Simultaneous Laparoscopic Kidney Tumor Resection and Pyelolithotomy Performed with Retroperitoneal Access

Introduction:

For more than 50 years surgery has remained the main method of treatment of kidney tumors in every stage of this disease, but the attitude to the management of renal masses underwent a rapid evolution during the last decade. ^1,2 Owing to a wide application of modern imaging techniques, especially ultrasonography and computed tomography, we have been observing the phenomenon of stage migration. This has caused the increase of a number of incidentally diagnosed renal tumors, many of which are small. Laparoscopic approach to renal tumors has gradually replaced open procedures for the treatment of low-stage renal tumors. ³

Case Description:

We present the case of a 60-year-old man who suffered from the pain in the left lumbar area. A plain film and intravenous urography showed a stone located in the left renal pelvis. The stone was recurrent because the patient already underwent the percutaneous lithotripsy a few years before. Computed tomography confirmed the presence of the stone and additionally showed the 20-mm tumor located in the lower pole of the same kidney. We assumed the presence of the tumor in the lower pole of the kidney as a contraindication for the next percutaneous nephrolithotripsy (PNL); thus, we suggested to the patient the simultaneous management of both conditions. We applied the retroperitoneal access with three trocars as a routinely used procedure in our center. The working space was created according to Gaur's technique. Two 10-mm and one 5-mm trocars were introduced under finger guidance and located in a shape of triangle with a base on a middle axillary line. In the beginning of the procedure, the Gerotaís fascia was widely opened to obtain the access to the kidney. Then, the kidney was mobilized and the tumor was localized. The cutting line around the tumor was marked with the argon beam coagulation. The tumor was completely enucleated without applying the warm ischemia. For larger masses we routinely obtain vascular control and attempt to take some normal renal tissue around the mass to ensure negative margins. Hemostasis of the lodge was obtained with argon-beam coagulation and Tachosil, which, combined together, entirely stopped the bleeding. To avoid the tumor spillage it was placed in the plastic bag of our own production, and then removed through the skin incision. Subsequently, pyelotomy was performed. The dissection of the renal hilum and the pelvis was constricted because of the presence of scary tissue after previously performed PNL. The stone was removed as a whole, placed in the same bag, and removed in the same way as the tumor. The Double-J catheter was placed intraoperatively along the guidewire to secure the water-tightness and the healing. The renal pelvis was reconstructed with the continuous suture. The hemostasis checkup was done and the drainage was placed.

Results:

Total operation time was 150 minutes; the blood loss was 200 mL. Postoperative course was uncomplicated. The patient was discharged from hospital on the 5th day after the surgery. Pathology report revealed the renal clear cell carcinoma, Fuhrman grade 2, with negative surgical margins.

Conclusions:

In our opinion, simultaneous kidney laparoscopic procedures are feasible and may be recommended in selected cases of coexisting disorders such as stones and tumors.

No competing financial interests exist.

Runtime of video: 9 mins