BERKELEY, CA (UroToday.com) - Even though the techniques reported were used in a very rare case of concomitant cancers in a native and a transplant kidney, the implications of this article can be viewed from several aspects for more practical use:
- The main concept is that if there are two separate pathologies at different body sites, to be treated at the same time, the use of a common incision that targets both sites can be approached and will significantly decrease the length of the wound and facilitate recuperation. Surgeons need to design the wound location to make it feasible to manage both pathologies effectively and cosmetically.
- The lower abdomen Gibson or Pfannenstiel incision is also very suitable for laparoendoscopic single-site (LESS) unilateral nephroureterectomy (NU) and bladder cuff resection. We have done several cases in this way. The special advantages of this approach for NU are that the lower ureter and bladder cuff can be first dissected and ligated to prevent tumor spillage in a traditional open fashion through the LESS incision, and the bladder opening can be securely suture-closed in 2 layers, so that the duration of postoperative urethral catherization can be minimized. Then, by means of the LESS incision, the remaining part of the ureter and the kidney can be dissected; finally the nephrectomy part is accomplished. The whole specimen is retrieved from the LESS incision. Again, as mentioned above in the first paragraph, the designed location of the single wound serves for multiple purposes.
- Due to word limit constraints of the publishing journal, our learning experience with respect to partial nephrectomy in a transplant kidney was not completely conveyed. What we learned is to never try an extra-peritoneal approach if nephron-sparing surgery is planned a transplanted kidney. Owing to significant immune inflammatory reactions, the renal capsule is usually very tightly attached with the surrounding soft tissues. An extra-peritoneal approach (as in transplant nephrectomy) often led to a sub-capsular dissection which is suboptimal for partial nephrectomy due to potential violation of the tumor margin - and the inability to insert the renorraphy sutures that rely on an intact capsule. During our transperitoneal dissection, we left the peritoneum covering the transplant kidney, which continued to be attached to the renal capsule, reinforcing the later renorraphy, We then cut through the peritoneum covering the lateral border of the transplant kidney. Thus a better dissection plane on the other side of the transplant kidney could be found in order to free it from the surrounding thick retroperitoneal scar tissues. This intra-peritoneal approach also facilitated hilar dissection because the proximal parts of the iliac vessels were easily visible and palpated, and dissections following the iliac artery disclosed the anastomotic site to the renal artery. This was much easier than tracing from the renal side to the iliac vessel. The other trick is to review the original transplant operation note beforehand. With that in mind, we were able to safely identify a second renal artery anastomoses in this case.
Shih-Chieh Jeff Chueh, MD, PhD1,2 and Bashir B. Sankari, MD1 as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
1. Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
2. Lerner College of Medicine, Cleveland Clinic, Cleveland, OH
Simultaneous laparoendoscopic single-site radical nephrectomy for native kidney and open nonischemic partial nephrectomy to treat concomitant renal cell carcinomas in native and transplant kidneys and to preserve allograft function - Abstract