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