OFF-CLAMP LAPAROSCOPIC PARTIAL NEPHRECTOMY FOR HILAR TUMORS 12. Rais-Bahrami S, Romero FR, Lima GC, et al. Elective laparoscopic partial nephrectomy in patients with tumors > 4 cm. Urology 2008;72:580–583. 13. Smaldone MC, Kutikov A, Egleston B, et al. Assessing performance trends in laparoscopic nephrectomy and nephron-sparing surgery for localized renal tumors. Urology 2012;80:286–291. 14. Gill IS, Patil MB, Abreu AL, et al. Zero ischemia anatomical partial nephrectomy: A novel approach. J Urol 2012;187:807–814. 15. Rais-Bahrami S, Lima GC, Varkarakis IM, et al. Intraoperative conversion of laparoscopic partial nephrectomy. J Endourol 2006;20:205–208. 16. Lattouf J-B, Beri A, D’Ambros OFJ, et al. Laparoscopic partial nephrectomy for hilar tumors: Technique and results. Eur Urol 2008;54:409–416. 17. Rais-Bahrami S, George AK, Herati AS, et al. Off-clamp versus complete hilar control laparoscopic partial nephrectomy: Comparison by clinical stage. BJU Int 2012;109:1376–1381. 18. Kaouk JH, Khalifeh A, Hillyer S, et al. Robot-assisted laparoscopic partial nephrectomy: Step-by-step contemporary technique and surgical outcomes at a single high-volume institution. Eur Urol 2012;62:553–561. 19. Chung BI, Lee UJ, Kamoi K, et al. Laparoscopic partial nephrectomy for completely intraparenchymal tumors. J Urol 2011;186:2182–2187. 20. George AK, Herati AS, Srinivasan AK, et al. Perioperative outcomes of off-clamp vs complete hilar control laparoscopic partial nephrectomy. BJU Int 2013;111: E235–E241.
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21. Richstone L, Montag S, Ost M, et al. Laparoscopic partial nephrectomy for hilar tumors: Evaluation of short-term oncologic outcome. Urology 2008;71:36–40. 22. Frank I, Colombo JR, Rubinstein M, et al. Laparoscopic partial nephrectomy for centrally located renal tumors. J Urol 2006;175:849–852.
Address correspondence to: Arvin Koruthu George, MD The Smith Institute for Urology North Shore-LIJ Hofstra School of Medicine 450 Lakeville Road Suite M1 New Hyde Park, NY 11040 E-mail: [email protected]
Abbreviations Used BMI ¼ body mass index EBL ¼ estimated blood loss GFR ¼ glomerular filtration rate LPN ¼ laparoscopic partial nephrectomy ORT ¼ operative time RCC ¼ renal cell carcinoma WIT ¼ warm ischemia time
DOI: 10.1089/end.2013.0713
Editorial Comment for Salami et al. Sherb Figenshau, MD
T
he authors show that complex hilar lesions can be resected using minimally invasive surgical techniques without clamping the renal vessels. Everyone agrees that short warm ischemic times are better than long ischemic times for preserving postoperative renal function. It remains to be proved that a case with no renal ischemia leads to improved postoperative renal function over a case performed with a short ischemic time. Case selection is crucial for success. Exophytic masses should be chosen initially. Dissection of the hilar vessels is prudent to allow for emergent vascular control in cases where bleeding occurs during off-clamp resection. At Washington University, we start the resection at the medial aspect of the mass. We dissect the mass away from the large vessels. Usually it is not difficult to develop this plane. In most cases, vessels feeding the mass are small and can be cauterized and divided. Once the mass has been mobilized away from the hilar vessels, the renal parenchyma on the cephalad, caudal, and lateral aspects can usually be divided with very little bleeding because most of the blood supply to
the mass has been controlled in the medial dissection. This technique evolved as we sought to minimize warm ischemic times by doing as much of the dissection as possible before clamping the vessels. Surprisingly, we found most masses could be resected without clamping the renal artery. Further study is needed to determine whether off-clamp minimally invasive partial nephrectomy improves patient outcomes. The authors have shown in this small series that excellent renal functional and oncologic outcomes can be achieved when managing complex renal masses without ischemia to the kidney using minimally invasive surgical techniques. Address correspondence to: Sherb Figenshau, MD Division of Urologic Surgery Washington University School of Medicine 4960 Children’s Place, Box 8242 St. Louis, MO 63110 E-mail: [email protected]
Division of Urologic Surgery, Washington University School of Medicine, St. Louis, Missouri.
195
21. Richstone L, Montag S, Ost M, et al. Laparoscopic partial nephrectomy for hilar tumors: Evaluation of short-term oncologic outcome. Urology 2008;71:36–40. 22. Frank I, Colombo JR, Rubinstein M, et al. Laparoscopic partial nephrectomy for centrally located renal tumors. J Urol 2006;175:849–852.
Address correspondence to: Arvin Koruthu George, MD The Smith Institute for Urology North Shore-LIJ Hofstra School of Medicine 450 Lakeville Road Suite M1 New Hyde Park, NY 11040 E-mail: [email protected]
Abbreviations Used BMI ¼ body mass index EBL ¼ estimated blood loss GFR ¼ glomerular filtration rate LPN ¼ laparoscopic partial nephrectomy ORT ¼ operative time RCC ¼ renal cell carcinoma WIT ¼ warm ischemia time
DOI: 10.1089/end.2013.0713
Editorial Comment for Salami et al. Sherb Figenshau, MD
T
he authors show that complex hilar lesions can be resected using minimally invasive surgical techniques without clamping the renal vessels. Everyone agrees that short warm ischemic times are better than long ischemic times for preserving postoperative renal function. It remains to be proved that a case with no renal ischemia leads to improved postoperative renal function over a case performed with a short ischemic time. Case selection is crucial for success. Exophytic masses should be chosen initially. Dissection of the hilar vessels is prudent to allow for emergent vascular control in cases where bleeding occurs during off-clamp resection. At Washington University, we start the resection at the medial aspect of the mass. We dissect the mass away from the large vessels. Usually it is not difficult to develop this plane. In most cases, vessels feeding the mass are small and can be cauterized and divided. Once the mass has been mobilized away from the hilar vessels, the renal parenchyma on the cephalad, caudal, and lateral aspects can usually be divided with very little bleeding because most of the blood supply to
the mass has been controlled in the medial dissection. This technique evolved as we sought to minimize warm ischemic times by doing as much of the dissection as possible before clamping the vessels. Surprisingly, we found most masses could be resected without clamping the renal artery. Further study is needed to determine whether off-clamp minimally invasive partial nephrectomy improves patient outcomes. The authors have shown in this small series that excellent renal functional and oncologic outcomes can be achieved when managing complex renal masses without ischemia to the kidney using minimally invasive surgical techniques. Address correspondence to: Sherb Figenshau, MD Division of Urologic Surgery Washington University School of Medicine 4960 Children’s Place, Box 8242 St. Louis, MO 63110 E-mail: [email protected]
Division of Urologic Surgery, Washington University School of Medicine, St. Louis, Missouri.
