Robotic Laparoendoscopic Single-Site Surgery Using GelPort as the Access Platform

Background

Laparoendoscopic single-site surgery (LESS) allows for the performance of major urologic procedures with a single small incision and minimal scarring. The da Vinci Surgical System provides advantages of easy articulation and improved ergonomics; however, an ideal platform for these procedures has not been identified.

Objective

To evaluate the GelPort laparoscopic system as an access platform for robotic LESS (R-LESS) procedures.

Design, setting, and participants

Since April 2008, 11 R-LESS procedures have been completed successfully in a single institutional referral center. For the last four consecutive cases, the GelPort has been used as an access platform through a 2.5–5-cm umbilical incision.

Intervention

R-LESS cases performed with the GelPort included pyeloplasty (n = 2), radical nephrectomy (n = 1), and partial nephrectomy (n = 1).

Measurements

Perioperative data were obtained for all patients including demographic data, operative indications, operative records, length of stay, complications, and pathologic analysis.

Results and limitations

For both pyeloplasty cases, average operative time (OR time) was 235 min and estimated blood loss (EBL) was 38 cm³. For the patient undergoing radical nephrectomy for a 5.1-cm renal tumor, OR time was 200 min and EBL was 250 cm³. The final patient underwent partial nephrectomy without renal hilar clamping for an 11-cm angiomyolipoma with OR time of 180 min and EBL of 600 cm³. All R-LESS procedures attempted with the GelPort were completed successfully and without complication. Average length of hospital stay was 1.75 d (range: 1–2). The partial nephrectomy patient required transfusion of 1 U of packed red blood cells.

Conclusions

Use of the GelPort as an access platform for R-LESS procedures provides adequate spacing and flexibility of port placement and acceptable access to the surgical field for the assistant, especially during procedures that require a specimen extraction incision. Additional platform and instrumentation development will likely simplify R-LESS procedures further as experience grows.     

Laparoscopic radical nephrectomy: a single-center experience of 51 cases

A modified technique of laparoscopic radical nephrectomy for treatment of renal cell carcinoma makes surgery easier, faster, and safer in terms of tumor cell spillage. We report our experience with this procedure in 51 consecutive cases. A transperitoneal approach was used in all cases. The average patient age was 62 years. The solid renal mass diameter was between 2 and 9 cm. Extrafascial mobilization of the kidney included limited lymph node dissection. In six patients the adrenal gland was removed simultaneously. The specimen was removed intact through a small muscle-splitting incision in the lower abdominal wall. The procedure was successful without conversion to open surgery in all 51 patients. The average operating time was 125 minutes, and the average postoperative hospital stay was 7.2 days. Major complications were seen in 4% of patients. Neither local recurrences nor metastases were observed in the following 7.9 (1-19) months. In our experience, laparoscopic radical nephrectomy is safe and efficient. Removing the specimen intact through a small muscle-splitting incision reduces operating time, avoids tumor cell spillage, and allows exact pathological staging.     

Laparoscopic radical nephrectomy for renal cell carcinoma--transperitoneal anterior approach

PURPOSE: To evaluate the usefulness of transperitoneal anterior approach in laparoscopic radical nephrectomy for patients with renal cell carcinoma. MATERIAL: Ten patients (Eight males and two females) with small renal cell carcinoma less than 7 cm in diameter were treated with laparoscopic radical nephrectomy between June 1997 and May 1999. Clinical stage was T1aN0M0 in 6 cases and T1bN0M0 in 4 cases. METHOD: Of the 10 patients, the initial four received preoperative embolization of the renal artery. Under general anesthesia laparoscopic radical nephrectomy via transperitoneal anterior approach was performed in all patients. This procedure facilitates initiated early access to the renal vessels as does open radical nephrectomy. The kidney was dissected en bloc with Gerota's fascia and delivered from the small skin incision without morcellation. RESULT: Two patients needed conversion to open surgery. The mean operating time of eight patients except for conversion cases was 247 minutes and the mean blood loss was 258 ml. There was no major complication associated with laparoscopic procedure. CONCLUSION: Transperitoneal anterior approach in laparoscopic radical nephrectomy is a suitable and useful procedure for the treatment of small renal cell carcinoma because it enables us to avoid possible tumor manipulation by early access to the renal vessels as open radical nephrectomy.     

Percutaneous Ureteral Elevation in Laparoendoscopic Single-Site Radical Nephrectomy

Background and Objectives:

To describe our technique of suture-assisted ureteral retraction during Laparoendoscopic Single-Site (LESS) radical nephrectomy.

Materials and Methods:

A healthy, 39-year-old woman with an incidental 5-cm enhancing left renal mass elected to undergo radical nephrectomy. A 2-cm skin incision was made in the left upper quadrant of the abdomen, and a Covidien SILS port was introduced using standard Hasson techniques. Straight and angled laparoscopic instruments were used to mobilize the kidney outside of Gerota''s fascia. To place the renal vessels on stretch and facilitate hilar dissection, the ureter and lower pole attachments were encircled with a 0-Vicryl suture inserted percutaneously via a disposable fascial closure device. The kidney was bagged and removed intact.

Results:

The procedure was performed without complication with a total operative time of 265 minutes. EBL was minimal at 25mL. The patient was discharged home on postoperative day 1, and final pathology revealed stage pT1b chromophobe renal cell carcinoma with negative surgical margins.

Conclusion:

LESS radical nephrectomy is feasible in select patients. Suture-assisted retraction of the ureter and lower pole attachments using a fascial closure device facilitates safe dissection and control of the renal hilum.     

Organ intact retrieval via umbilical incision after simultaneous bilateral laparoscopic radical nephrectomy for renal masses

PURPOSE: We report on two cases of laparoscopic bilateral nephrectomy for renal-cell carcinoma (RCC) in patients with end-stage renal disease. PATIENTS AND METHODS: Bilateral renal masses were detected in two patients with acquired renal cystic disease. They underwent bilateral laparoscopic nephrectomy. The specimens were removed intact via an umbilical incision. RESULTS: The operative times were 8 hours and 6 hours and the estimated blood loss was 154 mL and 120 mL. Both patients resumed oral intake on postoperative day 1 and were discharged on postoperative day 6. No intraoperative and postoperative complications occurred. The pathology report revealed bilateral RCC. The original length of the umbilical incision was 4 cm which shrank to 3 cm by 2 months after the operation. CONCLUSIONS: Bilateral laparoscopic radical nephrectomy including intact organ retrieval for bilateral renal masses via a small umbilical incision is feasible.     

Laparoscopic radical nephrectomy: incorporating advantages of hand assisted and standard laparoscopy

PURPOSE: We present an approach to laparoscopic radical nephrectomy and intact specimen extraction, which incorporates hand assisted and standard laparoscopic techniques. MATERIALS AND METHODS: A refined approach to laparoscopic radical nephrectomy is described and our experience is reviewed. A low, muscle splitting Gibson incision is made just lateral to the rectus muscle and the hand port is inserted. A trocar is placed through the hand port and pneumoperitoneum is established. With the laparoscope in the hand port trocar 2 additional trocars are placed under direct vision. The laparoscope is then repositioned through the middle trocar and standard laparoscopic instruments are used through the other 2 trocars including the one in the hand port. If at any time during the procedure the surgeon believes the hand would be useful or needed, the trocar is removed from the hand port and the hand is inserted. RESULTS: This approach has been applied to 7 patients. Mean estimated blood loss was 200 cc (range 50 to 300) and mean operative time was 276.7 minutes (range 247 to 360). Mean specimen weight was 767 gm. (range 538 to 1,170). Pathologically 6 specimens were renal cell carcinoma (grades 2 to 4) and 1 was oncocytoma. Mean length of hospital stay was 3.71 days (range 2 to 7). There were no major complications. CONCLUSIONS: We believe that this approach enables the surgeon to incorporate the advantages of the hand assisted and standard laparoscopic approaches.     

经脐单孔腹腔镜肾切除术2例报告

目的：初步探讨经脐单孔腹腔镜肾切除术的临床可行性和安全性。方法：2009年6～7月,对2例患者行经脐入路单孔腹腔镜肾切除术,1例右肾癌患者行单孔腹腔镜右肾根治性切除术,1例左侧积水性无功能肾患者行单孔腹腔镜单纯左肾切除术。患者取45。健侧卧位,作2．5cm绕脐“Z”形皮肤小切VI,Hasson法制备经腹腔入路单孔腹腔镜工作通道切口,置入单孔三通道腹腔镜操作通道。从单孔通道分别置人5mm腹腔镜和手术器械,按照标准的腹腔镜根治性肾切除术和单纯。肾切除术的手术操作步骤完成手术,切除标本均从脐部切口取出。结果：2例手术均顺利完成,手术时间分别为210min和90min,估计出血量分别为100ml和20ml,无中转开放及标准三孔腹腔镜手术,术中无并发症发生,短期随访无术后并发症发生。结论：小样本的临床研究结果初步显示了单孔腹腔镜。肾切除术良好的安全性和可行性。然而,该术式的临床治疗效果尚需大样本中远期随访和对照研究予以证实。     

Vaginal extraction of the intact specimen following laparoscopic radical nephrectomy.

PURPOSE: We report the detailed technique and results of transvaginal extraction of the intact laparoscopic radical nephrectomy specimen. MATERIALS AND METHODS: Since June 2000, 10 select female patients with a median age of 67 years underwent transvaginal extraction of the intact specimen after laparoscopic radical nephrectomy. In 5 patients open surgery had previously been performed on the uterus, including transabdominal hysterectomy in 2 and cesarean section in 3. Laparoscopic nephrectomy was performed via the transperitoneal and retroperitoneal approach in 5 cases each. After completion of the primary laparoscopic procedure a sponge stick was externally inserted into the sterile prepared vagina and tautly positioned in the posterior fornix. Laparoscopically a transverse posterior colpotomy was created at the apex of the tented up posterior fornix and the drawstring of the entrapped specimen was delivered into the vagina. After laparoscopic exit was completed the patient was placed in the supine lithotomy position. The specimen was extracted intact via the vagina and the posterior colpotomy incision was repaired transvaginally. Patients were mailed a linear scale analog questionnaire to assess various aspects of recovery with responses graded from 0--no pain and/or change to 10--severe pain and/or change. RESULTS: Vaginal extraction was successful in all 10 patients. Median operative time for the vaginal extraction procedure was 35 minutes. Blood loss was minimal. Median tumor size was 3.6 cm. (range 2.4 to 7.4) and median specimen weight was 327 gm. (range 152 to 484). No intraoperative complications occurred. Postoperatively blood spotting via the vagina in 1 patient resolved spontaneously. Postoperative questionnaires revealed excellent patient satisfaction and convalescence. CONCLUSIONS: Vaginal extraction is an efficacious and minimally morbid technique for removing the intact entrapped specimen after laparoscopic radical nephrectomy. It has now become our preferred technique of intact specimen extraction in appropriate female patients.     

Laparoscopic radical nephrectomy incorporating intraoperative ultrasonography for renal cell carcinoma with renal vein tumor thrombus

The purpose of this study was to describe the technique of laparoscopic right radical nephrectomy incorporating intraoperative, real-time ultrasonography in the management of renal cell carcinoma with level 1 renal vein tumor thrombus. With the patient in a modified flank position, a transperitoneal four-port approach was used to laparoscopically resect an 8.5-cm right renal mass with tumor thrombus extending to, but not into, the inferior vena cava. Early arterial control with gentle traction on the right renal vein provided a short proximal renal venous segment devoid of tumor on laparoscopic inspection. Intraoperative laparoscopic ultrasonography allowed confident identification of the proximal extent of the tumor thrombus. After hilar control, complete resection and intact removal of the renal specimen was performed using standard non-hand-assisted laparoscopic techniques. The actual surgical time was 180 minutes. Surgical resection was successfully performed laparoscopically. No postoperative complications or hospital readmission occurred. Pathologic examination confirmed T3b renal cell carcinoma with negative surgical margins. Laparoscopic right radical nephrectomy incorporating intraoperative, real-time ultrasonography is feasible in the management of renal cell carcinoma with a large-sized level 1 renal vein thrombus. Additional studies are necessary to evaluate its role in urologic oncologic surgery.     

Intact specimen extraction during renal laparoscopy: muscle-splitting versus muscle-cutting incision

PURPOSE: To determine whether a muscle-splitting extraction incision decreases patient morbidity after renal laparoscopic surgery. PATIENTS AND METHODS: Twenty-one patients undergoing laparoscopic simple nephrectomy, radical nephrectomy, or nephroureterectomy had intact specimen extraction through a muscle-splitting incision. The operative and recovery data of these patients were retrospectively compared with those of a matched cohort of 21 patients who underwent specimen extraction through a muscle-cutting incision. With the exception of a greater percentage of male patients in the muscle-cutting group (86% v 52%), there were no statistically significant differences between the two groups. RESULTS: In the muscle-splitting and muscle-cutting groups, there was no significant differences in regard to analgesic use (9.0 +/- 6.6 mg of morphine sulfate equivalent v 7.9 +/- 4.9; P < 0.51), hospital stay (31.2 hours v 30 hours; P < 0.79), recovery (6.7 +/- 4.7 days v 5.7 +/- 4.7 days; P < 0.38), or convalescence (4.2 +/- 2.2 weeks v 4.1 +/- 2.0 weeks; P < 0.90). CONCLUSION: A muscle-splitting incision for intact renal specimen extraction does not necessarily decrease postoperative morbidity compared with a muscle-cutting extraction.     

Laparoscopic radical nephrectomy: prospective assessment of impact of intact versus fragmented specimen removal on postoperative quality of life

PURPOSE: We prospectively compared postoperative recovery and quality of life for groups of patients undergoing laparoscopic radical nephrectomy with intact or fragmented specimen removal. PATIENTS AND METHODS: A prospective evaluation of 12 patients having a transperitoneal laparoscopic nephrectomy was completed. In each case, a radical dissection was performed regardless of the surgical indication. Fragmented specimens (N = 7) were extracted at the umbilical port, and intact specimens (N = 5) were extracted through an infraumbilical incision. Demographic and perioperative data including specimen removal incision, narcotic requirements, and recovery interval were recorded. Subjective pain and activity assessments were administered prospectively on postoperative days 1, 2, 7, and 14. RESULTS: The mean incision length for intact specimen removal was 7.6 cm and that for fragmented removal was 1.2 cm (P < 0.05). Pain and activity self-assessments improved over time in each group. No significant differences in pain or activity scores were noted between treatment groups at any queried interval. Time to return of normal activity was not significantly different in the two groups. CONCLUSIONS: In this pilot study, no subjective or objective advantage was demonstrated for kidney fragmentation during laparoscopic radical nephrectomy. A larger randomized study is required to better assess any clinical advantage to specimen morcellation.     

Novel approach to minimizing trocar sites during challenging hand-assisted laparoscopic surgery utilizing the Gelport: trans-gel instrument insertion and utilization

PURPOSE: We present a novel technique for modified application of a hand-assist device, the Gelport (Applied Medical Resources, Rancho Santa Margarita, CA), which uses a gel for intra-abdominal access. MATERIALS AND METHODS: A 53-year-old woman with a history of rectal cancer treated by abdominoperineal resection, ileostomy, subsequent reanastomosis, chemotherapy, and radiation presented with a 6-cm upper-pole left renal mass. Staging was negative, and a CT scan showed no evidence of lymphadenopathy or renal vein involvement. The patient elected to undergo a hand-assisted laparoscopic radical nephrectomy. Numerous intra-abdominal adhesions were encountered during initial periumbilical hand port placement. The initial adhesions were taken down in an open fashion; however, the proposed trocar sites still could not be exposed. The Gelport was placed, and a laparoscope was passed directly through the established central opening and the gel. A working instrument was then passed through the gel itself, allowing adhesiolysis under direct laparoscopic vision. RESULTS: The nephrectomy was completed laparoscopically in 4 hours and 15 minutes with lysis of adhesion occupying 90 minutes of the operative time. The estimated blood loss was 150 mL. Despite the technical difficulty of the case, the procedure was completed laparoscopically with two standard 12-mm trocars and a 5-mm lateral retraction trocar. CONCLUSION: The Gelport permits simultaneous insertion of the surgeon's hand and a working laparoscopic instrument. This allows for maximally efficient utilization of the incision made for hand-assist device placement and may minimize the need for additional trocars during challenging laparoscopic cases.     

A sealed laparoscopic nephroureterectomy: a new technique

OBJECTIVES: To describe a purely laparoscopic nephroureterectomy approach that avoids the disadvantages of transurethral bladder cuff excision and open/laparoscopic distal ureterectomy using the EndoGIA. METHODS: A standard transperitoneal laparoscopic nephrectomy is carried out through three or four ports in the flank. The ureter is dissected caudally into the pelvis. Two additional (5- and 10-mm) trocars are placed in the ipsilateral lower abdomen. Caudal ureteral dissection continues until the detrusor muscle fibers at the ureterovesical junction are identified. A 1-cm area of bladder adventitia around the ureterovesical junction is cleared. The ureter is retracted upward and laterally, tenting up the bladder wall. The bladder cuff is excised using a 10-mm LigaSure Atlas and detached from the bladder. A 6-cm lower-quadrant incision is used to remove the specimen in an Endocatch bag. An indwelling 16F Foley catheter is then placed. RESULTS: Thirteen adult patients with suspected upper-tract transitional cell carcinoma underwent this surgical technique (operative time: 170-270 min): none had local recurrence, and two had recurrence remote from the bladder cuff scar (follow-up: 1-23 months). CONCLUSIONS: The described procedure adheres strictly to oncologic principles (removal of the affected renal unit without opening the urinary tract), and circumvents the need for transurethral/intraureteral instrumentation and patient repositioning.     

100-minute retroperitoneoscopic radical nephrectomy: a new retroperitoneal approach with a hand assisted method

PURPOSE: A new approach for retroperitoneoscopic radical nephrectomy is introduced. The point of our surgical method is the application of a combination of hand assistance and pure laparoscopic procedures with appropriate surgical steps via the retroperitoneal approach. In our early series we had good surgical results and we completed radical nephrectomy in about 100 minutes using this procedure. MATERIALS AND METHODS: A total of 20 consecutive patients with renal cell carcinoma (cT1-2) who were operated on with this surgical method were analyzed. Surgical procedures occurred in 5 steps. In step 1 the retroperitoneal space was created manually from a pararectal incision at the umbilicus level. In step 2 the lateroconal fascia was incised and the renal hilar area was exposed with hand assistance. In step 3 hilar dissection was performed by pure laparoscopic procedure with another surgical instrument inserted from the hand device. Step 4 involved the application of hand assistance again for the quick mobilization of the kidney and adrenal gland. In step 5 the intact surgical specimen was retrieved from the hand device. RESULTS: Mean operative time and estimated blood loss were 103 +/- 21 minutes (range 70 to 145) and 49 +/- 85 ml (range 5 to 360), respectively. Mean days to oral intake and ambulation were 1.0 and 1.1, respectively. Operative times of the steps of hilar dissection and mobilization of the kidney and adrenal were shorter than in other series performed by standard retroperitoneoscopic radical nephrectomy. Major complications were not experienced. At this point, no metastasis has been experienced. CONCLUSIONS: Our surgical method may have the benefits of the retroperitoneal approach and hand assistance. The retroperitoneoscopic hand assisted method may be another important option in the 3 major approaches for laparoscopic radical nephrectomy, although longer-term followup is clearly required.     

Laparoscopic Radical Nephrectomy for Renal Tumor: The Washington University Experience

Purpose

We report our experience with laparoscopic radical nephrectomy in 17 consecutive patients with renal tumors.

Materials and Methods

The clinical data on 17 consecutive patients undergoing laparoscopic radical nephrectomy were reviewed. Of the patients 12 with stage pT1 or pT2 renal cell carcinoma 7 cm. in diameter or smaller undergoing laparoscopic radical nephrectomy were compared to 12 undergoing open radical nephrectomy for stage pT1 or pT2 renal cell carcinoma 6 cm. in diameter or smaller.

Results

Among the 17 patients undergoing laparoscopic radical nephrectomy average operative time was 6.9 hours (range 4.5 to 9) and average estimated blood loss was 105 cc (range 50 to 600). Average weight of the surgical specimen was 402 gm. (range 190 to 1,100). In 12 of 16 patients in whom laparoscopic radical nephrectomy was completed the specimen was removed intact. The patients required an average of 24 mg. morphine sulfate equivalent (range 2 to 220) for postoperative pain. Average hospital stay was 4.5 days (range 3 to 11) and average interval to resume normal activities was 3.5 weeks (range 2 to 4).The 12 patients in the open and laparoscopic radical nephrectomy groups were similar with respect to age, American Society of Anesthesiologists score and interval of surgery. Laparoscopic radical nephrectomy required significantly more operative time than open radical nephrectomy (6.9 versus 2.2 hours, respectively). However, the laparoscopic radical nephrectomy group compared to the open radical nephrectomy group had significantly less postoperative pain (24 versus 40 mg. morphine sulfate equivalent required for postoperative analgesia), shorter interval to resuming oral intake (1 versus 3 days), more rapid discharge from the hospital (4.5 versus 8.4 days) and more rapid return to normal activities (3.5 versus 5.1 weeks). The laparoscopic nephrectomy group also fully recovered more rapidly than the open surgical group (5.8 versus 39 weeks). To date, during a 4-year period there was no retroperitoneal recurrence or seeding of a port site.

Conclusions

Laparoscopic radical nephrectomy is a lengthy and demanding procedure. However, it affords patients with renal cell carcinoma a markedly improved postoperative course while accomplishing the necessary surgical goals.     

Hand-assisted laparoscopic nephrectomy for stage T1 and large stage T2 renal tumors

BACKGROUND AND PURPOSE: Standard laparoscopic nephrectomy (LN) has been shown to be as effective oncologically as open surgery for both stage T1 and stage T2 renal tumors. While much has been published regarding the increasing indications for laparoscopic nephrectomy, there is little in the literature regarding the advantages of hand-assisted laparoscopy (HAL) for the treatment of large (>7-cm) stage T2 renal tumors. To our knowledge, this study is the first to directly compare the results in pathologic stage T1 and stage T2 tumors. Our aim was to assess whether HAL nephrectomy for these larger tumors maintains the same advantages enjoyed by HAL for the smaller ones (<7 cm). PATIENTS AND METHODS: One hundred HAL renal extirpative procedures were performed over a 3-year period. Of these, 60 were radical nephrectomies for malignant disease, of which 50 tumors were stage T1 and 10 stage T2. Standard HAL nephrectomy was performed through a vertical midline or paramedian incision, and the specimen was sent for histologic examination and tumor staging. We retrospectively analyzed our charts to determine if HAL nephrectomy for T2 tumors was as advantageous as for T1 tumors. We collected data on patient age, ASA score, average tumor size, estimated blood loss, operative time, conversion rate, rate of complications, and length of hospital stay. Follow-up ranged from 4 to 26 months with a mean of 11 months. RESULTS: The mean size was 4.68 and 9.22 cm for stage T1 and T2 tumors, respectively. Intraoperatively, stage T2 tumors were associated with less blood loss than were T1 tumors (105 mL v 190 mL). Operative times were equivalent, at 190 and 185 minutes for stage T1 and T2, respectively. No open conversions were required in the T2 group v four (8.7%) in the T1 group. Three of these open conversions were seen in the first 25 HAL cases. No complications or conversions were seen in the stage T2 patients. Of note, the majority of the operations for stage T2 disease were performed after the learning curve had been surpassed. CONCLUSION: The HAL nephrectomy maintains the benefits associated with standard LN. Stage T1 and T2 tumors are equally amenable to HAL nephrectomy, enjoying the same perioperative advantages. The larger size of the higher-stage tumors does not appear to hinder intact organ removal via a 7-cm hand incision. For the novice laparoscopist, we recommend approaching smaller tumors first with HAL nephrectomy, as there is a learning curve. As surgical expertise with HAL nephrectomy increases, larger tumors (stage T2) can be removed safely and expeditiously with little blood loss and a low complication rate. In the short term, patients with stage T2 cancers appear to enjoy the same disease-free survival rate as those with tumors of lower stage. Longer-term follow-up is clearly needed; however, we anticipate the same excellent results as have been demonstrated by others performing conventional radical LN.     

Hand assisted laparoscopic radical nephrectomy for renal cell carcinoma with inferior vena caval thrombus

PURPOSE: To our knowledge we present the initial clinical report of hand assisted laparoscopic radical nephrectomy for renal cell carcinoma with tumor thrombus extending into the inferior vena cava. MATERIALS AND METHODS: A 76-year-old man was referred to our medical center with a 12.5 x 10 cm. stage T3b right renal tumor extending into the inferior vena cava. The caval thrombus was limited and completely below the level of the hepatic veins. After preoperative renal embolization via the hand assisted transperitoneal approach the right kidney was completely dissected with the renal hilum. Proximal and distal control of the inferior vena cava was obtained with vessel loops and a single lumbar vein was divided between clips. An endoscopic Satinsky vascular clamp was placed on the inferior vena cava just beyond its juncture with the right renal vein, thereby, encompassing the caval thrombus. The inferior vena cava was opened above the Satinsky clamp and a cuff of the inferior vena cava was removed contiguous with the renal vein. The inferior vena cava was repaired with continuous 4-zero vascular polypropylene suture and the Satinsky clamp was then removed. A literature search failed to reveal any similar reports of laparoscopic radical nephrectomy for stage T3b renal cell cancer. RESULTS: Surgery was completed without complication with an estimated 500 cc blood loss. Pathological testing confirmed stage T3b grade 3 renal adenocarcinoma with negative inferior vena caval and soft tissue margins. CONCLUSIONS: The introduction of vascular laparoscopic instrumentation and the hand assisted approach enabled us to extend the indications for laparoscopic radical nephrectomy to patients with minimal inferior venal caval involvement.     

LAPAROSCOPY-ASSISTED RADICAL NEPHRECTOMY IN COMBINATION WITH MINILAPAROTOMY: REPORT OF INITIAL 7 CASES

We recently developed a new procedure for laparoscopy-assisted radical nephrectomy in combination with minilaparotomy to remove kidneys with renal cell carcinoma. A pararectal incision approximately 7 cm in length was performed from the subcostal region. A 12-mm trocar was placed at the mid-clavicular line at the level of the umbilicus. An 11 -mm trocar was placed at the tip of the rib. Under laparoscopic and trans-minilaparotomic observation, intra-abdominal manipulation was begun. The contents of Gerota's fascia were freed from the surrounding tissues and removed through the abdominal incision. Seven patients have been successfully treated with this procedure. The operating time for this procedure was shorter than the time of laparoscopic nephrectomy. There were none of the adverse hemodynamic or ventilatory effects associated with pneumoperitoneum in this procedure. This procedure also resulted in less postoperative pain and a shorter convalescence period when compared with open nephrectomy.     

Mayo Clinic Scottsdale Experience with laparoscopic nephroureterectomy.

OBJECTIVES: To evaluate the efficacy of laparoscopic nephroureterectomy for patients with transitional cell carcinoma of the upper urinary tract. METHODS: Eighteen patients underwent attempted transperitoneal laparoscopic nephroureterectomy between June 2000 and October 2002. Mean patient age was 67.5 years. The specimen was removed intact through a 7- to 9-cm extraction incision in the lower midline. In the majority of patients, the distal ureter was dissected through the extraction incision. RESULTS: Sixteen cases were completed laparoscopically. Two cases required conversion to an open procedure. In these cases, dense fibrosis was present around the renal hilum preventing further dissection. The mean operative time was 180 minutes, and the mean estimated blood loss was 160 mL. The mean length of stay was 3.3 days. Complications included the 2 conversions, and 1 patient with a postoperative Mallory Weiss tear. No port-site or distant metastasis occurred; however, 1 patient developed a retroperitoneal recurrence. CONCLUSION: Laparoscopic nephroureterectomy is an alternative to open nephroureterectomy. Cases with high-stage and grade may cause the laparoscopic dissection to be difficult. The extraction incision allows for easy dissection of the distal ureter.     

Laparoscopic radical nephrectomy for cancer

Laparoscopic radical nephrectomy is a rapidly emerging technique for the treatment of renal cell carcinoma. Surgeons at multiple institutions have reported excellent technical results with this procedure, with encouraging safety and efficacy data and low complication rates comparable with the rates in open radical nephrectomy. Although debate continues regarding the pros and cons of the transperitoneal versus retroperitoneal approach and regarding morcellation versus intact specimen extraction, laparoscopic radical nephrectomy is beginning to approach standard-of-care status at select institutions for tumors less than 8 cm in size. Although generally accepted indications for laparoscopic radical nephrectomy include T1-T2N0M0 tumors, increasing experience and operator confidence have allowed expansion of these indications to include select patients with nodal disease, preoperatively staged level I renal vein thrombus, cytoreductive surgery before immunotherapy protocols, and the rare patient with a laterally directed locally invasive (pT4N0M0) renal cell carcinoma.