Laparoscopic Partial Nephrectomy for Completely Intraparenchymal Tumors

Purpose: Management for intraparenchymal renal tumors represents a technical challenge during laparoscopic partial nephrectomy since, unlike exophytic tumors, there are no external visual cues on the renal surface to guide tumor localization or excision. Also, hemostatic renorrhaphy and pelvicalyceal suture repair in these completely intrarenal tumors create additional challenges. We examined the safety and technical feasibility of this procedure in this cohort. Materials and Methods: Of 800 patients who underwent laparoscopic partial nephrectomy 55 (6.9%) had completely intraparenchymal tumors. Technical steps included intraoperative ultrasound guidance of tumor resection, en bloc hilar clamping, cold excision of tumor and sutured renal reconstruction. Results: Mean tumor size was 2.3 cm (range 1.0 to 4.5), mean blood loss was 236 cc (range 25 to 1,000) and mean warm ischemia time was 29.9 minutes (range 7 to 57). There were no positive margins. When we compared laparoscopic partial nephrectomy for intraparenchymal tumors to the same procedure in another 3 tumor groups, including completely exophytic tumors, tumors infiltrating up to sinus fat and tumors infiltrating but not up to sinus fat, there were no statistically significant differences among the groups in complications, positive margin rate, blood loss, or tumor excision or warm ischemia time. Conclusions: Laparoscopic partial nephrectomy for completely intrarenal tumors is a technically advanced but effective, safe procedure. Facility and experience with the technique, effective use of intracorporeal laparoscopic ultrasound and adherence to sound surgical principles are the keys to success. Most recently we have performed laparoscopic and robotic partial nephrectomy for such completely intrarenal tumors using a zero ischemia technique.