Since the initial description of laparoscopic nephrectomy by Clayman and associates in 1991, the technique and the principles of the procedure have evolved logically.
Aron and associates presented a cohort of more than 600 patients who underwent laparoscopic partial nephrectomy at the Cleveland Clinic (see, "Ischemic time, excised tissue affect post-LPN outcome,"). Using preoperative and postoperative renography and estimated glomerular filtration rate (GFR) calculations, the impact of warm ischemia time on renal function in these cases was assessed. Notably, patients with longer warm ischemia times (>40 minutes) had greater decreases in GFR, but the losses in renal function overall were assessed as negligible.
Today, the tolerable limits of warm ischemia, although debatable, allow enough time for most laparoscopic urologists to resect and repair the kidney. The parallel evolution of renal ablation has brought a more straightforward technique into the equation, although ablation is still lacking in long-term validation. Time will tell what role each procedure will play in managing small renal masses.
Although this study presents further retrospective data supporting the safety of en bloc ligation, several caveats should be noted. Hand-assisted procedures are better suited to this technique, as the ability to surround the entire hilum with your fingers facilitates safe stapler engagement. Although stapler malfunction is rare, the consequences of stapling too much tissue can be significant. Finally, the technique of dissecting out the renal hilum remains vital for the laparoscopic urologist, particularly when performing more complex procedures, such as partial nephrectomy. Do the benefits outweigh the risks? It depends on what you value.
For the practicing urologist, these reports demonstrate the technical progress of renal extirpative laparoscopy. Every bit of progress simplifies the transition for urologists from open to minimally invasive renal surgery.
Dr. Nakada, a Urology Times editorial consultant, is professor and chairman of urology at the University of Wisconsin, Madison.