A Novel Hybrid Surgical Technique for Large Renal Masses-Hybrid Technique of Laparoscopic-Assisted Open Radical...

Objective: The complex patient dynamic in India leads to diverse presentations of renal cell carcinoma, ranging from incidental small renal masses to large palpable renal masses. Minimally invasive surgical approaches pose challenges for patients with large renal masses (≥7 cm), prompting many urologists to opt for open radical nephrectomy. However, open surgery is associated with higher morbidity due to prolonged visceral exposure and increased intraoperative bleeding. Large renal masses often exhibit significant neovascularity, complicating dissection and elevating intraoperative blood loss risk. This problem led the authors to devise a novel hybrid technique of laparoscopic-assisted open radical nephrectomy (HLO-RN), which helps to decrease morbidity. In this article, the authors discuss this novel hybrid technique incorporating the benefits of both open and laparoscopic approaches (HLO-RN). Methods: The authors conducted an observational study to report the authors'. HLO-RN, in 5 patients with large renal masses (≥7 cm) suggestive of renal cell carcinoma. Patients with morbid obesity (BMI ≥40) were excluded. The hybrid technique involves initial laparoscopy, followed by open flank incision after vessel clipping. Conversion-to-open procedure can be adjusted based on intraoperative conditions. In patients with inferior vena cava (IVC) thrombus extension, conversion-to-open procedure is made after sequential clamping of renal vessels and IVC with or without hepatic mobilization. All the patients were followed for 6 months. Various parameters including patient characteristics, renal mass characteristics, staging, mean duration of laparoscopic and open procedures, intraoperative and postoperative complications, and duration of hospitalstay and duration to return to normal activity were recorded. Results: Five patients (mean age: 61.2 years) were included, with 2 presenting with venous tumor thrombus extension. The mean renal mass size was 10.7 cm (range: 7.8-14 cm). One patient with IVC Level I thrombus required open conversion after sequential vessel clamping due to significant neovascularity. Partial laparoscopic mobilization was feasible in the remaining patients. Procedure durations averaged 35.8 minutes (laparoscopic) and 35.6 minutes (open). All procedures were performed by the same senior urologist team. Patients were extubated immediately post-surgery, with one requiring intensive care unit admission for 1 day. No surgical site infections or major postoperative complications occurred. The drop in hemoglobin in this study was 0.84 g/dL. Conclusion: The authors' novel HLO-RN technique is a practical and feasible approach for large renal masses, including those with IVC thrombus extension. By reducing intra-operative blood loss and open procedure duration, this hybrid technique significantly decreases perioperative morbidity.