Advances in laparoscopic partial nephrectomy

The advantages of the laparoscopic approach in the management of kidney tumors are unequivocal and the role of laparoscopy in nephron-sparing surgery is evolving. In a selected group of patients with small exophytic renal tumors laparoscopic partial nephrectomy became an alternative to open partial nephrectomy. However, the application of laparoscopic partial nephrectomy to larger, centrally located tumors or tumors in unfavorable sites is limited by the difficulty of achieving adequate, prompt collecting system closure and hemostasis with a limited warm ischemia time. The most recent developments in laparoscopic partial nephrectomy are the subject of this review.

A number of sealant products have been used as an adjunct or principal hemostatic agent in the animal model. Their application in the clinical setting remains limited to small parenchymal bleeding; larger vessels and pelvicaliceal openings are better managed by vascular clamping and intracorporeal suturing. Vascular clamping confers warm ischemia, and attempts at renal hypothermia included cold kidney irrigation through either a ureteral stent or a renal artery cannulation, and the application of ice slush for parenchymal surface cooling.

Laparoscopic partial nephrectomy is technically demanding; efforts directed towards facilitating hemostasis, improving renal cooling or shortening the warm ischemia time will expand its indications further.