title: Hand-assisted laparoscopic partial nephrectomy without hilar vascular clamping using a saline-cooled, high-density monopolar radiofrequency device.
abstract: OBJECTIVE
  Nephron-sparing surgery is now accepted as an alternative treatment option for small renal tumors. However, hemostasis during laparoscopic partial nephrectomy can be technically challenging, especially without hilar vascular clamping. The aim of our study was to evaluate the technique of hand-assisted laparoscopic partial nephrectomy using the TissueLink (TissueLink Medical, Dover, NH), a saline-cooled monopolar radiofrequency device, without hilar vascular clamping.
  
  
  METHODS
  Using the hand-assisted laparoscopic approach, the kidney is mobilized transperitoneally, and the renal tumor with overlying perinephric fat is exposed. The tumor is excised with a 1-cm margin using a combination of the TissueLink device and endoscopic scissors. The tumor and a biopsy of the base of the tumor bed are sent for frozen-section examination. The bleeding vessels are controlled with digital compression and the TissueLink device. At the end of procedure, the tumor bed is covered with a hemostatic agent. Three female and four male patients ages 52 to 76 years (mean 66 years) were treated with this new device for incidental tumors detected during imaging studies (N = 6) or during work-up for gross hematuria (N = 1). Preoperative imaging studies included CT in six patients and MRI in three. The average tumor size was 2.2 cm (range 1.3-3 cm). Only peripheral tumors that did not approach the hilum or the collecting system were selected.
  
  
  RESULTS
  All of the patients underwent a hand-assisted laparoscopic partial nephrectomy using the TissueLink device without hilar vascular clamping. There were no intraoperative complications or conversions to open surgery. The mean operative time was 175 minutes, with an estimated blood loss of 186 mL (range 100-300 mL). Histologic examination demonstrated renal-cell carcinoma in five cases, oncocytoma in one, and an angiomyolipoma in one. The dimensions of the normal tissue around the tumor ranged from 1 to 4 mm, and frozen-section analysis showed tumor-free margins in all cases. Postoperatively, all patients recovered well except one patient who developed transient atrial fibrillation, which was treated medically in the immediate postoperative period. All patients were discharged in good condition at an average of 3 days (range 2-6 days).
  
  
  CONCLUSIONS
  Hand-assisted laparoscopic partial nephrectomy without vascular clamping using the TissueLink device is a safe and feasible technique for exclusion of small exophytic renal tissues.
authors.affiliation: Division of Urology, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA.
authors.forename: Yeh H
authors.initials: YH
authors.lastname: Tan
authors.forename: Matthew D
authors.initials: MD
authors.lastname: Young
authors.forename: James O
authors.initials: JO
authors.lastname: L'Esperance
authors.forename: Glenn M
authors.initials: GM
authors.lastname: Preminger
authors.forename: David M
authors.initials: DM
authors.lastname: Albala
mesh_terms: D000368:Aged; D016063:Blood Loss, Surgical; D004564:Electrocoagulation / Q000295:instrumentation*; D005260:Female; D006488:Hemostasis, Surgical; D006801:Humans; D007680:Kidney Neoplasms / Q000601:surgery*; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged; D009392:Nephrectomy / Q000295:instrumentation / Q000379:methods*