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European Urology
Volume 55, issue 6, pages 1251-1502, June 2009Letters to the Editor published online
Re: Matthew N. Simmons, Benjamin I. Chung, Inderbir S. Gill. Perioperative Efficacy of Laparoscopic Partial Nephrectomy for Tumors Larger than 4 cm. Eur Urol 2009;55:199–208
Hervé Baumert 
.
Accepted 2 February 2009, Published online 11 February 2009, page e103
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Refers to article:
Perioperative Efficacy of Laparoscopic Partial Nephrectomy for Tumors Larger than 4cm
Accepted 17 July 2008
January 2009 (Vol. 55, Issue 1, pages 199 - 208)
Article Outline
I have read with interest the paper from Simmons et al that evaluated the safety and efficacy of laparoscopic partial nephrectomy (LPN) for tumours >4 cm [1]. Reducing morbidity and warm ischaemia time (WIT) remain a challenge for such laparoscopic cases.
Our early unclamping technique, presented for the first time in Cleveland, Ohio, USA, in 2006 [2], and [3], is perfectly adapted to manage such cases. We described closure of the collecting system and early haemostasis by using a running suture on the tumour bed before removing the vascular clamp. The vascularised renal parenchyma was then closed over a surgical bolster [4].
Using this technique, which we published in 2007, the mean WIT was 13.7 min [4]. Even heminephrectomies could be performed with a WIT of <20 min [4]. This reduction of WIT for such challenging cases is not the only advantage of this technique. Indeed, this early unclamping technique also allows sutures to be applied to visibly bleeding vessels before parenchyma closure, reducing the risk of late bleeding. This targeted haemostasis cannot be performed when the clamp is removed after the parenchyma closure. Using this technique in 85 consecutive LPNs, we could decrease the postoperative transfusion rate to 1.2% (unpublished data).
Gill et al started to use our early unclamping technique a few months [5] after our presentations in Cleveland [2], and [3]. In 2008, Gill et al reported similar results to ours, with a WIT of 13.9 min [5]. This technique should be used to reduce WIT as much as possible in patients who are at risk of developing renal impairment, as shown by this recent paper from Simmons et al [1].
Conflicts of interest: The author has nothing to disclose.
References
- [1] M.N. Simmons, B.I. Chung, I.S. Gill. Perioperative efficacy of laparoscopic partial nephrectomy for tumors larger than 4 cm. Eur Urol 55 (2009) (199 - 208) Abstract, Full-text, PDF, Crossref.
- [2] A. Ballaro, N. Shah, O. Dumonceau, N. Saheb, W. Alame, H. Baumert. Technique allowing reduction of the warm ischemia time during laparoscopic partial nephrectomy: the video. 24th World Congress on Endourology. J Endourol 20 (Suppl 1) (2006) (A325)
- [3] A. Ballaro, N. Shah, N. Saheb, W. Alame, O. Dumonceau, H. Baumert. A technique enabling reduction of the warm ischemia time during laparoscopic partial nephrectomy. 24th World Congress on Endourology. J Endourol 20 (Suppl 1) (2006) (A297)
- [4] H. Baumert, A. Ballaro, N. Shah, et al.. Reducing warm ischaemia time during laparoscopic partial nephrectomy: a prospective comparison of two renal closure techniques. Eur Urol 52 (2007) (1164 - 1169) Abstract, Full-text, PDF, Crossref.
- [5] M.M. Nguyen, I.S. Gill. Halving ischemia time during laparoscopic partial nephrectomy. J Urol 179 (2008) (627 - 632) Crossref.
Footnotes
Department of Urology, Paris Saint Joseph Hospital Trust, 185 Rue Losserand, Paris, France
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