When
adjusting for stage, grade, histologic subtype, and
necrosis, no statistical difference concerning sur-
vival was noted. However, neither of the two series
distinguished between elective and necessary PN.
Recently, a multicenter study including >700 elec-
tive PNs showed that inthis highly selective group of
patients, there was absolutely no difference interms
of specific survival between tumors 4 and >4 cm
[7]. Since then, numerous published series have
confirmed the excellent survival outcome of
patients with T1b renal tumors treated by elective
PN(Table 1). Mitchell et al matched every patient of a
group of 33 T1b RCC treated by PN to two patients
with comparable tumors treated by RN. They
showed that surgical technique did not affect
survival and recurrence [8]. The analysis of a
prospective series of 196 patients led Dash et al to
the same conclusion [9]. Carini et al reported 71
tumorectomy procedures for renal lesions between
4 and 7 cm (including 31 pT1b tumors) with good
oncologic outcomes [10]. However, survival for T1b
tumors (83% at 5 yr) was inferior to those published
in previous series although it was not significantly
different from that of T1a tumors in this study
( p = 0.25). It should be noted that this series included
mandatory PN and that the patients who died in the
group of T1b tumors exhibited distant and not local
recurrences, illustrating that oncologic outcomes
are primarily driven by tumor biology rather than
surgical technique (as long as a complete tumor
excision is achieved). In another study, Becker et al
reported excellent cancer control with very long-
term follow-up (86.7% specific survival at 15 yr) in
patients treated by PNfor tumors >4 cm[11]. Finally,
in this issue of European Urology, Antonelli et al
analyzed the outcomes of patients with renal
tumors >4 cm treated by PN (n = 57) or RN (n = 346)
[2]. Their study also included a T1a control group.
Overall, they found increased progression and
inferior survival rates for larger tumors. However,
the type of surgery (PN or RN) did not have any
significant impact on the results. Interestingly, in
the larger tumor group, with a mean follow-up of
72 mo, the meanlocal recurrence rate was only 1.7%.
4. Widening the indications of PN: impact on
surgical morbidity
Raising the cut-off size for PN may be limited by an
increase in morbidity. In a recent multicenter study
by Patard et al, PNfor tumors >4 cmresulted inmore
perioperative bleeding, higher transfusion rates,
and a higher incidence of postoperative urinary
fistulae than PN for tumors 4 cm. Still, this greater
morbidity remains acceptable because the global
rate of medical and surgical complications as well
as length of stay did not differ between the two
groups [7].
Table 1 Studies assessing oncologic control following nephron-sparing surgery in relation to tumor size >4 or =4 cm
Authors No. of patients and
pT stage
Comparison
between radical
and partial
nephrectomy
Elective vs.
imperative
indication
Mean
follow-up,
mo
% local
recurrence
% death
from
cancer
Patard et al [5] 65 (pT1b only) Yes Elective and
imperative
51 3.6 6.2
Leibovich et al [6] 91 (30 pT1a, 60 pT1b et 1 pT3a) Yes Elective only 106 5.5 3.3
Carini et al [10] 71 (30 pT1a, 31 pT1b, 10 pT3,
simple enucleation)
No Elective and
imperative
74 4.2 12.7
Becker et al [11] 69 (62 pT1b, 4 pT2, 3 pT3a) No Elective only 74 1.4 0
Dash et al [9] 45 (41 pT1b and 4 pT3) Yes Elective only 21 2.2 /
Mitchell [8] 33 (21 pT1b and 12 pT3 ou +) Yes Elective and
imperative
34 3 3
Patard et al [7] 81 (pT1b only) No Elective only 36 1.3 2.7
Antonelli et al [2] 57 (T1b, T3a) Yes Elective and
imperative
72.1 1.7 /
e ur op e a n ur o l o g y 5 3 ( 2 0 0 8 ) 6 9 1 6 9 3 692
SURGEONS CRITERIA FOR LAP
PARTIAL: TUMOUR
lap Partial is operator dependant.
Time and efciency are critical!!!
Complexity of cases should only increase with experience
Dene your criteria!
1.5 - 3cm, >50% exophytic, polar or peripheral, solid and smooth normal
opposite kidney, hand assist
up to 4cm, min 30% exophytic, non hilar, solid, normal opposite kidney, no
BMI limit, hand assist if necessary.
SURGEONS CRITERIA FOR LAP
PARTIAL: TECHNICAL
Closure: Running sliding hemoloc, Hemoloc clip preloaded on
loop of barbed suture, Floseal, Snow, gel foam ready. Anchor
stitch in parenchyma before clamp.
Plan ahead
Consistant assistant
Prepare Scrub nurse for the next step while completing current
Time and Accuracy of dissection
CASE STUDY
42 yo lady, with history of melanoma, has multiple UTIs
Renal US imaging suggests complex cyst with calcication
CT ndings
CASE STUDY
CASE STUDY
Working Dx
Complex cyst with stone may be benign calyces diver tic
Decision, lap partial
Amenable to minimal lap partial?
Cystic component, risk of rupture and loss of planes.
Deep border irregular.
How would you approach this?
CASE STUDY
Clamp vs unclamp ?
Enucleation vs Standard Partial ?
Is this case in your criteria?
Path?
CASE STUDY
CASE STUDY
CASE STUDY
Approach? Partial vs Rad
Lap vs Open
Clamp vs non clamp
Standard Partial vs Enucleation
future.
CASE STUDY
What I did
Lap Partial
Clampless
Enucleation (Selective microdissection)
hemoloc on small vessels
Hilar Vessels dissected with vessel loops around
Bulldogs Near
Temp 20mm Co2 5min
EBL 100cc
Time 65min
future.

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ADVANCED LAPAROSCOPIC AND ROBOTIC UROLOGY SKILLS FORUM

BULLDOGS VS ENBLOC CLAMPING AND MINIMIZING WARM

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