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Urology Faculty Publications
Urology
Winter 2013
Unclamped hand-assisted laparoscopic partial
nephrectomy for predominantly endophytic renal
tumors
Jason D. Engel
George Washington University
Stephen B. Williams
St. Joseph Hospital, Orange, CA
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Part of the Urology Commons
Recommended Citation
Engel, J.D. & Williams, S.B. (2013). Unclamped hand-assisted laparoscopic partial nephrectomy for predominantly endophytic renal
tumors. Urology Journal, 10(1), 767-773.
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LAPAROSCOPIC UROLOGY
Unclamped Hand-Assisted Laparoscopic
Partial Nephrectomy for Predominantly
Endophytic Renal Tumors
Jason D. Engel,1 Stephen B. Williams2
1Department of Urology, George Washington
University Hospital, Washington, D.C., USA
2Associated Urologists of
Orange County, The Center
for Cancer Prevention and
Treatment at St. Joseph
Hospital, Orange, CA, USA
Purpose: 7R GHVFULEH RXU LQLWLDO H[SHULHQFH ZLWK XQFODPSHG ODSDURVFRSLF KDQGDVVLVWHG SDUWLDO
nephrectomy for predominantly endophytic renal masses in the setting of relative contraindication
WRZDUPLVFKHPLD
Materials and Methods: 8QFODPSHG ODSDURVFRSLF KDQGDVVLVWHG SDUWLDO QHSKUHFWRP\ ZDV SHUIRUPHGRQHLJKWFRQVHFXWLYHSDWLHQWVIURP-XQHWR0DUFK$OOSDWLHQWVKDGSUHGRPLQDQWO\HQGRSK\WLFUHQDOPDVVHVZLWKDSUHIHUHQWLDOHQKDQFLQJULPQRWHGRQWKHSUHRSHUDWLYHFRPSXWHG
WRPRJUDSK\7KHXQFODPSHGKDQGDVVLVWHGDSSURDFKZDVXWLOL]HGIRUQRZDUPLVFKHPLDPLQLPDO
EORRGORVVDQGHQKDQFHGYLVXDOL]DWLRQRIWKHWXPRUEHGZLWKLPSURYHGRSHUDWLYHH[SRVXUH
Results:0HDQDJHRIWKHSDUWLFLSDQWVZDV\HDUV$OOSDWLHQWVXQGHUZHQWXQFODPSHGKDQG
DVVLVWHGSDUWLDOQHSKUHFWRP\LH]HURLVFKHPLD0HDQHVWLPDWHGEORRGORVVZDVFFUDQJH
WRFFDQGPHDQRSHUDWLRQWLPHZDVPLQXWHVUDQJHWRPLQXWHV7KHUHZHUH
QRLQWUDRSHUDWLYHFRPSOLFDWLRQVDQGQRRSHQFRQYHUVLRQV7KHUHZDVRQHJUDGH,,LOHXVZLWKVPDOO
Corresponding Author:
SQHXPRWKRUD[DQGRQHJUDGH,9SXOPRQDU\HPEROLVPLQWKHGD\SHULRSHUDWLYHSHULRG7KHUH
Stephen B. Williams, MD
1801 N. Broadway, Santa
Ana, 92607, CA, USA
ZDVRQHSRVLWLYHVXUJLFDOPDUJLQZKLFKZDVUHFRJQL]HGLQWUDRSHUDWLYHO\
Tel: +1 714 6391915
Fax: +1 714 6391127
E-mail: [email protected]
Received August 2011
Accepted May 2012
Conclusion::KLOHRXUUHVXOWVDUHSUHOLPLQDU\ZHIHHOWKLVWHFKQLTXHSURYLGHVVXSHULRUYLVXDOL]DWLRQDQGDGHTXDWHKHPRVWDVLVZKLOHSUHVHUYLQJRQFRORJLFHI¿FDF\DQGUHQDOIXQFWLRQLQWKLVSDWLHQW
population.
Keywords: kidney neoplasms, hand-assisted laparoscopy, nephrectomy, ischemia
UROLOGY JOURNAL
Vol. 10 | No. 1 | Winter 2013 | 767
INTRODUCTION
DWDQDFDGHPLFFHQWHUEHWZHHQ-XQHDQG0DUFK
ith the increased utilization of cross-sectional
W
Prior to initiation of the study, the surgeon had performed
imaging, there has been an increased detection
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RI VPDOO UHQDO PDVVHV ZLWK VXUJLFDO H[WLUSD-
UDGLFDOQHSKUHFWRPLHVZLWKRUZLWKRXWKDQGDVVLVWDQFH!
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URERWLFSDUWLDOQHSKUHFWRPLHVDQG!URERWLFSURVWDWHFWR-
that partial nephrectomy results in improved long-term renal
mies as an attending surgeon.
IXQFWLRQDORXWFRPHVZLWKUHGXFHGFDUGLRYDVFXODUPRUELGLW\
&RPSOLFDWLRQVZHUHUHFRUGHGXVLQJWKH&ODYLHQFODVVL¿FDWLRQ
as compared to radical nephrectomy. The American Uro-
system.(6) The Chronic Kidney Disease Epidemiology Col-
ORJLF$VVRFLDWLRQ$8$JXLGHOLQHVIRUVWDJHVPDOOUHQDO
ODERUDWLRQ&.'(3,IRUPXODZDVXVHGWRHVWLPDWHJORPHU-
masses recommend partial nephrectomy for the manage-
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PHQWRIFOLQLFDO7UHQDOPDVVHVVXJJHVWLQJWKHLPSRUWDQFH
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of preservation of renal function.It has been demonstrated
RISRVLWLRQLQJLQDIXOOÀDQNSRVLWLRQDQGHQGHGDWSODFHPHQW
WKDWWKHUHLVDVLJQL¿FDQWGHFUHDVHLQUHQDOIXQFWLRQZKHQWKH
of the dressing.
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Laparo-
/DSDURVFRSLF DQGRU URERWLF SDUWLDO QHSKUHFWRP\ LV RXU
scopic partial nephrectomy may offer sooner return to con-
standard laparoscopic approach to small renal masses. Pa-
YDOHVFHQFHFRPSDUHGWRRSHQSDUWLDOQHSKUHFWRP\KRZHYHU
tients are selected for unclamped hand-assisted laparoscopic
ODSDURVFRSLF SDUWLDO QHSKUHFWRP\ KDV EHHQ DVVRFLDWHG ZLWK
SDUWLDOQHSKUHFWRP\ZKHQWXPRUVDUHSULPDULO\HQGRSK\WLF
LQFUHDVHGULVNRIXURORJLFFRPSOLFDWLRQVDQGORQJHUZDUPLV-
PXOWLIRFDOLQDVROLWDU\NLGQH\RUZKHQEDVHOLQHUHQDOLQVXI-
FKHPLDWLPHV$GGUHVVLQJWKHGLI¿FXOW\LQZLGHVSUHDGDGRS-
¿FLHQF\LVSUHVHQW)LJXUH7KHSUHVHQFHRIDK\SRGHQVH
tion of laparoscopic partial nephrectomy, several groups have
rim around the tumor on computed tomography (CT) is an
demonstrated the feasibility of robotic partial nephrectomy.
important indicator of the feasibility of this approach.
The concept of zero ischemia to eliminate any damage to
A hand port is placed either via a muscle-splitting Gibson in-
remaining nephrons during partial nephrectomy has been
FLVLRQULJKWRUWKURXJKDQGDERYHWKHXPELOLFXVOHIWZLWK
(2)
Unclamped laparoscopic partial nephrectomy
WZRDGGLWLRQDOPPSRUWVSODFHGLQWKHLUVWDQGDUGORFDWLRQV
ZLWKRUZLWKRXWWKHXVHRIWKHURERWKDVEHHQDWWHPSWHGE\
as for radical nephrectomy. A dissection identical to that of
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standard hand-assisted laparoscopic radical nephrectomy is
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performed. The tumor is localized, and the fat overlying the
WXPRUV UHPDLQV WR EH VKRZQ +DQGDVVLVWHG ODSDURVFRSLF
WXPRU LV GLVVHFWHG DZD\ DQG VHQW DV D VHSDUDWH SDWKRORJLF
partial nephrectomy may lead to an increased utilization of
specimen. A laparoscopic renal ultrasonography is performed
laparoscopic partial nephrectomy. We describe unclamped
WRFRQ¿UPWKHERXQGDULHVRIWKHWXPRUDQGWRKRSHIXOO\RE-
laparoscopic hand-assisted partial nephrectomy for pre-
VHUYHDK\SHUHFKRLFULPDURXQGWKHWXPRUZKLFKZRXOGLQ-
dominantly endophytic renal masses in the setting of relative
dicate encapsulation. The hilum is completely dissected, but
FRQWUDLQGLFDWLRQWRZDUPLVFKHPLD7KLVWHFKQLTXHRIIHUVHQ-
clamps are not applied. Mannitol or other diuretics are not
KDQFHGPRELOL]DWLRQDQGYLVXDOL]DWLRQZLWKDFFHSWDEOHEORRG
given.
ORVVWRFRPSOHWHO\HQXFOHDWHDQGH[FLVHQRWRQO\H[RSK\WLF
The renal capsule around the tumor is then scored circum-
EXW DOVR SUHGRPLQDQWO\ ! HQGRSK\WLF UHQDO PDVVHV
IHUHQWLDOO\ZLWKDKRRNHOHFWURGH*HQWOHVXFWLRQGLVVHFWLRQ
)XUWKHUPRUHWKLVWHFKQLTXHSUHVHUYHVUHQDOIXQFWLRQGXHWR
DWWKHEDVHRIWKHWXPRUZLOOJHQHUDOO\GHOLQHDWHDQH[FHOOHQW
ODFNRIZDUPLVFKHPLDDQGDOORZVIRUDPRUHFRPSUHKHQVLYH
SODQHDWWKHEDVHRIWKHWXPRUZKHUHLWPHHWVWKHSDUHQFK\PD
evaluation of pathologic margins before renal reconstruction.
7KHLQGH[¿QJHULVWKHQXVHGWREOXQWO\FRQWLQXHWKLVSODQH
H[SORUHG
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MATERIALS AND METHODS
dle in open surgery (Figure 2). The plane typically leaves a
$OO SDWLHQWV ZHUH RSHUDWHG RQ E\ D VLQJOH VXUJHRQ -'(
small amount of normal parenchyma on the tumor, and fol-
768 | Laparoscopic Urology
Unclamped Hand-Assisted Laparoscopic Partial Nephectomy | Engel and Williams
Figure 1. Computed tomography scan revealing a 2.2 cm enhancing lesion in the anterior mid-pole and a 1.6 cm enhancing
lesion in the postero-medial lower pole.
Figure 2. The lesion before and after enucleation with use of the finger fracture technique.
ORZVWKHLQKHUHQWS\UDPLGDODQDWRP\WRDVLQJOHDUWHU\DWLWV
pathologic analysis of the specimen.
EDVH7KLVDUWHU\LVSLQFKHGRIIEHWZHHQWKHWKXPEDQGLQGH[
In the setting of negative margins, no further resection is per-
¿QJHUDOORZLQJIRULPPHGLDWHUHPRYDORIWKHWXPRUIRUWKRU-
formed. If there is a positive margin, or if there is clinical
RXJK SDWKRORJLF H[DPLQDWLRQ IRU WXPRU W\SH DQG DGHTXDF\
VXVSLFLRQRILQDGHTXDWHUHVHFWLRQGHVSLWHQHJDWLYHPDUJLQV
of margins. As long as the plane has not been forced in any
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ZD\ KHPRVWDVLV HYHQ DW WKLV SRLQW LV JHQHUDOO\ H[FHOOHQW
blood loss to guide further resection. Nephrectomy is per-
ZLWKRQO\DIHZSRLQWVRIEOHHGLQJDWWKHEDVHRIWKHGHIHFW
IRUPHGZKHUHWKHUHDUHPXOWLIRFDOSRVLWLYHPDUJLQVRUZKHUH
$VLQJOH¿QJHUFDQJHQHUDOO\EHJHQWO\SODFHGLQWKHGHIHFWWR
deeper resection is not safe or feasible. Bulldog clamps may
KROGSUHVVXUH,IFRUWLFDOEOHHGLQJRFFXUVDVZHOOWKLVLVHDV-
be applied at this point if a more aggressive standard laparos-
ily managed by manual compression of the defect. Bleeding
copy or open partial nephrectomy is deemed feasible.
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$IWHUFKHFNLQJIRUFROOHFWLQJV\VWHPOHDNVZLWKDUHWURJUDGH
UROLOGY JOURNAL
Vol. 10 | No. 1 | Winter 2013 | 769
injection of methylene blue and spot suturing of defects or
KHPRVWDVLV DUH GLI¿FXOWLHV ZLWK WKH ODSDURVFRSLF RU URERWLF
pinpoint bleeding, the renal defect is closed as for all laparo-
approach. Furthermore, although the goal of zero ischemia
scopic partial nephrectomies at our institution. Argon beam
is preferred in order to preserve renal function,IHZFHQW-
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HUVKDYHDWWHPSWHGWKLVWHFKQLTXHLQWKHODSDURVFRSLFVHWWLQJ
standard closure of the renal defect is performed utilizing
collagen bolsters, pro-coagulants, and capsular sutures.
laparoscopic partial nephrectomy in order to further bridge
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these areas of uncertainty.
RESULTS
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(LJKWFRQVHFXWLYHSDWLHQWVZLWKWKHPHDQDJHRI\HDUV
WRHQXFOHDWHWXPRUVZLWKQHJDWLYHLQWUDRSHUDWLYHIUR]HQVHF-
ZHUHLQFOXGHGLQWKLVVWXG\7DEOH$OOSDWLHQWVXQGHUZHQW
WLRQPDUJLQVLQDUHODWLYHO\EORRGOHVV¿HOGZLWKRXWWKHQHHG
unclamped hand-assisted partial nephrectomy (ie, zero is-
IRUZDUPLVFKHPLD3ULRUVWXGLHVKDYHGHPRQVWUDWHGWKHIHD-
FKHPLD 0HGLDQ WXPRU VL]H ZDV FP UDQJH WR VLELOLW\ RI KDQGDVVLVWHG SDUWLDO QHSKUHFWRP\ KRZHYHU WKH
FP0HDQHVWLPDWHGEORRGORVVZDVFFUDQJHWR
XQFODPSHGWHFKQLTXHKDVRQO\EHHQGHVFULEHGXVLQJDVDOLQH
FF0HDQRSHUDWLRQWLPHZDVPLQXWHVUDQJH
FRROHGPRQRSRODUUDGLRIUHTXHQF\GHYLFHRQSULPDULO\VPDOO
WRPLQXWHVDQGPHDQKRVSLWDOVWD\ZDVGD\V7ZR
H[RSK\WLFWXPRUV The mean operation time and blood loss
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LQ WKDW VHULHV ZHUH PLQXWHV DQG FF UHVSHFWLYHO\
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7KHUH ZHUH QR RSHQ FRQYHUVLRQV DQG DOO PDUJLQV RI UHVHF-
VDF H[FLVLRQ 7KHUH ZHUH OLPLWHG FKDQJHV LQ SRVWRSHUDWLYH
WLRQZHUHQHJDWLYH:HSURYLGHVLPLODUUHVXOWVZLWKRXWWKH
hematocrit and eGFR.
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7KHUH ZHUH QR LQWUDRSHUDWLYH FRPSOLFDWLRQV DQG QR RSHQ
tumor and time elapsed for intra-operative frozen section
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analysis, there appeared to be enough compression time to
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DOORZ IRU FRQWUROOHG KHPRVWDVLV$Q\ IXUWKHU EOHHGLQJ ZDV
SXOPRQDU\ HPEROLVP LQ WKH GD\ SHULRSHUDWLYH SHULRG
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WLHQW ZKR VXIIHUHG IURP WKH SXOPRQDU\ HPEROLVP DOVR UH-
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RU OLJDWHG :H IHHO WKLV WDFWLOH IHHGEDFN ZDV LQYDOXDEOH LQ
agulation.
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)LQDOSDWKRORJ\UHYHDOHGFDVHVRIFOHDUFHOOFDUFL-
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hancing rim around the tumor on pre-operative CT imaging
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operative decision to perform a radical nephrectomy.
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in these sometimes challenging cases.
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DISCUSSION
Partial nephrectomy is emerging as the standard of care for
small renal masses.
Laparoscopic partial nephrectomy re
WKHQHHGIRUYDVFXODUFODPSLQJLQVHWWLQJVZKHUHLQWKHSDVW
it had been uniformly applied. Although the safe duration of
and may not
ZDUPLVFKHPLDUHPDLQVFRQWURYHUVLDO recent studies sug-
EHUHDGLO\XWLOL]HGE\XURORJLVWVZLWKOLPLWHGODSDURVFRSLFH[-
gest superiority of no vascular clamping in preserving renal
perience. Robotic-assisted laparoscopic partial nephrectomy
function.7KHUHQDOFRUWH[LVKLJKO\VHQVLWLYHWRFKDQJHVLQ
KDV EHHQ UHFHQWO\ VKRZQ WR KDYH DW OHDVW HTXLYDOHQW RQFR-
ZDUPLVFKHPLDSUHGRPLQDQWO\EHFDXVHRIWKHDHURELFPHWD-
logic results and peri-operative outcomes. 6RPH GUDZ-
EROLFHQYLURQPHQWDQGFRQVHTXHQWVWUXFWXUDOFKDQJHVLQFHO-
EDFNVLQFOXGHODFNRIWDFWLOHIHHGEDFNLQDFKLHYLQJDGHTXDWH
OXODUPHPEUDQHVZKLFKPD\XOWLPDWHO\OHDGWRFHOOGHDWK
mains a technically challenging procedure
770 | Laparoscopic Urology
Unclamped Hand-Assisted Laparoscopic Partial Nephectomy | Engel and Williams
Demographic characteristics and peri-operative outcomes.£
Hand-assisted
laparoscopic partial nephrectomy
(n = 8)
Characteristic
LVFKHPLDWREHLPSHUDWLYHLQSUHVHUYLQJPD[LPDOUHQDOIXQFtion during partial nephrectomy. Recent studies have sugJHVWHGOLPLWLQJZDUPLVFKHPLDWLPHVWROHVVWKDQPLQXWHV
ZKHQHYHUIHDVLEOHZKLFKLVIXUWKHUGHFUHDVHGIURPWKH
SULRU PLQXWH FXWRII(2):H VSHFL¿FDOO\ VHOHFWHG SDWLHQWV
Gender
Male, n (%)
Female, n(%)
4 (50)
4 (50)
Age, mean (range), y
55.8 (38 to 68)
PRUUHVHFWLRQLISDUWLDOQHSKUHFWRP\LVDWWHPSWHG7KXVZH
30.5 (26.5 to 37.4)
feel the ability to perform unclamped partial nephrectomy
2
Body mass index, mean (range), kg/m
ZLWK!HQGRSK\WLFUHQDOPDVVHVEHFDXVHWKHVHSDWLHQWV
RIWHQSRVHWKHJUHDWHVWULVNIRUEOHHGLQJDQGDGHTXDF\RIWX-
in this patient population should be thought of as an impor-
ASA score, mean (range)
2.3 (2 to 3)
Side
Left, n (%)
Right, n (%)
4 (50)
4 (50)
Tumor size, mean (range), cm
3.7(1.7 to 8.5)
7KLUGZHZHUHDEOHWRFRPSOHWHO\YLVXDOL]HWKHHQWLUHWXPRU
Anterior, n (%)
5 (62.5)
EHGDIWHUH[WLUSDWLRQWKXVYHULI\LQJDGHTXDF\RIUHVHFWLRQ
Posterior, n (%)
3 (37.5)
:KLOHHI¿FLHQWPRELOL]DWLRQGXULQJODSDURVFRSLFDQGURERWLF
Pre-operative eGFR, mean (range)
69.1 (46 to 94)
DSSURDFKHVLVIHDVLEOHWRSHUIRUPWKHUHVHFWLRQZHIHHOWKH
Operation time, mean (range), min
236.9 (175 to 272)
Estimated blood loss, mean (range), mL
368.8 (100 to 800)
Warm ischemia time, mean (range), min
0
Length of stay, mean (range), day
3.3 (2 to 6)
FRPSDULVRQVKDYHSURYHQWKLVWREHDQDGGHGEHQH¿WZHIHHO
Intra-operative complications, n
0
that the ability to hold and maneuver the kidney during resec-
WDQWWRROLQWKHXURORJLFVXUJHRQ¶VDUPDPHQWDULXPZKHQWKH
SURVSHFWRIZDUPUHQDOLVFKHPLDZRXOGEHEHVWDYRLGHGDQG
preservation of renal function is tantamount.
DGGHGEHQH¿WRIPDQXDOO\VKRZLQJWKHWXPRUEHGLQDYDULHW\
of angles to be unparalleled in comparison. Although no true
WLRQDOORZVWKHVXUJHRQWRWDNHWLPHDQGPHWLFXORXVO\UHVHFW
Post-op complications, Clavien Grade*
I
II
IIIa
IIIb
IV
V
0
1
0
0
1
0
Post-op transfusion, n (%)
1 (12.5)
Post-op hematocrit change, n (%)
-3.1 (-7.5)
Post-op eGFR change, n (%)
-1.6 (-2.4)
the tumor.
During standard laparoscopic or robotic partial nephrectomy
XWLOL]LQJYDVFXODUFODPSLQJWKHWXPRULVUHVHFWHGRIWHQZLWK
a small biopsy performed at the tumor base, and the renal
defect is immediately closed prior to clamp removal. Recent
studies have suggested the role of anatomical vascular miFURGLVVHFWLRQ ZLWK VHOHFWLYH FRQWURO RI WXPRU VSHFL¿F DUWHULDOEUDQFKHVLQRUGHUWRDOORZFRPSOH[WXPRUVWREHH[FLVHG
ZLWKRXWKLODUFODPSLQJ$QRWKHULQQRYDWLYHWHFKQLTXHWR
Pathology
4 (50)
DYRLGKLODUFODPSLQJZDVGHVFULEHGLQGXFLQJK\SRWHQVLRQLQ
Papillary, n (%)
3 (37.5)
SDWLHQWV ZKR XQGHUZHQW ODSDURVFRSLF RU URERWLF SDUWLDO QH-
Chromophobe, n (%)
1 (12.5)
SKUHFWRP\:KLOHWKHLQLWLDOUHVXOWVRIWKHVHQRYHOWHFKQLTXHV
Positive surgical margin, n (%)
1 (12.5)**
DSSHDUWRVXSSRUWWKHRQFRORJLFHI¿FDF\DQGSUHVHUYDWLRQRI
Clear cell, n (%)
£
Thus, it appears logical that minimizing or eliminating any
ASA indicates American Society of Anesthesiology; and eGFR:
estimated glomerular filtration rate.
*
Based on modified Clavien Classification.7
**
Positive surgical margin was identified intra-operatively.
UHQDOIXQFWLRQWKHVXUJHRQVLQWKHVHVHULHVDUHKLJKO\H[SHULHQFHGZKLFKPD\OLPLWGLVVHPLQDWLRQRIWKHLUWHFKQLTXHV
:LWKWKHKDQGDVVLVWHGXQFODPSHGDSSURDFKZHDUHDEOH
(3)
to fully inspect the tumor base, obtain a margin from the resected specimen, and re-biopsy the tumor bed several times
LIQHFHVVDU\:HEHOLHYHWKHIHDVLELOLW\RIWKLVWHFKQLTXHPD\
UROLOGY JOURNAL
Vol. 10 | No. 1 | Winter 2013 | 771
OHDGWRJUHDWHUGLVVHPLQDWLRQDPRQJXURORJLVWVH[FHOOHQWRQ-
higher-risk patient population.
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ZRUWKWKHDGGLWLRQDOLQFLVLRQUHTXLUHGIRUDKDQGSRUW
CONFLICT OF INTEREST
2XUVLQJOHLQVWDQFHRISRVLWLYHPDUJLQLQWKLVVHULHVZRXOG
None declared.
OLNHO\KDYHEHHQPLVVHGLIZHKDGXWLOL]HGRXUVWDQGDUGDSproach. Initial frozen section analysis of both tumor and
WXPRUEHGZDVQHJDWLYHLQWKLVFDVH+RZHYHUWDFWLOHIHHG-
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Winfield HN, Donovan JF, Lund GO, et al. Laparoscopic
partial nephrectomy: initial experience and comparison to
the open surgical approach. J Urol. 1995;153:1409-14.
9.
Janetschek G, Daffner P, Peschel R, Bartsch G. Laparoscopic
nephron sparing surgery for small renal cell carcinoma. J
Urol. 1998;159:1152-5.
10.
Rogers C, Sukumar S, Gill IS. Robotic partial nephrectomy:
the real benefit. Curr Opin Urol. 2011;21:60-4.
11.
Thompson RH, Lane BR, Lohse CM, et al. Every minute
counts when the renal hilum is clamped during partial
nephrectomy. Eur Urol. 2010;58:340-5.
12.
Thompson RH, Leibovich BC, Lohse CM, Zincke H, Blute ML.
Complications of contemporary open nephron sparing surgery: a single institution experience. J Urol. 2005;174:855-8.
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residual tumor, and close inspection of the tumor bed intraRSHUDWLYHO\DOORZHGIRULGHQWL¿FDWLRQDQGWDUJHWHGELRSV\RI
a small nest of carcinoma visualized at the deepest site of
resection. Therefore, the inadvertent leaving of tumor behind
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LQVSHFWWKHWXPRUEHGZLWKRXWVSHFL¿FWLPHFRQVWUDLQWVDQG
to obtain margins from both the resected specimen and the
tumor bed prior to renal reconstruction are perhaps the greatest advantages afforded to the patient by the hand-assisted
approach.
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design. First, this is a small series of patients and further studLHVRQDODUJHUQXPEHURISDWLHQWVDUHZDUUDQWHGWRYDOLGDWH
WKHVH SUHOLPLQDU\ ¿QGLQJV 6HFRQG ZH FDUHIXOO\ VHOHFWHG
SDWLHQWVZLWK!HQGRSK\WLFUHQDOPDVVHVZLWKUDGLRORJLF
IHDWXUHVVXJJHVWLQJWKDWWKLVDSSURDFKZDVIHDVLEOH7KHJHQeral applicability to all endophytic renal masses in all cases
has not been demonstrated here. Third, the larger incision reTXLUHGIRUWKHKDQGSRUWDVFRPSDUHGWRVWDQGDUGODSDURVFRS\
may lead to slightly higher morbidity and should be considHUHG ZKHQ GLVFXVVLQJ WKLV SURFHGXUH DV D WUHDWPHQW RSWLRQ
+RZHYHUZHIHHOWKHDGGHGEHQH¿WVGLVFXVVHGDERYHRI
performing an unclamped hand-assisted laparoscopic partial
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CONCLUSION
:HGHVFULEHRXUWHFKQLTXHRIXQFODPSHGKDQGDVVLVWHGSDUtial nephrectomy for predominantly endophytic renal masses
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$OWKRXJKRXUUHVXOWVDUHSUHOLPLQDU\ZHIHHOWKLVWHFKQLTXH
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772 | Laparoscopic Urology
Unclamped Hand-Assisted Laparoscopic Partial Nephectomy | Engel and Williams
13.
Lane BR, Babineau DC, Poggio ED, et al. Factors predicting
renal functional outcome after partial nephrectomy. J Urol.
2008;180:2363-8; discussion 8-9.
14.
Gill IS, Patil MB, Abreu AL, et al. Zero ischemia anatomical partial nephrectomy: a novel approach. J Urol.
2012;187:807-14.
15.
Ng CK, Gill IS, Patil MB, et al. Anatomic renal artery branch
microdissection to facilitate zero-ischemia partial nephrectomy. Eur Urol. 2012;61:67-74.
UROLOGY JOURNAL
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