Partial nephrectomy by hydrodissection. J.-V. Zambon, Urologist Orbis Medical Center Sittard / Laurentius Hospital Roermond

Transcription

1 Partial nephrectomy by hydrodissection J.-V. Zambon, Urologist Orbis Medical Center Sittard / Laurentius Hospital Roermond

2 Partial nephrectomy by hydrodissection J.-V. Zambon, Urologist Laurentius Hospital Roermond

3 Partial nephrectomy by hydrodissection J.-V. Zambon, Urologist Orbis Medical Center Sittard

4 Nephron Sparing Surgery Nephron sparing surgery provides recurrence-free and long-term survival rates similar to radical surgical procedures It has a protective effect on the risk of chronic kidney disease and cardiovascular events. Quoc-Dien Trinh, Urology 2012 Local recurrences occur in less than 1% of cases Van Poppel, J.Urol 1998

5 Nephron Sparing Surgery (N.S.S.) / Partial Nephrectomy Indications: Absolute: anatomical or functional mono-kidney Relative : impaired function contralateral kidney Elective : normal contralateral kidney 5

6 Nephron Sparing Surgery Elective N.S.S. is performed in case of tumours < 4 cm in diameter, limited to the kidney (T 1A) In tumours of 4-7 cm in diameter (T 1B) N.S.S. can be performed in case of an absolute or relative indication EAU Guidelines 2012

7 Nephron Sparing Surgery Open Partial Nephrectomy, classic resection Open Partial Nephrectomy by hydrodissection Laparoscopic Partial Nephrectomy Robot-assisted Laparoscopic Partial Nephrectomy Active surveillance Ablative technology (Cryo, Radiofrequency)

8 Nephron Sparing Surgery Open partial nephrectomy is standard of care. It has a lower complication rate and less risk of long-term reduction of renal function than laparoscopic partial nephrectomy. EAU Guidelines 2012

9 Surgical margins in N.S.S. Most kidney tumours have a pseudocapsule In the past a margin of healthy tissue of 1 cm was promoted Nowadays a rim of 1 mm of normal renal tissue is accepted Intra-operative frozen section is not advocated

10 Applications of hydrodissection Liver surgery Renal surgery Gastro-intestinal surgery (TEM procedure) Radical Prostatectomy TUR-bladder

11 N.S.S. with Erbejet 2 dissection N.S.S. with waterdissection technique Mobilisation of the kidney Isolation of the renal hilus on indication, in specific cases the renal artery is hold in a vessel loop. No hilar clamping Diathermic circular incision of the renal capsule Excision of the tumour by Hydrodissection Coagulation of small vessels Larger vessels and collecting system are secured with sutures Wound surface is dried by coagulation Wound surface is covered with Tachosil

12 Hydrodissection Technique in N.S.S. : advantages No renal ischaemia Minimal to moderate blood loss Excellent sight of operating field Adequate care of vessels and collecting system Perfect hemostasis by combination of Erbe Vio coagulation technique / Tachosil use

13 Hydrodissection Technique in N.S.S. Interpretation of surgical margins is difficult for pathologist Intensive follow up by CT scan or sonography is advised

14 61 Year old male massive tumour right kidney and small tumour left kidney Two stage procedure: Radical nephrectomy right side january Partial nephrectomy left side february Post operative course: no recurrence on sonographic control Impaired but stable kidney function (GFR 32)

15

16

17

18 Open tumournephrectomy

19 50 Year old woman with kidney tumour on left side Partial nephrectomy with Erbejet 2 waterdissection on june Histology: Renalcell carcinoma, radical resection Post operatieve course: no recurrence, normal kidney function

20

21

22

23

24

25

26

27

28

29

30

31 79 Year old woman with a double kidney tumor on the right side Partial nephrectomy with Erbejet 2 waterdissection on february Histology: Oncocytoma (benign tumor) on both locations

32

33

34

35

36

37 Partial nephrectomy Erbejet 2 From till patients underwent 39 partial nephrectomies 19 male and 19 female patients (50-83 years) Median operating time 90 minutes Median blood loss 200 ml ( ml)

38 Total follow-up

39 All cases: Blood loss during surgery

40 All cases: Duration hospital stay after surgery

41 Partial nephrectomy Erbejet 2 Histology: Renal cell carcinoma 27 Oncocytoma (benign) 8 Other benign pathology 4

42 Renal cell cancer Histology Frequency Percent Valid Percent Cumulative Percent CRCC 1 3,7 3,7 3,7 PRCC 3 11,1 11,1 14,8 Valid RCC 23 85,2 85,2 100,0 Total ,0 100,0

43 Partial nephrectomy Erbejet 2 Complications 1 Patient with urinary leakage, resolved after drainage 1 Patient had a superficial burning wound due to prolonged coagulation 1 Patient had an urinary retention

44 Partial nephrectomy Erbejet 2 Kidney function Stable 36 / 38 patients Diminished 2 / 38 patients (2 mono kidneys)

45 All cases: Renal function (pre and post surgery)

46 Partial nephrectomy Erbejet 2 Recurrence of tumour: None of 27 patients with renal cancer None of 12 patients with a benign disorder Median recurrence free period for renal cancer: 19 months

47 Renal cell cancer Radicality Frequency Percent Valid Percent Cumulative Percent Incomplete 10 37,0 37,0 37,0 Complete 12 44,4 44,4 81,5 Valid Unknown 5 18,5 18,5 100,0 Total ,0 100,0

48 Renal cell cancer Recurrence Frequency Percent Valid Percent Cumulative Percent No recurrence 23 85,2 85,2 85,2 Valid No follow-up yet 4 14,8 14,8 100,0 Total ,0 100,0