Transperitoneal Laparoscopic Partial Nephrectomy

Abstract

Since the introduction of cross-sectional imaging for the diagnosis of intra-abdominal pathologies, an increased number of small renal masses are being incidentally discovered. These lesions are often peripherally located, with a benign histology in less than half of the cases. Following removal, no significant differences in survival rates exist between patients who have undergone partial or radical nephrectomy. In addition, the local recurrence rate after nephron-sparing surgery (NSS) is less than 3%. For all of these reasons, and motivated by the benefits of decreased patient morbidity and fast recovery, laparoscopic partial nephrectomy is successfully becoming the standard of care for the surgical management of exophytic renal tumors 4 cm in diameter or smaller. However, despite the potential advantages of nephron-sparing surgery and the laparoscopic approach over open surgery, laparoscopic partial nephrectomy is still not widely performed because of technical difficulties inherent to the procedure. There is ongoing debate regarding the need for complete hilar clamping, warm ischemia time, and the use of haemostatic techniques after tumor removal. Even in skilled hands, this complex procedure is still evolving. The technique described uses a transperitoneal route and an extracorporeal clamp approach of delayed occlusion and early release of the renal pedicle to minimize warm ischemia time.