Laparoscopic retroperitoneal partial nephrectomy using an ergonomic chair: demonstration of technique and matched-pair analysis.

OBJECTIVES: To present the technique and long-term results of retroperitoneal laparoscopic partial nephrectomy (LPN), focusing on the impact of an ergonomic platform.

PATIENTS AND METHODS: Between January 2000 and May 2016, 287 patients (193 men, 94 women) underwent LPN performed by four surgeons. The median (range) patient age was 59 (19-85) years, tumour size 3.1 (1-9) cm and PADUA score 7.3 (6-12). Access was retroperitoneal in 235 cases (82%). Since October 2010, we have used the ETHOS(™) chair (ETHOS(™) , Seattle, WA, USA) during excision of the tumour in 130 patients (45.3%). A total of 51 tumours (17.7%) were excised without ischaemia and 226 (78.7%) under warm ischaemia, with clamping of the renal artery using an enucleo-resection technique. We suture the resection bed and perform renorrhaphy using a barbed-suture pre-loaded with absorbable LAPRA-TY(™) clips (Ethicon, Somerville, NJ, USA). The impact of the ETHOS chair was examined using a matched-pair analysis (66 with ETHOS chair vs 67 without ETHOS chair).

RESULTS: The median (range) operating time was 146 (60-325) min, the median (range) estimated blood loss was 99 (10-3 000) mL and the mean (range) warm ischaemia time (WIT) was 17.1 (7-47) min. Histology showed 240 (83.6%) renal cell carcinomas (RCCs) and 46 (15.9%) benign tumours. The cumulative overall disease-free survival rate after a median (range) follow-up of 84 (3-155) months was 100% for 203 pT1 RCCs and local recurrence was observed in one patient (0.4%), who was managed by radical nephrectomy. There were two conversions (0.7%) to open surgery, both to hand-assisted laparoscopy. Perirenal haematoma was observed in 13 patients (4.5%). A total of 20 patients (6.9%) required transfusions (2-11 units). We observed five urine leaks (1.7%) requiring prolonged drainage. The median (range) length of hospital stay was 5 (3-24) days. Three patients developed arteriovenous fistulas, which were successfully occluded by superselective embolization (1.0%). Use of the ETHOS chair resulted in shorter operating time (134.7 vs 168.5 min; P = 0.04), including WIT (13.1 vs 15.9 min; P = 0.01), and a lower complication rate (15 vs 29.8%; P = 0.02).

CONCLUSIONS: Laparoscopic partial nephrectomy is technically difficult but oncologically effective. Standardization and simplification of endoscopic suturing using the ETHOS chair significantly improved the outcomes of the surgical procedure.