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Laparoscopic Partial Nephrectomy: Tactics and Techniques

For Residents and Fellows

Since the first report of laparoscopic nephrectomy in 1991 by Clayman and colleagues, the indications for laparoscopic renal surgery have expanded tremendously. Although laparoscopic nephrectomy was initially thought to be most appropriate for benign renal disease, several series demonstrated equivalent oncologic control and safety when it and other laparoscopic procedures were compared with open radical nephrectomy with long-term follow-up. This success, combined with improvements in surgical techniques, hemostatic agents, and new devices, has prepared the way for other procedures including laparoscopic partial nephrectomy.

Despite the benefit of reduced duration and intensity of convalescence to patients, adoption of laparoscopic nephrectomy has been slow compared to adoption of laparoscopic procedures in other specialties such as laparoscopic cholecystectomy. One reason cited for the slow diffusion of laparoscopic renal surgery is the lack of a common and straightforward procedure through which urologists can master basic laparoscopic skills.

In addition, a burgeoning literature suggests that a large number of cases are required to achieve competence for certain laparoscopic procedures; this surgical volume may not be available to many practicing urologists.

The inclusion of laparoscopic experience in urology residency combined with postgraduate courses or “mini” fellowships to train practicing urologists in laparoscopic skills is likely to increase the use of laparoscopic techniques for renal surgery.

Partial Nephrectomy (PN)

Partial nephrectomy (PN) is the preferred management strategy for small renal masses (stage T1a, ≤ 4.0 cm) whenever feasible and is a reasonable option for larger tumors with risk factors for progressive  chronic kidney disease (CKD) and end-stage renal disease (ESRD). The aim is going to preserve the nephrons and avoid future renal failure.

As the closure of renal collecting system after tumor resection is considered technically challenging, several techniques for kidney closure are being developed. PN is preferred given long-term data demonstrating equivalent oncologic outcomes to radical nephrectomy (RN) and a greater appreciation for the deleterious effects of CKD.

Surgical principles of PN include preservation of normal renal parenchyma and minimization of prolonged warm ischemia. PN is associated with the highest risk of perioperative complications, including bleeding, urine leak, and other urologic complications (i.e., ureteral injury).

Laparoscopic Partial Nephrectomy (LPN)

Laparoscopic partial nephrectomy (LPN) compares favorably to traditional open nephron-sparing surgery (NSS) in terms of oncologic and surgical principles for kidney tumors. Studies have shown the modality to be feasible with similar oncologic efficacy and superior renal functional outcomes compared with laparoscopic radical nephrectomy (LRN) for tumors up to pT3a. The main advantages of LPN include marked improvements in estimated blood loss, decreased surgical site pain, shorter postoperative convalescence, better cosmesis, and nephron preservation .

Over the past decade, alternative modalities to LPN have been established including laparoscopic ablative techniques and robotic-assisted LPN (RALPN). However, recent studies have demonstrated that LPN has better long-term oncologic outcomes than laparoscopic cryoablation and better cost-efficacy compared with RALPN.

In experienced hands, LPN still serves as an excellent platform for NSS despite a more challenging learning curve. The key principles and mainstays of LPN have remained the same regardless of modifications to the technique; these are early and secure vascular control, limited warm ischemia time (WIT), adequate post-resection hemostasis, and renorrhaphy.

Indications

The indications for partial nephrectomy have expanded from the imperative setting to elective partial nephrectomy in the presence of a contralateral normal kidney. Indications also include cases of hereditary renal cell carcinoma (RCC), such as von Hippel-Lindau syndrome, hereditary papillary RCC, and Birt-Hogg- Dubé syndrome, where the risk of future development of additional renal lesions after surgery is high.

With advancement in technique and more experience, the indications of LPN have expanded beyond small (<4 cm), exophytic, and peripheral renal masses to include more technically difficult cases.

Contraindications

Hilar and deep infiltrating tumors in additional to tumors in solitary kidneys and larger or cystic lesions are no longer considered relative contraindications to the procedure.

Contraindications that remain include renal vein or inferior vena caval (IVC) thrombi and significant local tumor invasion; however, in expert hands such cases can be performed . Significant local tumor invasion, uncorrected coagulopathy, and inability to safely perform laparoscopy from intra-abdominal adhesions are additional contraindications. Moderate to complete renal insufficiency is a relative contraindication to complete hilar clamping.

Primary References
  1. Laparoscopic partial nephrectomy. Philip T.Zhao et al,  International Journal of Surgery, Volume 36, Part C, December 2016
  2. Complications Of Laparoscopic Renal Surgery. Alon Z et al. Complications of Urologic Surgery (Fourth Edition), Prevention and Management, 2010

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