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European Urology
Volume 55, issue 6, pages 1251-1502, June 2009Letters to the Editor published online
Reply to Hervé Baumert's Letter to the Editor 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
Matthew N. Simmons. Benjamin I. Chung. Inderbir S. Gill 
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Accepted 13 March 2009, Published online 31 March 2009, page e104
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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)
Refers to article:
Re: Matthew N. Simmons, Benjamin I. Chung, Inderbir S. Gill. Perioperative Efficacy of Laparoscopic Partial Nephrectomy for Tumors Larger than 4cm. Eur Urol 2009;55:199208
Accepted 2 February 2009
June 2009 (Vol. 55, Issue 6, page e103)
Article Outline
Ischemia remains a primary concern during open or laparoscopic partial nephrectomy (LPN). We fully agree with Dr Baumert's comments with regard to the early unclamping technique [1], and we compliment him and his team for publishing the initial report in 2007 [2]. Dr. Baumert's pioneering contribution is acknowledged and applauded. Also in 2007, Dr Bollens described his variation of an “on-demand” unclamping technique of LPN [3].
Our independent conceptualization and parallel development of our technique of early unclamping LPN and our experience in our first 50 patients, published in early 2008, has provided similarly excellent results [4]. Unique differences in our technique include use of radiolucent Hem-o-lok clips for rapid control of transected major intrarenal blood vessels, sutured hemostasis and collecting system repair with undersewing of Hem-o-lok clips, and complete elimination of the compressive bolster in approximately 85–90% of patients. Our current mean ischemia time is 13 min (91% of patients had ischemia ≤20 min, none had ischemia >30 min), and postoperative hemorrhage rate is 2.7% (K. Kamoi et al, unpublished data). Our single-surgeon overall experience is now >800 LPNs (I. S. Gill et al, unpublished data). Of these procedures, the most recent consecutive 300 LPNs were performed with the early unclamping technique, which is now our routine approach. This approach is used with anatomically complex hilar tumors, central tumors, completely intrarenal tumors, tumor in solitary kidney, and even bilateral single-session LPN. Any step toward reducing warm ischemia is a step forward.
Conflicts of interest: The authors have nothing to disclose.
References
- [1] Baumert H. 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. Eur Urol 2009;55:e103.
- [2] 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.
- [3] R. Bollens, A. Rosenblatt, B.P. Espinoza, et al.. Laparoscopic partial nephrectomy with “on-demand” clamping reduces warm ischemia time. Eur Urol 52 (2007) (804 - 810) Abstract, Full-text, PDF, Crossref.
- [4] M.M. Nguyen, I.S. Gill. Halving ischemia time during laparoscopic partial nephrectomy. J Urol 179 (2008) (627 - 632) Crossref.
Footnotes
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Stanford University School of Medicine, Stanford, CA, USA
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