V408: Retroperineoscopic Nephron Sparing Surgery For Renal Tumor More Than 4 Cm In Size
VideoIntroduction and Objectives
The laparoscopic treatment for renal tumors more than 4 centimeters in size, represents a binding challenge even in the hands of expert laparoscopists. We hereby demonstrate that when a peritumoral pseudocapsule is well documented it is possible to propose a pure enucleation of the neoplasty even for big neoplasies more than 4 cm, preserving renal function, with a reduced risk of bleeding, a short ischemic time.
The clinical case we report refers to 40 year old male patient, affected by a mesorenal neoplasm on the convex margin of the right kidney, 4.3 centimeters in size showing a peritumoral pseudocapsule in the T1 and T2 weighted images in magnetic resonance.After creating a retroperitoneal space using digital dissection we placed the 3 operative trocars. We made incision in the Gerota's fascia and, following the psoas muscle we gained access to the vascular peduncle, isolating the renal artery.Then, We moved on the dissection of the neoplasm from the perirenal fat tissue.We marked the limits of the neoplasm using laparoscopic hook so we placed a vascular bulldog clamp to the artery and we started infusion of 100 ml Mannitol 18%.The next phase of the intervention was represented by the cold incision of the peritumoral tissue with the complete enucleation of the neoplasm using forceps and aspirator. We completed the intervention placing sutures secured with Hem-O-Lok® clip on the renal medulla and, then, to the cortex.
In the end we removed the vascular clamp totalizing an ischemic time of 12 minutes and a blood loss of 290 cc.
In our experience, which consists of 21 cases, we found evidence that, each time imaging shows the presence of a renal tumor with a peritumoral capsule, we can propose the enucleation of the neoplasm minimizing the risks of bleeding with a trascurable percentage of positive surgical margins.