Strategies in the management of renal tumors amenable to partial nephrectomy.
OBJECTIVE
The laparoscopic approach to radical and partial nephrectomy is becoming the standard of care for treating patients with renal tumors. Hand-assisted laparoscopic partial nephrectomy (HALPN) provides some advantages over the pure laparoscopic approach which include manual manipulation of the kidney, tactile feedback, and timely specimen removal.


METHODS
We describe our technique for HALPN and emphasize the implementation of an in-room pathologist to examine gross margins during the period of renal arterial occlusion. Between 2004 and 2007, 46 patients underwent HALPN performed by the same surgeons. Mean patient age was 59.5 years and mean tumor size was 2.55 cm. Twelve of these patients underwent significant concomitant procedures.


RESULTS
Our mean operating time was 173.26 min (range 90-306 min) and our mean warm ischemic time was 28.32 min (range 14-54 min). Average estimated blood loss was 116.82 ml (range 10-1000 ml) with no transfusions. Thirty-six (78%) tumors were renal cell carcinoma, seven (15%) were oncocytomas, and three (7%) were angiomyolipomas. The average length of stay was 5.17 days (range 3-9 days) and there were no positive margins. There was one postoperative bleed (2%) and two postoperative urine leaks (4.3%).


CONCLUSIONS
In our institution, the hand-assist approach to laparoscopic partial nephrectomy has resulted in favorable perioperative outcomes. The use of an in-room pathologist to provide real-time assessment of gross tumor margins has allowed us to achieve a 0% positive final margin rate. We believe that the use of an in-room pathologist during the timely extraction of the specimen made possible by the hand-assisted approach provides a great advantage over pure laparoscopic partial nephrectomy. This low positive margin rate is also the result of maintaining a bloodless field of resection with temporary renal arterial occlusion as well as the avoidance of visual tissue distortion with cold, sharp scissor dissection.
McClean
Jacob M
JM
Department of Urology, Carolinas Medical Center, 1000 Blythe Boulevard, Charlotte, NC 28203, USA.
Kercher
Kent W
KW
Mah
Nicole A
NA
Zerey
Marc
M
Heniford
B Todd
BT
Irby
Pierce B
PB
Burks
R Tucker
RT
Weida
Carol
C
Teigland
Chris M
CM
D018249:Adenoma, Oxyphilic / Q000473:pathology / Q000601:surgery; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D018207:Angiomyolipoma / Q000473:pathology / Q000601:surgery; D002292:Carcinoma, Renal Cell / Q000473:pathology / Q000601:surgery*; D004564:Electrocoagulation; D005260:Female; D005500:Follow-Up Studies; D006488:Hemostasis, Surgical; D006801:Humans; D007680:Kidney Neoplasms / Q000473:pathology / Q000601:surgery*; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D009392:Nephrectomy / Q000379:methods*; D011183:Postoperative Complications / Q000453:epidemiology; D012189:Retrospective Studies; D016896:Treatment Outcome; D020535:Video-Assisted Surgery