Results

The evolving worldwide experience with laparoscopic partial nephrectomy for tumor is listed in Table 3. A multicenter European experience in 53 patients was reported by Rassweiler et al. (61) The average tumor size was 2.3 cm (range, 1.1-5). Transperitoneal approach was used in 28% of cases. Mean operating time was 3.2 hours (range, 1.5-5.3), and estimated blood loss 725 mL (range, 20-1500). Intraoperative complications included pneumothorax in one patient, and bleeding in four, of whom two underwent open conversion. Postoperative complications included bleeding requiring reintervention in one patient, and urinary leak in five patients. Two patients with urinary leak also had concomitant bleeding and were treated with nephrectomy. Histology showed 37 pT1 renal cancer case (69%), and 100% overall disease-free survival rate at three-year follow-up.

Jeschke et al. (62) reported outcomes of laparoscopic partial nephrectomy without hilar clamping in 51 patients with small (<2 cm), peripheral, exophytic, solid renal tumors. The Ultracision devicea was employed for tumor wedge resection, and hemo-stasis was achieved with bipolar coagulation with fibrin glue-coated cellulose. Mean

TABLE3 ■ Worldwide Experience with Pure Laparoscopic Partial Nephrectomy (Series Involving More Than 10 Cases)

Author

No. of pts Size

RCC

OR time

WI time

EBL

LOS

Compl.

Follow-up Recurrence

Harmon et al. (60)

15

2.3

80

170

368

2.6

0

8

0

Janetschek et al. (53)

25

1.9

76

162

287

5.8

12

22.2

0

Rassweiler et al. (61)

53

2.3

69

191

-

725

5.4

28

24a

0

Jeschke et al. (62)

51

2

76

132

-

282

5.8

10

34.2

0

Simon et al. (63)

19

2.1

130

-

120

2.2

26.3

8.7

Kim et al. (64)

79

2.5

79

181.9

26.7

391.2

2.8

19.7

19.8

0

Gill et al. (65)

100

2.8b

70

180b

27.8

125b

2b

19

>7.2

0

aMulti-institution experience. bMedian.

Abbreviations: RCC, renal cancer carcinoma; OR, operating room; EBL, estimated blood loss; LOS, length of stay; Compl, complications.

Source: From Ref. 58.

operative time was 2.2 hours (range, 1.2-5), mean blood loss was 282 mL (range, 20-800), and no open conversion was necessary. Complications occurred in 10% of patients, including pneumothorax (one), urinary leak (three), and late hemorrhage requiring open reintervention (one). Pathology confirmed renal cancer case in 76% of patients. At a mean follow-up of 34.2 months (range, 3-78), neither local recurrence nor distant metastasis occurred. One patient with papillary carcinoma presenting with metachronous de novo renal cancer case in the operated kidney one year after wedge resection was treated with laparoscopic radical nephrectomy.

Gill et al. (65) compared patients undergoing laparoscopic partial nephrectomy (n = 100) with open nephron-sparing surgery (n = 100) for a solitary <7 cm tumor. The median tumor size was 2.8 versus 3.3 cm in the laparoscopic versus open group, respectively (p = 0.005). The tumor was located centrally in 35% of cases in the laparoscopic group and in 33% of cases in the open group (p = 0.83). Indication for partial nephrectomy was imperative in 41% versus 54% of patients, respectively (p = 0.001). Comparing the laparoscopic and open groups, median surgical time (3 vs. 3.9 hrs; p < 0.001) and blood loss (125 vs. 250 mL; p < 0.001) were lesser in the laparoscopic group, while warm ischemia (warm ischemia) time was longer during laparoscopic partial nephrectomy (28 vs. 18 min; p < 0.001). Laparoscopic patients experienced less postoperative analgesia (20.2 vs. 252.5 mg of morphine sulfate equivalents; p< 0.001), shorter hospital stay (2 vs. 5 days; p < 0.001), and quicker convalescence (4 vs. 6 weeks; p < 0.001). Histology revealed renal cell carcinoma in 75% of patients in the laparoscopic group and 85% in the open group (p = 0.003). Positive surgical margins occurred in 3% and 0%, respectively (p = 0.11). Intraoperative and renal/urologic complications were higher in the laparoscopic (5% and 11%, respectively) versus open (0% and 2%, respectively) group (p = 0.02 and 0.01, respectively). No local or port-site recurrence occurred in the laparoscopic group. Based on these data, the authors concluded that although open partial nephrectomy remained the standard nephron-sparing surgery for renal tumors, laparoscopic partial nephrectomy was emerging as an effective minimally invasive alternative. At the Cleveland Clinic, the senior author's experience with laparoscopic partial nephrectomy now exceeds 420 cases (Table 4). In the initial 300 patients (66), the indication for laparoscopic partial nephrectomy was imperative in 40% of patients, median warm ischemia time was 32 minutes, median operative time was 3.3 hours, and median hospital stay was 2.6 days. Pathology confirmed renal cell carcinoma in 71% of patients.

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