Category: Laparoscopy: Upper Tract - Malignant
Introduction & Objective : In this video, we aimed to share our laparoscopic partial nephrectomy experience with near infrared fluorescence imaging using indocyanine green (ICG) dye to create super selective ischemia in a solitary kidney with vascular abnormalities.
58-year-old male patient was found to have an exophytic upper pole mass in the left kidney while being investigated for hypertension. CT angiography revealed a 51x58x63mm mass in the upper pole of the malrotated kidney which had 5 arteries and 3 veins. Patient was scheduled for a laparoscopic partial nephrectomy
A retrograde pyelogram which revealed bifid left renal pelvis was performed just before the operation. The ureteral catheter was left in situ for security purposes. Then the patient was placed in 60 degrees left lateral decubital position and pneumoperitoneum was achieved with a Veress needle that was placed lateral to the left rectus muscle. A 12-mm optical port was placed from that site and a 5-mm port for retraction from the substernal area and one 12-mm and one 5-mm working ports were placed on the anterior axillary line. Following medialization of the left colon, ureter was identified. Kidney was malrotated. A careful dissection of the renal hilum was performed and 5 renal arteries and 3 renal veins were identified and all of them were separately secured with vascular tapes. Intraoperative ultrasonography was brought into operative field and exophytic 5 cm upper pole mass was visualized and the borders were scored with hook cautery. Then ICG was administered intravenously and vessels feeding the mass was identified and two arteries were super selectively clamped. The mass was resected with cold scissors by removing some healthy neighboring tissue. Parenchymal defect was closed with 2/0 V-loc and 37 mm 2/0 vicryl sutures. After removing the bulldog clamps parenchymal defect was supported by approximating the perirenal fatty tissues with 3/0 vicryl sutures. The mass was placed in an endobag and removed from the 12-mm optical port site. The operation was completed by placing a drain in situ.
Insufflation duration and super selective ischemia time were 190 and 24 minutes respectively. The estimated blood loss was 200cc. Patient was discharged on postoperative day 3 after removal of the drain. Pathologic examination revealed clear cell type renal cell carcinoma, Fuhrman Grade 2, pT1b with negative surgical margins. Preoperative eGFR level was 73 mL/min/1.73m2 and postoperative 9 months was 60 mL/min/1.73m2.
In the surgical treatment of renal tumors advancing technology and increasing experience may help to safely accomplish nephron sparing surgery also in atypical complex cases.
Ender Ozden– Professor in Urology, Ondokuz Mayis University, School of Medicine, Department of Urology, Atakum, Samsun, Turkey
Murat Gulsen– Atakum, Samsun, Turkey
Suleyman Oner– atakum, Samsun, Turkey
Yakup Bostanci– Atakum, Samsun, Turkey
Yarkın Kamil Yakupoglu– Atakum, Samsun, Turkey
Professor in Urology
Ondokuz Mayis University, School of Medicine, Department of Urology
Atakum, Samsun, Turkey