ROBOTIC ASSISTED LAPAROSCOPIC PARTIAL NEPHRECTOMY

ROBOTIC ASSISTED LAPAROSCOPIC PARTIAL NEPHRECTOMY

Vol. 179, No. 4, Supplement, Monday, May 19, 2008 THE JOURNAL OF UROLOGY® gender, tumor location, histological subtype, N and M Stages had no impact...

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Vol. 179, No. 4, Supplement, Monday, May 19, 2008

THE JOURNAL OF UROLOGY®

gender, tumor location, histological subtype, N and M Stages had no impact on local recurrence rate. However, imperative indication (p<0.01), WXPRUELODWHUDOLW\ S WXPRUVL]H!FP S )XKUPDQJUDGH 3 or 4 (p=0.02), pT3 stage (p=0.04) and positive margins (p<0.01) ZHUHVLJQL¿FDQWO\DVVRFLDWHGZLWKORFDOUHFXUUHQFHULVN,QPXOWLYDULDWH DQDO\VLVWXPRUELODWHUDOLW\WXPRUVL]HDQGSUHVHQFHRISRVLWLYHPDUJLQV UHPDLQHGVLJQL¿FDQWSUHGLFWRUVIRU5&&ORFDOUHFXUUHQFH Predictive factors for local recurrence in multivariate analysis Incidence of recurrence Bilateral tumor / Unilateral tumor 9.19% / 1.46% 7XPRUVL]H!FP7XPRUVL]HFP 8.06% / 1.77% Positive margin / Negative margin 33.3% / 2.9%

Risk ratio (range) 6.31 (2.86 - 13.92) 4.57 (2.13 - 9.77) 11.5 (4.66 - 45.10)

p value < 0.01 < 0.01 < 0.01

CONCLUSIONS: RCC local recurrence risk after NSS DSSHDUVWREHDVVRFLDWHGZLWKWXPRUVL]HWXPRUELODWHUDOLW\ V\QFKURQRXV or asynchronous) and positive surgical margins. Careful follow-up should be advised in patients presenting such characteristics. Source of Funding: None

1095 PARTIAL RENAL ARTERIAL OCCLUSION IS RENO-PROTECTIVE DURING NEPHRON SPARING SURGERY IN A PORCINE MODEL Karim Bensalah*, Jay D Raman, Aditya Bagrodia, Ilia S Zeltser, Steven M Lucas, Wareef Kabbani, Jeffrey A Cadeddu. Dallas, TX. INTRODUCTION AND OBJECTIVE: There is a clear need for WHFKQLFDOUH¿QHPHQWVWRUHGXFHZDUPLVFKHPLDGXULQJQHSKURQVSDULQJ surgery (NSS). Partial occlusion of the renal artery is a seducing concept that could diminish renal hypoperfusion and thereby ischemic injury. Our objective was to compare the intra-operative and acute post-operative renal function outcomes between total and partial occlusion of the renal artery during NSS in a porcine model. METHODS: Twelve female pigs underwent two surgical procedures. First, a laparoscopic radical nephrectomy was completed to create a single kidney model. One week later, an open contralateral partial nephrectomy was carried out with either total (n=6) or partial (n=6) clamping (TC and PC) of the renal artery. Renal partial oxygen pressure (rPO2 ZDVPRQLWRUHGLQUHDOWLPHXVLQJDVSHFL¿F/LFR[ŠSUREH (Integra, San Diego, CA). Serum creatinine was assessed on day 0 and SRVWRSHUDWLYHGD\VDQG3LJVZHUHWKHQVDFUL¿FHGDQGWKHUHPDLQLQJ kidney sent for pathologic examination. RESULTS: Operating times were comparable in both groups. Estimated blood loss was greater in the PC group (p=0.04). rPO2 readings decreased less (58% vs 84%, p=0.03), took longer to reach nadir (23 min vs 8.7 min, p=0.04), and demonstrated shorter time to recover baseline or maximum rPO2 value (4.8 min vs 10.4 min, p=0.03) in the PC group. Baseline creatinine was comparable in both groups, EXWLQFUHDVHGVLJQL¿FDQWO\PRUHLQWKH7&JURXSDWGD\V YV mg/dl, p=0.026) and 7 (2.5 vs 1.7 mg/dl, p=0.009). Histologic analysis GHPRQVWUDWHGPLOGDFXWHLQÀDPPDWLRQLQERWKJURXSV CONCLUSIONS: In this acute recovery porcine model, partial occlusion of the renal artery was reno-protective during NSS. Intraoperative rPO2 monitoring may allow real time assessment and titration of partial kidney perfusion. Source of Funding: Association Francaise d’Urologie.

1096 NON-CLAMPED, NON-ISCHEMIC PARTIAL NEPHRECTOMY IN PATIENTS WITH COMPROMISED PREOPERATIVE RENAL FUNCTION OR WITH A SOLITARY KIDNEY Gjanje L Smith*, Michael S Cohen, Teodora Kurteva, John A Libertino. Burlington, MA. INTRODUCTION AND OBJECTIVE: Subjecting a kidney to either warm or cold ischemia during a partial nephrectomy remains controversial. Therefore, we describe our experience of performing a non-clamped, non-ischemic partial nephrectomy in patients with compromised preoperative renal function or with a solitary kidney. METHODS: We recorded the preoperative, operative, and postoperative parameters for all patients with a solitary kidney or with a preoperative creatinine greater than 1.5mg/dL who underwent nephron sparing surgery (NSS) at the Lahey Clinic Medical Center

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by a single surgeon (JAL). Patients undergoing bench surgery and DXWRWUDQVSODQWDWLRQZHUHH[FOXGHGKRZHYHUSDWLHQWVZLWK9RQ+LSSHO Lindau were included. RESULTS: From 1980 through 2007, 112 patients underwent NSS with either a preoperative creatinine greater than 1.5mg/dL or with a solitary kidney. In total, 92 (82.1%) patients had a non-clamped, non-ischemic partial nephrectomy, and only 20 (17.9%) required hilar clamping. The average warm ischemia clamp time was 14.9 minutes and four patients underwent cold ischemia with an average clamping time of PLQXWHV7KHDYHUDJHWXPRUVL]HZDVFPDQG  SDWLHQWV KDGDWXPRUVL]HJUHDWHUWKDQRUHTXDOWRFP  SDWLHQWVKDG multiple lesions removed at the time of their surgery with an average of 4.1 (range 2 - 13) lesions. The tumors were located at the hilum or midportion of the kidney in 56 (50%) patients. The pathology demonstrated benign disease in 8 (7.1%), T1a in 62 (55.4%), T1b in 22 (19.6%), T2 in 6 (5.4%) and T3 in 14 (12.5%). Margins were positive in 8 (7.1%) patients. A preoperative and postoperative creatinine was available in 65 (58%) patients. The mean preoperative creatinine was 1.6mg/dL, and mean postoperative creatinine was 2.2mg/dL. When comparing preoperative and postoperative creatinine, 24 (36.9%) had no change, 30 (46.2%) had a minor change in serum creatinine (more than 0% but less than or equal to 50%), and 11 (16.9%) had a major change in serum creatinine (greater than 50%). The mean blood loss was 1679cc with 34 (30.6%) patients having less than or equal to 500 cc of blood loss, 27 (24.3%) patients having between 501 and 1000cc of blood loss, and 50 (45.0%) patients having greater than 1000cc of blood loss. CONCLUSIONS: Non-clamped, non-ischemic partial nephrectomy can be performed safely in patients with either a solitary kidney or compromised preoperative renal function. More than 80% of patients have no change or only a minor change in renal function. Source of Funding: None

1097 ROBOTIC ASSISTED LAPAROSCOPIC PARTIAL NEPHRECTOMY James R Porter *. Seattle, WA. INTRODUCTION AND OBJECTIVE: Laparoscopic partial nephrectomy has become an accepted treatment alternative to open nephron sparing surgery for small renal masses. However, laparoscopic partial nephrectomy is a demanding reconstructive procedure requiring HI¿FLHQWVXWXULQJVNLOOVWRPLQLPL]HZDUPLVFKHPLDWLPH7KHGD9LQFL robot facilitates intracorporeal suturing and thereby allows the successful completion of reconstructive procedures. We present our experience using the da Vinci robot during robotic assisted laparoscopic partial nephrectomy (RALPN). METHODS: RALPN was performed using both a transperitoneal DQGUHWURSHULWRQHDODSSURDFK7KHWUDQVSHULWRQHDODSSURDFKXWLOL]HVD ¿YH SRUW FRQ¿JXUDWLRQ XVLQJ WKH IRXUWK DUP WR DLG LQ UHWUDFWLRQ DQG exposure. The camera is placed lateral to the left and right robotic arms. The retroperitoneal approach is performed after balloon dilation RI WKH UHWURSHULWRQHDO VSDFH DQG D IRXU SRUW FRQ¿JXUDWLRQ LV XWLOL]HG Laparoscopic bulldog clamps are employed for temporary vascular FRQWURO7KH PDVV LV H[WUDFWHG DQG DQDO\]HG XVLQJ JURVV DQDO\VLVRI the resection margin. This is performed during warm ischemia time to ensure an adequate margin of resection. RESULTS: RALPN has been performed in 21 patients. One patient was converted to open partial nephrectomy due to perinephric scarring, resulting in 20 evaluable patients. Mean age was 60.2 yrs. A retroperitoneal approach was used in 11 patients while a transperitoneal approach was used in nine patients. Hilar control was obtained in 19 of the 20 patients, and warm ischemia time for the group averaged 30.8 mins. Mean OR time was 166 minutes. Mean estimated blood loss was 145 cc. Mean length of stay was 3.05 days. A retroperitoneal procedure was converted to conventional laparoscopic partial nephrectomy due to access limitations. One patient developed a pseudoaneurysm 10 days DIWHUVXUJHU\UHTXLULQJDQJLRHPEROL]DWLRQ CONCLUSIONS: RALPN can be successfully performed using both the transperitoneal and retroperitoneal approach. Warm ischemia time is acceptable and patients have minimal morbidity. The da Vinci robot facilitates laparoscopic suturing thereby allowing precise DQGHI¿FLHQWFORVXUHRIUHQDOSDUHQFK\PDGXULQJODSDURVFRSLFSDUWLDO

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THE JOURNAL OF UROLOGY®

nephrectomy. The multiple degrees of freedom provided by the robotic instruments allows suturing in restrictive spaces. Source of Funding: None

1098 DECLININING BASELINE GFR IMPACTS SURVIVAL IN PATIENTS UNDERGOING PARTIAL OR RADICAL NEPHRECTOMY FOR RENAL CORTICAL TUMORS Joseph A Pettus*, Thomas L Jang, R Houston Thompson, Ofer Yossepowitch, Megan A Kagiwada, Paul Russo. New York City, NY. INTRODUCTION AND OBJECTIVE: Survival in renal cell cancer patients has not improved over time despite downward stage migration from increased detection of small incidental tumors. Declining renal function is independently associated with cardiovascular and overall morbidity and mortality. We evaluated the impact of baseline renal function and comorbidity on survival in patients with renal tumors. 0(7+2'6:HLGHQWL¿HGSDWLHQWVZKRXQGHUZHQWSDUWLDO RU UDGLFDO QHSKUHFWRP\ IRU FOLQLFDOO\ ORFDOL]HG UHQDO WXPRUV EHWZHHQ 1995 and 2005. Demographic, clinicopathologic, body mass index (BMI) and comorbidity data (assessed by Charleson-Romano index DQGK\SHUWHQVLRQ ZHUHUHWULHYHG:HXVHGWKHDEEUHYLDWHGPRGL¿HG GLHWDQGUHQDOGLVHDVH 0'5' HTXDWLRQWRHVWLPDWHJORPHUXODU¿OWUDWLRQ rate (GFR) using the last preoperative serum creatinine. BMI and GFR WLPHWUHQGVZHUHDQDO\]HGZLWKOLQHDUUHJUHVVLRQ7KHLPSDFWRI%0, comorbidity, and baseline GFR on disease-free and overall survival was studied using Cox regression controlling for pathologic stage, node and metastatic status. RESULTS: Over a 10 year interval, median BMI increased PRGHVWO\ IURP  ,QWHUTXDUWLOH 5DQJH >,[email protected]   WR  ,45 25,31, p=0.004), and median baseline GFR fell from 70 (IQR:58,80) to 63cc/min/1.73m2 (IQR: 57,78, p<0.001). Multivariable regression demonstrated an association between year of surgery and baseline GFR (p<0.001) even after adjusting for age, sex, comorbidity, BMI, and WXPRUVL]H:HUHSHDWHGWKHDQDO\VLVIRUSDWLHQWVDJHGDQGWKLV association persisted (p<0.001). Baseline GFR, BMI, and comorbidity were not associated with disease-free-survival after controlling for stage, nodal and metastatic status. However, moderately reduced GFR (45-60cc/min/1.73m2) and severely reduced GFR (<45cc/min/1.73m2) ZHUHVLJQL¿FDQWO\DVVRFLDWHGZLWKRYHUDOOVXUYLYDO KD]DUGUDWLR>[email protected] p=0.003 and HR 2.8, p<0.001, respectively). CONCLUSIONS: There has been a time-dependent decrease in Baseline GFR. Baseline GFR is an important preoperative consideration that independently affects overall survival.

Source of Funding: None

Vol. 179, No. 4, Supplement, Monday, May 19, 2008

1099 EX VIVO PARTIAL NEPRECTOMY AND AUTOTRANSPLANTATION FOR RENAL CELL CARCINOMA IN THE SOLITARY KIDNEY Taiji Nozaki*, Tsunenori Kondo, Yasunobu Hashimoto, Hirohito Kobayashi, Kazunari Tanabe. Tokyo, Japan. INTRODUCTION AND OBJECTIVE: Treatment for centrally located complex renal tumor patients with solitary functioning kidney still needs to be done prudently. Performing radical nephrectomy to these patients will obviously lead them to undergo permanent dialysis without any conditions. Although the evolution of the technique in nephron sparing surgery is outstanding, challenging in situ partial nephrectomy to these certain subset of complex renal tumor patients may be esoteric. In these cases, we performed ex vivo partial nephrectomy followed by autotransplantation. The aim of this study was to evaluate the complications and outcome of patients who underwent extracorporeal partial nephrectomy and autotransplantation. METHODS: Between 2003 and 2007, 7 patients underwent ex vivo nephron sparing surgery for renal cell carcinoma in a solitary kidney. 5 patients had previously undergone contralateral nephrectomy due to renal cell carcinoma and 2 patients had nephrectomy for benign disease. Median preoperative serum creatinine was 0.90 mg/dl (range 0.63-1.39). RESULTS: The tumor was excised completely in all patients ZLWKH[YLYRSDUWLDOQHSKUHFWRP\0HDQWXPRUVL]HZDVPP UDQJH 40-90). Warm ischemic time (WIT), total ischemic time (TIT), and operative time were 5 minutes (range 1-8), 253 minutes (range 182-346), and 620 minutes (range 528-694), respectively. Median blood loss was 1291ml (range 400-3250). 5 patients required intraoperative transfusion. 4 patients needed temporary hemodialysis postoperatively but all the patients subsequently recovered. 2 patients and one patient had hemorrage and urinary leakage, respectively. Median postoperative serum creatinine was 1.65 mg/dl (range 1.00-2.52). The median followup was 11.4 month (range 2-37). Evidence of local recurrence is not yet detected in all patients. CONCLUSIONS: Ex vivo partial nephrectomy followed by DXWRWUDQVSODQWDWLRQDSSHDUVWREHDJRRGRSWLRQIRUFHQWUDOO\ORFDOL]HG complex renal cell carcinoma patients with imperative indication especially in the point of saving the patient’s quality of life by avoiding permanent hemodialysis. Source of Funding: None

1100 PARTIAL NEPHRECTOMY FOR RENAL CELL CARCINOMA IN SINGLE KIDNEYS Alastair Henderson, Christopher Blick, Shazad Shah*, Elanor Ray, David Cranston, Timothy S O’Brien. London, United Kingdom, and Oxford, United Kingdom. INTRODUCTION AND OBJECTIVE: Renal cell carcinoma in a single kidney is an imperative indication for partial nephrectomy (PN) if technically feasible. Conventional indications for PN (single tumour, tumour<4cm) may be less relevant to the selection of patients without a contralateral kidney. PN in the setting of a single kidney may confer higher levels of morbidity than in the elective setting. We report outcomes from partial nephrectomy in single kidneys in 2 regional centres. METHODS: Retrospective case-note review of patients with single kidneys undergoing partial nephrectomy for renal cell carcinoma. RESULTS: 43 patients underwent a partial nephrectomy for a renal mass in a single kidneys. 1 patient had congenital single kidney, 3 patients had tumours in a horseshoe kidney or crossed fused renal ectopia and the remaining 39 patients had a nephrectomy following contra-lateral nephrectomy or nephroureterectomy. Median OHVLRQ VL]H RQ &7 ZDV PP PP  DQG PHGLDQ QXPEHU RI CT detected lesions was 1 (range 1-5 lesions). Median length of postoperative stay was 8 nights (range 3-38). Median operative time was 178minutes (range 70-350minutes). Median estimated blood loss (EBL) was <500ml though 8 patients had EBL>1litre and a further 4 had EBL>1.5litres. 6 Patients required intraoperative transfusion and a further 10 received blood transfusion before discharge. 3 patients had major peri-operative complications: 1 returned to theatre for bleeding, 1 was underwent radiological embolisation for postoperative bleeding