WHICH NEPHRECTOMY

1. WHICH NEPHRECTOMY

2. laparoscopic nephrectomy • Simple laparoscopic nephrectomy. • Donor laparoscopic nephrectomy. • Radical laparoscopic nephrectomy. • Partial laparoscopic nephrectomy. • laparoscopic nephroureterectomy.

3. Simple laparoscopic nephrectomy

9. laparoscopic nephrectomy • Simple laparoscopic nephrectomy. • Donor laparoscopic nephrectomy. • Radical laparoscopic nephrectomy. • Partial laparoscopic nephrectomy. • laparoscopic nephroureterectomy.

10. Donor laparoscopic Nephrectomy • Patient selection • Kidney work up • Surgeon preparation

11. LAPAROSCOPIC NEPHRECTOMY • COMMUNITY HOSPITAL. Michigan, USA HUYNH, HOLLANDER, J of Urol, February 2005

12. LAPAROSCOPIC DONOR NEPHRECTOMY • COMMUNITY HOSPITAL. Michigan, USA HUYNH, HOLLANDER, J of Urol, February 2005

13. Raftopoulos et al, Surgical Endoscopy Oct 2004

14. Raftopoulos et al, Surgical Endoscopy Oct 2004

15. Raftopoulos et al, Surgical Endoscopy Oct 2004

16. laparoscopic nephrectomy • Simple laparoscopic nephrectomy. • Donor laparoscopic nephrectomy. • Radical laparoscopic nephrectomy. • Partial laparoscopic nephrectomy. • laparoscopic nephroureterectomy.

17. Laparoscopic radical nephrectomy is indicated in patients with • T1 to T3a renal tumors. • ? T3b • ??? > T3b

25. Radical laparoscopic nephrectomy • Laparoscopic radical and partial nephrectomies provide equivalent cancer control vs open.     

26. Laparoscopic Radical Nephrectomy for RCC Long-Term Cancer-Specific Survival in 248 Patients Ono et al, 2005

27. Laparoscopic Radical Nephrectomy for RCC vs open • 67 laparoscopic vs 54 open Radical Nx • All were stage cT1 to cT2 N0 M0. • There were no differences in patient age, tumor size, and EBL. • laparoscopic group, have a shorter period of hospitalization. • The mean operating time was 193 min in the open group, vs 256 min laparoscopic group. • A significant OR time difference between the first 34 and last 33 laparoscopic radical nephrectomies Permpongkosol et al, 2005

28. Laparoscopic Radical Nephrectomy for RCC vs open • Disease-free survival rates for laparoscopic and open radical nephrectomy were 95% and 89%, respectively, at 10 years, • Actuarial survival rates for laparoscopic and open radical nephrectomy were 86% and 75%, respectively, at 10 years. • These differences were not statistically significant, and no laparoscopic trocar site implantation was identified. Permpongkosol et al, 2005

29. Laparoscopic Radical Nephrectomy for RCC vs open • One operative conversion (1.5%) was required in the laparoscopic group. • Complications occurred in: 10 patients (15%) in the laparoscopic group 8 (15%) in the open group. • Blood transfusions • 6 laparoscopic patients (8%), • 11 in the open group (20%). Permpongkosol et al, 2005

30. Important complications • Unrecognized laparoscopic bowel injuries: • usually present as indolent signs.    • occasionally afebrile with a normal to low serum WBC count, focal abdominal discomfort, and mild ileus.    • Vascular injuries • the most common cause of conversion to open. • This is more in patients with chronic inflammatory processes.

31. laparoscopic nephrectomy • Simple laparoscopic nephrectomy. • Donor laparoscopic nephrectomy. • Radical laparoscopic nephrectomy. • Partial laparoscopic nephrectomy. • laparoscopic nephroureterectomy.

37. Complications of Laparoscopic Partial Nephrectomy • Urinoma • Completion nephrectomy • Trocar site infection • Pneumothorax/tension pneumothorax • Pulmonary edema • Tumor fragmentation • Transfusion • Pneumonia • Renal insufficiency

38. laparoscopic nephrectomy • Simple laparoscopic nephrectomy. • Donor laparoscopic nephrectomy. • Radical laparoscopic nephrectomy. • Partial laparoscopic nephrectomy. • laparoscopic nephroureterectomy.

39. Radical nephroureterectomy with resection of a bladder cuff remains the "gold standard" for the treatment of upper tract tumors, especially those that are large, high grade, and invasive, and for large, multifocal or rapidly recurring, medium-grade, noninvasive tumors of the renal pelvis or proximal ureter

43. Precaution • The entire ureter, including the intramural portion and ureteral orifice, should be removed. • The risk of tumor recurrence in a remaining ureteral stump is 33-75%

44. Laparoscopic nephroureterectomy can be performed by: • pure laparoscopic technique or • hand-assisted technique with an incision in the lower abdomen. • The distal ureter can be managed through: • Laparoscopic • Open • endoscopic

45. A report described long-term cancer control in 89 patients treated laparoscopically with a variety of techniques for distal ureterectomy, • open in 36 cases • endoscopic stapling in 53 cases. • These data were compared with results seen by the authors with open NU. Hattori et al, 2005

46. Patients' survival and metastasis-free rates • 79% and 75% for the open group, • 80% and 80% for the combined laparoscopic and open group, • 78% and 72% for the pure laparoscopic group. • In this nonrandomized series, the authors reported no significant difference in the groups. Hattori et al, 2005

47. Laparoscopic Nephroureterectomy with Open Versus Endoscopic Management of the Distal Ureter

49. A ureteral catheter is placed, and two laparoscopic ports are placed transvesically. • The ureteral orifice is tented up; a loop is placed around the orifice to occlude the opening and to place traction on the ureter. • A Collins knife then facilitates the dissection to the extravesical space