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Laparoscopic Partial Nephrectomy of Hilar Tumors with Cold Ischemia
 

Laparoscopic Partial Nephrectomy of Hilar Tumors with Cold Ischemia

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Laparoscopic Partial Nephrectomy of Hilar Tumors with Cold Ischemia...

Laparoscopic Partial Nephrectomy of Hilar Tumors with Cold Ischemia

Juza Chen and Avi Bery
Director of Sexual Dysfunction Clinic
Department of Urology
Tel-Aviv Sourasky Medical Center
Sackler Faculty of Medicine Tel-Aviv University

Moscow 2010

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    Laparoscopic Partial Nephrectomy of Hilar Tumors with Cold Ischemia Laparoscopic Partial Nephrectomy of Hilar Tumors with Cold Ischemia Presentation Transcript

    • Laparoscopic Partial Nephrectomy of Hilar Tumors with Cold Ischemia J uza C hen and A vi B ery Director of Sexual Dysfunction Clinic Department of Urology Tel-Aviv Sourasky Medical Center Sackler Faculty of Medicine Tel-Aviv University Moscow 2010
    • Topics
      • Introduction
      • History
      • Patients
      • Trocar placement
      • landmark identification
      • Tumor visualization
      • Hilar Dissection and clamping
      • Tumor excision
      • Inner and outer layer reconstruction and homeostasis
      • Conclusions
    • Introduction
      • Laparoscopic partial nephrectomy requires advanced skills in laparoscopy to achieve precise tumor resection and renal reconstruction while minimizing warm ischemia times and minimizing the risk of complications, such as urinary fistula and postoperative bleeding
      • Complex renal tumors, such as hilar, endophytic, and multiple tumors, present additional challenges to a nephron-sparing approach using conventional laparoscopy
      • Renal cell carcinoma (RCC) accounts for 3% of adult solid tumors; and the highest incidence of RCC is detected between 50–70 years of age
      • Almost 20,000 renal cancer patients are estimated to be detected yearly in the European Union
      • Currently, most of the kidney masses are being detected incidentally up to 40% with smaller size due to widespread use of imaging modalities such as ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI)
      • This leads to increased RCC incidence worldwide with an earlier stage which can be cured by surgery
      • Overall and cancer-specific survival is 86% and 100%, respectively, at 5 years
      Introduction
    • History
      • Historically, a partial nephrectomy was recommended only for patients with imperative or relative indications for renal preservation
      • As the efficacy of partial nephrectomy was established in comparison to radical nephrectomy, surgeons expanded recommendations for partial nephrectomy to patients with unilateral, unifocal renal tumors less than or equal to 4 cm in maximum dimension
      • Presently, many surgeons believe that elective partial nephrectomies can be offered safely to patients with tumors up to 7 cm in size without compromising cancer control and survival
      • Winfield reported the first transperitoneal LPN in 1993
      • A year later, Gill described the technique of retroperitoneal LPN
      • Surgeon's choice of a transperitoneal or retroperitoneal approach is influenced by not only the location and size of the renal mass, but also the surgeon's experience
      • Indications for LPN includes: patients with bilateral kidney tumors, renal insufficiency, or a solitary kidney, as well as patients whose risk for renal deterioration or compromise was associated with urolithiasis, diabetes, or other medical co morbidities
      • A retroperitoneal LPN has been associated with decreased operating time, reduced estimated blood loss, and faster consumption of solid foods
      History
      • 46 years old patient
      • No previous medical history
      • Normal renal function
      • Incidental finding on US >>> MRI
      Patient
    •  
    •  
    •  
    • Approach Selection
      • Selection of the laparoscopic approach depends on tumor location
      • Posterior or posterolateral tumors are approached retroperitoneoscopically, while anterior, antero-lateral, or lateral tumors are approached transperitoneally
      • Precise preoperative imaging using three-dimensional computed tomography (CT) with volume-rendered video reconstruction, and real-time intraoperative ultrasonography of the tumor provide the surgeon with detailed information that facilitates the laparoscopic procedure
    • Trocar Placement
    • Warm or Cold Ischemia – This is a Question
      • Warm ischemia is the clamping of blood vessels without cooling the kidney (30 min)
      • Cold ischemia is the clamping of blood vessels with kidney cooling (45 min)
      • It is not yet known whether warm ischemia is more effective than cold ischemia in patients undergoing surgery for stage I kidney cancer
      • Our experience performing LPN for hilar renal tumor with cold ischemia
    • Cold ischemia
      • Ringer Lactat
      • + Mannitol 27 gm/L
      • =
      • Osm. 430 mosm/L
      • Temp. 4C
      • Continued medial reflection of the bowel allows for exposure of the gonadal vessels and the ureter
      • These structures are retracted anteriorly, exposing the underlying psoas muscle
      • Dissection then proceeds towards the renal hilum
      • The Maryland bipolar forceps are used to place the kidney on stretch and the renal hilar vessels are dissected to allow access for clamp placement
      • Lateral renal attachments are left in place to aid in counter traction
      • Venous branches can be ligated as needed for exposure
      Anatomical Landmarks
    •  
    • Conclusions
      • LPN is a safe and feasible approach for select patients with complex renal tumors including hilar tumors in the hands of experienced laparoscopic surgeons
      • The features of the laparoscopic system can facilitate the technical challenges of a minimally invasive approach to partial nephrectomy for these difficult cases, but the advantages must be weighed against its costs
      • For complex renal cancer cases, laparoscopic assistance may provide patients the benefit of minimally invasive surgery without the need for total nephrectomy or open surgery
      • Oncological results seem excellent, but further follow-up is needed for accurate long-term assessment of this surgical approach
    • THANK YOU FOR YOUR ATTENTION