Clinical Applications In Urology

Limited clinical applications have been reported in urology for partial nephrectomy, radical prostatectomy and retroperitoneal lymphadenectomy using the hydro-jet technique. The majority of these procedures were completed using open technique. In a clinical study, 24 patients underwent open renal sparing surgery for various indications including renal tumors (21). The dissection was performed without hilar control. The dissection time was 14 to 40 minutes with no significant blood loss. A pressure range of 16 to 22 bar was utilized. In a preliminary study at the University of Toronto, we performed six open partial nephrectomies using hydro-jet (unpublished data). The procedure was successful in all subjects with selective preservation of blood vessels, which were controlled using bipolar or monopolar forceps or selective ligation. Temporary hilar control was achieved in the majority of patients. In our experience, lack of hilar control was associated with more blood loss during larger resections. The time spent for dissection was 20 to 30 minutes. The mean estimated blood loss was 265 mL (range: 150-500 mL). There were no intraoperative or postoperative complications. The pathology revealed renal cell carcinoma in all patients. At a mean follow-up of 12 months, all patients were disease free. Currently, there is no reported experience with this technology for laparoscopic partial nechrectomy in human.

Hydro-jet technology also has been used for nerve-sparing approach during open and laparoscopic radical prostatectomy (unpublished data). The use of this technique facilitates isolation and preservation of neuromuscular bundles. However, no long-term functional data are currently available.

More recently, we have reported preliminary data using this technology for nervesparing retroperitoneal lymphadenectomy (20). The optimal pressure used for retroperitoneal lymphadenectomy was in the range of 225 to 305 psi (16-21 bar) in human. The dissection properties in this pressure range are similar to higher pressure with preservation of smaller blood vessels and nerves. Retroperitoneal lymphadenec-tomy was performed in five men with testicular cancer. The lymphadenectomy was primary in two and post chemotherapy in three patients. The primary diagnosis was seminoma in one and nonseminoma in four.

Hydro-jet nerve-sparing retroperitoneal lymphadenectomy permitted tissue selectivity with preservation of vascular structures and sympathetic nerves. The soft tissue and lymphatics were removed with the high-pressure saline stream assisted by blunt dissection. The nerve fibers were grossly resistant to the pressure used and were isolated individually. Sympathetic nerve fibers leading to the hypogastric plexus were isolated and preserved (Fig. 6).

The dissection time was comparable to the conventional technique. The mean estimated blood loss was 450 mL. There were no intraoperative or postoperative complications. The pathology revealed residual embryonal carcinoma in one, teratoma in two and fibrosis in two. At a mean follow-up of 24 months, all patients reported return of ejaculation and no retroperitoneal recurrences have occurred.

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