Difficulties in Laparoscopic Partial Nephrectomy

Abstract

Renal masses are more frequently diagnosed with the advent of routine abdominal imaging like ultrasound followed by computerized tomography (CT) scan, which has resulted in the need for more intervention. Among the different approaches, partial nephrectomy has proved the test of time. This has been duplicated by laparoscopic partial nephrectomy. Gill et al. have published the largest comparative study between laparoscopic partial versus open partial nephrectomy, in which they proved that laparoscopic partial nephrectomy (LPN) had a very comparable oncological benefit with superior functional outcome and minimal morbidity.¹ This highly advanced laparoscopic technique is being utilized in more centers around the world with very similar results to what has been published. In this chapter, the technique of laparoscopic partial nephrectomy that the authors utilize will be described and the important steps will be explained. This includes surgeon and patient preparation, intraoperative steps including laparoscopic approach, kidney dissection, intraoperative ultrasound, hilar control, partial nephrectomy, renal bed management, and finishing the procedure.² Difficult case scenarios that require special attention will also be discussed, such as renal impairment, solitary kidney, hilar mass, central mass, multiple renal arteries, renal masses with vascular pathology, and previously operated kidneys. LPN in obese patients, cystic masses, renal masses with ureteropelvic junction pathology, and horseshoe kidney will also be discussed. The authors’ aim in this chapter is to provide practical guidelines and to review common and uncommon difficulties and explain ways to overcome them. This chapter will highlight important technical aspects of LPN that are done in the standard laparoscopic way; hand-assisted or robot-assisted techniques will not be discussed.