AUA 2003 Selected Abstracts — Endourology & Laparoscopy

295

ENDOSCOPIC MANAGEMENT OF UPPER TRACT TRANSITIONAL CELL CARCINOMA- LONG TERM EXPERIENCE

Siamak Daneshmand*, Jeffrey L Huffman, Los Angeles, CA.

Introduction and Objective: We determined the efficacy and long-term results of endoscopic management of upper tract transitional cell carcinoma. We evaluated the accuracy of endoscopic biopsy in regards to tumor grade in the subset of patients who underwent open surgical excision.

Methods: Between 1987 to 2001, 50 patients underwent ureteroscopy and resection of unilateral upper tract transitional cell carcinoma. Seventeen patients had a solitary kidney. Nine patients had no follow-up beyond the initial biopsy. Eleven patients underwent ureterectomy or nephroureterectomy shortly following endoscopic biopsy based on evidence for high-grade disease. The remaining 30 patients underwent endoscopic ablation of their primary tumor with laser (Holmium or Neo:YAG) or electrofulguration at time of the initial biopsy. Patients were followed by close endoscopic surveillance of their urinary tract at 3 to 4 month intervals.

Results: For the 30 patients who had endoscopic treatment of their tumors, mean and median follow-up was 36.5 and 29 months respectively, (range 4-102 months). On initial biopsy, 7 tumors were low grade (1 or 1-2), 4 were intermediate grade (2), and 14 were high grade (2-3, 3 or CIS). Grading was not available for 5 patients who had low grade appearing tumors on endoscopy. Each patient underwent an average of 6.3 endoscopic procedures. There were an average of 3.1 recurrences with average time to first recurrence of 7 months. Ten of the 30 patients underwent open resection (6 ureterectomies, 3 nephroureterectomies, 1 partial nephrectomy for a metastatic renal cell carcinoma to the ureter) during their follow-up. Six patients had progression of their tumor during follow-up. One of these patients, whose initial tumor was grade 2, developed distant metastatic disease. Three of these patients underwent open resection and are currently alive without disease progression. During the follow-up period, one patient died from recurrent disease, and 6 died from other causes. Endoscopic biopsy accurately predicted the grade of the tumor in 8 of the 9 patients who had open resection of their tumor within 2 months of the last biopsy and 10 of 11 patients who had open resection shortly following initial endoscopic biopsy (overall 18/20, 90%).

Conclusions: Endoscopic treatment of focal low-grade superficial transitional cell carcinoma of the upper urinary tract is feasible and safe provided vigilant follow-up and endoscopic surveillance is performed. Endoscopic biopsy provides accurate information regarding tumor grade.

J Kellogg Parsons*, Ioannis Varkarakis, Koon H Rha, Thomas W Jarrett, Peter A Pinto, Louis R Kavoussi, Baltimore, MD.

Introduction and Objective: We longitudinally analyzed complications of abdominal urologic laparoscopy at a single institution over a 5-year period after maturation of the institutional learning curve.

Methods: From 1996 to 2001, we identified 894 abdominal laparoscopic procedures performed at our institution: 600 nephrectomies (live donor, simple, radical, partial), 112 pyeloplasties, 61 renal biopsies, 35 retroperitoneal lymph node dissections, 18 adrenalectomies, and 68 other procedures. Charts were retrospectively reviewed for complications, which were classified as operative, post-operative, or medical. Complications were correlated with patient age and American Society of Anesthesiologists (ASA) score. Statistical analysis was performed with the Fisher′s exact and chi square tests.

Results: A total of 118 (13.2%) complications occurred. Two (0.2%) patients died and 14 (1.7%) underwent operative re-intervention for complications. The most common intraoperative complications were vascular (n=25), bowel (n=13), and adjacent organ (n=12) injuries. Of the intraoperative complications, 12 (23%) of 52 prompted conversion to open procedure. The most common postoperative complications were neuromuscular pain (n=12), wound infection (n=8), and hematoma (n=8). Differences in annual complication rates for all procedures did not attain significance (p=.5). Among all procedures excluding live donor nephrectomy, complications of any kind correlated with higher patient ASA scores (p=.01).

Conclusions: The overall incidence of laparoscopic complications did not change significantly over a 5-year period at our institution. Factors contributing to this observation likely included the progression of inexperienced individual surgeons through the learning curve, the introduction of new, more sophisticated laparoscopic procedures, and stable rates of patient co-morbidity. This experience may represent the average complication rates one may expect for laparoscopic abdominal surgery at a large volume academic training center after maturation of the institutional learning curve.

Yoshinari Ono*, Tsuneo Kinukawa, Ryohei Hattori, Momokazu Gotoh, Nagoya, Japan; Shin Yamada, Okazaki, Japan; Osamu Kamihira, Komaki, Japan; Shinichi Ohshima, Nagoya, Japan.

Introduction and Objective: To evaluate the efficacy of laparoscopic radical nephrectomy for patients with renal cell carcinomas, we analyzed clinical outcome of 243 patients who were laparoscopically treated between July 1992 and Sep 2002.

Methods: Of the 243 patients, 231 had pathologically proven renal cell carcinomas. Two hundred and twenty-four patients had localized disease and 7 had metastatic disease including 3 with lymphnode metastasis. Of the 224 patients, 203 had pT1 disease, 5 had pT2, 8 had pT3a, 4 had pT3b (thrombus within renal vein) and 2 had pT4. The patient follow-up lasted until September 30, 2002.

Results: In pT1 disease group (follow-up period; 1 to 122, median; 38 months), disease-free survival was 95% at 5 years and 90% at 10 years, and overall patient survival was 91% at 5 years and 81% at 10 years. Five pT2 disease patients are alive without recurrent disease during 5 to 50, median; 9 months follow-up period. Eight pT3a disease patients followed-up for 4 to 58, median; 31 months and four pT3b disease patients followed-up for 1to 20, median; 3 months also are alive without any recurrent disease. Two pT4 disease patients were converted to open surgery due to invasion to the psoas muscle and colon, respectively. Three patients with lymphnode disease are alive during 9 to 56 months follow-up period, but 2 have recurrent disease. Of 4 patients with metastatic disease, one is alive for 27 months and 3 died in 12 to 20 months after surgery.

Conclusions: Laparoscopic radical nephrectomy is an alternative to open radical nephrectomy for patients with localized renal cell carcinomas. However, a long-term follow-up is necessary to confirm its efficacy for patients with pT2 and pT3b disease.

RETROPERITONEOSCOPIC NEPHROURETERECTOMY FOR TRANSITIONAL CELL CARCINOMA OF THE RENAL PELVIS AND URETER: NAGOYA EXPERIENCE

Ryohei Hattori*, Yoshinari Ono, Momokazu Gotoh, Yasushi Yoshino, Shinichi Ohshima, Nagoya, Japan.

Introduction and Objective: To evaluate the efficacy of retroperitoneal laparoscopic nephroureterectomy for patients with transitional cell carcinomas of the renal pelvis and ureter, the outcomes of laparoscopy treated 65 patients were analyzed and were compared to those of 44 patients treated by open nephroureterectomy.

Methods: Sixty-five patients with transitional cell carcinoma of the upper urinary tract underwent retroperitoneal laparoscopic nephroureterectomy between August 1997 and August 2002. Patients' ages ranged from 36 to 86 years (mean: 66 years). In the initial 37 patients, the kidney was laparoscopically dissected in en bloc fashion together with the perirenal fatty tissue, lymph nodes and/or adrenal gland, and the lower ureter was resected with a bladder cuff through an additional 10 cm-length pararectal incision. In the latter 28 patients, the whole procedures of nephroureterectomy were accomplished laparoscopically, the ureteral end with a bladder cuff being transected using endoscopic GIA stapler. The dissected specimen was removed intact in both procedures.

Results: There were no significant differences in mean operating time (5.0 vs. 5.3 hours) and mean estimated blood loss (445 vs. 766ml) between the laparoscopy group and the open surgery group. Mean time to recovery to normal activity was significantly shorter in the laparoscopy group (29 vs. 65 days p<0.01). During the median follow-up period of 29 months in the laparoscopy group and 33 months in the open surgery group, the cause specific patient survival rate was 94% at 1 year and 91% at 5 years in the laparoscopic group and 95% at 1 year and 83% at 5 years in the open surgery group. The metastasis free survival rate was 88% at 1 year 72% at 5 years in the laparoscopy group, and 87% at 1 year and 75% at 5 years in the open surgery group. The bladder recurrence free survival rate was 80% at 1 year and 78% at 5 years in the laparoscopy group, 73% at 1 year and 55% at 5 years in the open surgery group.

Conclusions: Retroperitoneal laparoscopic nephroureterectomy is less invasive and might be an alternative to open nephroureterectomy. Retroperitoneal laparoscopic resection of the ureteral end with a bladder cuff is feasible, being a faster procedure. However, long-term follow-up is necessary to confirm the efficacy for a patient with transitional cell carcinoma of the renal pelvis and ureter.

300

THE INITIAL EVALUATION OF THE CYBERKNIFE TECHNOLOGY FOR EXTRACORPOREAL RENAL TISSUE ABLATION

Lee E Ponsky*, Micheal J Rosen, Edward E Cherullo, Elias Castillo, Jennifer Brainard, Raymond Rodebaugh, Richard Crownover, Andrew C Novick, Cleveland, OH.

Introduction and Objective: It is the intent of this study to determine whether the Cyberknife technology can be applied to renal tissue safely and effectively. The goal is to achieve the high efficacy of a surgical treatment, with the low morbidity of a non-invasive intervention.

Methods: The Cyberknife divides a beam of high dose radiation necessary to completely ablate a lesion, in up to 1200 beams, instead of the 1 traditionally utilized for standard radiation therapy. Each one of these beams of radiation has a significantly reduced dose. Therefore, the individual dose of each beam is essentially benign to the pathway and surrounding tissue. However, at the focal point of these beams, the dose is additive, and the desired ablative dose is attained.Predetermined bilateral kidney lesions in eight pigs were treated in-vivo. The kidneys were treated with a prescription dose escalated from 24 up to 40 Gray. Approximately 100 individual beams were used for each treatment, based upon the computer generated treatment plan. Kidneys were harvested at 4, 6 or 8 weeks after treatment. Histologic evaluation was performed.

Results: Sixteen kidneys were treated and analyzed for this study. Radiation changes were more evident after a longer treatment interval. In the targeted area,zones of complete fibrosis were characterized by dense, paucicellular connective tissue completely devoid of all normal kidney elements including tubules and glomeruli. Surrounding the targeted area, zones of partial fibrosis were characterized by loose, cellular fibrosis and granulation tissue with focal preservation of tubules and preservation of glomeruli. The renal parenchyma surrounding the area of partial fibrosis, was histologically normal in all kidneys.There was no evidence of any gross injury to any of the surrounding organs at the time of the kidney harvest.

Conclusions: The Cyberknife provides state-of-the-art radiosurgery. The major potential benefits of radiosurgical ablation of tumors of the kidney are; definative local control,non-invasive, minimal to no radiation-induced injury to nearby healthy tissue, and complete treatment in a one time session. This technique could potentially become the most effective and least invasive option for the treatment of renal cell carcinoma. This initial evaluation of the Cyberknife for the extracorporeal renal tissue ablation appears to be very promising. The technology is safe and effective in a porcine model. We are currently planning to evaluate its effect on renal tumors in humans.

ENDOSCOPIC SUBCUTANEOUS MODIFIED INGUINAL LYMPH NODE DISSECTION (ESMIL) FOR SQUAMOUS CELL CARCINOMA OF THE PENIS

Jay T Bishoff*, Lackland AFB, TX; Joseph W Basler, Joel M Teichman, Ian M Thompson, San Antonio, TX.

Introduction and Objective: Penile cancer frequently requires staging of inguinal lymph nodes to determine prognosis and survival. Lymphadenectomy can also be curative when cancer is isolated to the penis and regional nodes. Due to the substantial morbidity associated with inguinal lymphadenectomy, controversy surrounds the utility of bilateral and prophylactic dissection. The objective of this study was to determine the feasibility of applying laparoscopic techniques in an endoscopic subcutaneous modified inguinal lymphadenectomy (ESMIL), to decrease morbidity of the procedure by preserving the continuity of the lymphatic and vascular supply to the overlying skin.

Methods: ESMIL was performed in two fresh cadavers and one patient with T3N1M0 cancer. Elastic bandages were placed above the knee, around the penis, scrotum and torso to prevent subcutaneous emphysema. A 2.5-cm incision was made over the saphenous vein 15 cm below the pubic tubercle. Scissors developed a plane of dissection deep to Scarpa's fascia for 4-5 cm towards the femoral triangle and a Hasson trocar was inserted. A second 2.5-cm incision was placed 15 cm below the middle of the inguinal ligament. After the correct plane of dissection joined with the first, a Hasson trocar was inserted for the laparoscope. The working space was insufflated to a pressure of 5 mm Hg. A 5 mm threaded trocar was placed 15 cm below the iliac crest. The saphaneous vein was identified and lymph node bearing tissue dissected from the fascia lata to the fossa ovalis. Using ultrasonic energy, lymphatic and fatty tissue was removed from the adductor longus medially, the femoral artery laterally, the spermatic cord superiorly and the fossa ovalis inferiorly.

Results: An adequate working space was readily created after initial dissection into the correct plane at the initial trocar site. Hasson and threaded trocars prevented escape of C02 during dissection. A working pressure of 5 mm Hg was sufficient to maintain visualization and avoided spontaneous infiltration beyond the edge of dissection. Key landmarks were readily identified and transillumination of the skin facilitated orientation. The small space required frequent evacuation of accumulated water vapor for visualization. Adequate dissection of the fixed node at the fossa ovalis was difficult due to lack of manipulation superiorly.

Conclusions: ESMIL is a feasible new technique that may decrease morbidity associated with lymphadenectomy. Fixed nodal disease can be difficult to dissect due to limitations of the approach.

302

LAPAROSCOPIC RETROPERITONEAL LYMPH NODE DISSECTION FOR STAGE 1 NSGCT

James R Porter*, Paul H Lange, Seattle, WA

Introduction and Objective: The application of laparoscopic techniques to urologic procedures continues to evolve. Conventional open retroperitoneal lymphadenectomy (RPLND) for the staging of testicular cancer involves significant morbidity for the patient. Laparoscopic RPLND has been performed in limited series and we present our experience with this procedure as an alternative to the open technique.

Methods: Candidates for laparoscopic RPLND were diagnosed with clinical stage 1 NSGCT with negative markers or normalization of markers after orchiectomy. Preoperative CT scan of the chest and abdomen was negative in all patients. A transperitoneal approach was performed using a modified template dissection. Five ports were used on the right side and four ports on the left. A complete nodal dissection was performed including the interaortocaval and retrocaval nodes, as well as excision of the spermatic cord stump. Post-ganglionic splanchnic nerves were spared in select patients.

Results: 24 patients underwent 27 laparoscopic RPLND. Lap RPLND was performed on the right side in 10 patients, the left side in 11 and bilateral in 3 patients. The mean age of the group was 30.6 years. Mean operative time was 5.1 hours and mean estimated blood loss was 270cc. Pathologic review of the surgical specimens revealed a mean of 17 lymph nodes with 15 of 24 patients demonstrating positive lymph nodes. Complications occurred in three patients. One patient suffered flank neuropathy from positioning which resolved while another two patients experienced chylous ascites. The chylous ascites resolved with conservative measures. One patient with chylous ascites was discharged on post-operative day 12 and returned to normal activity at 6 weeks. Excluding this patient the mean day of discharge was post operative day 2.05, and the mean time of return to normal activity was 1.9 weeks. All patients report normal antegrade ejaculation. No patient required conversion to open to complete the procedure.

Conclusions: Laparoscopic retroperitoneal lymph node dissection is a viable technical alternative for the staging of testicular cancer. A complete lymph node dissection may be achieved with this technique. Patients benefit from reduced post operative pain, shorter hospital stay, and earlier return to normal activities.

304

A PROSPECTIVE COMPARISON OF ROBOT-ASSISTED ANATOMIC PROSTATECTOMY AND CONVENTIONAL RADICAL RETROPUBIC PROSTATECTOMY (RRP): THE VATTIKUTI UROLOGY INSTITUTE EXPERIENCE

Ashutosh Tewari*, Ram Desari, Ashok Hemal, James Peabody, M Hassan, Aditya Bansal, Richard Sarle, Mani Menon, Detroit, MI

Introduction and Objective: Robotic assistance enhances the precision of anatomical dissection and increases the feasibility of performing laparoscopic radical prostatectomy for most surgeons. We performed a prospective comparison of operative parameters in recent 312 patients under going Robot- Assisted Anatomical Prostatectomy (Vattikuti Institute Prostatectomy-VIP) and contemporary patients undergoing conventional Radical Retropubic Prostatectomy (RRP) at our institution.

Methods: The study design was a prospective non-randomized comparison of VIP performed with the daVinci Surgical System by a single surgical team . We evaluated a) baseline patient and tumor characteristics- age, serum Prostate Specific Antigen (PSA), biopsy, Gleason, clinical stage, body weight and height, b) intraoperative parameters- operative time, blood loss, need for transfusion, number of unites transfused c) post operative parameters- pain score, duration of hospitalization, percent of patients discharged in less than 1 day, catheter duration, d) histopathological parameters and e) complications in the two groups.

Results: The preoperative parameters were comparable for both groups. The mean operating time was 163 minutes (incision to closure) for RRP and 187 minutes hours for RAP (p<0.018). The mean blood loss was 910 ml for RRP and 167 ml for VIP (p<0.001). The drop in hemoglobin was greater in the RRP group 4.4 g vs. 1.2 g in VIP; p<0.05). Greater numbers of intra operative blood units were transfused in RRP group than VIP patients (75% versus 0%, p

Conclusions: In our analysis the VIP was safe and effective operation for the treatment of clinically localized prostate cancer. The blood loss, postoperative pain, Hemoglobin drop, hospitalization, catheter duration and margin status were favorable in VIP arm.

LAPAROSCOPIC ASSISTED PERCUTANEOUS NEPHROLITHOTOMY: BEST DONE TUBELESS?

Samuel C Kim*, Ramsay L Kuo, Ryan F Paterson, James E Lingeman, Indianapolis, IN.

Introduction and Objective: Treatment of urolithiasis in pelvic kidneys can be problematic. As the anatomical location of the pelvic kidney can vary, each individual case can present unique challenges. Some pelvic kidneys requiring percutaneous nephrolithotomy (PNL) are not anatomically amenable to a standard posterior flank approach. Laparoscopy can assist in placement of percutaneous access in these cases. Previous studies report placing ureteral catheters, nephrostomy tubes and/or abdominal drains after laparoscopic assisted percutaneous nephrolithotomy (Lap PNL). We present our experience of tubeless Lap PNL.

Methods: Lap PNL was performed on 5 patients. With the patient in dorsal lithotomy, a ureteral catheter was placed followed by a 3-port laparoscopic approach: an umbilical camera port, a right lower quadrant port, and a left lower quadrant port. Access was established using both fluoroscopic and visual guidance. Standard rigid and flexible PNL instruments were used through a 30F Amplatz sheath. The nephrotomy site was laparoscopically sutured with absorbable material. Either an open-ended catheter or an indwelling ureteral stent was placed for drainage. Follow-up noncontrast computed tomography (CT) or intravenous pyelogram (IVP) was performed and stone free was defined as negative radiographic imaging.

Results: Lap PNL was successfully performed on all 5 patients. Two patients had previous midline abdominal incisions requiring an alternate port configuration. Four patients had pelvic kidneys (2 right, 2 left) and 1 had a left-to-right crossed fused ectopia. Three patients were male; 2 were female. Mean hospital stay was 3 days. All patients were rendered stone free with a single procedure: 4 had negative CTs and 1 had a negative IVP. Stents were routinely removed 1 to 2 weeks post-operatively. One patient had an antegrade endopyelotomy performed concurrently and had stent removal after 6 weeks. This patient also had laparoscopic repair of a ventral hernia and another patient had concurrent contralateral ureteroscopy performed. No blood transfusions were required and no complications occurred.

Conclusions: Lap PNL should be considered when dystopic kidneys require PNL but are not able to be approached in the standard posterior flank fashion. Lap PNL can be performed successfully without the need for a nephrostomy tube and without complication with only ureteral catheter/stent drainage.

V421

LAPAROSCOPIC PARTIAL NEPHRECTOMY IN COLD ISCHEMIA: A NOVEL TECHNIQUE

Guenter Janetschek*, Hassan Al-Zahrani, George Vrabec, Karl Leeb, Linz, Austria; Michael Marberger, Vienna, Austria; Manfred Wirth, Dresden, Germany.

Introduction and Objective: The objectives of laparoscopic partial nephrectomy for renal cell carcinoma (RCC) should be similar to the open technique. Cold ischemia permits optimal tumor excision and renal reconstruction while preserving renal function. However, cold ischemia with laparoscopic partial nephrectomy remains unsolved. Our video presents a new technique obtaining cold ischemia during laparoscopy.

Methods: Cold ischemia is achieved by cold arterial renal perfusion. Prior to laparoscopy an angiocatheter is passed into the main renal artery through a femoral puncture. The renal artery is clamped by a tourniquet. The renal vein is secured with an umbilical tape, but not occluded. Perfusion is initiated with iced Ringer Lactate at 4 degrees celsius at a rate of 50 cc/min. Renal temperature is continously monitored with a thermoprobe residing in the parenchyma. When a parenchymal temperature of 25 degrees celsius is reached perfusion is reduced to maintain a steady state. Tumor excision is performed in a bloodless field with biopsy taken from the tumor bed. The collecting system is repaired, and renal reconstruction is performed using parenchymal sutures over a hemostatic bolster. All steps are done similar to the open partial nephrectomy. Between November 01 and September 02 nine patients (RCC: 8, pyelonephritic lower pole: 1) were operated using this technique. There were 6 men and 3 woman with a mean age of 52 years (29-67). Mean tumor size was 2.4 cm (2-3.5).

Results: Bloodless field was achieved in 8 cases and minor oozing from an accessory renal artery occured in one case. Total ischemia time was 27 to 71 minutes (mean 36 min). Renal hypothermia was maintained at 25 degrees celsius. Estimated blood loss was 30-650 cc (mean 135 cc); only one patient required transfusions. Adequate tumor excision with negative margins was acheived in all cases. One patient had a delayed bleeding which was managed by laparoscopic reexploration. No other postoperative complications were encountered. Postoperative renal function could be investigated in 4 patients with isotope nephrography and was essentially unchanged in all of them.

Conclusions: Our initial experience of incorporating cold ischemia into laparoscopic partial nephrectomy shows the feasibility and safety of this technique. We believe this approach will allow duplication of the principles of the open procedure and makes laparoscopic partial nephrectomy for RCC and complex renal pathology safe and reliable.

V422

LAPAROSCOPIC PARTIAL NEPHRECTOMY FOR RENAL TUMOR ASSISTED BY A WATER-COOLED HIGH-DENSITY MONOPOLAR RADIOFREQUENCY DEVICE WITHOUT RENAL VASCULAR CLAMPING

Ramakrishna Venkatesh*, David I Lee, Richard Vanlangendonk, Jamil Rehman, St. Louis, MO; Chandru P Sundaram, Indiana, IN; Jaime Landman, St. Louis, MO.

Introduction and Objective: Laparoscopic partial nephrectomy without renal hilar vascular control can be challenging due to hemorrhage and inadequate visualization of the surgical margin. We describe a technique of partial nephrectomy assisted by water-cooled high-density monopolar radiofrequency device (TissueLink Floating Ball-FB).

Methods: Initial device application was performed in a porcine model. Subsequently, partial nephrectomy with the assistance of FB (Tissue Link Medical Inc., Dover, NH) without hilar vascular clamping is demonstrated in a clinical case. The tumor was exposed through a transperitoneal approach and perinephric fat was dissected from the renal surface except overlying the tumor. The tumor was resected with cold laparoscopic scissors after application of the FB. After laparoscopic closure, the integrity of the collecting system was confirmed by administration of intravenous indigo carmine. The tumor bed was closed over oxidized Gelfoam gauze with intracorporeal suturing and covered with perinephric fat. No other hemostatic modalities were required.

Results: Between May 2002 and September 2002, we performed resection of 18 renal masses in 16 renal patients with the assistance of the FB. Twelve procedures were performed by a transperitoneal and 4 via a retroperitoneal approach. The mean renal mass size was 2.7 cm (range= 1-4 cm) and 75% of the lesions were partially exophytic. Solid and complex cystic lesions accounted for 82% and 18% of lesions respectively. Midrenal tumors accounted for 64% and the rest were in the polar regions. The mean patient age was 60 years (range=43-75), the mean ASA score was 3 (2-4). The mean operative time was 190 min (range= 70-340 min), and all the resection margins were free of tumor with 1-10mm margin. Two patients required closure of the collecting system. The average estimated blood loss was 370mL (range= 50-975mL) with 1 (6%) patient requiring blood transfusion. All the procedures were successfully completed laparoscopically. The hospital stay was 2 days (range= 2-4). There were 2 (12.5%) post-operative complications; a urinoma in one patient and ileus in one another.

Conclusions: In our experience, the FB facilitated effective and safe resection of small renal tumors with good parenchymal hemostasis without renal vascular control. FB partial nephrectomy can be performed without vascular control in the midrenal region close to the renal hilum without the need for intracorporeal suturing for hemostasis.

Herve Baumert*, Shahram S Gholami, Hugo Bermudez, Hugues Widmer, Antonio Renda, Xavier Cathelineau, Guy Vallancien, Paris, France.

Introduction and Objective: Medical management of lower urinary tract disease as well as alternative minimaly invasive therapies for bladder outlet oubstruction has contributed to decrease in the number of simple prostatectomies performed today. In order to minimize the morbidity of open adenomectomy, we have selected to treat these patients laparoscopicaly. In this video, we present our technique for laparoscopic simple prostatectomy.

Methods: Laparoscopic simple prostatectomy was performed in 20 patients, 10 simple retropubic and 10 simple suprapubic. The patients are positioned supine in a steep Tredelenburg position using a 5-port retroperitoneal technique. We demonstrate the simple retropubic adenomectomy in the video. The procedure is comprised of 7 steps. 1-Port placement. 2-Development of the retropubic space and clearing of anterior prostatic fat. 3-Dissection of the adenoma and incision of the distal urethra. 5-Urethrovesical anastomosis. 6- Closure of the prostatic capsule and placement of the drain. No bladder irrigation is needed.

Results: Laparoscopic simple prostatectomy was succesfully performed in 20 cases. Hospital stay varies from 3 to 4 days. Catheter is removed prior to discharge. We had two complications. One urinary leakage noted on post-operative day 1 which resolved with 7 days of suction drainage and one case of urinary retention on post-operative day 6 which resolved with one week of catheterisation. Our mean blood loss was 412cc. Two patients received blood transfusions.

Conclusions: Efficacious laparoscopic resection of prostate adenoma is possible with good control of hemostasis. The ultimate goal is outpatient treatment of large adenoma. The initial clinical experience is presented in the video.

COST COMPARISON FOR HAND-ASSISTED LAPAROSCOPIC NEPHRECTOMY AND OPEN NEPHRECTOMY: ANALYSIS OF INDIVIDUAL PARAMETERS

Yair Lotan*, David A Duchene, Jeffrey A Cadeddu, Kenneth S Koeneman, Dallas, TX

Introduction and Objective: Hand-assisted laparoscopic nephrectomy (HAL) is an effective approach to nephrectomy that is less morbid than open nephrectomy (ON). Our objective was to identify the cost components of HAL that could be targeted to reduce the cost of the procedure.

Methods: A literature review was performed to determine operative parameter and length of stay (LOS) for contemporary series of HAL and ON. We compared the overall cost and individual cost centers for HAL and ON at a large metropolitan county hospital. A model was created using the DATA program (TreeAge software 3.5) to compare the costs of treatment with either HAL and ON. Weighted means were derived from the data. We conducted a series of 1- and 2-way sensitivity analyses to evaluate the costs of HAL and ON while varying hospital LOS, operative time, and cost of laparoscopic equipment.

Results: The literature yielded 6 and 9 papers with 127 and 419 patients for ON and HAL, respectively. Mean LOS was 5 and 3 days for ON and HAL, respectively. Mean OR time was 169 and 204 minutes for ON and HAL, respectively. ON was less costly overall than HAL by $205 ($6,882 vs. $7,087) due to shorter OR time and lower OR supply costs ($75 vs. $923). One-way sensitivity analyses showed that HAL is less costly if: (1) the OR time of HAL is less than 184 minutes; (2) LOS following HAL is less than 2.5 days; or (3) HAL OR supply costs are less than $718.

Conclusions: The sensitivity analyses enable individual surgeons and institutions to determine the cost impact of ON and HAL given their unique clinical scenarios. HAL is more cost effective than ON when OR times and LOS are low. The decreased morbidity and quicker return to work of patients after HAL offer indirect patient and cost benefits to the HAL approach.