Laparoscopic Partial Nephrectomy, Pyeloplasty, and Massive BPH

INTRODUCTION AND OBJECTIVE: The objectives of laparoscopic partial nephrectomy for renal cell carcinoma (RCC) should be similar to the open technique. Cold ischemia permits optimal tumor excision and reual reconstruction while preserving renal function. However, cold ischemia with laparoscopic partial nephrectomy remains unsolved. Our video presents a new technique obtaining cold ischemia during laparoscopy. METHODS: Cold ischemia is achieved by cold arterial renal perfusion. Prior to laparoscopy an angiocatheter is passed into the main renal artery through a femoral puncture. The renal artery is clamped by a tourniquet. The renal vein is secured with an umbilical tape, but not occluded. Perfusion is initiated with iced Ringer Lactate at 4 degrees celsius at a rate of 50 cc/min. Renal temperature is continously monitored with a thermoprobe residing in the parenchyma. When a parenchymal temperature of 25 degrees celsius is reached perfusion is reduced to maintain a steady state. Tumor excision is performed in a bloodless field with biopsy taken from the tumor bed. The collecting system is repaired, and renal reconstruction is performed using parenchymal sutures over a hemostatic bolster. All steps are done similar to the open partial nephrectomy. Between November 01 and September 02 nine patients (RCC: 8, pyelonephritic lower pole: 1) were operated using this technique. There were 6 men and 3 woman with a mean age of 52 years (29-67). Mean tumor size was 2.4 ern (2-3.5). RESULTS: Bloodless field was achieved in 8 cases and minor oozing from an accessory renal artery occured in one case. Total ischemia time was 27 to 71 minutes (mean 36 min). Renal hypothermia was maintained at 25 degrees celsius. Estimated blood loss was 30-650 cc (mean 135 cc); only one patient required transfusions. Adequate tumor excision with negative margins was acheived in all cases. One patient had a delayed bleeding which was managed by laparoscopic reexploration, No other postoperative complications were encountered. Postoperative renal function could be investigated in 4 patients with isotope nephrography and was essentially unchanged in all of them. CONCLUSIONS: Our initial experience of incorporating cold ischemia into laparoscopic partial nephrectomy shows the feasibility and safety of this technique. We believe this approach will allow duplication of the principles of the open procedure and makes laparoscopic partial nephrectomy for RCC and complex renal pathology safe and reliable. Source of Funding: None.