Laparoscopic Partial Nephrectomy: An Useful Method of Decision Making for Determining the Approach and Surgical Method Based on the Systematic Classification of Tumor Location

Kyung Yun Kim; Seung-Hyo Woo; Eun Tak Kim; Seung Bae Lee; Dae Kyung Kim

doi:10.4111/kju.2008.49.12.1067

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Kim, Woo, Kim, Lee, and Kim: Laparoscopic Partial Nephrectomy: An Useful Method of Decision Making for Determining the Approach and Surgical Method Based on the Systematic Classification of Tumor Location

Original Article

Korean J Urol 2008;49(12):1067-1073.

Published online: 20 January 2008

DOI: https://doi.org/10.4111/kju.2008.49.12.1067

Laparoscopic Partial Nephrectomy: An Useful Method of Decision Making for Determining the Approach and Surgical Method Based on the Systematic Classification of Tumor Location

Kyung Yun Kim, Seung-Hyo Woo, Eun Tak Kim, Seung Bae Lee¹, Dae Kyung Kim

From the Department of Urology, Eulji University School of Medicine, Daejeon, Korea

¹Boramae Hospital, Seoul National University College of Medicine, Seoul, Korea

Received 21 July 2008 Revised 25 September 2008

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

Laparoscopic patial nephrectomy is still one of challenging surgeries in laparoscopic urologic field and needs skillful technique of surgeons. When performing laparoscopic partial nephrectomy, initial plan of how to approach affects the whole course of the surgery. To propose a systematic decision guideline, we used the tumor location as the determining factor for selecting initial plan and analyzed our initial experience.

Materials and Methods

From September 2005 to April 2008, we performed 22 LPNs for small renal tumors less than 40mm in diameter, as measured from the preoperative computed tomography scans. We divided the tumor locations into 18 categories with the combinations of the anterior and posterior renal axes, and the upper, middle, lower parts of the kidney and the peripheral, central and hilar locations of the tumor. According to the tumor location categories, we performed LPNs through the retroperitoneal simple and complex approaches, and the transperitoneal simple and complex approaches.

Results

Twenty of twenty-two tumors (91%) were removed successfully through 4 different approaches, but 2 cases were converted to laparoscopic radical nephrectomies (LRNs). The mean operation time was 203 minutes, including a mean warm ischemic time (WIT) of 30.7 minutes. Among the 17 cases of RCC, 15 tumors were successfully removed via LPNs, and there were no cases with positive margins and no tumor recurrence during a mean of 14.9 months follow-up with a maximum follow-up period of 34 months.

Conclusions

Dividing the tumor location into 18 categories is useful for deciding on the appropriate laparoscopic approach.

Keywords: Laparoscopy, Nephrectomy, Warm ischemia, Kidney neo-

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Fig. 1.

The representative preoperative computed tomography images. (A, B) Hilar tumor; the tumor mass comes close to the branches of the renal vessels and the renal pelvis. (C, D) Central tumor; the inner margin of the tumor approaches to the renal sinus fat.

Table 1.

Patient characteristics

No. of patients	22
Age (mean, years)	60.7 (45–76)
Male:Female	16:6
Body mass index (mean, kg/m²)	25.6 (20.5–29.5)
Comorbidities	19 (86.4%)
Hypertension	11
Diabetes mellitus	7
Chronic obstructive pulmonary disease	1
History of stroke	2
History of acute myocardial infarction	1
Chronic kidney disease	1
Gastric cancer	2
Liver cirrhosis	2
Gall bladder stone	4
HBV carrier	1
Tumor size (mean, mm)	22.2 (12–39)
Tumor site
Right:Left	13:9
Tumor locations
Peripheral	11
Central	6
Hilar	5
No. solitary kidney	2 (synchronous RCC)
Preoperative Cr (mean, mg/dl)	1.04 (0.7–1.7)
Preoperative eCcr (mean, ccs/min)	71.67 (47.79–104.78)
Follow-up period (mean, months)	14.2 (3–34)

HBV: hepatitis B virus, Cr: creatinine, eCcr: estimated creatinine clearance rate, RCC: renal cell carcinoma

Table 2.

The operative results, complications and oncologic outcomes of the current study and the recent series in Korea

						Complications
Author	No. of patients	Mean tumor size (mm)	Operation time (min)	Mean WIT (min)	Mean EBL (ml)	No. transfused (%)	Urine leak (%)	Conversion (%)	Positive surgical margin (%)	Local recurrence (%)	Mean follow-up (months)
Current study	22	22.2	203 (86–360)	30.7 (17–47)	256	2 (9.1)	1 (4.5)	2 (9.1), LRN	0^‡	0^‡	14.9^‡
Hong et al⁵	27	25	193 (120–300)	27.8 (15–43)	493	2 (7.4)	0	1, LRN	15∗	0	11.4^†
Seo et al⁶	15	33	180.7 (110–360)	32.5 (23–50)	NA	8 (60)	1	0	0	0	11.4^†
Bang et al⁷	56	20.8	208∗ (139–357)	34.4∗ (5–75)	NA	8 (14.3)	2	1, OPN	0	NA	6.3^†

WIT: warm ischemic time, EBL: estimated blood loss, LRN: laparoscopic radical nephrectomy, OPN: open partial nephrectomy, NA: not available, ∗: calculated from the results of the literature,

^† : including benign tumors,

^‡ : results from 17 cases of renal cell carcinoma

Table 3.

The operative results and the differences of Cr and eCcr among the three groups according to the tumor location in 19 cases, with excluding 2 LRN cases and 1 calyceal diverticular

	Peripheral (n=10)	Hilar (n=5)	Central (n=4)
Operation time (mean±SE, min)	176.1±45.9	198.6±25.5	259.2±70.2∗
WIT (mean±SE, min)	29.6±8.4	26.6±2.3	41.2±6.7
EBL (mean±SE, ml)	213±184	175±86	456±301
ΔCr (mean±SE, mg/dl)	−0.07±0.15	−0.02±0.13	0.03±0.19
ΔeCcr (mean±SE, ccs/min)	4.7±8.7	1.9±10.4	−1.8±15.5

Cr: creatinine, eCcr: estimated creatinine clearance rate, LRN: laparoscopic radical nephrectomy, SE: standard error, WIT: warm ischemic time, EBL: estimated blood loss. ∗: p-value＜0.05 by Mann-Whitney test

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