Published in Cancer Detection and Prevention 2000; 24(Supplement 1).

Preserving renal function by nephron-sparing operation techniques in renal cell carcinoma - WaterJet cutting vs ligature - online-partial nephrectomy

RF Basting MD, N Djakovic MD, D Händel MD

Kreiskrankenhaus Alt Neuotting, Academic Hospital, Dept Urology/ Pediatric Urology, Altotting, Germany,

AIM: Nephron-sparing operations in renal cell carcinoma (RCC) are of major interest in urology because on one hand they save kidneys and they save renal function for further immunotherapy or chemotherapy. We started in 1987 nephronsparing operations combined with adjuvant Interferon -alpha therapy in low-grade isolated RCCs of less than 4 cm in diameter. Limiting factor of the nephronsparing techniques was so far renal function impairment induced by clamping the renal pedicle during the partial nephrectomy. Various surgical techniques have been developed to reduce the intra- and postoperative complications during dissection of renal tissue and tumor resection. We reported, as first center , our experience with WaterJet Technology to perform partial nephrectomies and heminephrectomies without any clamping of the pedicle thus avoiding any renal function impairment - we call it online- partial nephrectomy - because there is no interrupted blood perfusion at any time ( AUA,Atlanta 2000 ) .WaterJet cutting divides tissue without damaging the tissue when using adequate pressure but it has no hemostasis capabilities. After introducing WaterJet technology in urology we started to combine it with the ligature system thus combining tissue dividing capability with selective bipolar hemostasis. We also present the first case of online-partial nephrectomy with the ligature system only. METHODS: 22 patients underwent partial nephrectomy for different renal tumors between April 1999 and April 2000 . We present an audiovisual presentation of partial nephrectomy with two different WaterJet devices and the bipolar ligature system. This is the first report of an online-partial nephrectomy with the ligature system only. With the ligature system blood vessels are welded using a computerized system that measures the temperature between the welding poles 200 times per The multimedia show presents the different types of nephronsparing techniques combined with adjuvant Interferon alpha treatment to obtain a maximum of survival in low-grade low-stage Renal Cell Carcinoma. We intend to encourage other institutes to join our prospective study of adjuvant therapy in low-grade RCCs of less than 4cm in diameter in partial nephrectomy plus low-dose iInterferon-alpha therapy. RESULTS: By applying WaterJet resection device tissue was dissected effectively avoiding damage to vascular and pelvicaliceal structures, which then could be ligated and cut selectively or easily welded by the ligature-system. The tumors were resected completely with tumor-free margins; operating time differed between 14 and 35min. Intraoperative blood loss was minimal and no significant problems were seen postoperatively. CONCLUSIONS: The results demonstrate that WaterJet technology is a tool well applicable for transsection of renal parenchyma in tumor surgery.It has proven to reduce the risk of blood loss significantly compared to other techniques.Tissue damage was reduced to a minimum, while tumors were completely removed. There seems to be no absolute advantage of one WaterJet device over the others and the combination with the ligature-system makes sense to save blood but is not budget-friendly. We performed the first ligature-only online partial-nephrectomy without any intraoperative problems. We intend to include the ligature-system into the multicenter trial T1 and T2 RCCs with partial NE plus adjuvant Interferon alpha ; because it seems to be cost efficient.

KEY WORDS: Interferon alpha, adjuvant treatment, Renal cell carcinoma, waterjet, ligature, online-partial nephrectomy, nephron-sparing operation, jetcutting.

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Paper presented at the International Symposium on Impact of Biotechnology on Cancer Diagnostic & Prognostic Indicators; Geneva, Switzerland; October 28 - 31, 2000; in the section on novel therapies.