Zero Ischemia Laparoscopic Partial Nephrectomy

John YuenSingapore Moderator Technical Pearls: Total Extraperitoneal TechniquePractice-Changing Development in RaLRP

Andrew Kennedy SmithNew Zealand Speaker Zero Ischemia Laparoscopic Partial NephrectomyNephron preservation with complete tumour excision and without complications remain the goals of surgery for early-stage kidney tumours. This surgery remains technically challenging using a minimally invasive platform, and there remain variations of technique. We present what is now an established approach within our centre, but has been enhanced by progressive improvements in the specific surgical instrumentation. The technique is achievable in a smaller centre with lower surgical volumes. We perform a laparoscopic partial nephrectomy using waterjet and advanced bipolar energy without vascular clamping and without renorrhaphy, supplemented with topical hemostatic agents, reliably achieving the stated goals of this surgery. Ischaemia and delayed complications are minimised by avoiding renorrhaphy and vascular clamping during dissection.Zero Ischemia Laparoscopic Partial Nephrectomy for Hilar TumorsOur technique for hilar tumours remains similar to that for peripheral tumours, again using waterjet and advanced bipolar energy without vascular clamping and without renorrhaphy, supplemented with topical hemostatic agents. Waterjet may be safely used directly on major vessels and collecting system structures, and directly on the tumour capsule, to perform either conventional partial nephrectomy with parenchymal margin or tumour enucleation. With hilar dissection, it is possible to visualise and control arterial supply directly to the tumour, reducing the potential for blood loss. The stated goals of this surgery are achieved. The technique which avoids renorrhaphy is particularly relevant in hilar tumours where renorrhaphy may not be technically achievable.