Download - WHICH NEPHRECTOMY
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WHICH NEPHRECTOMY
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laparoscopic nephrectomy
• Simple laparoscopic nephrectomy.• Donor laparoscopic nephrectomy.• Radical laparoscopic nephrectomy.• Partial laparoscopic nephrectomy.• laparoscopic nephroureterectomy.
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Simple laparoscopic nephrectomy
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laparoscopic nephrectomy
• Simple laparoscopic nephrectomy.• Donor laparoscopic nephrectomy.• Radical laparoscopic nephrectomy.• Partial laparoscopic nephrectomy.• laparoscopic nephroureterectomy.
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Donor laparoscopic Nephrectomy
• Patient selection• Kidney work up• Surgeon preparation
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HUYNH, HOLLANDER, J of Urol, February 2005HUYNH, HOLLANDER, J of Urol, February 2005
LAPAROSCOPIC NEPHRECTOMY COMMUNITY HOSPITAL. Michigan, USA
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HUYNH, HOLLANDER, J of Urol, February 2005HUYNH, HOLLANDER, J of Urol, February 2005
LAPAROSCOPIC DONOR NEPHRECTOMY COMMUNITY HOSPITAL. Michigan, USA
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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
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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
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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
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laparoscopic nephrectomy
• Simple laparoscopic nephrectomy.• Donor laparoscopic nephrectomy.• Radical laparoscopic nephrectomy.• Partial laparoscopic nephrectomy.• laparoscopic nephroureterectomy.
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• Laparoscopic radical nephrectomy is indicated in patients with– T1 to T3a renal tumors.– ? T3b– ??? > T3b
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Radical laparoscopic nephrectomy
• Laparoscopic radical and partial nephrectomies provide equivalent cancer control vs open.
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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
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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
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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
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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
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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.
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laparoscopic nephrectomy
• Simple laparoscopic nephrectomy.• Donor laparoscopic nephrectomy.• Radical laparoscopic nephrectomy.• Partial laparoscopic nephrectomy.• laparoscopic nephroureterectomy.
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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
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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
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Complications of Laparoscopic Partial Nephrectomy
• Urinoma • Completion nephrectomy • Trocar site infection• Pneumothorax/tension pneumothorax • Pulmonary edema• Tumor fragmentation• Transfusion• Pneumonia• Renal insufficiency
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laparoscopic nephrectomy
• Simple laparoscopic nephrectomy.• Donor laparoscopic nephrectomy.• Radical laparoscopic nephrectomy.• Partial laparoscopic nephrectomy.• laparoscopic nephroureterectomy.
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• 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
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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%
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• 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
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• 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
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• 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
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Laparoscopic Nephroureterectomy with Open Versus Endoscopic Management of the Distal Ureter
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• 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
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