LAPAROSCOPIC AND ROBOT-ASSISTED TUMORAL ENUCLEATION FOR TREATMENT OF SMALL RENAL MASSES: PRELIMINARY EXPERIENCE AND EXAMINATION OF POSSIBLE INDICATIONS

Objectives: Laparoscopic partial nephrectomy (LPN) is oncologically safe for the treatement of renal masses with advantages of mininvasive surgery. Open Tumoral Enucleation (TE) ensures excellent oncological safety allowing maximum preservation of functional kidney tissue. We report our laparoscopic and robot-assisted TE experience (LTE), describing our surgical technique and veryfing the feasibility and the possible indications. Patients and Methods: From November 2007 to December 2010, 93 patients underwent LPN. We performed 15 (16%) LTE and 78 LPN. After location of the lesion, the limit between tumour and safe tissue was delineated by a monopolar hook. Then the vascular pedicle was clamped and the mass was enucleated by blunt dissection and by scissors using the aspirator for dissection too. If identified the peritumoral capsule was isolated by blunt dissection using the natural cleavage plane between the peritumoral capsule and normal parenchyma. Then resection bed is sutured by a running suture with Monocryl 3-0. Then resection bed was filled by sealants as FloSeal and oxidize cellulose sheets as Tabotamp and renorraphy was finished by interrupted or double sutures with Vicryl 2-0 across renal capsule or by sliding-clip technique. Results: For cortical tumours (CT), LTE and LPN were performed respectively in 5 (5/55; 9%) and 50 (50/55; 91%). For corticomidollar tumours (CMT), LTE and LPN were performed respectively in 10 (10/38; 26%) and 28 (28/38; 74%) cases .Regarding location of the masses, LTE was always performed for peri-hilar tumoral masses (4 cases) and in 11 tumoral masses (11/89; 12%) with other location. The median (range) pathological size of tumours treated by LTE was 2.6 (1.2-5.3) cm and the median operative time was 134 min. The median (range) ischemia time was 21 (12-35) min. The median (range) operative blood loss was 340 (100-1500) cc. We found intaoperative bleeding in 2 (13.3%) cases, both for incomplete clamp with need of hemotransfusions. Then we found 1(6.6%) case of urinary fistula treated by positioning of double j uretheral stent. The medium time of drain removal was 3 (2- 10) days. Histopathological analysis revealed no positive surgical margins. We found no local recurrence during a median (range) follow-up of 15 months (1-37). Conclusion: LTE is a feasable technique even if not absolutely recommended for pT1a tumours, except for the treatment of peri-hilar masses when LTE let a better preservation of functional renal tissue and near structures. LTE has a low rate of perioperative complications and, as OPN, is not associated with a major risk of positive surgical margins.