Laparoscopic partial nephrectomy

Abstract

Background and purpose: The technique of laparoscopic partial nephrectomy has matured significantly over the past decade and is emerging as an oncologically sound procedure for the management of small renal tumors. Methods of tumor excision as well as parenchymal reconstruction in a hemostatically controlled field have evolved to make this procedure safer. Improved techniques to minimize warm renal ischemia are being developed. Finally, methods to prevent positive surgical margins during laparoscopic surgery are crucial to a satisfactory oncologic outcome. These important technical issues, as well as the current results of laparoscopic partial nephrectomy, are discussed.

Materials and methods: The urologic peer-review literature related to nephron-sparing surgery was reviewed. Controversial issues with respect to the surgical approach, methods of hemostatic control, acceptable time of warm ischemia, and cooling techniques were reviewed and collated. Perioperative results from larger series of laparoscopic and open partial nephrectomy were evaluated.

Results: Open nephron-sparing surgery for renal tumors < or =4 cm has cancer control equivalent to that of open radical nephrectomy. Evidence is now emerging that laparoscopic partial nephrectomy will provide similar oncologic results, although clinical follow-up is still early. Blood loss, postoperative pain, and convalescence seem to be favor the laparoscopic approach. Complication rates, primarily postoperative bleeding and urine leak, may be higher than for open nephron-sparing surgery. Methods of laparoscopic hemostatic control favor soft vascular clamping for larger tumors that are more endophytic and central. Smaller exophytic lesions may be managed without renal vascular control using a variety of coagulative and hemostatic tools. Data related to warm renal ischemia suggest that the time used for tumor excision and renal reconstruction should be 30 minutes or less. Techniques for laparoscopic renal cooling are being developed.

Conclusions: Laparoscopic nephron-sparing surgery is a technique in evolution but with a promising outlook. The urologic peer-review literature reflects an exponential growth in interest, which suggests that this minimally invasive approach is practical and may benefit our patient population so as to allow them to return to normal healthy living more quickly.