V5-07: Off-clamp laparoscopic partial nephrectomy in a horseshoe kidney
VideoIntroductions and Objectives
Horseshoe kidney is the most prevalent fusion anomaly, occurring in 1 of every 400 births. In 95% of the cases the kidneys join at the lower pole, the isthmus is usually composed of parenchymatous tissue and has its own blood supply. Although surgery is the standard treatment for renal tumors, in these patients it is technically challenging due to the abnormal vascularization. Till now, only three cases of laparoscopic partial nephrectomy have been published, all with arterial clamping.
We present the case of an asymptomatic 59 years-old male patient with history of ESWL due to left ureteral lithiasis, who during follow up is diagnosed of 6 cm solid lesion in the region of the lower pole of the left kidney. With the patient in flank position, a transperitoneal access is performed, followed by mobilization of descending colon and spleen liberation. Dissection of the medial aspect of left side of the horseshoe kidney is performed with exposure of abdominal aorta and common iliac artery. Renal isthmus is identified and tumor location is confirmed in the left inferoanterior part of the isthmus using intraoperative ultrasonography. Dissection of the arterial branch supplying the isthmus and of a direct tumoral branch is performed, with the latter being selective ligated. Tumor excision is performed without additional vascular clamping and selective coagulation is performed. An opening in the collecting system is repaired using a 3/0 V-loc® running suture. Finally, human thrombin (Floseal®) is placed in tumor resection bed. Operative specimen is placed in an Endo-bag and a Jackson-Pratt drain is placed.
Operative time was 180 minutes, with estimated blood losses of 500cc. Hospital stay was 6 days. Pathologic evaluation revealed a clear cell carcinoma pT1b Fuhrman II. Serum creatinine and estimated glomerular filtration rate at 6 months remain unaltered (65umol/L and >90 mL/min/m2, respectively). Follow up CT is negative for local recurrence.
To our knowledge this is the first description of a zero ischemia laparoscopic partial nephrectomy in a horseshoe kidney. Though technically demanding, laparoscopic nephron-sparing surgery seems feasible and could be considered in these cases.