Laparoendoscopic Single-site Partial Nephrectomy
Table 1: Operative Parameters in Available Laparoendoscopic Single-site Surgery Series Author,
Year Desai and
Aron, 200917 White, 200818 Kaouk, 200819
Time (Minutes) (ml) 475
422 260
100 171 207 6 0
15 4 7 2
Rais-Bahrami, 3 0 200920
Choi, 201121 59 56 Our series 14 0 3
3.01 2.1
2.5 2.6 2.5 270
196 165
149 212 125 7.2
4.5 3.3
2 4.5 4.4 20 NA 0 26
0 in 6 patients 14 16 in 1 patient 27
0 27.5 0 13 0
n Robotic Mean Tumour Mean Operative Mean EBL Length of Mean Ischaemia Transfusion Complication Additional Size (cm)
Stay (Days) Time (Minutes) Rate (%) ≥Grade III Clavien
2/6
0/15 0/7
1/3 1/59 2/14
Trocars % (Diameter)
100 % (6 x 2 mm; 1 x 5 mm) 13 % (NA) 14 % (NA) 0 %
Most of the cases (12 mm)
50 % (2 x 3 mm; 5 x 5 mm)
EBL = estimated blood loss; NA = not applicable; pts = patients.
Recent advances in the field of minimally invasive laparoendoscopic surgery have included the introduction of single-site surgery in urological oncology. Since its initial clinical use in urology, laparoendoscopic single-site surgery (LESS) has been greeted with increasing enthusiasm and a continuous growing interest. LESS has proven to be immediately applicable and safe in the hands of experienced laparoscopic surgeons in well-selected cases.10,11
Laparoscopic NSS, by combining the preservation of renal function and the minimal invasiveness of laparoscopy, represents a robust alternative to open surgery. Another argument in favour of the nephron-sparing approach is the high incidence of benign lesions on final histopathology (nearly 30 %) in small incidentally discovered renal masses.12,13
A = Transverse plane; B = Coronal plane.
It is true that laparoscopic partial nephrectomy (NSS) still remains a technically demanding procedure. In the last decade, laparoscopic NSS gained increased popularity among urologists and an expansion of its indications. Besides the standard transperitoneal or retroperitoneal laparoscopic approaches, laparoscopic partial nephrectomy has also been attempted by a LESS approach. Until today the entire spectrum of urological procedures for both the upper and lower urinary tract has been accomplished with the use of LESS. LESS has shown to be safe and feasible, even for advanced reconstructive procedures and major extirpative procedures as described in the first worldwide multi-institutional database.14
Although almost every laparoscopic procedure in urology has been duplicated by using a LESS approach, only a few studies have reported problems and challenges encountered during LESS partial nephrectomy.15–21
Analysis of the Available Literature A PubMed search revealed six surgical series of LESS NSS (Desai and Aron, White, Kaouk, Rais-Bahrami, Choi and Cindolo/Schips), describing 104 cases overall including the authors’ updated experience. No randomised or comparative clinical trials were found. The operative data are shown in Table 1. Overall, renal masses <3 cm were selected for a LESS NSS with a mean operative time (OR time) of 125–270 minutes. The mean estimated blood loss (EBL) ranged between 100 ml and 475 ml. The occurrence of severe post-operative complications (≥ grade III according to the Clavien classification) was reasonably low at six out of 104 (5.7 %).
EUROPEAN UROLOGICAL REVIEW
Figure 2: Single-port Trocar Placement for Laparoendoscopic Single-site Surgery Nephron-sparing Surgery
Figure 1: Contrast-enhanced Computed Tomography Scan Showing an Exophytic, Enhancing Mass on the Medial Aspect of the Left Kidney in both Transverse and Coronal Views
AB
Issues in Laparoscopic Single-site Nephron-sparing Surgery To Clamp or Not to Clamp?
Clamping of the hilar vessels is a controversial issue for both open and laparoscopic NSS, given the belief that even a short ischaemia time seems to cause clinical and subclinical renal injury at long-term follow-up.22,23
There is convincing evidence that the 133
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