Laparoscopic partial nephrectomy guided by high definition laparoscopic ultrasound

Transcription

1 Rev Mex Urol 2014;74(1):55-59 ÓRGANO OFICIAL DE DIFUSIÓN DE LA SOCIEDAD MEXICANA DE UROLOGÍA Clinical case Laparoscopic partial nephrectomy guided by high definition laparoscopic ultrasound J. G. Campos-Salcedo a,*, E. I. Bravo-Castro b, M. Castro-Marín c, A. Sedano-Lozano d, J. C. López-Silvestre d, M. A. Zapata-Villalba d, L. A. Mendoza-Álvarez d, C. E. Estrada-Carrasco d, H. Rosas-Hernández d and J. L. Reyes-Equihua d 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 Laparoscopic partial nephrectomy; Highdefinition laparoscopic ultrasound; Partial nephrectomy; Mexico Abstract Laparoscopic partial nephrectomy was described in 1993 and its indications extended due to the benefits of maintaining oncologic results and sparing the renal parenchyma. The aim of this report was to describe a patient with the diagnosis of a right renal tumor, stage T1a N0 M0, that underwent a laparoscopic partial nephrectomy guided by high definition laparoscopic ultrasound, with clamping of the renal artery. Surgery duration was 240 minutes, there was minimum blood loss, a minimum of postoperative 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 realtime resection control for carrying out complete renal tumor excision. Palabras clave Nefrectomía parcial laparoscópica; Ultrasonido laparoscópico de alta definición; Nefrectomía parcial laparoscópica guiada por ultrasonido laparoscópico de alta definición Resumen La nefrectomía parcial laparoscópica fue descrita en 1993, sus indicaciones se extendieron por sus beneficios al mantener los resultados oncológicos y preservación de 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 Cabral, Delegación Miguel Hidalgo, CP 11200, México D.F., México. Telephone: (01) , ext drjgaducampos@hotmail.com (J. G. Campos-Salcedo).

2 56 J. G. Campos-Salcedo et al Nefrectomía parcial; México. de tumor renal derecho T1aN0M0, a la que se le realizó nefrectomía parcial laparoscópica guiada por ultrasonido laparoscópico de alta definición. Se somete paciente a dicho 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 Revista Mexicana de Urología. Publicado por Elsevier México. Todos los derechos reservados. Introduction Laparoscopic partial nephrectomy was first described in It indications and use have been extending due to its benefits of offering adequate oncologic control, while conserving part of the patient s renal function, as well as the added value of being a minimally invasive technique. 1-5 In the last few years, the new modalities in radiology studies and their relative access in the majority of Mexican hospitals, have not only brought about an increase in renal tumor diagnosis, but also at earlier stages. The survival rate at 5 years for a localized renal tumor is approximately 90%, justifying treatment for these patients. 6 Curative treatment of localized renal tumors is surgical and the treatment of choice continues to be nephrectomy. Partial nephrectomy has shown similar oncologic control to radical surgery. The initial indications for partial nephrectomy were a single anatomic or functional kidney. These indications gradually broadened, as the safety of the technique was confirmed and adequate oncologic results were achieved. 3,7 Moreover, with the increase in experience, larger and deeper tumors have been treated and renal parenchyma hemostasis, waterproof repair of the calyces through suturing after tumor excision, and complete tumor resection are among the principal surgical goals The aim of this report was to document how the use of a high definition laparoscopic ultrasound transducer was an important aid in achieving complete tumor excision. Case presentation A woman in the seventh decade of life had a past history of diabetes and chronic stage 2 nephropathy of the National Kidney Foundation (NKF), 4 cesarean sections, appendectomy, hysterectomy, tubal ligation, and ventral hernia repair through mesh placement. She was admitted to our hospital for a diarrheic syndrome. Computed tomographic urography was ordered as a complementary study and revealed a right 14 mm renal mass with 20 HU in the plain phase and 80 HU in the venous phase, suggestive of a tumor. It was staged T1aN0M0 (fig. 1) and laparoscopic partial nephrectomy was proposed. Total surgery duration, blood loss, intra and postoperative complications, hospital stay, and oncologic control were evaluated. The procedure was performed with the following surgical technique: the patient was given general anesthesia 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.

3 Laparoscopic nephrectomy guided by high-definition laparoscopic ultrasound 57 Figure 2 Tumor image before high-definition laparoscopic ultrasound. Figure 3 Introduction of the 4 channel 10 mhz BK Pro-Focus 2202 high definition laparoscopic ultrasound flexible transducer for identifying the tumor. lumbar region. Three trocars were placed: a 12 mm blunttip transumbilical trocar, a 10 mm trocar at the subcostal level, and a 5 mm trocar at the mid-clavicular line. The transperitoneal approach was employed. The ureter and the gonadal vein were identified and laterally retracted. Dissection was performed along the psoas muscle and the renal hilum was dissected en bloc. Gerota s fascia was dissected, separating it from the kidney. The renal tumor was identified at the lower pole and the adjacent perirenal fat was dissected (fig. 2). The 4-channel 10 mhz BK ProFocus 2202 high definition laparoscopic ultrasound transducer was then introduced through the 10 mm trocar (fig. 3) identifying the tumor edges and depth (fig. 4). Once this was done, the silk threads that were the reference points for the renal artery and vein were tightened. The tumor was resected with a laparoscopic cold scissors (fig. 5). Upon finishing the resection, the laparoscopic transducer was introduced again to make sure there were no areas of residual tumor, after which renorrhaphy with Vicryl 1-0 was done, anchoring the sutures with Hem-o-Lok (Weck Closure System, Research Triangle Park, NC). The traction of the renal vessels was then freed with a warm ischemia time of 30 minutes. A control ultrasound showed no evidence of residual mass (fig. 6) Hemostasis was achieved at the renorrhaphy site with the biologic sealant Floseal (Baxter, Mountain View, CA) with no apparent signs of bleeding. The tumor was put in a waterproof bag and removed through the 10 mm port. A drain was placed, the ports were removed under direct vision and the wounds were closed with the usual technique. The procedure took 180 minutes, with blood loss of 100 cc. There was no need for blood transfusion, the patient had a favorable postoperative period with minimal doses of analgesic. Pain was adequately controlled without rescue doses. The patient began to walk at 24 hours and the drain was removed after 48 hours. Control renal ultrasound at 48 hours showed no signs of perirenal hemorrhage and the patient was released 72 hours after surgery. She was checked 4 weeks later and had adequate progression. There was no evidence of recurrence at the control appointment at 3 months. Discussion Since the first published works by Robson, radical nephrectomy has been accepted as the reference treatment in localized renal carcinoma. 5 Nevertheless, the new technologies that have been developed, along with the rise in minimally invasive surgery, have resulted in their being compared. Partial nephrectomy has shown better conservation of renal function than radical nephrectomy, as well as having good oncologic results and being a safe option for treating tumors under 4 cm. In addition, recurrence and the risk of death from tumor disease are low; they have been related to pathologic stage and Fuhrman grade, but not to positive margins that can be found in 1.4% of the patients that undergo this treatment. Free-from-disease survival at 2 and 5 years has been reported at up to 99% and 97%, respectively. 12 The approaches are retroperitoneal or transperitoneal, as with our patient. In the end, the choice of the approach will depend on the surgeon s preferences, taking into account the size of the mass, location, body mass index or history of previous surgery, with no big differences in the complication rate between the approaches. 3 One of the reported complications with the laparoscopic technique is parenchymal bleeding related to tumor size and depth, and added to the time limitation and the precision of laparoscopic suture placement, it does not compare with an open procedure. Nevertheless, these effects can be reduced with adequate control of the hilum through appropriate instruments for that purpose, 13 and secondarily through the use of hemostatic agents like Floseal. Another disadvantage associated with the procedure is the difficulty of achieving satisfactory surgical margins due to the limited angulation of the laparoscopic instruments, which tends to lessen the deeper the tumor, plus the poor visibility after beginning the parenchymal incision; 13 this is where the use of intraoperative ultrasound provides better information as to the depth of the tumor and how far the

4 58 J. G. Campos-Salcedo et al Figure 4 Intraoperative laparoscopic ultrasound for defining the edges and depth of the resection. Figure 5 Image showing tumor resection after laparoscopic ultrasound. 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. References Figure 6 Image after resection and renorrhaphy for documenting the absence of residual tumor. resection should be extended to confirm the existence of residual tumor. In the present case, we observed the advantages of the laparoscopic approach that have been reported in other case series: short hospital stay and good pain control; for our patient it was 72 hours and she did not need to be given narcotics, only the common anti-inflammatory agents, and not at rescue doses. 7,11-13 Conclusions Renal cell carcinoma management continues to be surgical. However, unlike the first reports on the procedure, laparoscopic partial nephrectomy, when performed by an experienced urologist, has been shown to be a safe technique with lower morbidity and satisfactory oncologic results, compared with the open technique. However, 1. McDougall EM, Clayman RV, Chandhoke PS, et al. Laparoscopic partial nephrec- tomy in the pig model. J Urol 1993;149(6): Winfield HN, Donovan JF, Godet AS, et al. Laparoscopic partial nephrectomy: initial case report for benign disease. J Endourol 1993;7(6): Rassweiler J, Abbou C, Janetschek G, et al. Laparoscopic partial nephrectomy. The European experience. Urol Clin North Am 2000;27: Gill I, Desai M, Kaouk J, et al. Laparoscopic partial nephrectomy for renal tumor: duplicating open surgical techniques. J Urol 2002;167: Robson C, Churchill B, Anderson W. The results of radical nephrectomy for renal cell carcinoma. J Urol 1969;101: Consultado en enero de csr/1975_2006/ 7. Lau W, Blute M, Weaver A, et al. Matched comparison of radical nephrectomy vs. nephron-sparing surgery in patients with unilateral renal cell carcinoma and a normal contralateral kidney. Mayo Clin Proc 2000;75: Janetschek G, Jeschke K, Peschel R, et al. Laparoscopic surgery for stage T1 renal cell carcinoma-radical nephrectomy and wedge resection. Eur Urol 2000;38(2): Kim FJ, Rha KH, Hernandez F, et al. Laparoscopic radical versus partial nephrec- tomy - assessment of complications. J Urol 2003;170(2 Pt 1):

5 Laparoscopic nephrectomy guided by high-definition laparoscopic ultrasound Simon SD, Ferrigni RG, Novicki DE, et al. Mayo Clinic Scottsdale experience with laparoscopic nephron sparing surgery for renal tumors. J Urol 2003;169(6): Maclennan S, Imamura M, Lapitan MC, et al. Systematic Review of Perioperative and Quality-of-life Outcomes Following Surgical Management of Localised Renal Cancer. Eur Urol 2012;62(6): Favaretto RL, Sanchez-Salas R, Benoist N, et al. Oncologic Outcomes After Laparoscopic Partial Nephrectomy: Mid-Term Results. J Endourol 2013;27(1): Gill IS, Matin SF, Desai MM, et al. Comparative analysis of laparoscopic versus open partial nephrectomy for renal tumors in 200 patients. J Urol 2003;170(1):64-68.