Laparo-endoscopic single site retroperitoneal partial nephrectomy: a novel concept

Abstract

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. 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. 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. 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.