Laparoscopic Partial Nephrectomy

Partial nephrectomy is emerging as the standard of care for small exophytic renal tumors <4cm regardless of renal function status. In comparison to radical nephrectomy, studies have demonstrated equivalent oncologic control and decreased risk of renal insufficiency. While laparoscopic radical nephrectomy has been widely adopted as the procedure of choice for large renal masses, laparoscopic partial nephrectomy (LPN) requires a higher level of expertise. However, recent advances in technology, instrument design, and greater facility with laparoscopy among urologists have made this procedure more accessible. There is little long-term follow-up, but some recent large series demonstrate positive margins <3% and local recurrence <5%, commensurate with the open procedure. A transperitoneal approach is often used for anterior and polar tumors and a retroperitoneal approach for posterior and posterolateral lesions; however, if hilar control is felt to be needed, then a transperitoneal approach is usually used regardless of the lesion’s location. In addition to standard laparoscopy, a hand-assisted approach can be used to facilitate suturing during renal reconstruction. Warm ischemia, up to 30 min, is usually necessary for large, complex, or centrally located tumors. When longer periods of warm ischemia are anticipated, cold ischemia may be employed via surface, transureteral, or intraarterial cooling. Advances in surgical sealants continue to facilitate hemostasis; these include glues as well as hemostatic agents.