WHICH NEPHRECTOMY

laparoscopic nephrectomy Simple laparoscopic nephrectomy. Donor laparoscopic nephrectomy. Radical laparoscopic nephrectomy. Partial laparoscopic nephrectomy. laparoscopic nephroureterectomy.

Simple laparoscopic nephrectomy

laparoscopic nephrectomy Simple laparoscopic nephrectomy. Donor laparoscopic nephrectomy. Radical laparoscopic nephrectomy. Partial laparoscopic nephrectomy. laparoscopic nephroureterectomy.

Donor laparoscopic Nephrectomy Patient selection Kidney work up Surgeon preparation

HUYNH, HOLLANDER, J of Urol, February 2005 LAPAROSCOPIC NEPHRECTOMY COMMUNITY HOSPITAL. Michigan, USA

HUYNH, HOLLANDER, J of Urol, February 2005 LAPAROSCOPIC DONOR NEPHRECTOMY COMMUNITY HOSPITAL. Michigan, USA

Raftopoulos et al, Surgical Endoscopy Oct 2004

laparoscopic nephrectomy Simple laparoscopic nephrectomy. Donor laparoscopic nephrectomy. Radical laparoscopic nephrectomy. Partial laparoscopic nephrectomy. laparoscopic nephroureterectomy.

Laparoscopic radical nephrectomy is indicated in patients with – T1 to T3a renal tumors. – ? T3b – ??? > T3b

Radical laparoscopic nephrectomy Laparoscopic radical and partial nephrectomies provide equivalent cancer control vs open.

Laparoscopic Radical Nephrectomy for RCC Pathologic StageNo. of Patients5 Year10 Year T1a N0 M016994%88% T1b N0 M06990%NA T2 N0 M010100%NA Ono et al, 2005

Laparoscopic Radical Nephrectomy for RCC vs open 67 laparoscopic vs 54 open Radical Nx All were stage cT1 to cT2 N0 M0. There were no differences in patient age, tumor size, and EBL. laparoscopic group, have a shorter period of hospitalization. The mean operating time was 193 min in the open group, vs 256 min laparoscopic group. A significant OR time difference between the first 34 and last 33 laparoscopic radical nephrectomies Permpongkosol et al, 2005

Laparoscopic Radical Nephrectomy for RCC vs open Disease-free survival rates for laparoscopic and open radical nephrectomy were 95% and 89%, respectively, at 10 years, Actuarial survival rates for laparoscopic and open radical nephrectomy were 86% and 75%, respectively, at 10 years. These differences were not statistically significant, and no laparoscopic trocar site implantation was identified. Permpongkosol et al, 2005

Laparoscopic Radical Nephrectomy for RCC vs open One operative conversion (1.5%) was required in the laparoscopic group. Complications occurred in: 10 patients (15%) in the laparoscopic group 8 (15%) in the open group. Blood transfusions – 6 laparoscopic patients (8%), – 11 in the open group (20%). Permpongkosol et al, 2005

Important complications Unrecognized laparoscopic bowel injuries: – usually present as indolent signs. – occasionally afebrile with a normal to low serum WBC count, focal abdominal discomfort, and mild ileus. Vascular injuries – the most common cause of conversion to open. – This is more in patients with chronic inflammatory processes.

laparoscopic nephrectomy Simple laparoscopic nephrectomy. Donor laparoscopic nephrectomy. Radical laparoscopic nephrectomy. Partial laparoscopic nephrectomy. laparoscopic nephroureterectomy.

Author No. Pts Tumor Size (cm) TP/RP* Ischemic Time (min) Renal Cooling OR Time (min) Mean EBL (mL) Hospital Stay (days) Mean Follow- up (Mo) Ramani et al, cm122 TP29 (15-58) NA200 (45-360) 247 ( NA 76 RP Baughman et al, TP/6 RP20.5 (20-55) Select cases / Intrarenal 193 (50-300) 188 (50-800) Allaf et al, TPNA 38 (32-81 ) Janetschek et al, TP40 (27-101) Yes185 ( ) 160 (30-650) NA 1 RP Bermudez et al, TP28.5Yes Intrarenal 125 (60-210) 290 ( ) 5 (2-10) 3 Simon et al, TPNo clamps used No130 (60-120) 120 ( ) 2.48 Rassweiler, et al, TPNA 191 (90-320) 725 ( ) 5.424

Author No. Pts Pathology/Margin StatusComplications Ramani et al, NATwo cases converted to open surgery. Intraoperative hemorrhage 4%, delayed hemorrhage after discharge 4%, urine leakage 5%, 4 patients required reoperation. Baughman et al, RCC: 12 benign/all margins negative, mean margin distance = 4.18 mm (range: mm) 3 Urinomas; 3 trocar site infections; 1 each: pneumothorax, pulmonary edema, open conversion; no recurrence to date. Allaf et al, RCC: 1 positive margin/2 recurrences NA Janetschek et al, RCC: 13 AML, 2 positive margins Reoperation for hemorrhage in 1 patient Bermudez et al, RCC: 3 oncocytomas, 5 AML/ mean margin 3 cm, all margins negative Two transfusions, 4 renal insufficiency Three-month follow-up, no recurrences Simon et al, RCC: 1 AML, 3 oncocytoma, 3 benign Tumor fragmentation, postoperative dyspnea, bleeding, pneumonia Rassweiler, et al, RCC: 15 benign, 3 oncocytoma, 1 lymphoma Argon beam coagulator - induced pneumothorax, 4 conversion to open, 1 reoperation for bleeding and 14 urinomas

Complications of Laparoscopic Partial Nephrectomy Urinoma Completion nephrectomy Trocar site infection Pneumothorax/tension pneumothorax Pulmonary edema Tumor fragmentation Transfusion Pneumonia Renal insufficiency

laparoscopic nephrectomy Simple laparoscopic nephrectomy. Donor laparoscopic nephrectomy. Radical laparoscopic nephrectomy. Partial laparoscopic nephrectomy. laparoscopic nephroureterectomy.

Radical nephroureterectomy with resection of a bladder cuff remains the "gold standard" for the treatment of upper tract tumors, especially those that are large, high grade, and invasive, and for large, multifocal or rapidly recurring, medium-grade, noninvasive tumors of the renal pelvis or proximal ureter

Precaution The entire ureter, including the intramural portion and ureteral orifice, should be removed. The risk of tumor recurrence in a remaining ureteral stump is 33-75%

Laparoscopic nephroureterectomy can be performed by: – pure laparoscopic technique or – hand-assisted technique with an incision in the lower abdomen. The distal ureter can be managed through: – Laparoscopic – Open – endoscopic

A report described long-term cancer control in 89 patients treated laparoscopically with a variety of techniques for distal ureterectomy, – open in 36 cases – endoscopic stapling in 53 cases. These data were compared with results seen by the authors with open NU. Hattori et al, 2005

Patients' survival and metastasis-free rates – 79% and 75% for the open group, – 80% and 80% for the combined laparoscopic and open group, – 78% and 72% for the pure laparoscopic group. In this nonrandomized series, the authors reported no significant difference in the groups. Hattori et al, 2005

Laparoscopic Nephroureterectomy with Open Versus Endoscopic Management of the Distal Ureter

A ureteral catheter is placed, and two laparoscopic ports are placed transvesically. The ureteral orifice is tented up; a loop is placed around the orifice to occlude the opening and to place traction on the ureter. A Collins knife then facilitates the dissection to the extravesical space