d.shorter convalescence.

e.all of the above.

.When compared with traditional laparoscopic renal surgery, robotic-assisted laparoscopic renal surgery has been shown to provide:

a.improved oncologic outcomes.

b.reduced cost.

c.more surgeons the ability to offer a laparoscopic approach.

d.improved operative times.

e.shorter hospital stay.

Answers

1.c. Flat and upright intravenous pyelogram. Ptotic kidneys often present with a history similar to that of a ureteropelvic junction obstruction, with the primary exception that the associated pain is often positional and relieved after a period of lying down. The supine position often eliminates the transient renal ischemia or urinary obstruction that may be the cause of discomfort. The demographic most commonly afflicted with renal ptosis is a young, thin female similar to the patient described. Determining renal descent of approximately two lumbar vertebral bodies with supine and erect intravenous pyelograms makes the diagnosis of a ptotic kidney. A secondary evaluation option is power Doppler sonography performed with the patient in both the supine and erect positions. Nephropexy should not proceed before definitively establishing the diagnosis of a ptotic kidney.

2.d. Intraoperative renal ultrasound to localize the kidney. In this case, the patient's obese body habitus and associated retroperitoneal fat pose a challenge in proper orientation and identification of the kidney from the retroperitoneoscopic approach. In obese patients, intraoperative ultrasonography may be required to localize the kidney when copious retroperitoneal or perinephric fat is present. Beyond simply assisting in identification of the kidney, it may allow for precise tissue sampling, particularly in the setting of a failed prior percutaneous biopsy attempt.

3.d. Multiple Hem-o-lok clips on the artery, stapler ligation of the vein.

There are multiple safe and acceptable methods of ligating the renal vessels during a laparoscopic nephrectomy. Commonly, an endovascular gastrointestinal anastomosis stapler is used to ligate the renal hilar vessels separately, first ligating the artery followed by ligation of the vein.

En bloc stapling of the renal hilar vessels has not been shown to result in significantly different blood pressures, presence of bruits, or rates of arteriovenous fistulization in a randomized control trial compared to separate staple ligation. In cases where clips are employed, multiple titanium clips are recommended on the remnant patient side of the vessels. Based on safety data derived in the laparoscopic donor nephrectomy population, the use of Hem-o-lok clips (Weck Closure Systems, Research Triangle Park, NC) is contraindicated for the ligation of the renal artery per recommendations of the manufacturer as well as the Food and Drug Administration.

4.d. Untreated infection. Untreated infection is an absolute contraindication for laparoscopic renal surgery, as are uncorrected coagulopathy and hypovolemic shock. Laparoscopic partial nephrectomy has been reported as a feasible, safe approach in appropriately selected patients with intravascular stents on aspirin therapy, multiple prior abdominal operations, history of prior ipsilateral renal surgery (open and laparoscopic), and morbid obesity.

5.e. Electrocautery scatter. The clinical scenario described represents a classic presentation of an unrecognized bowel injury. Although blunt dissection, sharp dissection, and transmission of thermal energy from electrocautery are each responsible for approximately equal proportions of bowel injuries, electrocautery scatter is the most frequent cause of unrecognized bowel injury. Delayed necrosis and perforation of the bowel wall from electrocautery may lead to atypical or delayed presentation and most commonly presents between postoperative days 3 and 5. Trocar placement and bowel ischemia are both infrequent causes of bowel injury.

6.d. Renal angiography with angioembolization. A patient who has recently undergone traditional laparoscopic or robot-assisted laparoscopic partial nephrectomy presenting with gross hematuria and hemodynamic changes likely has a postoperative bleed resulting from an arteriovenous fistula or pseudoaneurysm formation. Although a CT scan with intravenous contrast may help diagnose and localize a postoperative bleed, this will ultimately delay treatment. Immediate renal angiogram with selective arterial embolization allows for diagnosis, localization, and definitive treatment in the same setting. Furthermore, immediate angiography avoids the systemic contrast bolus required for CT angiography.

7.a. Continue the drain and observe. This patient with continued drain output with elevated drain fluid creatinine following laparoscopic heminephrectomy

likely has a perinephric urinary extravasation. Urinary extravasation after laparoscopic partial nephrectomy is more common in cases of centrally located tumors or larger resections requiring more extensive reconstruction.

These urinary leaks will almost always resolve with observation. If the drain output does not decrease, then ureteral obstruction is likely to be present, and placement of a ureteral stent is indicated. There is no indication at this point for either a nephrostomy tube or completion nephrectomy.

8.c. Nonsteroidal anti-inflammatory drug (NSAID) administration. Chyluria is caused by lymphatic rupture or fistulous connection into the pyelocalyceal system, often diagnosed as described in the clinical scenario posed. Most cases are self-limited and improve with no intervention.

Laparoscopic nephrolysis should only be undertaken after attempts at more conservative management methods, including changing to a low-fat diet, treatment course of diethylcarbamazine, and retrograde injection of sclerosing agents into the collecting system.

9.b. Distal pancreatectomy with an endoscopic GIA stapler. Deep injuries to the pancreas should be intraoperatively addressed because pancreatic leak may lead to significant postoperative morbidity. The distal pancreas is most often manipulated during the medial mobilization of the spleen, pancreas, and descending colon during transperitoneal laparoscopic or robotic left-sided renal or adrenal surgery. The best approach is typically to isolate the injury and seal it using an endovascular GIA stapling device (Medtronic, Minneapolis, MN). This is the same approach used with much success during intentional distal pancreatectomy and closes both the pancreatic stump and duct, if injured. Application of a biologic glue or sealant may be used as an adjuvant but should not be the primary means of addressing the pancreatic

injury. Drain placement and observation may be used for superficial but not deep pancreatic injuries. Bowel rest and use of somatostatin are not sufficient treatment to prevent sequelae of a deep pancreatic injury that may have resulted in leakage from the pancreatic duct.

.e. All of the above. Trocar placement for renal surgery should be individualized based on patient characteristics and surgical approach planned. Patient body habitus, prior surgical history, intraoperative findings (including adhesions), renal pathology, surgical indication, and surgical approach (transperitoneal vs. retroperitoneal, robotic-assistance vs. conventional laparoscopy vs. laparoendoscopic single-site surgery [LESS]) are all factors to

consider to optimize trocar placement.

.c. 69-year-old man with 7-cm endophytic right renal mass with 25 Hounsfield unit enhancement on abdominal CT. Laparoscopic simple nephrectomy is removal of the entire kidney for the treatment of a variety of benign renal diseases. Of the clinical scenarios provided, all are indications for laparoscopic simple nephrectomy except that of the 69-year-old male with a contrast-enhancing renal mass on abdominal CT imaging. This is likely representative of a malignant renal cortical neoplasm, and a laparoscopic

simple nephrectomy should not be pursued for management of a suspected malignancy.

.e. a, b, and c. In cases of prior abdominal surgery, obtaining access for laparoscopic renal surgery should be performed with care. Insertion of a

Veress needle away from prior surgical scars is one method to avoid potential adhesions and injury to the bowel. Also, other options to help decrease the risk of bowel injury in the setting of prior abdominal surgery include open trocar placement by using a Hasson technique or avoiding the peritoneal space by developing the retroperitoneal space and performing retroperitoneoscopic renal surgery.

.b. Place a pedicle of autologous fat in the defect. Laparoscopic cyst decortication may be challenging in cases of central or perihilar cysts, in which it is often not feasible to remove a portion of the cyst wall adjacent to the hilar vessels or renal collecting system. In such cases, a portion of the cyst wall may be retained and a pedicle of autologous fat can be draped within the defect to serve as a wick.

.c. 10% rate of lymph node metastasis. In a study of patients without suspicion for lymph node involvement on preoperative imaging, a 10% rate of lymph node metastases was noted in patient undergoing laparoscopic radical

nephrectomy. Those with positive lymph nodes were found to harbor higher-grade lesions, with T3 or T4 disease on pathology. Although there may be potential benefit of lymphadenectomy for a portion of clinically nodenegative patients, lymphadenectomy in the setting of laparoscopic radical nephrectomy with clinically negative lymph nodes has not been shown to improve overall or cancer-specific survival.

.e. Improved overall survival. Laparoscopic cytoreductive nephrectomy provides the benefits of a minimally invasive surgical approach with decreased blood loss, shorter perioperative hospitalization, shortened convalescence, and, in some studies, shortened interval duration to

commencement of systemic therapy. Studies of laparoscopic and open approaches to cytoreductive nephrectomy have demonstrated no significant difference in survival.

.a. Internal hernia. Formation of a mesenteric defect during colonic reflection should be managed with careful closure of the defect to prevent an internal hernia through which loops of small bowel may pass and incarcerate. Care should be taken during repair of a mesenteric defect to not compromise the blood supply to the colon, which traverses the mesentery. Degree of adhesion

formation, risk of postoperative hemorrhage, and rates of colonic injury are not reportedly different in the setting of colonic mesenteric defects.

.b. Placement of imbricating stiches to repair the area of serosal disruption. When recognized intraoperatively, the area of a suspected bowel

injury should be carefully examined to ensure that a deeper defect into the muscular layers or a full-thickness bowel wall defect is not present. Serosal disruption, particularly as a result of blunt or sharp dissection without risk of electrocautery scatter, may be oversewn to repair and reinforce the area. There is no need for segmental resection, diversion, or colostomy formation. Conservative management without intraoperative repair is not recommended in these cases as the depth of injury may potentially be more significant than what is intraoperatively recognized.

.e. All of the above. All of the above are well-established benefits of laparoscopy compared with open surgery for a variety of renal surgeries.

.c. More surgeons the ability to offer a laparoscopic approach. Data support the proposition that introduction of robotic assistance has increased the number of surgeons who are providing laparoscopic renal surgical options to their patients in the form of robotic-assisted laparoscopy. The use of the Da Vinci Robotic System (Intuitive Surgical, Sunnyvale, CA) has not consistently demonstrated improvement in operative times, cost, length of hospitalization, or oncologic outcomes.

Chapter review

1.Obesity is associated with an increased risk of open conversion.

2.Transperitoneal laparoscopy provides the largest working space with greater versatility of angles and instrumentation

3.When a laparoscopic nephrectomy is performed, the renal artery should be divided first, followed by division of the renal vein. The vascular stapler will provide three rows of staples left on the stump.

4.In obese patients, intraoperative ultrasonography may be helpful in localizing the kidney.

5.One must be careful not to mistake the inferior vena cava for the renal vein, particularly when using retroperitoneal access, in which anatomic landmarks may be more subtle.

6.En bloc hilar stapling (artery and vein together) has not been shown to result in arteriovenous fistula formation.

7.In patients undergoing partial nephrectomy (open or laparoscopic), there is no demonstrated difference in long-term outcome for those who have positive surgical margins versus those who do not. Nonetheless, negative surgical margins should always be the goal of any oncologic renal surgery.

8.Patients with unrecognized bowel injury following laparoscopy typically present with persistent and increased trocar-site pain at the site closest to the bowel injury.

9.Port-site tumor implantation is usually associated with high-grade renal transitional-cell carcinoma and less commonly with renal cell carcinoma. It is often associated with intraoperative tumor spillage.

10.When renal hilar vascular clamping is used during partial nephrectomy, there may be less injury to the kidney when artery-only clamping is performed rather than artery and vein clamping.

11.Blunt dissection, sharp dissection, and transmission of thermal energy from electrocautery are each responsible for approximately equal proportions of bowel injuries; electrocautery scatter is the most frequent cause of unrecognized bowel injury.

12.Chyluria is caused by lymphatic rupture or fistulous connection into the pyelocalyceal system. Most cases are self-limited and improved with no intervention.