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Adult Urology

perative Outcomes of Upper Poleaparoscopic Partial Nephrectomy:omparison of Lower Pole Laparoscopicnd Upper Pole Open Partial Nephrectomy

evin C. Zorn, Edward M. Gong, Frederick P. Mendiola, Albert A. Mikhail,arcelo A. Orvieto, Ofer N. Gofrit, Gary D. Steinberg, and Arieh L. Shalhav

BJECTIVES The intraoperative complexity of laparoscopic partial nephrectomy (LPN) for upper pole renaltumors is recognized. We report on the technical feasibility and operative outcomes of LPN forupper pole tumors (UPLPN) and lower pole tumors (LPLPN), and open partial nephrectomy(UPOPN) for upper pole tumors.

ETHODS We retrospectively reviewed our database of LPNs performed by a single surgeon from October2002 to February 2006. All solitary, upper and lower pole tumors in patients with a normalcontralateral kidney were included. The perioperative outcomes were assessed. UPOPNs per-formed in the same institution by a separate surgeon were analyzed and compared separately withthe UPLPN group.

ESULTS Three groups, UPLPN (20 patients), LPLPN (33 patients), and UPOPN (24 patients), wereanalyzed. The UPLPN and LPLPN groups had similar perioperative outcomes. The intraopera-tive and postoperative major complications were also comparable between the UPLPN andLPLPN groups (17% versus 12%, P � 0.68 and 22% versus 6%, P � 0.07, respectively). Themean pathologic tumor size was larger (3.2 versus 2.3 cm, P � 0.05) and the mean operative timesignificantly shorter (187 versus 244 minutes, P � 0.02) in the UPOPN group than in theUPLPN group. The UPOPN group had a trend toward fewer intraoperative complicationscompared with the UPLPN group (4% versus 17%, P � 0.17). The final pathologic surgicalmargins were negative in all three groups.

ONCLUSIONS LPN for upper pole renal tumors is technically feasible and may have comparable outcomes toLPN for lower pole tumors. However, performing open nephron-sparing surgery is still thestandard of care because it may offer fewer complications and reduce the risk of ischemic damage

to the kidney. UROLOGY 70: 28–34, 2007. © 2007 Elsevier Inc.

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aparoscopic partial nephrectomy (LPN) is becom-ing an established therapeutic modality in themanagement of small renal masses.1 Despite the

mergence of several minimally invasive ablative thera-ies, such as cryotherapy and radiofrequency ablation,PN is still the most comparable and oncologicallyquivalent alternative to open partial nephrectomyOPN) for small renal tumors.2 With increasing surgicalxperience and the advancement of laparoscopic instru-entation, the indications for nephron-sparing surgery

NSS) and LPN have expanded.3–6 However, despite therowing experience, the inherent intraoperative techni-

rom the Section of Urology, Department of Surgery, University of Chicago Pritzkerchool of Medicine, Chicago, Illinois

Reprint requests: Kevin C. Zorn, M.D., Section of Urology, Department of Surgery,niversity of Chicago Pritzker School of Medicine, 5841 South Maryland Avenue,

wC6038 J-653, Chicago, IL 60637. E-mail: kevinzorn@hotmail.comSubmitted: September 18, 2006; accepted (with revisions): February 27, 2007

8 © 2007 Elsevier Inc.All Rights Reserved

al complexity of this procedure has limited its accep-ance as the standard of care in the general urologicommunity.7

Several institutions have described surgical techniqueso simplify LPN and improve the surgical outcome.8,9

owever, for a novice laparoscopist with less LPN expe-ience, certain preoperative considerations might influ-nce the decision to perform laparoscopic NSS. Thesenclude the tumor characteristics such as an upper or ailar location, collecting system involvement, renal in-ufficiency, and tumor size. These factors can result inore technically demanding surgery, increase the warm

schemia time,10 and result in poorer outcomes.Several investigators have reported their LPN experi-

nces with challenging tumor characteristics,3–5,11 suchs a hilar location. To the best of our knowledge, noublished studies have assessed the difficulty associated

ith upper pole renal tumors. We present our experience

0090-4295/07/$32.00doi:10.1016/j.urology.2007.02.059

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igure 1. (a) Right kidney with upper pole, lateral, exophytic renal tumor (A). Traction suture (B) has been placed justuperior to renal tumor at upper lateral aspect of kidney, but not yet passed through abdominal wall and tumor not in optimalosition for excision. (b) Right renal tumor (arrow) after traction suture has been pulled and secured at skin level. Tumor in

riangulation with surgical instruments and camera for optimal excision.

Table 1. Comparison of baseline demographic data on upper and lower pole LPN and OPN for renal tumor

Characteristic Lower Pole LPN P Value* Upper Pole LPN P Value† Upper Pole OPN

Patient dataPatients (n) 33 20 24Age (yr) 0.78 0.71

Mean 61.2 61.2 62.2Range 35–81 37–83 37–81

BMI (kg/m2) 0.18 0.34Mean 30.9 28.9 27.9Range 22.4–44.1 21.5–38.8 21.1–41.7

ASA score 0.68 0.62Mean 2.3 2.2 2.4Range 2–3 1–4 1–3

Sex 0.54 0.87Male 17 12 15Female 16 8 9

Preoperative creatinine (mg/dL) 0.23 0.17Mean 1.0 1.1 1.2Range 0.5–2.6 0.6–2.9 0.6–4.5

Previous abdominal surgery (n) 0.19 0.42Yes 16 6 10No 17 14 14

Tumor dataRadiographic tumor size (cm) 0.08 0.10

Mean 3.1 2.4 2.8Range 1.3–4.5 1–4 2–4.7

Laterality (n) 0.30 0.51Right 18 8 12Left 15 12 12

Tumor location (n) 0.22 0.44Anterior 9 (27) 8 (40) 11 (46)Posterior 10 (30) 2 (10) 5 (21)Lateral 14 (43) 10 (50) 8 (33)

Tumor depth (n) 0.72 0.72Exophytic 25 (76) 17 (85) 18 (75)Mesophytic 5 (15) 2 (10) 4 (17)Endophytic 3 (9) 1 (5) 2 (8)

LPN � laparoscopic partial nephrectomy; OPN � open partial nephrectomy; BMI � body mass index; ASA � American Society ofAnesthesiologists.Data in parentheses are percentages.* Between lower pole and upper pole LPN.

† Between upper pole LPN and upper pole OPN.

ROLOGY 70 (1), 2007 29

3

Table 2. Perioperative and pathologic outcomes among all groups

VariableLower Pole

LPN (n � 33) P Value*Upper Pole

LPN (n � 20) P Value†Upper Pole

OPN (n � 24)

Surgical dataOR time (min) 0.70 0.02

Mean 236 244 187Range 122–396 140–447 110–260

EBL (mL) 0.55 0.006Mean 244 197 306Range 20–1700 5–600 100–800

Ischemia time (min) 0.91 �0.001Mean 34.3 32.4 23.5Range 20–55 13–75 15–38

Collecting system injury and repair (n) 0.45 0.50Yes 18 (55) 13 (80) 21 (88)No 15 (45) 7 (20) 3 (12)

Open conversions (n) 1 (3) 0.48 2 (10) — NAHospital stay (days) 0.98 0.002

Mean 2.7 2.8 5.8Range 1–7 1–14 4–9

Postoperative creatinine (mg/dL) 0.72 0.21Mean 1.2 1.2 1.4Range 0.6–2.2 0.8–2.1 0.7–5.9

Transfusion rate (n) 2 (6) 0.05 5 (25) 0.04 1 (4)Intraoperative 1 2 0Postoperative 1 3 1

Complications (n)Intraoperative

MajorVascular hemorrhage 3 (9) 0.63 1 (6) 0.24 0Renal parenchymal 1 1 0Liver or spleen laceration 0 1 1Total 4 (12) 0.68 3 (17) 0.17 1 (4)

MinorSubcutaneous emphysema 1 0 0Total 1 (3) 0.45 0 0.94 0

Postoperative‡

MajorUrine leak 0 0 1 (4)Hemorrhage 1 (3) 0.08 3 (17) 0.17 1 (4)Pulmonary embolism 1 1 0Pleural effusion/pneumothorax 0 0 0.06 4 (17)Total 2 (6) 0.07 4 (22) 0.83 6 (25)

MinorArrhythmia 0 0 2UTI 1 0 0Atelectasis 0 1 1Blurry vision 0 1 0Acute tubular necrosis 0 1 0Epididymitis 0 1 0Hip pain 1 0 0Muscle spasm 1 0 0Total 3 (9) 0.21 4 (22) 0.40 3 (12)

Pathologic data‡

Tumor size (cm) 0.06 0.05Mean 2.9 2.3 3.2Range 0.8–4.6 0.9–4.1 1.3–5

Positive surgical margin (n) 0 0.37 1 (5) 0.45 0Pathologic stage (n) 0.97 0.89

pT0§ 6 (19) 3 (17) 3 (13)pT1a 24 (75) 14 (78) 19 (79)pT1b 2 (6) 1 (5) 2 (8)

Histologic findings (n) 0.85 0.70Malignant 26 (81) 15 (83) 21 (87)

Clear cell RCC 20 12 15Chromophobe RCC 3 1 2Papillary RCC 3 2 4

Continued

0 UROLOGY 70 (1), 2007

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ith LPN in patients with upper pole renal tumors,escribing the modifications in operative technique toddress the technical considerations. We also retrospec-ively reviewed our results with LPN and compared co-orts of LPN of lower pole tumors and OPN of upper pole

esions.

ATERIAL AND METHODS

review of our database from October 2002 through February006 was performed after obtaining institutional review boardpproval. A total of 256 laparoscopic procedures for patientsith renal tumors were performed at our institution by a single

urgeon (A.L.S.), of which 166 were laparoscopic radical ne-hrectomy and 90 were LPN. Patients with a localized renalumor with a normal contralateral kidney were included in theeview. Patients with tumors involving the middle pole werexcluded from the study. A total of 20 patients underwent LPNor upper pole lesions (UPLPN group) and 33 patients under-ent LPN for lower pole lesions (LPLPN group). A “tumor

ize”-matched cohort of 24 patients who underwent OPN forpper pole tumors (UPOPN group) were randomly selectedrom our database of 186 OPNs performed from April 1995 touly 2005 by an open surgeon (G.D.S.).

Preoperatively, the patients were evaluated with a medicalistory, physical examination, urinalysis, chest x-ray, laboratorytudies, including serum creatinine determinations, and abdom-nal computed tomography to allow for intraoperative surgicallanning. The tumors were characterized as described by Finleyt al.12: tumor that extended less than 40%, 40% to 60%, andore than 60% off the natural surface of the kidney was defined

s endophytic, mesophytic, and exophytic, respectively.

PN Surgical Techniqueur LPN technique has previously been reported.8,13–15 In

rief, after hilar dissection, a laparoscopic ultrasonic probe wassed to delineate the tumor extent. Vascular clamping waserformed using endoscopic bulldog clamps (Klein Surgical,an Antonio, Tex). Tumor excision was performed with coldcissors, maintaining a safety margin of normal parenchyma oft least 0.5 cm. Argon beam coagulation of the tumor bed,ollowed by freehand suturing of the collecting system andajor bleeding sites, anchored and secured with a LapraTy clip,as then completed. Defect closure was completed with indi-

Table 2. Continued

VariableLower Pole

LPN (n � 33)

Benign 6 (19)Oncocytoma 2Angiomyolipoma 3Benign cyst 1

OR � operating room; EBL � estimated blood loss; UTI � urinaryTable 1.Data in parentheses are percentages.* Between lower pole and upper pole LPN.† Between upper pole LPN and upper pole OPN.‡ Excluding open conversions.§ Pathologic benign disease.

idual parenchymal sutures, securely cinched with the LapraTy r

ROLOGY 70 (1), 2007

lip. FloSeal was then placed in the closed defect space tourther secure hemostasis.

pper Pole LPN: Triangulation Techniqueur technical alterations for LPN have been previously de-

cribed with modifications depending on the tumor location.8,16

n brief, after mobilizing the entire kidney, the perinephric fatas dissected off the capsule, except for the peritumoral fat,hich was left over the tumor. Intraoperative ultrasonographyas used to delineate the tumor margins. Depending on thexact tumor location, a suspensory traction system was used toptimize and stabilize the kidney position. This traction sutureith a LapraTy clip on its end was passed as a figure-of-eight, 2m deep and 1.5 cm along the renal capsule, and then brought

ut through a preplanned site in the abdominal wall using aarter-Thomason suture closure device. The suture location on

he renal capsule, the direction of traction, and the abdominallacement of the suture all depend on the anteroposteriorocation of the tumor and whether it was a polar, medial, orateral tumor. A hemostat held the suture extracorporeally athe level of the skin. The suspension created by the tractionuture allowed the kidney to be positioned for optimal tumorisualization, excision, and suturing (triangulation between thewo working laparoscopic instruments; Fig. 1). The sling wassed for all upper pole tumors and only as needed (17%) for theower pole tumors.

PN Surgical TechniquePN was routinely performed through a transperitoneal ap-

roach. Intraoperative ultrasonography helped delineate theumor margins. Unlike LPN, in which the ischemia time oc-urred in a warm environment, OPN was performed with iceooling of the kidney. After cold scissor tumor excision withufficient margins, argon beam coagulation of the renal de-ect was performed. Injury of the collecting system was thenepaired with sutures, followed by meticulous oversewing ofhe individual blood vessels. Parenchymal closure was per-ormed with individual sutures with Surgicel bolsters forissue compression.

tatistical Analysistatistical comparisons were made between cohorts using base-

ine demographic data and were compared using the chi-squareest. Continuous variables are shown as mean values and com-ared using Student’s t tests and Fisher’s exact test, with cor-

alue*Upper Pole

LPN (n � 20) P Value†Upper Pole

OPN (n � 24)

3 (17) 3 (13)0 00 13 2

infection; RCC � renal cell carcinoma; other abbreviations as in

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elation between variables performed using the Pearson’s cor-

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elation coefficients, with P �0.05 considered statisticallyignificant.

ESULTShe baseline patient demographics are summarized inable 1. Three groups (UPLPN, LPLPN, and UPOPN)ere compared according to surgical approach and tumor

ocation. Age, sex, body mass index, American Society ofnesthesiologist scores, and preoperative serum creati-ine levels were similar between the UPLPN group andhe other groups. The mean radiographic tumor size inhe UPLPN group was comparable with that in thePLPN group (2.4 versus 3.1 cm, P � 0.08). Similarly, noignificant difference was noted in the tumor size betweenhe UPLPN and UPOPN groups (2.4 versus 2.8 cm, P �.10). The tumors were mostly exophytic in all groups,ith no significant differences in tumor depth among theroups. No differences were noted in tumor locationanterior, posterior, or lateral) or tumor literality betweenhe UPLPN group and the other study groups.

The intraoperative data are summarized in Table 2.he mean operative time, estimated blood loss, and ische-ia time were not significantly different between thePLPN and LPLPN groups. The UPOPN group, how-

ver had a significantly shorter mean operative time (187ersus 244 minutes, P � 0.02), shorter ischemia time23.5 versus 32.4 minutes, P �0.001), and higher esti-ated blood loss (306 versus 197 mL, P � 0.006)

ompared with the UPLPN group. All patients in thePOPN group required collecting system repair com-

ared with 65% and 55% in the LPLPN and UPLPNroups, respectively.

One open conversion (3%) was required in the LPLPNroup and two (10%) in the UPLPN group (P � 0.48).he LPLPN open conversion occurred because of persis-

ent parenchymal bleeding on hilar unclamping. An at-empt at laparoscopic resuturing was unsuccessful before aecision to convert to an open approach was made. Ofhe 2 patients requiring open conversion in the UPLPNroup, 1 had brisk renal arterial bleeding after an injuryo the renal artery and 1 had positive margins on frozenection analysis.

As expected, the hospital stay was significantly longeror the UPOPN group than for the UPLPN group (P �.002). A similar hospital stay length was noted betweenhe LPLPN and UPLPN groups.

The incidence of major and minor intraoperative com-lications was similar among all groups (Table 2). Thencidence of major postoperative complications wasreater in the UPLPN group than in the LPLPN group22% versus 6%, P � 0.07). Most such complicationsere hemorrhagic (17% versus 3%, P � 0.08). In thePOPN group, 1 patient had a perinephric fluid collec-

ion secondary to a urine leak that eventually resolvedfter radiographic replacement of a Jackson-Pratt drain.he incidence of minor postoperative complications did

ot differ significantly among the three groups. c

2

Renal cell carcinoma was confirmed in 83%, 81%, and7% of the patients in the UPLPN, LPLPN, and UPOPNroups, respectively. The mean pathologic size wasignificantly larger in the UPOPN group than in thePLPN group (3.2 versus 2.3 cm, P � 0.05). Other than

he 1 patient in the UPLPN group with a positive surgicalargin noted intraoperatively whose surgery was con-

erted to an open approach for management, no otherositive surgical margin was noted in all groups on finalathologic examination.

OMMENTPN remains the established standard for NSS of renal

umors.16 Recently published series have stated thatelective” NSS provides optimal long-term oncologicfficacy in properly selected patients with localized renalell carcinoma.18 With the expanding criteria for NSSnd the advancement of laparoscopic instrumentationnd pharmaceutical hemostatic agents, the indicationsor this procedure have expanded.

Because of rib cage encasement, upper pole lesionsepresent a significant technical challenge for the open,nd more so for the laparoscopic, approach. The limitedisualization and compromised tumor positioning forapid and efficient suturing of resected upper pole tumorsre an impediment to the novice laparoscopist. Thisifficult anatomic tumor location is the reason manyatients with a small renal tumor in the upper pole whoight otherwise be a candidate for NSS are undergoingPN or laparoscopic radical nephrectomy.19

In our series, we used techniques to facilitate renalositioning (using a suspension traction system and otherodifications), thereby allowing better upper pole access

or precise tumor excision and efficient hemostasis andenal reconstruction during the critical steps of LPN16

Fig. 1). The principle of leaving a handle of fat on topf the tumor is very helpful in providing increased ma-euverability after renal positioning by the traction sys-em. Our data have demonstrated the similarity in oper-tive outcomes in both LPN groups, which could bettributed to our surgical modifications.

In their initial LPN experience, Ramani et al.20 re-orted that the most common complications were relatedo intraoperative hemorrhage. Our study demonstratedomparable intraoperative hemorrhage results with a sim-lar incidence in the UPLPN and LPLPN groups (P �.63). The likely causes of persistent parenchymal bleed-ng were an unoccluded renal artery in the settingf multiple vessels or bulldog clamp malfunction, both ofhich were not associated with the primary location of

he tumor.Our study did demonstrate that upper pole renal tu-ors, relative to lower pole tumors, were associated withtrend toward a greater incidence of postoperative hem-rrhage after LPN, although statistical significance wasot reached (17% versus 3%, P � 0.08). These compli-

ations occurred even though complete hemostasis on

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ilar unclamping had been noted in all cases. No obviousrecipitating factor could be found in these cases, al-hough inadequate parenchymal repair might be the mostlausible explanation. Gill et al.21 emphasized that theest management of postresection parenchymal hemor-hage is preventive through well-functioning vascularnstruments for hilar control and meticulous oversewingf transected vessels.Our results are similar to previously reported series byill et al.21 in that LPN, compared with OPN, requiredlonger warm ischemia time and resulted in less blood

oss, shorter hospital stay, and more rapid convalescence.hey also concluded that LPN was associated with areater incidence of intraoperative and renal/urologicomplications compared with those in the open group.21

n our study, despite the larger pathologic tumor size inhe open group compared with the laparoscopic upperole group, the latter had a greater incidence of intraop-rative and postoperative hemorrhagic complications.

No urinary leakage was observed in either LPN group,nd 1 patient in the OPN group (5%) had a significantostoperative urine leak. This difference could have beenelated to the larger pathologic tumor size (requiringeeper resection) and greater need for collecting systemepair in the OPN group. Other series have reportedimilar urinary leakage rates after OPN.22 Our data haveeaffirmed that watertight suture repair of the collectingystem can be accomplished with similar efficacy usinghe laparoscopic approach regardless of tumor location.

This study had several limitations that warrant discus-ion. The retrospective nature of the study using datarom a single institution, with small patient numbers,ust be noted. Furthermore, the comparison between

wo surgeons’ experience also might have added an in-erent weakness to the study. However, a cohort ofatients with upper pole lesions of comparable radiologicumor size was selected from the OPN database for com-arison. A significant difference between the radio-raphic and pathologic tumor size was noted. Such ahange could have been related to the three-dimensionalumor configuration, in that the largest radiographiceasurement taken with standard axial imaging mightot have been accurate, especially for the OPN group forhom the imaging was performed between 1995 and005. Ultimately, the UPOPN group had a significantlyarger tumor size compared with those of the UPLPNroup.

Our study has highlighted the technical feasibility ofPN in upper pole tumors. The similarity in the opera-ive outcomes between the UPLPN and LPLPN groupsas proved that the difficulty associated with tumor lo-ation can be overcome with modifications in surgicalechnique. With regard to positive surgical margins, theesults in our LPN groups were comparable with those ofther OPN21,23,24 and LPN series.6,17,18,21,25 However, its important to realize that this procedure is associated

ith a very steep learning curve.25,26 At present, OPN

ROLOGY 70 (1), 2007

till offers lower complication rates compared with theaparoscopic approach. We believe that with continuousrowth in experience and additional developments inechnique and pharmacologic and hemostatic tools,chieving comparable results to OPN could be possible.

ONCLUSIONSPN can be performed in patients with peripheral smallenal tumors, regardless of location. We believe that withechnical modifications, LPN for upper pole lesions cane performed with optimal tumor positioning for excisionnd repair, thereby replicating surgery for lower poleumors. The decision to perform NSS laparoscopicallyill ultimately depend on the surgeon’s level of experi-nce. Performing open NSS is still the standard of careecause it seems to result in fewer complications andeduce the risk of ischemic damage to the kidney.

eferences1. Albqami N, and Janetschek G: Laparoscopic partial nephrectomy.

Curr Opin Urol 15: 306–311, 2005.2. Finelli A, and Gill IS: Laparoscopic partial nephrectomy: contem-

porary technique and results. Urol Oncol 22: 139–144, 2004.3. Gill IS, Colombo JR Jr, Frank I, et al: Laparoscopic partial nephrec-

tomy for hilar tumors. J Urol 174: 850–854, 2005.4. Reisiger K, Venkatesh R, Figenshau RS, et al: Complex laparo-

scopic partial nephrectomy for renal hilar tumors. Urology 65:888–891, 2005.

5. Finelli A, Gill IS, Desai MM, et al: Laparoscopic heminephrectomyfor tumor. Urology 65: 473–478, 2005.

6. Rassweiler JJ, Abbou C, Janetschek G, et al: Laparoscopic partialnephrectomy: the European experience. Urol Clin North Am 27:721–736, 2000.

7. Gerber GS, and Stockton BR: Trends in endourologic practice:laparoscopic partial nephrectomy. J Endourol 19: 21–24, 2005.

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UROLOGY 70 (1), 2007