The prevalence of malignancy in satellite renal lesions and its surgical implication during nephron sparing surgery

PURPOSE: We examined the prevalence of malignancy in a synchronous ipsilateral renal lesion identified during partial nephrectomy and evaluated its clinical significance. MATERIALS AND METHODS: We retrospectively reviewed the records of 112 patients (114 renal units) who underwent nephron sparing surgery for a clinically localized sporadic renal mass between May 1995 and September 2005. RESULTS: In 37 patients (32%) an additional lesion was diagnosed and excised intraoperatively, while in 67% these lesions were known before the operation and believed to be simple cysts. During surgery the additional mass was suspicious in 8 cases and in the remainder the mass was described as simple cysts that were excised. The mean size of the primary mass was 3.1 cm (SD 1.4). In 29 (78%) cases the primary mass was malignant, in 23 (79%) of these the second mass was benign and in the remainder renal cell carcinoma was diagnosed. In 8 cases (22%) the primary mass was benign and in 2 (25%) the secondary mass was malignant. Overall 22% of all second masses were malignant, and all were low grade and low stage. We found that 7% of second ipsilateral masses could be expected to harbor malignancy. CONCLUSIONS: Based on our data it is questionable whether total nephrectomy is mandatory as an immediate response to an ipsilateral synchronous second renal mass. The present findings may represent an increased appreciation of ipsilateral multicentricity compared to historical data.     

Parenchymal sparing surgery for central renal tumors in patients with hereditary renal cancers

PURPOSE: Nephron sparing surgery has become accepted surgical practice for removing of renal tumors. The resection of central lesions has been thought to be more surgically challenging than that of peripheral tumors. We analyzed our experience with renal preservation surgery in patients with small hereditary central renal tumors. MATERIALS AND METHODS: From 1992 to 2000 we performed 116 partial nephrectomies with 44 kidneys (38%) demonstrating central renal masses. Central renal tumors were defined radiologically as those completely encircled by parenchyma or transgressing the interpapillary line on computerized tomography. We compared this group to a similar series of 67 patients with hereditary renal cancer with only peripheral based tumors. RESULTS: Mean tumor size was 3.2 cm (range 1.5 to 7.5). Mean operative time was 352 minutes (range 70 to 830). Renal hypothermia and vascular clamping were used in 19 of 44 procedures (41%). Mean ischemic time was 55 minutes (range 16 to 143). Mean blood loss was 4.6 l (range 0.1 to 23). The complication rate was 23% (10 of 44 cases) and with 18% (8 of 44) directly related to surgical technique. The mean transfusion requirement was 6.7 U (range 0 to 32) and 12 of 44 procedures (27%) required no blood products. Mean preoperative and postoperative serum creatinine was 1.05 (range 0.6 to 1.8) and 1.08 mg/dl (range 0.6 to 2.1), respectively. Mean followup was 33.7 months. No metastasis developed during followup. CONCLUSIONS: Central renal tumors are a common manifestation of hereditary renal cell carcinoma. There was no statistical difference found between common operative parameters when central and peripheral nephron sparing surgeries were compared. However, mean operative blood loss and transfusion requirements were increased in the central tumor group.     

基于肾单位精细解剖的后腹腔镜肾部分切除术方法改进与应用

目的：探索基于肾单位精细解剖的后腹腔镜保留肾单位肾部分切除的手术方法和技巧,借助解剖方法减少出血和尿瘘的可能性。方法：我院2012年1～12月期间住院的肾脏肿瘤患者31例,男19例,女12例,年龄28468岁,平均（56．1±13．8）岁。肿瘤直径1．2～6．0cm,平均（3．4±0．7）cm。术中阻断肾动脉后,距肿瘤边缘3～5mm剪开肾包膜及肾皮质,在肾实质的切口内,沿肾锥体髓放线钝性加锐性向深处和基底分离,使包裹一层肾髓质的瘤体与保留的肾脏髓质分开,显露出的基底部的血管应用双极电凝后剪断。仔细剥离肾小盏,以可吸收线两层缝合,关闭肾脏创面。记录动脉阻断时间、手术时间、术中出血量、术后引流量、病理结果和手术并发症。结果：本组31例患者采用切开包膜实质剥离髓质方法均获成功。其中19例可见基底部1支血管,8例可见2支血管,19例可见肾盏。平均手术时间（95．5±27．1）min;平均术中动脉阻断时间（21．2±7．2）min;平均术中出血量（55．7±18．9）ml;平均术后引流量（92．3±28．9）ml,平均术后住院时间（6．1±0．6）d;术后无继发出血、漏尿等并发症发生。所有标本呈完整楔形块状,切缘均为阴性。术后病理证实：肾透明细胞癌27例、嗜酸细胞腺瘤1例、肾小球旁细胞瘤1例、嫌色细胞癌2例。TNM分期：T1a期28例,T1b期3例。结论：采用切开包膜和实质剥离肾髓质改良的后腹腔镜保留肾单位肾部分切除术,切除瘤体部所附着肾组织确切完整,有利于切缘阴性。基底部止血确实,处理累及的肾盏确切,可以减少术后继发出血及漏尿的发生。     

Nephron sparing surgery for central renal tumors: experience with 33 cases

PURPOSE: Nephron sparing surgery is standard treatment for small, peripherally located renal cell carcinoma. In patients with a solitary kidney, bilateral tumors or impaired renal function nephron sparing surgery provides the only option to nephrectomy and subsequent hemodialysis or transplantation. We retrospectively investigated the value of nephron sparing surgery for centrally located renal cell carcinoma. MATERIALS AND METHODS: Between 1969 and 1997, 311 renal tumor enucleations were performed at our institution. The tumor was centrally located in 33 cases. The indication for enucleation was elective in 7 cases and imperative in 26, including bilateral tumor in 16 (metachronous in 9 and synchronous in 7), chronic renal failure in 4 and solitary kidney in 6. Four patients had metastasis at enucleation. RESULTS: Convalescence was unremarkable in 28 cases. Hemorrhage occurred in 1 patient, a urinary fistula in 2 and a local abscess secondary to a urinary fistula in 1. One patient died postoperatively of heart failure. Average serum creatinine was 1.25, 1.63 and 1.33 mg./dl. preoperatively, at hospital discharge and at a mean followup of 33 months, respectively. Hemodialysis was necessary transiently during convalescence in 1 patient and permanently starting 6 years after enucleation in another. Definitive histology revealed oncocytoma in 4 cases and renal cell carcinoma in 29. Disease was stages pT1 to pT3 in 9, 18 and 2 cases, and grades 1 to 3 in 6, 18 and 5, respectively. Local recurrence developed in 2 patients. Mean followup was 5.2 years (range 0.3 to 16.7). At a mean followup of 6.2 years (range 0.7 to 16.7) 20 patients were free of disease. In addition to the patient who died postoperatively, 9 died of renal cell carcinoma at a mean of 1.6 years (range 0.3 to 5.3) and 3 died of other causes at 5, 11 and 12 years postoperatively, respectively. No patient who underwent elective enucleation died. CONCLUSIONS: Nephron sparing surgery for centrally located kidney tumors is technically feasible and associated with an acceptable complication rate. Local tumor control is excellent, and the overall prognosis depends on contralateral disease and metastasis. Benign tumors may be diagnosed and removed without loss of the kidney. By avoiding hemodialysis quality of life is improved.     

Complications of contemporary open nephron sparing surgery: a single institution experience

PURPOSE: Open nephron sparing surgery (NSS) is now the standard of care for small renal tumors irrespective of overall renal function. More recently laparoscopic NSS with hilar clamping has emerged, albeit with relatively longer ischemic times. We reviewed our experience with contemporary open NSS, comparing complication rates to those of historical controls and updating data for comparison with minimally invasive procedures. MATERIALS AND METHODS: From 1985 to 2001, 823 open NSSs were performed at our institution. Early (within 30 days of NSS) and late (30 days to 1 year) complications were compared using the chi-square and Wilcoxon rank sum tests between procedures performed in 1985 to 1995 (control group of 343 patients) and 1996 to 2001 (contemporary group of 480). RESULTS: In the control vs the contemporary group there were significant decreases in intraoperative blood loss (median 550 vs 350 cc, p <0.001), chronic renal insufficiency/failure (14.6% vs 8.1%, p = 0.003), dialysis need (7.0% vs 2.1%, p <0.001) and any early (13.4% vs 6.9%, p = 0.002) or late (32.4% vs 24.6%, p = 0.014) complication. In the contemporary group 50% of patients did not require pedicle clamping, 32% underwent warm ischemia (median 12 minutes) and 18% underwent cold ischemia (median 27 minutes). In addition, patients with a warm ischemia time of 20 minutes or less had fewer early complications than patients with greater than 20 minutes of ischemia, although this did not attain statistical significance (3.8% vs 13.6%, p = 0.063). CONCLUSIONS: Complications resulting from open NSS have significantly decreased with time. Contemporary open NSS is associated with minimal morbidity, and decreases the need for pedicle clamping and overall ischemia time.     

Nephron sparing surgery for renal cell carcinoma using selective renal parenchymal clamping.

PURPOSE: We describe a technical artifice facilitating nephron sparing surgery for renal cell carcinoma without clamping the renal pedicle. MATERIALS AND METHODS: Selective renal parenchymal clamping was performed using a large curved DeBakey aortic clamp placed around and sufficiently far from the tumor. The lesion was resected with a surrounding margin of normal renal parenchyma. The intrarenal vessels were suture ligated and the collecting system was closed as necessary. Time was not limited since the artery was not clamped. RESULTS: Ten patients with renal cell carcinoma in whom nephron sparing surgery was indicated underwent selective renal parenchymal clamping. The indication was elective in 8 patients and urgent in 2. The tumor was at the renal pole in 3 cases and peripheral in 7. Mean tumor size was 32 mm. (range 19 to 52). Blood loss was insignificant. Operative time was 81 minutes (range 61 to 125) and there were no perioperative or postoperative complications. CONCLUSIONS: Selective renal parenchymal clamping is a simple and efficient technical maneuver for facilitating nephron sparing surgery without pedicle dissection and clamping for renal peripheral or pole tumors. Neoplasm location and size are the limiting factors of this technique.     

Prospective comparison of the immunological and stress response following laparoscopic and open surgery for localized renal cell carcinoma

PURPOSE: We prospectively compared the systemic immune and stress response of patients who underwent laparoscopic total nephrectomy (LRN) (14) and open nephrectomy (ON) (10) for renal cell carcinoma. The ON group comprised open radical (4), open total (2) and open partial (4) nephrectomy cases. MATERIALS AND METHODS: Only patients with no history of cancer or autoimmune disease and American Society of Anesthesiologists score 2 or less who were not using immunosuppressive drugs were selected. Peripheral venous blood was collected preoperatively and intraoperatively, and 24 hours, 2 weeks, 4 weeks and 3 months postoperatively. Blood was analyzed for stress markers (adrenalin, noradrenalin and cortisol), inflammatory response markers (C-reactive protein, white blood count and leukocyte count), lymphocytic response markers (CD3, CD4 and CD8), cytokines interleukin-2 and 4, interferon-alpha and tumor necrosis factor-alpha), HLA-DR expression and the proliferative response to mitogen stimulation using concanavalin A, phytohemagglutinin 10, and pokeweed mitogen. RESULTS: Mean tumor size +/- SD for ON and LRN was 5.6 +/- 2.4 and 4.5 +/- 1.6 cm, respectively (p = 0.21). The trends with time for all measured postoperative parameters were similar in the 2 groups. Inflammatory and stress response markers were statistically similar for in the groups at all time points. A significant difference between the groups was noted for the percentage of CD4+ and CD8+ lymphocytes. However, this difference was present preoperatively and there was no significant absolute change in these 2 parameters. The cytokine response and HLA-DR expression were similar in the 2 groups at all time points. Likewise, the lymphocytic stimulation index for concanavalin A, phytohemagglutinin and pokeweed mitogen were statistically similar for LRN and ON at all time points. CONCLUSIONS: The immunological and stress response after LRN and ON for renal cell carcinoma is similar. The few differences observed in measured parameters likely reflect preoperative differences in baseline and/or the contributory effect of anesthesia.     

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.     

保留肾单位的腹腔镜肾肿瘤切除手术方法及技巧

目的 介绍腹腔镜下钳夹法肾蒂阻断、锐性切除肿瘤以及创面直接缝合行保留肾单位的肾肿瘤切除术方法及手术技巧.方法 2003年6月至2005年6月,收治肾外生性实性肿瘤患者16例.男5例,女11例.年龄29～56岁,平均46岁.肿瘤位于左侧9例,右侧7例.肾细胞癌5例,肿瘤直径2.0～3.5 cm;肾错构瘤11例,肿瘤直径3.0～5.5 cm,其中1例肾错构瘤继发出血.经腹腔路径行保留肾单位的腹腔镜肾肿瘤切除术,手术在无损伤钳钳夹肾蒂控制血管后距肿瘤0.5～1.0 cm正常实质处锐性切除,创面缝合止血.结果 16例手术均成功.手术时间70～150 min,平均104min.肾蒂阻断时间14～32 min,平均21 min.术中出血量50～700 ml,平均158 ml.5例肾细胞癌患者病理检查示切缘阴性.16例术后无尿瘘、无继发出血,肾功能未见异常.2～4 d肛门排气,平卧1周出院.随访1～24个月,16例B超复查、11例CT检查肿瘤无复发,IVU复查肾显影良好.结论 可靠的肾血管控制是腹腔镜下行保留肾单位的肾肿瘤切除术的基本保证,无烟雾锐性切除肿瘤和创面的缝合处理能有效减少肾缺血时间,是保留、保护肾单位的有效手段,也是最有效的止血方法.本手术创伤小、出血少、痛苦少、并发症少、恢复快,能有效切除肿瘤和保留或保护肾功能.     

Fibrin glue-oxidized cellulose sandwich for laparoscopic wedge resection of small renal lesions

Purpose:We present our experience with standard laparoscopic wedge resection of small renal tumors using a fibrin glue-oxidized cellulose sandwich for hemostasis.Materials and Methods:From May 2002 to December 2003, 15 patients underwent laparoscopic wedge resection for a total of 15 nonhilar renal masses. Renal hilar clamping was performed in 1 patient and no sutures were placed. We used ultrasonic shears and an argon beam coagulator to resect and then coagulate the tumor bed. Tisseel (Baxter Corp., Deerfield, Illinois) was applied to the resection bed, followed by a layer of oxidized, regenerated cellulose (Surgicel, Ethicon, Somerville, New Jersey) and a final layer of Tisseel.Results:Mean preoperative tumor size was 2.2 × 2.2 × 2.1 cm. Lesions were subdivided based on the percent of the lesion that extended beyond the renal parenchymal border on computerized tomography as exophytic—greater than 60% in 6 cases, endophytic—less than 40% in 4 and mesophytic—40% to 60% in 5. Mean operative time was 3.8 hours (range 3 to 5). Mean blood loss was 108 ml (range 20 to 300). No patient required blood transfusion. There was no significant difference in blood loss or change in creatinine among the endophytic, exophytic and mesophytic groups (150, 121 and 93 ml, and 0.03, 0.07 and 0.04 mg/dl, respectively). Margin status was negative in all cases (mean thickness 3.2 mm). Average hospital stay and time to the resumption of oral intake were 2.7 and 1.4 days, respectively.Conclusions:Small exophytic or mesophytic renal lesions can be safely excised laparoscopically without vessel clamping. Excellent hemostasis was achieved in each case with the newer hemostatic agents.     

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.     

Comparison of 1,800 laparoscopic and open partial nephrectomies for single renal tumors

PURPOSE: Laparoscopic partial nephrectomy is an increasingly performed, minimally invasive alternative to open partial nephrectomy. We compared early postoperative outcomes in 1,800 patients undergoing open partial nephrectomy by experienced surgeons with the initial experience with laparoscopic partial nephrectomy in patients with a single renal tumor 7 cm or less. MATERIALS AND METHODS: Data on 1,800 consecutive open or laparoscopic partial nephrectomies were collected prospectively or retrospectively in tumor registries at 3 large referral centers. Demographic, intraoperative, postoperative and followup data were compared between the 2 groups. RESULTS: Compared to the laparoscopic partial nephrectomy group of 771 patients the 1,028 undergoing open partial nephrectomy were a higher risk group with a greater percent presenting symptomatically with decreased performance status, impaired renal function and tumor in a solitary functioning kidney (p<0.0001). More tumors in the open partial nephrectomy group were more than 4 cm and centrally located and more proved to be malignant (p<0.0001 and 0.0003, respectively). Based on multivariate analysis laparoscopic partial nephrectomy was associated with shorter operative time (p<0.0001), decreased operative blood loss (p<0.0001) and shorter hospital stay (p<0.0001). The chance of intraoperative complications was comparable in the 2 groups. However, laparoscopic partial nephrectomy was associated with longer ischemia time (p<0.0001), more postoperative complications, particularly urological (p<0.0001), and an increased number of subsequent procedures (p<0.0001). Renal functional outcomes were similar 3 months after laparoscopic and open partial nephrectomy with 97.9% and 99.6% of renal units retaining function, respectively. Three-year cancer specific survival for patients with a single cT1N0M0 renal cell carcinoma was 99.3% and 99.2% after laparoscopic and open partial nephrectomy, respectively. CONCLUSIONS: Early experience with laparoscopic partial nephrectomy is promising. Laparoscopic partial nephrectomy offered the advantages of less operative time, decreased operative blood loss and a shorter hospital stay. When applied to patients with a single renal tumor 7 cm or less, laparoscopic partial nephrectomy was associated with additional postoperative morbidity compared to open partial nephrectomy. However, equivalent functional and early oncological outcomes were achieved.     

保留肾单位手术治疗小肾癌的可行性与疗效评估

目的:探讨保留肾单位手术(NSS)治疗小肾癌的可行性和疗效.方法:报告20例行NSS治疗小肾癌患者(NSS组)和21例和根治性肾切除术(RN)治疗的同种患者(RN组)的临床资料,比较两组的手术时间、术中出血量、术后住院时间、并发症、复发情况及存活率.结果:两组手术均顺利完成.NSS组平均手术时间、术中出血量、并发症发生率大于RN组(P<0.05);但两组间术后住院时间、肿瘤复发率及长期存活率方面,差异无统计学意义.结论:NSS切除治疗小肾癌具有安全有效性.但要严格掌握适应证,对于大于4cm的肾癌,尽可能行RN.     

Parenchymal sparing surgery in patients with hereditary renal cell carcinoma: 10-year experience

PURPOSE: von Hippel-Lindau disease, hereditary papillary renal cell carcinoma, the Birt-Hogg-Dubé syndrome and familial renal oncocytoma are familial renal tumor syndromes. These hereditary disorders are noteworthy for the development of multiple bilateral renal tumors and the risk of new tumors throughout life. One management strategy is observation of solid renal tumors until reaching 3 cm, then performing parenchymal sparing surgery. We present a 5-year update on our experience. MATERIALS AND METHODS: From May 1988 to October 1998, 49 patients with hereditary renal cell carcinoma, including von Hippel-Lindau disease in 44, hereditary papillary renal cell carcinoma in 4 and the Birt-Hogg-Dubé syndrome in 1, and 1 with familial renal oncocytoma underwent exploration to attempt renal parenchymal sparing surgery. Patients were followed prospectively with periodic screening for recurrence, metastasis and loss of renal function. Median followup was 79.5 months (range 0.7 to 205). RESULTS: A total of 50 patients underwent 71 operations resulting in unilateral nephrectomy in 6, bilateral nephrectomy in 1 and partial nephrectomy in 65, with 1 to 51 tumors removed from each kidney (mean 14.7). Mean patient age was 39.5 years (range 18 to 70). Of the 65 (40%) partial nephrectomies 26 were performed with cold renal ischemia. Mean blood loss was 2.9 +/- 0.5 l (range 0.15 to 23). Postoperative complications included renal atrophy in 3 patients. Mean preoperative serum creatinine was 1.05 +/- 0.03 mg/dl (range 0.6 to 1.8), and postoperative creatinine was 1.06 +/- 0.04 mg/dl (range 0.6 to 2.0). No patient who underwent renal parenchymal sparing surgery required renal replacement therapy. Metastatic disease developed in 1 patient with a 4.5 cm renal tumor. CONCLUSIONS: Parenchymal sparing surgery with a 3 cm threshold in patients with hereditary renal cancer appears to be an effective therapeutic option to maximize renal function while minimizing the risk of metastatic disease.     

Hand assisted laparoscopic partial nephrectomy for peripheral and central lesions: a review of 30 consecutive cases

PURPOSE: We reviewed our first 30 hand assisted laparoscopic partial nephrectomies and compared the results of 8 centrally located vs 22 peripherally located tumors. MATERIALS AND METHODS: Tumors were classified by computerized tomography as central (less than 5 mm from the pelvicaliceal system or hilar vessels) or peripheral. The hand assisted technique consisted of mobilization and manual parenchymal compression without vascular occlusion or ureteral stent placement. Argon beam coagulation and a fibrin glue bandage were used for hemostasis. RESULTS: Mean tumor size was 2.6 cm (range 1.0 to 4.7). Mean operative time was 199 and 271 minutes, and estimated blood loss was 240 and 894 ml for peripheral and central lesions, respectively. No case required open conversion. The final diagnoses were renal cell carcinoma in 21 patients, angiomyolipoma in 4, benign or hemorrhagic cyst in 3 and oncocytoma in 2. Initial positive margins were found in 5 of 30 specimens (16.7%) (1 central and 4 peripheral) and all final resection margins were negative. Four central (50%) and 2 peripheral (9.1%) tumor cases required transfusion. Drain creatinine was elevated in 6 patients (20%) postoperatively, of whom 3 had a central and 3 had a peripheral lesion. All responded to conservative management except 1 patient (3.3%) who required stent placement. Postoperative bleeding in a central tumor case required transfusion of 4 units. There were no short-term local recurrences and 1 patient had an asynchronous tumor. CONCLUSIONS: Hand assisted laparoscopic partial nephrectomy is safe with excellent immediate cancer control. Careful dissection and frozen section analysis are mandatory to ensure a negative tumor margin. Blood loss and transfusion rates were higher in patients with centrally located tumors and renal hilar vascular control should be considered for central lesions.     

Nephron‐sparing surgery for small incidental renal cell carcinoma

Background : Nephron‐sparing surgery is currently an accepted treatment for renal cell carcinomas in patients with bilateral tumours, solitary kidneys and when overall renal function is impaired or at risk from medical disease. Its role in patients with a normal contralateral kidney remains controversial. Methods : The authors’ experience in 23 patients undergoing partial nephrectomy for small peripheral lesions between 1995 and 2000 is reported here. Results : Twenty‐three patients (13 men and 10 women) with a mean age of 56 years underwent partial nephrectomy. All but three of these patients had a normal contralateral kidney. Mean operating time was 141 min with a mean reduction of haemoglobin of 28 g/dL. Three patients required transfusion. Serum creatinine did not change significantly between preoperative and postoperative values. Two JJ stents were placed prophylactically during surgery to minimize urinary leak. There were no intraoperative or early postoperative deaths and at mean follow up of 16 months there was no evidence of recurrent tumour in 23 patients. Seventeen per cent of lesions removed were benign. Conclusions : Partial nephrectomy for small peripheral lesions is a safe procedure with low morbidity. No definite recurrences are evident at an early stage of follow up, although longer review (probably more than 10 years) will be required to assess cancer‐specific survival following this procedure.     

Complications of laparoscopic nephrectomy: the Mayo clinic experience

PURPOSE: We present the incidence of complications and conversions during laparoscopic nephrectomy performed for various indications and discuss methods to help prevent future complications. MATERIALS AND METHODS: From June 1999 to February 2003 at our institution 285 laparoscopic nephrectomy cases were performed, consisting of 113 radical nephrectomies, 101 donor nephrectomies, 27 simple nephrectomies, 23 partial nephrectomies and 21 nephroureterectomies. We reviewed the data base of patients who underwent laparoscopic nephrectomy to examine complications and analyze factors related to conversion to an open surgical procedure. RESULTS: Major complications occurred in 16 patients (5.6%). Major complications were surgical in 12 patients and medical in 4. Of the major surgical complications 3, 6, 1, 1 and 1 occurred during laparoscopic radical nephrectomy, donor nephrectomy, nephroureterectomy, simple nephrectomy and partial nephrectomy, respectively. The predominant major surgical complication was bleeding requiring conversion to an open surgical procedure. The overall conversion rate was 4% (12 patients), consisting of 6 emergency and 6 elective conversions. The remaining 27 patients experienced minor surgical or postoperative medical problems, such as urinary retention or wound infection. The mortality rate in our series was 0%. CONCLUSIONS: Laparoscopic renal surgery is becoming a routine procedure in the armamentarium of many urologists. Complications that are unique to laparoscopy exist but they should decrease with time with repetition and experience. We have learned many different precautions and procedures that should help decrease the risk of future complications associated with laparoscopic renal surgery.