Laparoscopic Partial Nephrectomy For Hilar Tumors

Partial nephrectomy for hilar tumor represents a technical challenge not only for laparo-scopic but also for open surgeons. Tumors located in the region of the renal hilum, in actual physical contact with the main renal vessels, have been considered by many to be beyond the scope of laparoscopic techniques. Further, the application of probe-ablative therapies such as cryoablation and radio frequency ablation for hilar tumors have the real potential of causing thermal injury to the renal vascular endothelium, resulting in thrombosis.

Gill et al. (124) recently reported the technical feasibility and perioperative outcomes of laparoscopic partial nephrectomy for hilar tumors. In 362 patients undergoing laparoscopic partial nephrectomy for tumor by a single surgeon between 01/2001 and 09/2004, 25 (6.9%) had a hilar tumor. Hilar tumor was defined as a tumor located in the renal hilum and demonstrated to be in physical contact with the renal artery and/or renal vein on preoperative three-dimensional computed tomography. En bloc hilar clamping with cold excision of tumor, including its delicate mobilization from the renal vessels, followed by sutured renal reconstruction was performed routinely. Laparoscopic surgery was successful in all cases, without any open conversion or operative reintervention. Mean tumor size was 3.7 cm (range, 1-10.3); four patients (16%) had a solitary kidney, and indication for laparoscopic partial nephrectomy was imperative in 10 (40%). Pelvicalyceal repair was performed in 22 patients (88 %): mean warm ischemia time was 36.4 minutes (range, 27-48), blood loss was 231 cm3 (range, 50-900), total operative time was 3.6 hours (range, 2-5), and hospital stay was 3.5 days (range, 1.5-6.7). Histopathology confirmed renal cancer case in 17 patients (68%), all with negative margins. Hemorrhagic complications occurred in three patients (12%), all in 2002 or prior. No kidney was lost for technical reasons. The authors offered five specific caveats for performing laparoscopic partial nephrectomy in the setting of a hilar tumor: (i) preoperative three-dimensional computed tomograpgy scan with 3 mm cuts and video rendering to accurately assess (a) laparoscopic resectability as regards anatomic characteristics of the tumor and (b) the individual surgeon's comfort level in performing laparoscopic partial nephrectomy for that particular tumor; (ii) considerable dissection of the renal artery and/or vein towards the renal sinus to dissect the tumor off the renal vessels prior to hilar clamping; (iii) tumor excision to be performed in a preplanned manner from a lateral to medial direction to allow safer initial renal parenchymal and subsequent tumor retraction out of the partial nephrectomy bed (on occasion, direct feeding blood vessels entering the tumor directly from the main renal artery and/or vein can be identified, clipped, and divided); (iv) dedicated inspection to identify any arteriotomy, venotomy, or pelvicalyceal entry, and its precise suture repair, with routine use of Floseal as a hemostatic adjunct, as needed; (v) extreme care during sutured renal reconstruction not to compromise the main arterial blood supply and venous drainage of the renal remnant.

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