Advertisement

Strategies in the management of renal tumors amenable to partial nephrectomy

Abstract

Purpose

The laparoscopic approach to radical and partial nephrectomy is becoming the standard of care for treating patients with renal tumors. Hand-assisted laparoscopic partial nephrectomy (HALPN) provides some advantages over the pure laparoscopic approach which include manual manipulation of the kidney, tactile feedback, and timely specimen removal.

Materials and methods

We describe our technique for HALPN and emphasize the implementation of an in-room pathologist to examine gross margins during the period of renal arterial occlusion. Between 2004 and 2007, 46 patients underwent HALPN performed by the same surgeons. Mean patient age was 59.5 years and mean tumor size was 2.55 cm. Twelve of these patients underwent significant concomitant procedures.

Results

Our mean operating time was 173.26 min (range 90–306 min) and our mean warm ischemic time was 28.32 min (range 14–54 min). Average estimated blood loss was 116.82 ml (range 10–1000 ml) with no transfusions. Thirty-six (78%) tumors were renal cell carcinoma, seven (15%) were oncocytomas, and three (7%) were angiomyolipomas. The average length of stay was 5.17 days (range 3–9 days) and there were no positive margins. There was one postoperative bleed (2%) and two postoperative urine leaks (4.3%).

Discussion

In our institution, the hand-assist approach to laparoscopic partial nephrectomy has resulted in favorable perioperative outcomes. The use of an in-room pathologist to provide real-time assessment of gross tumor margins has allowed us to achieve a 0% positive final margin rate. We believe that the use of an in-room pathologist during the timely extraction of the specimen made possible by the hand-assisted approach provides a great advantage over pure laparoscopic partial nephrectomy. This low positive margin rate is also the result of maintaining a bloodless field of resection with temporary renal arterial occlusion as well as the avoidance of visual tissue distortion with cold, sharp scissor dissection.

This is a preview of subscription content, log in to check access.

Access options

Buy single article

Instant unlimited access to the full article PDF.

US$ 39.95

Price includes VAT for USA

References

  1. 1.

    Beasley KA, Al Omar M, Shaikh A, Bochinski D, Khakhar A, Izawa JI, Welch RO, Chin JL, Kapoor A, Luke PPW (2004) Laparoscopic vs open partial nephrectomy. Urology 64:458–461

  2. 2.

    Gill IS, Matin SF, Desai MM, Kaouk JH, Steinberg A, Macha E, Thornton J, Sherief MH, Strzempkowski B, Novick AC (2003) Comparative analysis of laparoscopic versus open partial nephrectomy for renal tumors in 200 patients. J Urol 170:64–68

  3. 3.

    Kercher KW, Heniford BT, Matthews BD, Smith TI, Lincourt AE, Hayes DH, Eskind LB, Irby PB, Teigland CM (2003) Laparoscopic vs open nephrectomy in 210 consecutive patients. Surg Endosc 17:1889–1895

  4. 4.

    Novick AC (2004) Laparoscopic and partial nephrectomy. Clin Cancer Res 10:6322–6327

  5. 5.

    Albqami N, Janetschek G (2006) Indications and contraindications for the use of laparoscopic surgery for renal cell carcinoma. Nat Clin Pract Urol 3:32–37

  6. 6.

    Schiff JD, Palese M, Vaughan ED, Sosa RE, Coll D, Del Pizzo JJ (2005) Laparoscopic vs open partial nephrectomy in consecutive patients: the Cornell experience. BJU Int 96:811–814

  7. 7.

    Shuford MD, McDougall EM, Chang SS, LaFleur BJ, Smith JA, Cookson MS (2004) Complications of contemporary radical nephrectomy: comparison of open vs. laparoscopic approach. Urol Oncol 22:121–126

  8. 8.

    Kercher KW, Joels CS, Matthews BD, Lincourt AE, Smith TI, Heniford BT (2003) Hand-assisted surgery improves outcomes for laparoscopic nephrectomy. Am Surg 69:1061–1066

  9. 9.

    Ponsky LE, Cherullo EE, Banks KLW, Greenstein M, Streem SB, Klein EA, Zippe CD (2003) Laparoscopic radical nephrectomy: incorporating the advantages of hand assisted and standard laparoscopy. J Urol 169:2053–2056

  10. 10.

    Fazio LM, Downey D, Nguan CY, Karnik V, Al-Omar M, Kwan K, Izawa JI, Chin JL, Luke PPW (2006) Intraoperative laparoscopic renal ultrasonography: use in advanced laparoscopic renal surgery. Urology 68:723–727

  11. 11.

    Merten GJ, Burgess WP, Gray LV, Holleman JH, Roush TS, Kowalchuk GJ, Bersin RM, Van Moore A, Simonton CA 3rd, Rittase RA, Norton HJ, Kennedy TP (2004) Prevention of contrast-induced nephropathy with sodium bicarbonate: a randomized controlled trial. JAMA 291:2328–2334

  12. 12.

    Ramani AP, Desai MM, Steinberg AP, Ng CS, Abreu SC, Kaouk JH, Finelli A, Novick AC, Gill IS (2005) Complications of laparoscopic partial nephrectomy in 200 cases. J Urol 173:42–47

  13. 13.

    Strup SE, Hubosky S (2004) Hand-assisted laparoscopic partial nephrectomy. J Endourol 18:345–349

  14. 14.

    Brown JA, Hubosky SG, Gomella LG, Strup SE (2004) Hand assisted laparoscopic partial nephrectomy for peripheral and central lesions: a review of 30 consecutive cases. J Urol 171:1443–1446

  15. 15.

    Lane BR, Gill IS (2007) 5-year outcomes of laparoscopic partial nephrectomy. J Urol 177:70–74

Download references

Acknowledgements

We would like to thank our body imaging team (Michael Lavelle, MD, James Oliver, MD, Peter Chang, MD, Stuart Hartley, MD and Richard Redvanly, MD) for their contributions to the small kidney tumor program at the Carolinas Medical Center.

Author information

Correspondence to Chris M. Teigland.

Electronic supplementary material

(WMV 14690 kb)

(WMV 14690 kb)

Rights and permissions

Reprints and Permissions

About this article

Cite this article

McClean, J.M., Kercher, K.W., Mah, N.A. et al. Strategies in the management of renal tumors amenable to partial nephrectomy. Surg Endosc 23, 2161–2166 (2009) doi:10.1007/s00464-008-9961-5

Download citation

Keywords

  • Cancer
  • Renal (kidneys)
  • Surgical < Technical
  • Urology