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 2005HUYNH, HOLLANDER, J of Urol, February 2005

LAPAROSCOPIC NEPHRECTOMY COMMUNITY HOSPITAL. Michigan, USA

HUYNH, HOLLANDER, J of Urol, February 2005HUYNH, HOLLANDER, J of Urol, February 2005

LAPAROSCOPIC DONOR NEPHRECTOMY COMMUNITY HOSPITAL. Michigan, USA

Raftopoulos et al, Surgical Endoscopy Oct 2004 Raftopoulos et al, Surgical Endoscopy Oct 2004 Raftopoulos et al, Surgical Endoscopy Oct 2004 Raftopoulos et al, Surgical Endoscopy Oct 2004

Raftopoulos et al, Surgical Endoscopy Oct 2004 Raftopoulos et al, Surgical Endoscopy Oct 2004 Raftopoulos et al, Surgical Endoscopy Oct 2004 Raftopoulos et al, Surgical Endoscopy Oct 2004

Raftopoulos et al, Surgical Endoscopy Oct 2004 Raftopoulos et al, Surgical Endoscopy Oct 2004 Raftopoulos et al, Surgical Endoscopy Oct 2004 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 Stage No. of Patients 5 Year 10 Year

T1a N0 M0 169 94% 88%

T1b N0 M0 69 90% NA

T2 N0 M0 10 100% NA

Ono et al, 2005Ono et al, 2005Ono et al, 2005Ono 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, 2005Permpongkosol 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, 2005Permpongkosol 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, 2005Permpongkosol 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. PtsTumor 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 cm 122 TP 29(15-58)

NA 200 (45-360)

247 (25-1500

NA NA76 RP

Baughman et al, 2005

47 2.141 TP/6 RP 20.5 (20-55)

Select cases/Intrarenal

193 (50-300)

188 (50-800)

2.422

Allaf et al, 2004

48 2.4TP NA NA NA NA NA 38 (32-81 )

Janetschek et al, 2004

15 2.714 TP 40 (27-101)

Yes 185 (135-220)

160 (30-650)

NA NA

1 RPBermudez et al, 2003

19 25.8TP 28.5 Yes Intrarenal

125 (60-210)

290 (25-1200)

5 (2-10)

3

Simon et al, 2003

19 2.1TP No clamps used

No 130(60-120)

120 (200-400)

2.48

Rassweiler, et al, 2000

53 2.415 TP NA NA 191 (90-320)

725 (20-1500)

5.424

AuthorNo. Pts Pathology/Margin Status Complications

Ramani et al, 2005

200 NA Two 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

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, 2005Hattori 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, 2005Hattori 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