Laparoscopic partial nephrectomy guided by high definition laparoscopic ultrasound
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Rev Mex Urol 2014;74(1):55-59
ÓRGANO OFICIAL DE DIFUSIÓN DE LA SOCIEDAD MEXICANA DE UROLOGÍA
www.elsevier.es/uromx
Clinical case
Laparoscopic partial nephrectomy guided by high definition
laparoscopic ultrasound
J. G. Campos-Salcedoa,*, E. I. Bravo-Castrob, M. Castro-Marínc, A. Sedano-Lozanod, J. C.
López-Silvestred, M. A. Zapata-Villalbad, L. A. Mendoza-Álvarezd, C. E. Estrada-Carrascod,
H. Rosas-Hernándezd and J. L. Reyes-Equihuad
a
Urology Ward Management, Hospital Central Militar, Mexico City, Mexico
b
Urology Speciality Residency, Escuela Militar de Graduados de Sanidad, Mexico City, Mexico
c
Department of Urology Management, Hospital Central Militar, Mexico City, Mexico
d
Department of Urology, Hospital Central Militar, Mexico City, Mexico
KEYWORDS Abstract Laparoscopic partial nephrectomy was described in 1993 and its indications extended
Laparoscopic partial due to the benefits of maintaining oncologic results and sparing the renal parenchyma. The aim
nephrectomy; High- of this report was to describe a patient with the diagnosis of a right renal tumor, stage T1a N0
definition M0, that underwent a laparoscopic partial nephrectomy guided by high definition laparoscopic
laparoscopic ultrasound, with clamping of the renal artery.
ultrasound; Partial Surgery duration was 240 minutes, there was minimum blood loss, a minimum of postoperative
nephrectomy; Mexico pain, adequate urinary output, and short hospital stay. Imaging studies revealed satisfactory
oncologic control.
Laparoscopic partial nephrectomy is similar to radical nephrectomy in relation to survival in
patients, such as ours, with localized tumors. Laparoscopic ultrasound is a tool for identifying
and controlling tumor resection.
In conclusion, the use of laparoscopic ultrasound in intraoperative tumor resection enables real-
time resection control for carrying out complete renal tumor excision.
Palabras clave Nefrectomía parcial laparoscópica guiada por ultrasonido laparoscópico de alta
Nefrectomía parcial definición
laparoscópica;
Ultrasonido Resumen La nefrectomía parcial laparoscópica fue descrita en 1993, sus indicaciones se
laparoscópico de alta extendieron por sus beneficios al mantener los resultados oncológicos y preservación de
definición; parénquima renal. El objetivo del presente artículo es describir a una paciente con diagnóstico
* Corresponding author at: Hospital Central Militar. Blvd. Manuel Ávila Camacho s/n, Lomas de Sotelo, Av. Industria Militar y General Ca-
bral, Delegación Miguel Hidalgo, CP 11200, México D.F., México. Telephone: (01) 5557 3100, ext. 1246. Email: drjgaducampos@hotmail.com
(J. G. Campos-Salcedo).
56 J. G. Campos-Salcedo et al
de tumor renal derecho T1aN0M0, a la que se le realizó nefrectomía parcial laparoscópica
Nefrectomía parcial; guiada por ultrasonido laparoscópico de alta definición. Se somete paciente a dicho
México. procedimiento, con pinzamiento de la arteria renal.
Se realiza cirugía con un tiempo de 240 minutos, presenta sangrado mínimo, dolor postoperatorio
mínimo y adecuado gasto urinario, tiempo corto de estancia hospitalaria; en estudios de imagen
se encuentra con adecuado control oncológico.
La nefrectomía parcial laparoscópica es similar a la nefrectomía radical en sobrevida en tumores
localizados, como se demostró en la paciente, y el ultrasonido laparoscópico es una herramienta
para la identificación del control de la resección tumoral.
En conclusión, el uso de ultrasonido laparoscópico en la resección del control transoperatorio
de tumores, es una herramienta que permite el control de la resección en tiempo real, además
es un control para realizar la escisión tumoral renal completa.
0185-4542 © 2014. Revista Mexicana de Urología. Publicado por Elsevier México. Todos los derechos reservados.
Introduction complete tumor resection are among the principal surgical
goals.8-11
Laparoscopic partial nephrectomy was first described in The aim of this report was to document how the use of a
1993. It indications and use have been extending due to its high definition laparoscopic ultrasound transducer was an
benefits of offering adequate oncologic control, while important aid in achieving complete tumor excision.
conserving part of the patient’s renal function, as well as
the added value of being a minimally invasive technique. 1-5
Case presentation
In the last few years, the new modalities in radiology
studies and their relative access in the majority of Mexican A woman in the seventh decade of life had a past history of
hospitals, have not only brought about an increase in renal diabetes and chronic stage 2 nephropathy of the National
tumor diagnosis, but also at earlier stages. The survival rate Ki d n e y F o u n d a t i o n ( N K F ) , 4 c e s a r e a n s e c t i o n s ,
at 5 years for a localized renal tumor is approximately 90%, appendectomy, hysterectomy, tubal ligation, and ventral
justifying treatment for these patients.6 hernia repair through mesh placement. She was admitted
Curative treatment of localized renal tumors is surgical to our hospital for a diarrheic syndrome. Computed
and the treatment of choice continues to be nephrectomy. tomographic urography was ordered as a complementary
Partial nephrectomy has shown similar oncologic control to study and revealed a right 14 mm renal mass with 20 HU in
radical surgery. The initial indications for partial the plain phase and 80 HU in the venous phase, suggestive
nephrectomy were a single anatomic or functional kidney. of a tumor. It was staged T1aN0M0 (fig. 1) and laparoscopic
These indications gradually broadened, as the safety of partial nephrectomy was proposed.
the technique was confirmed and adequate oncologic Total surgery duration, blood loss, intra and postoperative
results were achieved. 3,7 Moreover, with the increase in complications, hospital stay, and oncologic control were
experience, larger and deeper tumors have been treated evaluated. The procedure was performed with the following
and renal parenchyma hemostasis, waterproof repair of surgical technique: the patient was given general anesthesia
the calyces through suturing after tumor excision, and and put in the left lumbotomy position to have access to the
Figure 1 Coronal and axial views of abdominal tomography scan showing a right renal tumor.
Laparoscopic nephrectomy guided by high-definition laparoscopic ultrasound 57
Figure 3 Introduction of the 4 channel 10 mHz BK Pro-Focus
Figure 2 Tumor image before high-definition laparoscopic ul- 2202 high definition laparoscopic ultrasound flexible transducer
trasound. for identifying the tumor.
lumbar region. Three trocars were placed: a 12 mm blunt- Discussion
tip transumbilical trocar, a 10 mm trocar at the subcostal
level, and a 5 mm trocar at the mid-clavicular line. The Since the first published works by Robson, radical
transperitoneal approach was employed. The ureter and the nephrectomy has been accepted as the reference treatment
gonadal vein were identified and laterally retracted. in localized renal carcinoma. 5 Nevertheless, the new
Dissection was performed along the psoas muscle and the technologies that have been developed, along with the rise
renal hilum was dissected en bloc. Gerota’s fascia was in minimally invasive surgery, have resulted in their being
dissected, separating it from the kidney. The renal tumor compared.
was identified at the lower pole and the adjacent perirenal Partial nephrectomy has shown better conservation of
fat was dissected (fig. 2). The 4-channel 10 mHz BK ProFocus renal function than radical nephrectomy, as well as having
2202 high definition laparoscopic ultrasound transducer was good oncologic results and being a safe option for treating
then introduced through the 10 mm trocar (fig. 3) identifying tumors under 4 cm. In addition, recurrence and the risk of
the tumor edges and depth (fig. 4). Once this was done, the death from tumor disease are low; they have been related
silk threads that were the reference points for the renal to pathologic stage and Fuhrman grade, but not to positive
artery and vein were tightened. The tumor was resected margins that can be found in 1.4% of the patients that
with a laparoscopic cold scissors (fig. 5). Upon finishing the undergo this treatment. Free-from-disease survival at 2 and
resection, the laparoscopic transducer was introduced again 5 years has been reported at up to 99% and 97%,
to make sure there were no areas of residual tumor, after respectively.12
which renorrhaphy with Vicryl® 1-0 was done, anchoring the The approaches are retroperitoneal or transperitoneal, as
sutures with Hem-o-Lok® (Weck Closure System, Research with our patient. In the end, the choice of the approach will
Triangle Park, NC). The traction of the renal vessels was depend on the surgeon’s preferences, taking into account
then freed with a warm ischemia time of 30 minutes. A the size of the mass, location, body mass index or history of
control ultrasound showed no evidence of residual mass (fig. previous surgery, with no big differences in the complication
6) Hemostasis was achieved at the renorrhaphy site with the rate between the approaches.3
biologic sealant Floseal® (Baxter, Mountain View, CA) with One of the reported complications with the laparoscopic
no apparent signs of bleeding. The tumor was put in a technique is parenchymal bleeding related to tumor size
waterproof bag and removed through the 10 mm port. A and depth, and added to the time limitation and the
drain was placed, the ports were removed under direct precision of laparoscopic suture placement, it does not
vision and the wounds were closed with the usual technique. compare with an open procedure. Nevertheless, these
The procedure took 180 minutes, with blood loss of 100 effects can be reduced with adequate control of the hilum
cc. There was no need for blood transfusion, the patient through appropriate instruments for that purpose, 13 and
had a favorable postoperative period with minimal doses of secondarily through the use of hemostatic agents like
analgesic. Pain was adequately controlled without rescue Floseal®.
doses. The patient began to walk at 24 hours and the drain Another disadvantage associated with the procedure is
was removed after 48 hours. Control renal ultrasound at 48 the difficulty of achieving satisfactory surgical margins due
hours showed no signs of perirenal hemorrhage and the to the limited angulation of the laparoscopic instruments,
patient was released 72 hours after surgery. She was which tends to lessen the deeper the tumor, plus the poor
checked 4 weeks later and had adequate progression. There visibility after beginning the parenchymal incision;13 this is
was no evidence of recurrence at the control appointment where the use of intraoperative ultrasound provides better
at 3 months. information as to the depth of the tumor and how far the58 J. G. Campos-Salcedo et al
Figure 5 Image showing tumor resection after laparoscopic
ultrasound.
Figure 4 Intraoperative laparoscopic ultrasound for defining
the edges and depth of the resection.
patients should be well selected and auxiliary techniques,
such as laparoscopic ultrasound used in the case presented
herein, should be employed in order to achieve resection
margins guaranteeing long-term oncologic control.
Conflict of interest
The authors declare that there is no conflict of interest.
Financial disclosure
No financial support was received in relation to this article.
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