Recent advances in laparoscopic partial nephrectomy: comparative study of electrosurgical snare electrode and ultrasound dissection.

Although technically feasible, laparoscopic partial nephrectomy (LPN) using conventional instrumentation presents the intraoperative challenge of hemostasis, creating a flush (i.e., precise guillotine) incision, and closure of the collecting system. In an effort to resolve these technical problems, we used a unique electrosurgical snare electrode (ESE) in combination with an ERBE electrosurgical generator and compared its effectiveness with that of two ultrasonic dissectors (Cavitron Ultrasonic Surgical Aspirator [CUSA] and harmonic scalpel [HS]) in performing LPN. Twelve female minipigs underwent right lower-pole LPN using one of the aforementioned modalities. Six weeks later, in the same animals, a left lower-pole LPN was performed using the same device, thereby providing an acute and chronic renal remnant to examine. The animals were harvested, and transverse and perpendicular histologic sections were prepared of the cut surface of each specimen. The weights of the LPN specimens and the remaining kidney were also recorded. The time required for partial nephrectomy, degree of hemostasis (i.e., blood loss), ease of excising the targeted tissue, changes in renal function, tissue reactivity, and depth of damage to the surface of the remaining renal parenchyma were measured for each device. All 12 procedures were successful using the ultrasonic dissection, and 11 procedures were successful using the ESE. The ESE was significantly faster than the two forms of ultrasonic dissection (p < 0.0001) and produced less intraoperative bleeding (P = 0.002). Both forms of ultrasonic energy produced significantly deeper parenchymal injury in the acute surgical specimen (P = 0.03) and more parenchymal fibrosis and chronic inflammation in the chronic surgical specimens (P = 0.007) than the ESE. None of the animals exhibited any extravasation from the incised collecting system when studied by retrograde pyelography 6 weeks postoperatively at the time of left LPN and harvest. The function of the renal remnant was consistent with the size of the partial nephrectomy specimen. No hypertension developed in any of the study animals. Our results using a unique electrosurgical snare probe show it to have potential advantages as a rapid, hemostatic method for performing a partial nephrectomy. We believe that this instrument may represent an important tool for performing nephron-sparing surgery via an open or laparoscopic approach. Clinical trials are in progress.