Laparoscopic partial nephrectomy: the European experience.

Abstract

Laparoscopic partial nephrectomy is technically difficult but oncologically effective. The operation should be performed in centers with expertise. Hemostasis can be achieved using bipolar coagulation and fibrin glue-coated cellulose. Further studies will determine whether less invasive alternatives (focused ultrasound, cryotherapy) will meet the high standard of open (or laparoscopic) nephron-sparing surgery for small renal cell carcinoma. Commentary The technique of laparoscopic partial nephrectomy for the treatment of renal cell carcinoma (RCC) is in its very early stages. The cumulative experience reported in the literature comprises fewer than 100 cases and these have been confounded by a lack of standardized technique and variable experience. There has been difficulty in reproducing the essential elements of open partial nephrectomy using contemporary laparoscopic instrumentation. In this large multicenter European study, hemostasis was achieved with bipolar coagulation and fibrin-coated cellulose. Notwithstanding that case selection was limited to very small (≤3 cm) peripheral renal tumors, the morbidity of partial nephrectomy in this study was greater than that of open partial nephrectomy for small peripheral tumors. At the Cleveland Clinic, we have recently developed a technique for laparoscopic partial nephrectomy which duplicates established open surgical principles. The key technical steps in this approach include: Since August 1999, this technique has been used to perform laparoscopic partial nephrectomy in 36 patients with small, exophytic renal tumors. Mean tumor size was 2.9 cm (range 1.4–7.0 cm). The operation was successful in all cases without any open conversions. Mean operative time was 2.9 h, warm ischemia time was 20 min and blood loss was 237 ml. Formal calyceal suture repair was performed in 7 patients. Mean hospital stay was 1.7 days. The final pathology revealed renal cell carcinoma in 20 patients and other tumors in the remainder. All margins of resection were negative for tumor. Our initial experience suggests that laparoscopic partial nephrectomy can be performed for small exophytic renal tumors with adherence to established principles and techniques of the open surgical approach and with significant benefits for the patient. Andrew C. Novick, M.D.