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LAPARO-ENDOSCOPIC
SINGLE SITE RETROPERITONEAL PARTIAL NEPHRECTOMY: A NOVEL CONCEPT
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video
Vol. 37 (1): 136-137, January - February, 2011
doi: 10.1590/S1677-55382011000100032
ALEJANDRO R. RODRIGUEZ, TARIQ HAKKY, PHILIPPE
E. SPIESS
Department
of Urology, Moffitt Cancer Center and Research Institute and University
of South Florida, Tampa, Florida
ABSTRACT
Purpose:
Various treatment options are available for small incidentally detected
kidney masses, including surveillance, partial nephrectomy and probe ablative
therapies. When partial nephrectomy is considered, the procedure can be
safely approached laparoscopically, either pure or robot assisted, in
experienced hands. Laparo-endoscopic single site (LESS) surgery is a novel
approach for partial nephrectomies in well selected cases. In this video,
we present our experience with the LESS retroperitoneal partial nephrectomy
using the Gelpoint device.
Material and Methods: A 63 year old male
patient with a BMI of 31, and a history of a T1c prostate cancer, had
a 1.5 cm right posterior lower pole renal enhancing mass discovered incidentally
on a three phase CT scan. With the patient under general anesthesia, and
in a full flank position, a LESS retroperitoneal partial nephrectomy was
performed using a 3 cm transverse incision below the tip of the 12th rib.
The following instruments and devices were used: A gelpoint device for
single incision port of entry, one 10 mm and two 5 mm trocars used through
the gelpoint, one 5 mm Olympus HD endoeye flexible tip camera, one roticulator
scissors, and one articulating graspers.
Results: Operative time, EBL, and hospital
stay were 1 hour, 5 ml, and 23 hours, respectively. The pathology result
confirmed a benign hemorrhagic cystic mass. The visual analog scale (0-10)
for pain at recovery, 6 hours post op, and 23 hours post op was 5, 3,
and 1 point, respectively. The patient tolerated clear liquids and regular
diet at 6 and 16 hours, after the procedure. At one month of follow-up,
the patient is asymptomatic and practically scarless.
Conclusions: LESS retroperitoneal partial
nephrectomy is safe and feasible in selected cases such as small exophytic
posterior renal masses. The retroperitoneal approach avoids mobilization
of the colon and kidney to access the posterior surface. Instrument clashing,
limited range of motion, and CO2 leakage, can be some difficulties encountered
during single port retroperitoneal surgery. However, the Gelpoint device
gives a great seal in the flank position and allows the relocation of
trocars, without loss of CO2 pressure, to prevent instrument clashing
during different parts of the procedure.
Int
Braz J Urol. 2011; 37 (Video #2): 136_7
Available at: www.brazjurol.com.br/videos/january_february_2011/Rodriguez_136_137video.htm
_______________________
Correspondence address:
Dr. Alejandro R. Rodriguez
Department of Urology
Moffitt Cancer Center
8203 Whistling Pine Way
Tampa, FL, 33647, USA
E-mail: armbkdd@yahoo.com
EDITORIAL
COMMENT
In
this novel video by Rodriguez and colleagues, a novel approach for a small
exophytic renal lesion is presented. Since the first laparoscopic single
site surgery (LESS) report in the urological literature by Rane in 2007,
different urological procedures including pyeloplasty, renal cryotherapy,
adrenalectomy, varicocelectomy, ureterolithotomy have been described (1).
This approach uses a single surgical access following the same general
principles of pure laparoscopic surgery, with its inherent benefit of
minimal surgical trauma. Previously, White et al. described eight LESS
retroperitoneal procedures including one partial nephrectomy (2). Aaron
et al. reported 5 partial nephrectomy using a transperitoneal (trans-umbilical)
LESS approach using a 2 mm port in the axillary line (hybrid technique)
(3). Recently, Cindolo et al. reported six LESS cases using a transperitoneal
approach, all performed without hilar clamping, one of which required
conversion to a standard laparoscopic approach to control bleeding and
two necessitating an extra port for renal parenchyma suturing and liver
retraction (4).
Single port surgery is considered minimally
invasive laparoscopy, and is an alternative to standard laparoscopy in
appropriately selected cases. It however remains a technically challenging
procedure even for experienced laparoscopists. Instruments for LESS are
rapidly evolving in order to avoid clashing and compensate for their limited
range of motion. In this regard, robotic technology is trying to eliminate
these current limitations.
It remains that partial nephrectomy is a
very challenging procedure when a minimally invasive approach is chosen.
In this regard, it is imperative to have careful patient selection when
a new technique such as this is employed. Carefully chosen cases such
as the one shown in the present video by Rodriguez et al. can translate
into excellent peri- and postoperative outcomes. Future randomized trials
comparing pure laparoscopic and LESS surgery will help delineate the role
and merit of this technique. At the present time, careful patient selection
remains the key factor predicting a favorable outcome with these novel
new surgical techniques to the small enhancing renal mass.
REFERENCES
- Rane
A, Rao P, Bonadio F, Rao P: Single port laparoscopic nephrectomy using
a novel laparoscopic port (R-port) and evolution of single laparoscopic
port procedure (SLIPP). J Endourol. 2007: 21 (Suppl 1): A287, V18-11.
- White
WM, Goel RK, Kaouk JH: Single-port laparoscopic retroperitoneal surgery:initial
operative experience and comparative outcomes. Urology. 2009; 73: 1279-82.
- Aron
M, Canes D, Desai MM, Haber GP, Kaouk JH, Gill IS: Transumbilical single-port
laparoscopic partial nephrectomy. BJU Int. 2009; 103: 516-21.
- Cindolo
L, Berardinelli F, Gidaro S, Schips L: Laparoendoscopic single-site
partial nephrectomy without ischemia. J Endourol. 2010; 24: 1997-2002.
Dr.
Jose Jaime Correa
Urologic Oncology Department
Hospital Pablo Tobon Uribe
Medellin, Colombia
E-mail: jocorreao@uces.edu.co
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