1. WHICH NEPHRECTOMY

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

3. Simple laparoscopic nephrectomy

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

10. Donor laparoscopic Nephrectomy Patient selection Kidney work up Surgeon preparation

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

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

13. Raftopoulos et al, Surgical Endoscopy Oct 2004

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

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

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

26. 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

27. 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

28. 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

29. 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

30. 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.

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

35. 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, 2005 2002.9 cm122 TP29 (15-58) NA200 (45-360) 247 (25-1500 NA 76 RP Baughman et al, 2005 472.141 TP/6 RP20.5 (20-55) Select cases / Intrarenal 193 (50-300) 188 (50-800) 2.422 Allaf et al, 2004 482.4TPNA 38 (32-81 ) Janetschek et al, 2004 152.714 TP40 (27-101) Yes185 (135-220) 160 (30-650) NA 1 RP Bermudez et al, 2003 1925.8TP28.5Yes Intrarenal 125 (60-210) 290 (25-1200) 5 (2-10) 3 Simon et al, 2003 192.1TPNo clamps used No130 (60-120) 120 (200-400) 2.48 Rassweiler, et al, 2000 532.415 TPNA 191 (90-320) 725 (20-1500) 5.424

36. Author No. Pts Pathology/Margin StatusComplications Ramani et al, 2005 200 NATwo cases converted to open surgery. Intraoperative hemorrhage 4%, delayed hemorrhage after discharge 4%, urine leakage 5%, 4 patients required reoperation. Baughman et al, 2005 47 35 RCC: 12 benign/all margins negative, mean margin distance = 4.18 mm (range: 0.5-7 mm) 3 Urinomas; 3 trocar site infections; 1 each: pneumothorax, pulmonary edema, open conversion; no recurrence to date. Allaf et al, 2004 48 48 RCC: 1 positive margin/2 recurrences NA Janetschek et al, 2004 15 RCC: 13 AML, 2 positive margins Reoperation for hemorrhage in 1 patient Bermudez et al, 2003 19 11 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, 2003 19 14 RCC: 1 AML, 3 oncocytoma, 3 benign Tumor fragmentation, postoperative dyspnea, bleeding, pneumonia Rassweiler, et al, 2000 53 37 RCC: 15 benign, 3 oncocytoma, 1 lymphoma Argon beam coagulator - induced pneumothorax, 4 conversion to open, 1 reoperation for bleeding and 14 urinomas

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

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

39. 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

43. 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%

44. 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

45. 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

46. 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

47. Laparoscopic Nephroureterectomy with Open Versus Endoscopic Management of the Distal Ureter

49. 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