This document summarizes guidelines and techniques for partial nephrectomy. It discusses:
1. Indications for partial nephrectomy based on AUA guidelines.
2. Patient positioning and port placement techniques.
3. Methods for renal cooling, clamping techniques, and the debate around mannitol use.
4. Techniques for complex tumors like hilar and endophytic lesions, including the use of intraoperative ultrasound.
Colorectal anastomosis leaks are most difficult to manage for a surgeon carrying morbidity and mortality. Discussion on risk factors as well as management of anastomotic leak.
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http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
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Colorectal anastomosis leaks are most difficult to manage for a surgeon carrying morbidity and mortality. Discussion on risk factors as well as management of anastomotic leak.
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http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
Management of renal cell carcinoma - presented at Asian Oncology Summit 2013Siewhong Ho
Dr Ho lectured at the Asian Oncology Summit 2013 in Bangkok on the surgical opinion on management of renal cell carcinoma. He presented to a varied audience of medical oncologist, radiation oncologist, urologists, researchers, para clinical staff and nurses. The most interesting aspect of the lecture was on the role of urologists in management of Stage 4 kidney cancer in the era of 'targeted therapy'. The role of cytoreductive nephrectomy was reviewed potential future developments in this area was discussed
A prostate biopsy is a procedure used to obtain tissue samples from the prostate gland in order to detect cancer. The biopsy is best performed with a spring-driven needle core biopsy device (or biopsy gun)
No prostate-specific antigen (PSA) value can establish with absolute certainty whether a patient has prostate cancer. Thus, the decision to proceed with prostate biopsy must be individualized. Urinary biomarkers have been shown to be useful in identifying patients at risk for prostate cancer prior to the initial biopsy. [1]
Even more difficult is the decision to perform a repeat biopsy. Patients with atypical small acinar neoplasia have an absolute indication for repeat biopsy soon after the initial biopsy. However, patients with focal high-grade prostatic intraepithelial neoplasia (HGPIN) do not need to undergo automatic biopsy, because they are not at significantly higher risk for prostate cancer. By contrast, patients with multifocal HGPIN are at significant risk for prostate cancer and should undergo delayed interval biopsy every 3 years as long as they remain healthy. Patients who have persistently abnormal or rising PSA levels or very low percentages of free PSA (< 13%) are at some risk for harboring unrecognized prostate cancer and thus should be considered for repeat biopsy.
Contraindications for prostate biopsy include the surgical absence of a rectum or the presence of a rectal fistula.
The complications encountered after TRUS biopsy are commonly minor and self-limited, including mild hematuria, hematospermia, and transient rectal bleeding. Urinary tract infection is another frequently noted complication of prostate biopsy.
Dr Ho Siew Hong shared his experience on how to perform the ideal puncture for PCNL in a lecture to Asian urologists during the Advanced Urology Course 2008 in Singapore
Minimal invasive Surgery in Management of colorectal cancerpiyushpatwa
Laparoscopic Anterior resection. After insertion of ports with patient in steep trendelenburg position Inferior mesenteric artery was identified and high ligation done with division of left colic artery and then medial to lateral dissection was done. Subsequently inferior mesenteric vein was dissected and clipped and divided. Distal dissection proceeded just behind the superior rectal artery and after identification and preservation of the hypogastric nerves, upper rectum was mobilised. Division of bowel was done at upper rectum after giving adequate distal margin and end to end anastomosis was done using circular stapler.
Surgical and Medical management of Chronic Pancreatitis
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
Management of renal cell carcinoma - presented at Asian Oncology Summit 2013Siewhong Ho
Dr Ho lectured at the Asian Oncology Summit 2013 in Bangkok on the surgical opinion on management of renal cell carcinoma. He presented to a varied audience of medical oncologist, radiation oncologist, urologists, researchers, para clinical staff and nurses. The most interesting aspect of the lecture was on the role of urologists in management of Stage 4 kidney cancer in the era of 'targeted therapy'. The role of cytoreductive nephrectomy was reviewed potential future developments in this area was discussed
A prostate biopsy is a procedure used to obtain tissue samples from the prostate gland in order to detect cancer. The biopsy is best performed with a spring-driven needle core biopsy device (or biopsy gun)
No prostate-specific antigen (PSA) value can establish with absolute certainty whether a patient has prostate cancer. Thus, the decision to proceed with prostate biopsy must be individualized. Urinary biomarkers have been shown to be useful in identifying patients at risk for prostate cancer prior to the initial biopsy. [1]
Even more difficult is the decision to perform a repeat biopsy. Patients with atypical small acinar neoplasia have an absolute indication for repeat biopsy soon after the initial biopsy. However, patients with focal high-grade prostatic intraepithelial neoplasia (HGPIN) do not need to undergo automatic biopsy, because they are not at significantly higher risk for prostate cancer. By contrast, patients with multifocal HGPIN are at significant risk for prostate cancer and should undergo delayed interval biopsy every 3 years as long as they remain healthy. Patients who have persistently abnormal or rising PSA levels or very low percentages of free PSA (< 13%) are at some risk for harboring unrecognized prostate cancer and thus should be considered for repeat biopsy.
Contraindications for prostate biopsy include the surgical absence of a rectum or the presence of a rectal fistula.
The complications encountered after TRUS biopsy are commonly minor and self-limited, including mild hematuria, hematospermia, and transient rectal bleeding. Urinary tract infection is another frequently noted complication of prostate biopsy.
Dr Ho Siew Hong shared his experience on how to perform the ideal puncture for PCNL in a lecture to Asian urologists during the Advanced Urology Course 2008 in Singapore
Minimal invasive Surgery in Management of colorectal cancerpiyushpatwa
Laparoscopic Anterior resection. After insertion of ports with patient in steep trendelenburg position Inferior mesenteric artery was identified and high ligation done with division of left colic artery and then medial to lateral dissection was done. Subsequently inferior mesenteric vein was dissected and clipped and divided. Distal dissection proceeded just behind the superior rectal artery and after identification and preservation of the hypogastric nerves, upper rectum was mobilised. Division of bowel was done at upper rectum after giving adequate distal margin and end to end anastomosis was done using circular stapler.
Surgical and Medical management of Chronic Pancreatitis
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
Presentation delivered at 2020 AAOS annual meeting by Dr Adnan Saithna, Professor of Orthopedic Surgery, Overland Park, Kansas. This randomised controlled study demonstrates that combined ACL and anterolateral ligament reconstruction is not associated with an increased risk of adverse events when compared to isolated ACL reconstruction
review of literature for transjugular intrahepatic portosystemic shunt placement and balloon occluded retrograde transvenous obliteration in management of patients with varices hemorrhage
Ureteric stent versus percutaneous nephrostomy for acute ureteral obstruction - clinical outcome and quality of life: a bi-center prospective study
Urology Journal Club
Treatment of Pancreatic Neuroendocrine NeoplasmsDhaval Mangukiya
Information about Treatment of Pancreatic Neuroendocrine Neoplasms in clinical practice guidelines, management and tumors, practice changing study, Gastric NETs etc. by Dr Dhaval Mangukiya.
Details of Low Anterior Resection(LAR), Arterial Supply, Venous Drainage, Ports, Position, Modified Lithotomy, Vessel Ligation, Lymph Nodes, Nerves Anatomy, Superior Hypogastric Plexus, Lateral Pelvic Nerves, Correct TME, Anastomosis etc.
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http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
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Background: Resectability Criteria for Colorectal Liver Metastases (CRLM) have expanded, and advances in liver surgery have increased the number of patients eligible for resection. Identifying risk factors for early recurrence to help stratify CRLM patients will contribute to targeted management of these patients, including surveillance follow-up.Objectives: To identify risk factors for early recurrence post-resection for CRLM in a contemporary cohort of patients. Early recurrence was defi ned based on unit protocol as evidence of recurrent disease on follow-up imaging within one year of surgery.Methods: From January 2012 to December 2016, 133 patients with CRLM underwent liver resection in our Unit; 115 patients followed up for at least a year were eligible. We analysed pre-operative variables (sex, age, BMI, comorbidities, CEA and Liver function tests (LFTs), lesion number, size of largest liver lesion, neoadjuvant chemotherapy), operative variables (anatomical vs non-anatomical, major vs minor, redo liver surgery, concomitant use of ablation techniques, blood loss, blood transfusions, Pringle’s manoeuvre), and post-operative variables (complications, length of hospital stay, histological parameters) were analysed.
Endoscopic ultrasonography (EUS) is an outpatient procedure
During an EUS procedure, an upper gastrointestinal (GI) scope is inserted into the esophagus through the mouth to obtain ultrasonographic as well as endoluminal images of various upper gastrointestinal pathologies.
Radical Salvage Prostatectomy with Pelvic Lymphadenectomy Extended Post Primary Treatment with Prostate Radiotherapy - Case Report and Literature Review by Daniel Savoldi Juraski, MD; Rodrigo Galves Mesquita Martins, MD; Diogo Eugenio Abreu da Silva, MsC; Tomás Accioly de Souza, MD and José Anacleto Dutra de Resende* in Experimental Techniques in Urology & Nephrology
Fast-track surgery - the role of the anaesthesiologist in ERASscanFOAM
A presentation by Narinder Rawal at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
Empowering ACOs: Leveraging Quality Management Tools for MIPS and BeyondHealth Catalyst
Join us as we delve into the crucial realm of quality reporting for MSSP (Medicare Shared Savings Program) Accountable Care Organizations (ACOs).
In this session, we will explore how a robust quality management solution can empower your organization to meet regulatory requirements and improve processes for MIPS reporting and internal quality programs. Learn how our MeasureAble application enables compliance and fosters continuous improvement.
How many patients does case series should have In comparison to case reports.pdfpubrica101
Pubrica’s team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
https://pubrica.com/academy/case-study-or-series/how-many-patients-does-case-series-should-have-in-comparison-to-case-reports/
Global launch of the Healthy Ageing and Prevention Index 2nd wave – alongside...ILC- UK
The Healthy Ageing and Prevention Index is an online tool created by ILC that ranks countries on six metrics including, life span, health span, work span, income, environmental performance, and happiness. The Index helps us understand how well countries have adapted to longevity and inform decision makers on what must be done to maximise the economic benefits that comes with living well for longer.
Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
Professor Orazio Schillaci, Minister of Health, Italy
Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
Dr Karin Tegmark Wisell, Director General, Public Health Agency of Sweden
CRISPR-Cas9, a revolutionary gene-editing tool, holds immense potential to reshape medicine, agriculture, and our understanding of life. But like any powerful tool, it comes with ethical considerations.
Unveiling CRISPR: This naturally occurring bacterial defense system (crRNA & Cas9 protein) fights viruses. Scientists repurposed it for precise gene editing (correction, deletion, insertion) by targeting specific DNA sequences.
The Promise: CRISPR offers exciting possibilities:
Gene Therapy: Correcting genetic diseases like cystic fibrosis.
Agriculture: Engineering crops resistant to pests and harsh environments.
Research: Studying gene function to unlock new knowledge.
The Peril: Ethical concerns demand attention:
Off-target Effects: Unintended DNA edits can have unforeseen consequences.
Eugenics: Misusing CRISPR for designer babies raises social and ethical questions.
Equity: High costs could limit access to this potentially life-saving technology.
The Path Forward: Responsible development is crucial:
International Collaboration: Clear guidelines are needed for research and human trials.
Public Education: Open discussions ensure informed decisions about CRISPR.
Prioritize Safety and Ethics: Safety and ethical principles must be paramount.
CRISPR offers a powerful tool for a better future, but responsible development and addressing ethical concerns are essential. By prioritizing safety, fostering open dialogue, and ensuring equitable access, we can harness CRISPR's power for the benefit of all. (2998 characters)
Explore our infographic on 'Essential Metrics for Palliative Care Management' which highlights key performance indicators crucial for enhancing the quality and efficiency of palliative care services.
This visual guide breaks down important metrics across four categories: Patient-Centered Metrics, Care Efficiency Metrics, Quality of Life Metrics, and Staff Metrics. Each section is designed to help healthcare professionals monitor and improve care delivery for patients facing serious illnesses. Understand how to implement these metrics in your palliative care practices for better outcomes and higher satisfaction levels.
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
R3 Stem Cells and Kidney Repair A New Horizon in Nephrology.pptxR3 Stem Cell
R3 Stem Cells and Kidney Repair: A New Horizon in Nephrology" explores groundbreaking advancements in the use of R3 stem cells for kidney disease treatment. This insightful piece delves into the potential of these cells to regenerate damaged kidney tissue, offering new hope for patients and reshaping the future of nephrology.
Telehealth Psychology Building Trust with Clients.pptxThe Harvest Clinic
Telehealth psychology is a digital approach that offers psychological services and mental health care to clients remotely, using technologies like video conferencing, phone calls, text messaging, and mobile apps for communication.
Deep Leg Vein Thrombosis (DVT): Meaning, Causes, Symptoms, Treatment, and Mor...The Lifesciences Magazine
Deep Leg Vein Thrombosis occurs when a blood clot forms in one or more of the deep veins in the legs. These clots can impede blood flow, leading to severe complications.
One of the most developed cities of India, the city of Chennai is the capital of Tamilnadu and many people from different parts of India come here to earn their bread and butter. Being a metropolitan, the city is filled with towering building and beaches but the sad part as with almost every Indian city
2. 1 – INDICATIONS
• AUA guidelines (2017) –
– Prioritize PN for cT1a renal mass
– Prioritize PN – solid / complex cystic (Bosniak 3/4)
renal masses in patients with –
• Solitary Kidney – Anatomic / Functional
• Bilateral tumors
• Known Familial RCC
• Pre-existing CKD or Proteinuria
3. – Consider PN – solid / complex cystic (Bosniak 3/4)
renal masses in patients with –
• Young Patients
• Multifocal masses
• Comorbidities likely to impact renal function – DM/HTN
• T1b & T2 tumors – good oncologic results, but with
increased risk of peri-operative complications*
• Mir MC, Derweesh I, Porpiglia F, Zargar H, Mottrie A, Autorino R. Partial Nephrectomy Versus
Radical Nephrectomy for Clinical T1b and T2 Renal Tumors: A Systematic Review and Meta-
analysis of Comparative Studies. Eur Urol. 2017 Apr;71(4):606–17.
4. 2 – Patient Positioning
Modified Flank Full Flank
Used in (Approach) Transperitoneal Retroperitoneal
Flank up angle 45° 90°
Axillary Roll Not required Required
Neuromuscular Injury
•Rhabdomyolysis 0-5%
•Brachial plexus injury 1-3%
Reduced Risk
9. 5 – Renal Cooling
• Used for complex lesions with prolonged expected
warm ischemia time (>30min)
• Methods –
– Surface cooling with ice-slush
– Retrograde cold saline instillation via ureteral catheter
– Intra-arterial cold perfusion
10. • Cold ischaemia during RAPN (Ramirez et al.)*
– Feasible with good safety profile. (Ice slush)
– 13% improvement in preservation of postoperative eGFR.
– No difference at 6-month follow-up.
Ramirez D, Caputo PA, Krishnan J, Zargar H, Kaouk JH. Robot-assisted partial nephrectomy with
intracorporeal renal hypothermia using ice slush: step-by-step technique and matched
comparison with warm ischaemia. BJU Int. 2016 Mar;117(3):531–6.
11. 6 – MANNITOL
• NO evidence for mannitol use.
• Mannitol use did NOT improve short- or long-term
renal function even in patients with lower pre-
operative renal function (Wong et al)*
Wong NC, Alvim RG, Sjoberg DD, Shingarev R, Power NE, Spaliviero M, et al. Phase III Trial of
Intravenous Mannitol Versus Placebo During Nephron-sparing Surgery: Post Hoc Analysis of 3-yr
Outcomes. Eur Urol Focus. 2019 Nov;5(6):977–9.
12. • Intra-operative 12.5gm mannitol infusion during NSS
did not result in renal function improvement at 6m
(RCT by Spaliviero et al)*
Spaliviero M, Power NE, Murray KS, Sjoberg DD, Benfante NE, Bernstein ML, et al. Intravenous
Mannitol Versus Placebo During Partial Nephrectomy in Patients with Normal Kidney Function:
A Double-blind, Clinically-integrated, Randomized Trial. Eur Urol. 2018;73(1):53–9.
13. 7 – Method of Artery clamping
• Laparoscopic Satinsky clamp –
– Faster en-block clamping.
– Requires an additional 10-12mm port.
– Risk of inadvertent slippage.
– Not useful in retroperitoneal approach – less space.
• Bulldog clamp –
– application requires meticulous artery dissection
– Technical difficulty in manipulation – may increase WIT.
14. • Vascular Torniquet*
– Doesn’t require additional port.
– Not limited by number of vessels.
– Can be left in-situ after reperfusion for emergency re-
occlusion if needed.
Shefler A, Ghazi A, Zimmermann R, Janetschek G. Renal hilus clamping with tourniquet
during laparoscopic partial nephrectomy. BJU Int. 2011 May 1;107(10):1688–93.
16. 8 – Artery-Vein vs Artery-only clamp
• Recent Meta-analysis by Cao et al*
• AO clamping group had significantly lower RENAL score.
• No significant difference detected w.r.t. warm ischemia,
operating time, and estimated blood loss.
• No significant difference in early postop renal function
• Significantly better renal function (eGFR) preservation in long-
term with AO clamping group.
Cao J, Zhu S, Ye M, Liu K, Liu Z, Han W, et al. Comparison of Renal Artery vs Renal Artery-Vein
Clamping During Partial Nephrectomy: A System Review and Meta-Analysis. J Endourol. 2020
Apr;34(4):523–30.
17. • Postop decrease in regional (99m)Tc-MAG3 uptake
was significantly less in the AO group when the
ischemic time was ≥25 minutes (Funahashi et al)
Funahashi Y, Kato M, Yoshino Y, Fujita T, Sassa N, Gotoh M. Comparison of renal ischemic
damage during laparoscopic partial nephrectomy with artery-vein and artery-only clamping. J
Endourol. 2014 Mar;28(3):306–11.
18. 9 – Off-clamp Partial Nephrectomy
• Meta-analysis (Liu et al)* – Off-clamp PN had a –
• Higher blood transfusion rate
• Lower overall postoperative complication rate
• Lower positive margin rate
• Better preservation of renal function
Liu W, Li Y, Chen M, Gu L, Tong S, Lei Y, et al. Off-clamp versus complete hilar control partial
nephrectomy for renal cell carcinoma: a systematic review and meta-analysis. J Endourol. 2014
May;28(5):567–76.
19. • Meta-analysis (Antonelli et al)* –
• Off-clamp robot-assisted PN is reserved to smaller &
less complex renal masses.
• Under such conditions, no differences with the on-
clamp approach.
Antonelli A, Veccia A, Francavilla S, Bertolo R, Bove P, Hampton LJ, et al. On-clamp versus off-
clamp robotic partial nephrectomy: A systematic review and meta-analysis. Urologia. 2019
May;86(2):52–62.
20. Off-clamp techniques
• Enucleation and laser ablation of the tumor bed
• Focal radio-frequency coagulation
• Nonischemic hydrodissection
• Sharp resection with parenchymal clamping
• Preoperative superselective transarterial embolization
(P-STE)
21. • Selective arterial clamping
• Anatomical zero-ischemia MIPN - microsurgical clips
on tumor-specific tertiary or higher-order arterial
branches
22. Warm Ischemia Time
• Traditional safety limit of WIT – 30min
• Study by Dong et al* – 401 patients undergoing PN
• Each additional 10min of warm ischemia associated
with only 2.5% decline in recovery from ischemia.
Dong W, Wu J, Suk-Ouichai C, Caraballo Antonio E, Remer EM, Li J, et al. Ischemia and Functional
Recovery from Partial Nephrectomy: Refined Perspectives. Eur Urol Focus. 2018;4(4):572–8.
23. • Study by Rosen et al* –
• Extended WIT – worse perioperative outcomes with AKI &
short term decline in renal function.
• Extended WIT – Not significantly associated with renal
function decline at 1 year.
Rosen DC, Kannappan M, Paulucci DJ, et al. Reevaluating Warm Ischemia Time as a Predictor of
Renal Function Outcomes After Robotic Partial Nephrectomy. Urology. 2018;120:156‐161.
doi:10.1016/j.urology.2018.06.019
24. • Recent Meta-analysis (Greco et al)* showed that none of
the available ischemia techniques, Cold, Warm, or
Zero ischemia, is universally superior to the others.
Greco F, Autorino R, Altieri V, Campbell S, Ficarra V, Gill I, et al. Ischemia Techniques in
Nephron-sparing Surgery: A Systematic Review and Meta-Analysis of Surgical, Oncological, and
Functional Outcomes. Eur Urol. 2019;75(3):477–91.
25. Margin estimation without haptic feedback
• IOUS
• Image guided surgery (IGS) – three dimentional
constructed image used to guide resection.
26. • TilePro image guidance software for intra-op
tumor anatomy delineation
Hughes-Hallett, A., Pratt, P., Mayer, E., Martin, S., Darzi, A., & Vale, J. (2014). Image Guidance for
All—TilePro Display of 3-Dimensionally Reconstructed Images in Robotic Partial Nephrectomy.
Urology, 84(1), 237–243. doi:10.1016/j.urology.2014.02.051
27. IOUS
• Estimate tumor size & depth.
• Especially useful in complex tumors –
– Hilar tumors
– Predominantly Endophytic tumors
• Indications not standardized.
28. • Review article* – IOUS for NSS in patients with
technically challenging tumors
– promising oncological results – >90% negative margin rate,
comparable to exophytic tumor PN.
Rodríguez-Monsalve M, Del Pozo Jiménez G, Carballido J, Castillón Vela I. [The role of intraoperatory
ultrasound in laparoscopic partial nephrectomy for intrarenal tumors.]. Arch Esp Urol.
2019;72(8):729‐737.
29. Hilar & Completely Endophytic tumor
• Hilar Tumor – located in renal hilum in direct contact
with renal artery and/or vein.
• Central tumor – Tumor abutting or invading central
renal sinus fat and/or collecting system.
• IOUS – required to delineate tumor-parenchyma
interface.
30. • Recent systematic review* – completely endophytic
tumors – feasible with experienced surgeons
• Radio-guided occult lesion localization technique
(ROLL) facilitates localization and complete excision.
Perez-Ardavin J, Sanchez-Gonzalez JV, Martinez-Sarmiento M, et al. Surgical Treatment of
Completely Endophytic Renal Tumor: a Systematic Review. Curr Urol Rep. 2019;20(1):3.
Published 2019 Jan 16. doi:10.1007/s11934-019-0864-x
31. • Comparative study by Komninos et al*
– Increased risk of positive margins
– No increased risk of recurrence free survival
– No increased mortality
Komninos C, Shin TY, Tuliao P, et al. Robotic partial nephrectomy for completely endophytic
renal tumors: complications and functional and oncologic outcomes during a 4-year median
period of follow-up. Urology. 2014;84(6):1367‐1373. doi:10.1016/j.urology.2014.08.012
32. Posterior Tumors
• Retroperitoneal approach more favourable
• Meta-analysis – Posterior tumor location, did not
impact robotic partial nephrectomy outcomes*
Cacciamani GE, Gill T, Medina L, et al. Impact of Host Factors on Robotic Partial Nephrectomy
Outcomes: Comprehensive Systematic Review and Meta-Analysis. J Urol. 2018;200(4):716‐730.
doi:10.1016/j.juro.2018.04.079
33. • Polar Flip technique – Posterior hilar tumor
– Kidney is rotated by around 45 -60 degrees
– Lower pole faces anteriorly and upper pole posteriorly
– Increased posterior surface exposure & maneuverability
– initial flipping with dissection in Gil Vernet's plane to clip
posterior segmental renal artery
Chiruvella M, Ghouse SM, Tamhankar AS. "Polar flip" technique for transperitoneal
laparoscopic partial nephrectomy - Evolution of a novel technique for posterior hilar
tumors. Indian J Urol. 2019;35(3):230‐231. doi:10.4103/iju.IJU_235_18
34. Renorraphy over hemostatic bolster
• Achieve approximation, local compression and
hemostasis
• Multi-institutional survey (Europe and US)1: 16 out of
18 centers routinely used hemostatic bolster
[1042/1347 cases(70%)]
• SURGICEL® (Ethicon)-Oxidized Regenerated
Methylcellulose
• Spongostan®(Johnson & Johnson)porcine gelatin
absorbable sponge
Breda A, Stepanian S V, Lam J S, Liao J C, Gill I S, Colombo J R, Schulam P G. Use of
Haemostatic Agents and Glues during Laparoscopic Partial Nephrectomy: A Multi-Institutional
Survey from the United States and Europe of 1347 Cases. European Urology, 52(3), 798–803.
35. • Definitive advantage not proved by prospective study
• Parenchymal suturing with fibrin sealant and no
bolster has similar results in select(central) tumours
when PCS is not violated2
Weight, Christopher J., Brian R. Lane, and Inderbir S. Gill. Laparoscopic Partial Nephrectomy for
Selected Central Tumours: Omitting the Bolster. BJUI 100, no. 2 (August 2007): 375–78.
37. • No proper recommendation : lack of prospective
randomized trials
• Adjuncts to proper laparoscopic suturing – Not
substitutes
Galanakis, I, N Vasdev, and N Soomro. “A Review of Current Hemostatic Agents and Tissue Sealants
Used in Laparoscopic Partial Nephrectomy.” Reviews in Urology 13, no. 3 (2011): 131–38.
38. FIBRIN GLUE vs SUTURED BOLSTER
• Postoperative hemorrhage and urine leakage: 9% vs
2%
these cases were larger and nearer to the hilum
• Operating room time: 185 vs 210 minutes
• Blood loss : 398 vs 247 cc
• Hospital stay : 2.9 vs 2.6 days
Johnston William K., Montgomery Jeffrey S., Seifman Brian D., Hollenbeck Brent K., and Wolf J.
Stuart. “Fibrin Glue v Sutured Bolster: Lessons Learned during 100 Laparoscopic Partial
Nephrectomies.” Journal of Urology 174, no. 1 (July 1, 2005): 47–52.
39. • Closure using fibrin glue products -when the CS or
renal sinus is not entered
• When CS or renal sinus violated-sutured bolster is
recommended
40. Effect of suture material
• WIT is the strongest modifiable surgical risk factor for
postoperative chronic kidney disease
• Polyglactin 910 – Braided , resistance on tissue passage
• Polydioxonone – monofilament, stiff, difficult knotting
• Polyglecaperone- Monofilament, pliable – easy passage
and better knotting.
Riccardo B, Campi R, Klatte T, Kriegmair MC, Mir MC, Ouzaid I, Salagierski, et al. “Suture Techniques
during Laparoscopic and Robot-Assisted Partial Nephrectomy: A Systematic Review and Quantitative
Synthesis of Peri-Operative Outcomes.” BJU International 123, no. 6 (June 1, 2019): 923–46.
41. • Newer suture- V-LOC [Poly(glycolide-trimethylene
carbonate) copolymer]- self retaining
• Barbed suture significantly reduced warm ischemia
time.
Lin Y, Liao B, Lai S, et al. The application of barbed suture during the partial nephrectomy may
modify perioperative results: a systematic review and meta-analysis. BMC Urol. 2019 ;19(1):5.
Published 2019 Jan 10. doi:10.1186/s12894-018-0435-3