Laparoscopic partial nephrectomy and wedge resection for the treatment of renal malignancy

The widespread use of abdominal ultrasonography, CT, and MRI has led to an increase in the number of incidentally detected renal masses, some of which are malignant. Numerous studies suggest that partial nephrectomy or wedge resection of these lesions yield cure rates similar to those obtained with radical surgery. Laparoscopic nephron-sparing surgery is one of the more challenging minimally invasive surgical techniques, and its use is largely restricted to specialized medical centers. The techniques and available results are described.     

Laparoscopic partial nephrectomy

We retrospectively reviewed the clinical results of 24 patients who underwent laparoscopic partial nephrectomy by a diagnosis of renal cell carcinoma (RCC) between 1999 and 2004, including 16 elective cases and 8 imperative cases. Twenty-two were successfully treated laparoscopically; two cases in the imperative group required conversion to open surgery because of uncontrollable bleeding. A vascular clamp was used in 12 cases for an average of 26 minutes. The creatinine clearance changed from 98 to 93 ml/min in the elective cases and from 49 to 44 ml/min in the imperative cases. Pathological evaluation revealed RCC in 10 elective cases and 6 imperative cases. Local recurrence (renal hilum lymph node and ipsilateral kidney) was found in 2 patients in the imperative group. Although laparoscopic partial nephrectomy is useful, long-term follow-up is necessary for evaluating the tumor control.     

Laparoscopic partial nephrectomy

ObjetivesTo analyze the surgical and oncologic outcome of prospective experience with laparoscopic partial nephrectomy. We describe the surgical technique and mid term oncological results achieved.Material and methods60 patients were operated with this technique between June 2005 and June 2009. The mean age of patients was 58.9 [38-77] years, being 40 (66.7%) males and 20 (33.3%) women. The average BMI was 26.8 [18-40]. Laterality was 28 (46.7%) tumors rights and 32 (53.3%) left, being located in the upper pole in 14 (23.3%) patients, in the middle third in 13 (21.7%) in the lower pole in 22 (36.7%) and hiliar region in 11 (18.3%). In 23 cases (38.3%) tumors were located in the anterior valve, in 24 (40%) in posterior valve, in 10 (16.7%) at the outer edge and 3 (5%) at the inner edge. The average size tumor on CT was 3.3 [1-6.4] cm and in the surgical specimen 3.1 [1.2-7] cm.ResultsThe mean operative time was 107.17 [50-185] min, with a warm ischemia time of 33 [0-70] min. In 56 cases (93.3%) had a single artery and 4 (6.7%) cases had 2 arteries. The artery was clamped alone in 15 patients (25%), artery and vein in 44 (73.3%) and no clamping was performed in 1 (1.7%). We repaired the urinary tract in 32 patients (53.3%), leaving ureteral catheter in all patients. 20% of patients (12) required transfusion. Intraoperative complications occurred in 5 patients (8.7%). These were: 1 splenic injury requiring splenectomy (1.7%), 1 tear in the vena cava, sutured laparoscopically (1.7%) and 3 cases of bleeding due to bulldog malfunction (5%). Postoperative complications occurred in 11 patients (18.7%) and these were: 1 wall hematoma that required reoperation (1.7%), 1 urinary fistula ending in renal atrophy and subsequent nephrectomy (1.7%), 3 intracavitary hematomas hich resolved conservatively (5%), 1 arteriovenous fistula that needed embolization (1.7%), 1 urinoma that was resolved with percutaneous drainage (1.7%) and 3 cases of postoperative fever (5%). Margins were positive in 1 patient (1.7%). In 49 cases (81.7%) histology was renal cell carcinoma, in 8 (13.3%) oncocytoma, in 2 (3.3%) angiomyolipoma and 1 (1.7%) metastasis. The average stay was 5 [3-29] days. Median follow up was 31 [12-61] months. There was a local recurrence at 16 months (hiliar primary tumor 2.5 cm) and an ipsilateral adrenal metastasis at 34 months (primary tumor 5.6 cm in left lower pole).ConclusionsIn this series of laparoscopic partial nephrectomy low rate of complications, good oncologic results and low recurrence rate in the short term are shown. More patients and further monitoring is required to strengthen the functional and oncological outcomes of this surgical technique.     

Laparoscopic partial nephrectomy

BACKGROUND AND PURPOSE: The technique of laparoscopic partial nephrectomy has matured significantly over the past decade and is emerging as an oncologically sound procedure for the management of small renal tumors. Methods of tumor excision as well as parenchymal reconstruction in a hemostatically controlled field have evolved to make this procedure safer. Improved techniques to minimize warm renal ischemia are being developed. Finally, methods to prevent positive surgical margins during laparoscopic surgery are crucial to a satisfactory oncologic outcome. These important technical issues, as well as the current results of laparoscopic partial nephrectomy, are discussed. MATERIALS AND METHODS: The urologic peer-review literature related to nephron-sparing surgery was reviewed. Controversial issues with respect to the surgical approach, methods of hemostatic control, acceptable time of warm ischemia, and cooling techniques were reviewed and collated. Perioperative results from larger series of laparoscopic and open partial nephrectomy were evaluated. RESULTS: Open nephron-sparing surgery for renal tumors < or =4 cm has cancer control equivalent to that of open radical nephrectomy. Evidence is now emerging that laparoscopic partial nephrectomy will provide similar oncologic results, although clinical follow-up is still early. Blood loss, postoperative pain, and convalescence seem to be favor the laparoscopic approach. Complication rates, primarily postoperative bleeding and urine leak, may be higher than for open nephron-sparing surgery. Methods of laparoscopic hemostatic control favor soft vascular clamping for larger tumors that are more endophytic and central. Smaller exophytic lesions may be managed without renal vascular control using a variety of coagulative and hemostatic tools. Data related to warm renal ischemia suggest that the time used for tumor excision and renal reconstruction should be 30 minutes or less. Techniques for laparoscopic renal cooling are being developed. CONCLUSIONS: Laparoscopic nephron-sparing surgery is a technique in evolution but with a promising outlook. The urologic peer-review literature reflects an exponential growth in interest, which suggests that this minimally invasive approach is practical and may benefit our patient population so as to allow them to return to normal healthy living more quickly.     

Laparoscopic partial nephrectomy

BACKGROUND AND PURPOSE: With continuing rapid changes in endourology, we conducted a new survey of practice trends and expanded our sampling to include non-American urologists. MATERIALS AND METHODS: The survey was done via the Internet using the database for the 2003 World Congress of Endourology. Approximately 1100 surveys were sent, and responses were received from 193 urologists, who had been in practice for a mean of 9.9 years (median 8 years). Of these, 52% spend >50% in endourology, and 48% devote >20% of their practice to laparoscopy. RESULTS: More than half of the respondents (56%) perform laparoscopic partial nephrectomy (LPN), and 65% chose LPN as the procedure of choice for patients with an uncomplicated 3-cm renal mass. The majority obtain vascular control, most commonly by clamping the renal artery only. Most respondents do not use ureteral stents unless the collecting system is entered. CONCLUSIONS: These results and a review of the literature indicate a growing acceptance among endourologists of LPN as the procedure of choice for patients with small renal masses who are to undergo nephron-sparing surgery. Disagreement remains concerning the role and type of vascular control, the use of hemostatic agents, and the value of stents when the collecting system is entered.     

Laparoscopic partial nephrectomy

In properly selected patients, partial nephrectomy yields oncologic efficacy similar to that of traditional radical nephrectomy. We have performed more than 415 laparoscopic radical nephrectomies over the 5-year period beginning in September 1999. All patients undergo a three-dimensional CT scan with 3-mm sections prior to the operation. We generally prefer the transperitoneal approach, although for posterior tumors, a retroperitoneal approach is preferred. The kidney is dissected using standard technique. Intraoperative hydration is given to maintain diuresis. Detailed real-time ultrasonographic delineation of the tumor is obtained to facilitate planning of the resection. We prefer en-bloc hilar clamping. The renal capsule is scored circumferentially with the "L" hook electrocautery. Parenchymal incision and tumor resection is performed using heavy reuseable scissors. The base of the resection defect is closed using a running 2-0 Vicryl on a CT-1 needle. The water-tightness of pelvicaliceal repair is tested by repeat gentle injection of indigo carmine through a ureteral catheter. Next, the parenchyma is closed with 1 Vicryl on a CTX needle placed over an oxidized cellulose bolster. The specimen is extracted within an entrapment bag. Initially, a surgeon should be highly selective, including patients with small, mostly exophytic, tumors. With increasing comfort and experience, the criteria can expand.     

Laparoscopic partial nephrectomy

PURPOSE OF REVIEW: This review defines the current role, indications, contraindications, advances, complications, and outcomes of laparoscopic partial nephrectomy in the management of renal tumors. RECENT FINDINGS: Recent publications have widened the scope for the application of this technology. The new advances in the management of renal tumors and the tools for tumor excision, renal parenchymal reconstruction, hemostasis, renal vascular control to establish renal ischemia, and the ability to avoid positive surgical margins have made the procedure safe and feasible in the hands of an experienced laparoscopist. SUMMARY: The trend toward nephron-sparing surgery has become stronger even in the presence of normal contralateral functioning kidney. Data on oncologic efficacy are promising, and partial nephrectomy is becoming a standard therapy for renal tumors less than 4 cm in size in many centers. Laparoscopic partial nephrectomy has evolved significantly during the past 10 years in our experience as well as that of others. It cannot be considered as a standard yet, but it is being performed in rapidly increasing numbers with good surgical efficiency and oncologic efficacy parallel to that of open surgery.     

Laparoscopic total and partial nephrectomy

Laparoscopic radical nephrectomy has established its role as a standard of care for the management of renal neoplasms. Long term follow-up has demonstrated laparoscopic radical nephrectomy has shorter patient hospitalization and effective cancer control, with no significant difference in survival compared with open radical nephrectomy. For renal masses less than 4cm, partial nephrectomy is indicated for patients with a solitary kidney or who demonstrate impairment of contralateral renal function. The major technical issue for success of laparoscopic partial nephrectomy is bleeding control and several techniques have been developed to achieve better hemostatic control. Development of new laparoscopic techniques for partial nephrectomy can be divided into 2 categories: hilar control and warm ischemia vs. no hilar control. Development of a laparoscopic Satinsky clamp has achieved en bloc control of the renal hilum in order to allow cold knife excision of the mass, with laparoscopic repair of the collecting system, if needed. Combination of laparoscopic partial nephrectomy with ablative techniques has achieved successful excision of renal masses with adequate hemostasis without hilar clamping. Other techniques without hilar control have been investigated and included the use of a microwave tissue coagulator. In conclusion, laparoscopic radical nephrectomy for renal cell carcinoma has clearly demonstrated low morbidity and equivalent cancer control. The rates for local recurrences and metastatic spread are low and actuarial survival high. Furthermore, laparoscopic partial nephrectomy has demonstrated to be technically feasible, with low morbidity. With short term outcomes demonstrating laparoscopic partial nephrectomy as an efficacious procedure, the role of laparoscopic partial nephrectomy should continue to increase.     

Laparoscopic surgery for stage T1 renal cell carcinoma: radical nephrectomy and wedge resection

OBJECTIVES: Renal cell carcinoma (RCC) is likely to become one of the most important indications for laparoscopic surgery. We herein report our experience. METHODS: From April 1994 until April 1999, 98 patients presenting with RCC were treated laparoscopically by either radical nephrectomy (RN; n = 73) or wedge resection (WR; n = 25). The mean age was 62.3 years. The mean tumour diameters were 3.8 cm (RN) and 1.9 cm (WR). All tumours were clinical stage T1 lesions. The transperitoneal approach was used for RN in all patients. For WR either the transperitoneal or the retroperitoneal approach was used. In 15 patients, the adrenal gland was removed simultaneously. The specimen was entrapped in an organ bag and removed intact through a small muscle-splitting incision in the lower abdominal wall. RESULTS: RN: The mean operating time was 142 (range 86-230) min, the mean blood loss was 170 (range 0-1,500) ml, and the mean postoperative hospital stay was 7.4 (range 3-32) days. Minor complications occurred in 4.0% of the patients, while major complications were seen in 8.0% of them. WR: The mean operating time was 163.5 (range 90-300) min, the mean blood loss was 287 (range 20-800) ml, and the postoperative hospital stay was 8.0 (range 3-8) days. Minor complications: 4%, major complications: 8%. Histology revealed RCC stage T1 in 77 patients, stage T3a in 7, and stage T3b in 3 patients, oncocytoma in 2 patients, angiomyolipoma in 2, renal adenoma in 1, renal metastasis in 1, multilocular cysts in 4, and renal abscess in 1 patient. Over mean follow-up periods of 13.3 and 22.2 months for RN and WR, respectively, neither local recurrences nor metastases have been observed among patients with histologically confirmed RCC. CONCLUSIONS: Laparoscopic surgery for clinical stage T1 RCC is safe and efficient. Excellent tumour control can be achieved. However, longer follow-up periods will be necessary to confirm these results.     

Laparoscopic approach in partial nephrectomy

Except for segmental parenchymal atrophies, partial nephrectomy is more and more often indicated when treating isolated small renal tumours. During the last few years this technique has been increasingly accepted for the excision of tumours less than 4 centimetres. In order to diminish the operative morbidity, the laparoscopic approach has been proposed. During the last decade, laparoscopic partial nephrectomy "has come to maturity" and this technique is now well standardized. Knowledge and operative skills are required for both trans-peritoneal and extra-peritoneal route. Extra-peritoneal approach is more suitable for posterior lesions or at the level of the lower pole while the trans-peritoneal route is preferred in case of tumours near the renal hilum or on the anterior surface. Different methods offering temporary arrest of renal perfusion have been elaborated. There is a clear tendency for renal parenchyma sectioning without the use of any kind of thermal energy. This allows a better identification of renal lesions. Sectioned collecting system, blood vessels and renal parenchyma are systematically sutured. Despite its complexity, this technique has become reproducible and reliable in specialized laparoscopic centres.     

Laparoscopic partial nephrectomy: technique and outcomes

The indication of laparoscopic partial nephrectomy (LPN) has evolved considerably, and the technique is approaching established status at our institution. Over the past 5 years, the senior author has performed more than 450 laparoscopic partial nephrectomies at the Cleveland Clinic. Herein we present our current technique, review contemporary data and oncological outcomes of LPN.     

Laparoscopic partial nephrectomy in infants and toddlers

Background/Purpose

The aim of this report is to assess the technique and outcome of laparoscopic partial nephrectomy in infants and toddlers.

Methods

From January 2001 to January 2005, 7 consecutive patients, ages 5 to 15 months, underwent laparoscopic partial nephrectomies. All patients had duplicated systems associated with ureteroceles (5), severe reflux (1), ectopic ureter (1), and nonfunctioning systems. Follow-up ranged from 4 to 51 months.

Results

All procedures were completed successfully using 4 ports (2 × 5 and 2 × 3 mm) except one, which required an additional port. The distal ureter, renal parenchyma, and hilar vessels were all transected using the harmonic scalpel. The mean operating time was 179 minutes with minimal blood loss in each case. The average hospital stay was 2.4 days (range, 1-5 days). The first case in the series, initially attempted retroperitoneally, was converted to a transabdominal approach because of lack of space. All subsequent approaches were transabdominal. One patient required ureteral stump reexcision because of frequent urinary tract infections associated with a distal ureteral diverticulum.

Conclusions

Laparoscopic partial nephrectomy can be performed safely. The harmonic scalpel divides the parenchyma bloodlessly. The cosmetic result is excellent. A transabdominal approach with division of the ureteral cuff flush with the bladder is recommended.     

Laparoscopic partial nephrectomy: fifty cases

PURPOSE: Laparoscopic partial nephrectomy (LPN) is a technically challenging procedure. The goal of this study is to describe the outcomes of 50 consecutive patients undergoing LPN performed by one surgeon. MATERIALS AND METHODS: Records were reviewed for clinical, pathologic, and follow-up information for patients undergoing LPN. Clinical parameters were assessed in both the first 25 and last 25 cases to see if there was a measurable learning curve. RESULTS: Fifty-two patients underwent attempted LPN; 50 were successful and 2 were converted to open partial nephrectomy. Mean operating room time was 155 minutes, mean estimated blood loss was 172 mL, and mean pathologic size was 2.6 cm. Final pathology revealed malignancy in 60% of cases and oncocytoma in 22% of cases. Margins were clear for all of the primary lesions. Overall complications were 16%, with cardiopulmonary complications being the most common. There were no significant differences in the outcomes of the first 25 and the last 25 patients, with the exception of length of stay (3.1 days v 2.5 days). CONCLUSIONS: After laparoendoscopic fellowship training in LPN, acceptable outcomes are achievable, and the learning curve is minimal. Long-term studies are needed on the efficacy of LPN, and further studies need to be performed to optimize the learning process for this technique.     

Laparoscopic partial nephrectomy: hand-assisted technique

Laparoscopic partial nephrectomy (LPN) is a challenging procedure that has become more popular as techniques have evolved and made the procedure more standardized. We present our hand-assisted technique for LPN. In order to meet the challenges of larger, deeper lesions and to address complications, our technique has evolved from pure hand assistance to hand assistance with hilar clamping and hemostatic adjuncts. We discuss patient selection, preparation and access, renal exposure, preparation of hemostatic agents, resection of the mass, hemostasis, and closure. The results of 76 hand-assisted LPNs (HALPNs) are summarized. While our technique will undoubtedly continue to evolve, HALPN appears to be safe and effective for minimally invasive nephron-sparing surgery.     

Laparoscopic partial nephrectomy in solitary kidney

PURPOSE: We report our experience with LPN for tumor in a solitary kidney. MATERIALS AND METHODS: Of 430 patients undergoing LPN since February 1999 at our institution 22 (5%) underwent LPN for tumor in a solitary kidney, as performed by a single surgeon. The laparoscopic technique that we used duplicated open principles, including hilar clamping, cold cut tumor excision and sutured renal reconstruction. RESULTS: Mean tumor size was 3.6 cm (range 1.4 to 8.3, median 3 cm), median blood loss was 200 cc (range 50 to 500), warm ischemia time was 29 minutes (range 14 to 55), total operative time was 3.3 hours (range 2.2 to 4.5) and hospital stay was 2.8 days (range 1.3 to 12). Two cases (9%) were electively converted to open surgery. Pathological findings confirmed renal cell carcinoma in 16 patients (73%) with negative surgical margins in all those with LPN. Major complications occurred in 3 patients (15%) and minor complications developed in 7 (32%). Median preoperative and postoperative serum creatinine (1.2 and 1.5 mg/dl) and estimated glomerular filtration rate (67.5 and 50 ml per minute per 1.73 m2) reflected a change of 33% and 27%, respectively, which appeared proportionate to the median amount of kidney parenchyma excised (23%). One patient (4.5%) required temporary hemodialysis. At a median followup of 2.5 years (range 0.5 to 4.5) cancer specific and overall survival was 100% and 91%, respectively. No patient with LPN had local or port site recurrence, or metastatic disease. CONCLUSIONS: LPN can be performed efficaciously and safely in select patients with tumor in a solitary kidney. To our knowledge we present the largest series in the literature. Advanced laparoscopic experience and expertise are necessary in this high risk population.