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Nefrectomía parcial laparoscópica en angiomiolipoma gigante* Laparoscopic partial nephrectomy in giant renal angiomyolipoma

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    ABSTRACT: To present our experience with laparoscopic nephron sparing surgery (NSS) over a decade. Seventy-eight patients underwent NSS since 1994. Two techniques were used-partial nephrectomy without ischemia (group 1) in 29 patients, and with ischemia (group 2) which was in cold or warm ischemia in 24 and 25 patients respectively. The mean tumour size was 1.97 and 2.2 cm in groups 1 and 2 respectively. Renal reconstruction evolved in our hands during this period. We changed many technical details and now we depend more on clips for securing the sutures rather than free hand knotting. The mean operative time was 162 and 216 minutes in groups 1 and 2 respectively. Mean ischemia time for patients with cold and warm ischemia was 44.9 and 33.8 minutes respectively. 3 patients in group 2 were converted to open surgery. Mean blood loss was 254 and 212 ml for group 1 and 2 respectively with two major bleedings in group 2. Minor intra-operative complication occurred in 3 patients, and major and minor postoperative complication in 15 patients. At a mean follow-up of 23.9 and 12.2 months for groups 1 and 2 respectively there was no recurrence. Warm and cold ischemia have widened the indications for laparoscopic NSS to more complex tumours and allow renal reconstruction with acceptable complication rate.
    European Urology 05/2005; 47(4):488-93; discussion 493. · 10.48 Impact Factor
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    ABSTRACT: The oncological efficacy of partial nephrectomy is related to obtaining a negative surgical margin intraoperatively. This study assesses the oncological outcomes of patients undergoing laparoscopic partial nephrectomy for a renal tumor who had positive surgical margin on final pathology. The experiences of 2 surgeons with 511 patients with a pathological diagnosis of renal cell carcinoma treated with laparoscopic partial nephrectomy were reviewed. Patients with a positive surgical margin were identified retrospectively. Oncological outcomes were assessed by followup with chest x-ray and computerized tomography every 6 to 12 months for 5 years. There were 9 patients (1.8%) with a positive margin on final pathology. Mean tumor size was 2.8 cm (range 1.7 to 4.0). Two patients underwent secondary completion radical nephrectomy, one at 4 days and the other at 2 months following laparoscopic partial nephrectomy. No residual tumor was identified in the nephrectomy specimen in either patient. Of the remaining 7 patients who elected surveillance, 1 with von Hippel-Lindau disease died of metastatic renal cell carcinoma to pancreas 10 months after laparoscopic partial nephrectomy. The remaining patients were disease-free for a median followup of 32 months (range 6 to 76). No patient in the series had port site seeding. A positive margin following laparoscopic partial nephrectomy does not necessarily indicate residual disease. However, vigilant monitoring is mandatory. While midterm outcomes parallel those of patients with a negative margin, longer followup is necessary to determine the ultimate oncological outcomes in this subgroup of patients.
    The Journal of Urology 01/2007; 176(6 Pt 1):2401-4. · 3.70 Impact Factor
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    ABSTRACT: To present our experience with laparoscopic partial nephrectomy (LPN) in patients with an incidentally detected Stage pT2, pT3a, or pT3b renal mass. Of 525 patients undergoing LPN, 21 (4%) had pT2 or worse disease. LPN routinely involved en bloc excision of the overlying perirenal fat, along with the tumor and a healthy parenchymal margin. The preoperative computed tomography scans of these 21 patients were reviewed again by an unblinded radiologist to determine whether any suspicious radiologic signs of clinical Stage T2 or worse disease were present. The tumors were Stage pT2 in 1 (0.2%), pT3a in 19 (3.6%), and pT3b in 1 (0.2%). The mean pathologic tumor size was 3.7 cm (range 1.8 to 7.4). In the patient with pT3b disease, a tumor thrombus invading a renal vein branch was detected laparoscopically. The renal parenchymal and perirenal fat surgical margins were negative for cancer in all 21 patients (100%). The repeated nonblinded review of the preoperative computed tomography scans suggested definitive evidence, equivocal evidence, and no evidence of pT3a disease in 0, 5 (26%), and 14 (74%) patients, respectively, and suspicion for pT3b disease in the 1 patient. One patient with a 2.5-cm pT3a sarcomatoid renal cell carcinoma with negative surgical margins developed distant metastasis and died. During a mean follow-up of 29 months (range 1 to 58), the cancer-specific survival rate was 95%. The results of our study have demonstrated that adherence to surgical principles allows LPN to be performed for occult Stage pT2 and pT3 tumors with negative surgical margins and good oncologic outcomes. We have highlighted the importance of routine en bloc laparoscopic excision of the overlying perirenal fat along with the tumor, and intact specimen extraction, mirroring open surgery.
    Urology 12/2006; 68(5):976-82. · 2.42 Impact Factor

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