Laparoscopic partial nephrectomy.
In properly selected patients, partial nephrectomy yields oncologic efficacy similar to that of traditional radical nephrectomy. We have performed more than 415 laparoscopic radical nephrectomies over the 5-year period beginning in September 1999. All patients undergo a three-dimensional CT scan with 3-mm sections prior to the operation. We generally prefer the transperitoneal approach, although for posterior tumors, a retroperitoneal approach is preferred. The kidney is dissected using standard technique. Intraoperative hydration is given to maintain diuresis. Detailed real-time ultrasonographic delineation of the tumor is obtained to facilitate planning of the resection. We prefer en-bloc hilar clamping. The renal capsule is scored circumferentially with the "L" hook electrocautery. Parenchymal incision and tumor resection is performed using heavy reuseable scissors. The base of the resection defect is closed using a running 2-0 Vicryl on a CT-1 needle. The water-tightness of pelvicaliceal repair is tested by repeat gentle injection of indigo carmine through a ureteral catheter. Next, the parenchyma is closed with 1 Vicryl on a CTX needle placed over an oxidized cellulose bolster. The specimen is extracted within an entrapment bag. Initially, a surgeon should be highly selective, including patients with small, mostly exophytic, tumors. With increasing comfort and experience, the criteria can expand.