LAPAROSCOPIC PARTIAL NEPHRECTOMY - PowerPoint Presentation

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LAPAROSCOPIC PARTIAL NEPHRECTOMY AS A NEPHRON SPARING SURGERY

PROF. DR. METE KİLCİLER

DEPARTMENT OF UROLOGY,

SCHOOL OF MEDICINE,

BAHÇEŞEHİR UNIVERSITY

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IntroductionThe incidence of small incidental renal tumors is increasingNephron-sparing surgery -new trendNSS - 4 cm or small localized RCC (Novick)

Open partial nephrectomy

-

gold standard

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IntroductionThe first LPN was described in 1993 (J. Endourol,7:521,1993)It is an advanced laparoscopic procedure Dissection, renal

hilum clamping, renal

parenchymal

hemostasis

,

pelvicaliceal

reconstruction

and

renorraphy

Steps

are essentially duplicating those of open partial

nephrectomy

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IndicationsClassical indications:Small renal tumorsPeripheral locationSuperficialExophyticAs the surgeon’s experience increases

:more complex tumors can be done

tumors

invading the parenchyma to the collecting system

,

or

renal

sinus

complete

intrarenal

tumors

tumor

in a solitary

kidney

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ContraindicationsRenal vein thrombusMultiple renal tumorsLocally advanced diseaseBleeding diathesisMorbid obesityPrior renal surgeryGeneral C/I to laparoscopic surgery

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C/I to lap. surgeryAbsolute contraindications:Uncorrectable coagulopathyIntestinal obstructionAbdominal wall infectionMassive hemoperitoniumPeritonitis

Suspected malignant ascites

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C/I to lap. surgeryRelative contraindications:Morbid obesityPrior abdominal or

pelvic s

urgery

Pelvic

f

ibrosis

Organomegaly

Ascites

Pregnancy

Hernia

Iliac or

a

ortic

a

neurysm

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Pre-op. PreparationSame as for open surgeryBasic blood countAccurate stagingThree dimensional CT scan

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Informed consent (for lap and open) Bowel prep (empty bowel)Foley catheter (empty bladder)NG or OG tube (empty stomach)DVT prophylaxis (sequential compression stockings) +/- AntibioticsShave prepPre-op. Preparation

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Surgical techniqueTransperitonealanteriorantero-lateral

lateralupper pole

-

apical

Retroperitoneal

p

osterior

posterolateral

Lower

pole

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approach

depends

on

localization

of

tumor

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Transperitoneal

Position

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Retroperitoneal Position

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Retroperitoneal Access

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Surgical technique-1Cystoscopy, ureteral catheterizationPort placementBalloon dilatation

(for retroperitoneal

way

)

Mobilizing

the

colon

(

for

transperitoneal

way

)

Hilar

dissection

Mobilize

the

kidney

and

dissect

fat

tissue

Identify tumor

Laparoscopic

us

and circumferential

scoring

Clamping

vessels

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Surgical technique-2Tumor excisionRenal tumor bed biopsy and frozen sectionPelvicaliceal repair (if necessary)

Sutures

to control transected

parenchymal

vessels

Hemostatic

renorraphy

over

bolsters

Unclamp

hilum

, confirm

hemostasis

Jackson-Pratt drain

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Hemostatic techniquesArgon beam coagulatorElectrocauteryHarmonic scalpelFibrin glueGelatin spongesUltrasonic surgical aspiratorLaserMicrowave tissue coagulator

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Surgical technique – TLPN position

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Surgical technique – RLPN position

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TLPN TechniqueIndividual dissection of the renal artery and vein is not necessary Laparoscopic satinsky clamp is used to control the renal

hilum en bloc

The

inset shows a four-port arrangement, with a 2-mm needle port positioned

laterally

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RLPN TechniqueOwing to the somewhat restricted retroperitoneal operative space, the Satinsky clamp is not used Instead, the renal artery and vein are dissected individually and controlled with separate laparoscopic bulldog clamps Inset

shows the three-port retroperitoneoscopic approach

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Bigger tumors or unclear parenchyma borders need ultrasound and experienced radiologist

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Lap. Partial nephrectomyTumor excision performed with cold EndoshearsThe calyx abutting the tumor is entered deliberately, as necessary, to maintain an adequate parenchymal margin

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Lap. Partial nephrectomy Retrograde injection of indigo carmine through an indwelling ureteral catheter precisely describe the site of caliceal entry in the partial nephrectomy

bed

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Lap. Partial nephrectomy Caliceal suture repair performed using intracorporeal freehand laparoscopic suturing. A CT-1 needle with 2-0 Vicryl is employed to achieve a watertight closure.

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Lap. Partial nephrectomyRenal parenchymal reconstruction A GS-25 needle with 0 Vicryl is employed to place wide parenchymal sutures

Typically, three to four sutures are needed.

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Lap. Partial nephrectomy Pre-prepared bolsters of surgicel are placed in the parenchymal defect before cinching down the sutures.

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Warm ischemia time < 30 min Tumor excision

Suturing collecting

system

Suturing

parenchyma

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Complications of Laparoscopic Partial NephrectomyUrinoma Total nephrectomy Trocar site infection

PneumothoraxPulmonary edema

Tumor fragmentation

Transfusion

Pneumonia

Renal insufficiency

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Financial analysisItem

Lap.

Open

P value

Intraop

.

c

ost

20.1% greater

< 0.001

Postop. cost

55% lesser

< 0.001

Overall hospital cost

15.6% lesser

0.002

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ConclusionsLPN is an advanced procedureCarries higher intraop./postop. complicationsAs surgeon experience increases, the rate of complications decreases, and the indications for more complex cases increasesEmerging as a viable and efficient treatment option in the minimally invasive armamentarium