Laparoscopic Partial Nephrectomy
Indications
The majority of kidney cancers are being discovered incidentally when they are small and localized. For tumors less than 4 cm in size and in a favorable location a partial nephrectomy is considered the procedure of choice. When there are tumors in both kidneys, or the patient has only one kidney or has pre-existing renal failure a partial nephrectomy is required. Multiple studies have demonstrated that removing only the piece of kidney where the tumor is located (partial nephrectomy, nephron sparing surgery) is as effective as removing the entire kidney in terms of long term cancer control. In addition, long term kidney function is better preserved utilizing the principals of nephron sparing surgery.
Traditionally, a partial nephrectomy was performed only through a flank or abdominal incision. The traditional incision is 10-20 inches long, cuts through multiple layers and often requires removal of a rib. AT NYU we almost exclusively use laparoscopic techniques to peform our partial nephrectomies. We have performed
over 150 cases including lesions as large as 6cm with invasion into the collecting system and hilum as well as in patients with solitary kidneys. We have developed new techniques to improve outcomes and minimize complications. The laparoscopic technique allows the same operation to be performed as in open techniques but instead through small one centimeter incisions. The mass is removed from a 1 to 2 inch incision often hidden in one's umbilicus (belly button).
Procedure
The procedure is performed by placing 3-4 small tubes (trocars) through the abdominal wall and insufflating CO2 into the abdominal cavity to increase the working space. A video-telescope, called a laparoscope, is placed through one of the trocars. The laparoscope provides the surgeon a magnified view of the operating field and allows identification of vessels and structures with more clarity and infinite unobstructed angles than is not possible in open surgery. Specially designed laparoscopic instruments are placed through the other trochars (tubes) and the surgeon is able to secure the renal vessels and excise the mass from the kidney with similar accuracy and better visualization than traditional open techniques. Once excised, the defect in the kidney is secured for bleeding and collecting system repaired using similar open techniques including suturing and paranchymal bolsters.
Video procedures:
Results
Not only does the surgeon benefit from better visualization but also the patient benefits by significantly less post-operative pain, shorter hospital stay and quicker recovery to baseline.
Several investigators, including our group, have compared laparoscopic partial nephrectomies to standard open partial nephrectomies. All concluded that the pain medication requirement , length of stay in the hospital and time to return to work is significantly less in the laparoscopic group. Approximately 80% of our patients who present with an incidentally discovered renal mass are candidates for a partial nephrectomy and undergo a laparoscopic partial nephrectomy to treat their kidney cancer and require no other therapy.
