Laparoendoscopic Single-Incision Triangulated Umbilical Surgery for Partial Nephrectomy: Early Experience in the First 13 Cases

Abstract

Introduction: Nephron sparing surgery is the standard treatment for cT1a renal tumors. It has been shown consistently that laparoscopic partial nephrectomy (LPN) has similar oncological outcomes as open partial nephrectomy (OPN).1 In comparison to the open approach, LPN offers reduced morbidity, less pain, and a shorter convalescence. Laparoendoscopic single-site surgery (LESS) is the most recent approach to further minimize invasiveness of laparoscopic surgery. We introduced the concept of laparoendoscopic single-incision triangulated umbilical surgery (SITUS) in 2009.2 This concept was later applied in several clinical scenarios.3–6 The purpose of this study was to report our technique and initial experience with LESS partial nephrectomy in SITUS technique in clinical practice. Methods: From January 2010 to December 2012, patients treated by SITUS-PN were evaluated. Patients with small exophytic renal tumors were selected. Patients' characteristics, clinical data, PADUA and RENAL scores, perioperative, hematologic, and pathologic data, as well as pain evaluation using the Visual Analogue Pain Scale (VAPS) were assessed prospectively. Operative Principle: Patients were positioned in a standard 70° flank position. First, a “c”-shaped incision was performed in the umbilical crease. After dissection of the rectus fascia, the periumbilical skin was mobilized. A pneumoperitoneum was achieved by the Veress technique. A 5-mm camera trocar was placed in the paramedian line. The skin incision was stretched with Langenbeck hooks. A cranial 5-mm working trocar and, in a distance of 5 to 10 cm, an 11-mm caudal trocar were placed through the umbilical incision. Triangulation of the instruments was achieved, similar to conventional laparoscopy. The kidneys were exposed as in conventional laparoscopic surgery. To control bleeding from the renal cortex, one of the three different approaches were chosen: (1) The respective segment artery was clamped with a 2.0 Vicryl loop tagged standard laparoscopic bulldog clamp. (2) A parenchymal compression sling was placed below the tumor. (3) Two to three transparenchymal compression sutures were placed below the dissection level. Excision of the tumor was performed as in OPN. Finally, the defect was sealed with Tissucol fibrin glue. The specimen was removed and a drain was placed. Results: Thirteen patients (8 males and 5 females) with a mean age of 57 years (range, 39–81 years) underwent LESS/SITUS-PN (6 right/7 left renal units). The mean BMI was 28 ± 4 kg/m2, the mean PADUA and RENAL scores were 7.5 ± 1.0 and 5.6 ± 1.7, respectively, and the mean preoperative tumor size was 2.5 ± 1.1 cm. One patient was converted to conventional laparoscopy requiring two additional ports to treat a bleeding from renal vein. Ten patients were treated without hilar clamping. The average warm ischemia time was 22 ± 9 minutes (n = 3). The average operation time was 186 minutes (range, 135–251 minutes), and a mean blood loss of 2.1 g/dL (range 0.5–4.5 g/dL) in hemoglobin was noted. Pathology confirmed renal cell carcinoma in nine patients, oncocytoma in one patient, and benign cyst in three patients. No positive surgical margin was observed. During discharge, minimal discomfort was noted (VAPS = 0.2 ± 0.6 [range 0–2]/10]. Conclusion: LESS partial nephrectomy in SITUS technique is a viable option for the treatment of selected exophytic tumors. We declare that there were no commercial associations that might create a conflict of interest in connection with this article. Runtime of video: 6 mins