Laparoscopic Partial Nephrectomy

Indications

Laparoscopic partial nephrectomy is a surgical option for the treatment of patients with relatively small, easily accessible renal tumors. Partial nephrectomy should be considered whenever there is an indication for conservation of the renal function of the affected kidney, such as in cases of:
Absence or reduced function of the contralateral kidney
Bilateral renal tumors
Systemic diseases that may affect renal function in the future
- Diabetes mellitus – especially if poor glycemic control
- Hypertension
Renal conditions that may affect renal function in the future
- Extensive stone disease
- Chronic pyelonephritis
- Renal artery stenosis
- Vesicoureteral reflux
The ideal indication for partial nephrectomy is a single, <4cm exophytic renal tumor, although larger tumors may also be attempted. The ideal localization is in the lower pole, but masses in all other locations may be removed. Centrally located masses may also be resected, albeit with larger difficulty due to its location closer to the renal vessels. Laparoscopic partial nephrectomy is a challenging intervention, and as such, should be attempted only in centers with significant laparoscopic experience.

Surgical access is done in the same fashion as for a radical nephrectomy.
Hilar dissection should be performed in all cases (even for small tumors where clamping will not be performed) in order to have immediate access to the renal vessels.
A Satinsky clamp is inserted for renal vessel occlusion through an additional trocar inserted for this purpose. Alternatively, bulldog clamps could be inserted for vessels occlusion

The plane of excision should be decided before renal vessel clamping. The placement of the Satinsky clamp should be performed only when the vessels are adequately prepared and the excision is planned
The excision of the tumour is performed with the use of scissors with care to avoid any tumour positive surgical margin
The dissection should be performed rapidly since the warm ischemia time should not overcome 30 minutes
If the collecting system has been opened during tumor excision, reconstruction with continuous sutures is performed to close the lesion. The reconstruction of the renal parenchyma is performed with continuous suture
Additional Hem-o-lok clips are placed on the suture to ensure the tight approximation of the renal parenchyma
A bolster of haemostatic gauze is placed underneath the suture in order to provide haemostasis
During the suturing of the interstitial layer of the parenchyma, deep bites should be avoided as major vascular compromise to the kidney is possible. Satinsky clamps are removed after the complete suturing of the renal. The use of fibrin glue over the suture line for additional haemostasis is advised
Gerota’s fascia is finally closed and specimen contained within the endoscopic bag is retrieved.

Warm ischaemia time (WIT) is a concern when planning and performing partial nephrectomy. Warm ischaemia time should be kept to a minimum, in order to minimize the risk of ischemic renal injury. In centers with substantial experience, WIT times for laparoscopic partial nephrectomies are slightly higher to ischaemia times for open surgery, without posing extra risks to renal activity. In cases of small (<4cm) exophytic tumors, enucleation or partial nephrectomy may be performed without vessel clamping. Placement of vessel clamps should only be done when:
The vessels are clearly seen and have been adequately dissected
The tumor has been visualized and prepared
The line of dissection has been visualized

Materials for hemostasis (sutures, bolsters,etc) are prepared at the nurse’s table
Suturing angles have been visualized in the surgeon’s mind. If an extra trocar is necessary, now is the time to place it.
Proper hemostatic control is paramount in partial nephrectomy, independently of vessel clamping status. The tumor bed should be thoroughly visualized for bleeding vessels and breaches into the collecting system that may have to be sutured. The borders of the tumor bed are then sutured together and a hemostatic bolster is placed in the tumor bed for optimal control. Care is taken in this step, as renal tissue may be easily torn by suture placed with excessive tension. A solution our department uses is the use of Lapra-Ty tm suture clips and conventional tissue clips to maintain steady tension while suturing the tumor bed. The oncological outcomes for patients with T1 renal tumors are similar when comparing laparoscopic partial nephrectomy to open surgery. Moreover, partial nephrectomy had been shown to be superior to radical nephrectomy in similar cohorts when comparing overall survival due to a smaller incidence of renal insufficiency and smaller rates of cardiovascular events.