Category: Laparoscopy: Upper Tract - Malignant
Introduction & Objective :
Recent reports have suggested that LESS is feasible option for treatment of renal tumors. However, the procedure may be technically difficult in patients with large renal tumors and in the presence of complex renal vasculature. In this video we present the step by step technique of LESS radical nephrectomy of a large renal tumor with complex vascular supply.
Methods : We present a 50 years old female who presented with accidently discovered right renal mass. Her body mass index was 37 kg/m2. Triphasic Computed tomography of the abdomen revealed an enhanced right renal mass that measured 11x 11 X7 cm with cystic degeneration and replacing most of the renal parenchyma. The RENAL nephrometry score was 10. The patient had no associated co-morbidities. LESS radical nephrectomy was done using the covidien (SILS™) port that was inserted through 2.5 cm midline umbilical skin incision. During LESS radical nephrectomy we used both articulating and straight instruments as well as 5-mm EndoEye camera. Dissection started by incision of the posterior peritoneum that was followed medial reflection of the right ascending colon and the duodenum. Then the lower pole of the kidney was mobilized. While exerting counter lateral traction on the lower pole of the kidney with the left hand, dissection was continued upwards along the medial aspect of the kidney with the right hand by combining both sharp and blunt dissection. A small right renal vein was identified while the main renal vein was located upwards behind the liver. Two renal arteries were found being located posterior and in between the two renal veins and when dissected their common stump was located behind the inferior vena cava. Renal vessels were dissected then clipped by the Hem-O-Lock and divided between clips. Then the ureter was clipped and divided. En-block dissection of the kidney with the tumor was done using both sharp and blunt dissection. The specimen was removed through a Pfannenstiel incision.
The operative time was 142 minutes. Blood loss was 100 c.c. No extra-port was added. There were no intraoperative or postoperative complications. The Pfannenstiel skin incision after retrieval of the tumor was 6 cm. Hospital stay was 2 days. Visual analogue pain scale at discharge was 2. Histopathology confirmed the diagnosis of clear cell renal cell carcinoma PT2bG3 where the specimen size measured 15x13x7 cm while tumor size measured 13.5x10.5x7 cm
LESS radical nephrectomy is feasible and safe option for treatment of large renal tumors with complex renal vasculature. Although technically difficult, the procedure has low morbidity and high patient satisfaction.
Aly Abdel-Karim– Professor of Urology, Alexandria University, Alexanderia, Al Iskandariyah, Egypt
Mohamed Yehia– Consultant Urological Surgeon, Wrexham Maelor Hospital NHS Wales, Betsi Cadwaladr University Health Board, Wrexham, Wales, United Kingdom, Wrexham, Wales, United Kingdom
Ahmed Abulkhair– Alexandria, Al Iskandariyah, Egypt
Salah Elsalmy– Alexandria, Al Iskandariyah, Egypt
Professor of Urology
Alexanderia, Al Iskandariyah, Egypt
Consultant Urological Surgeon
Wrexham Maelor Hospital NHS Wales, Betsi Cadwaladr University Health Board, Wrexham, Wales, United Kingdom
Wrexham, Wales, United Kingdom