Urology Video Journal (Mar 2022)
Pure laparoscopic nephroureterectomy in horseshoe kidney with complex vascular anatomy
Abstract
Objective: To report our technique for pure laparoscopic nephroureterectomy in horseshoe kidney, specifically focusing on vascular anatomy and surgical tips & tricks. Patient and surgical procedure: The clinical case of a 69 years-old woman with normal body mass index and controlled hypertension is presented. The patient came to our observation with gross hematuria. Cystoscopy was negative but urine cytology showed high grade atypia suggestive for transitional cell carcinoma. Computed tomography scan with urography showed a right-sided mid-lower calyx 28 mm lesion, in the setting of a horseshoe kidney. The 3D reconstruction showed the altered vascular anatomy, and the proximity of the renal isthmus to the caudal portion of the abdominal aorta. The patient was counseled for pure laparoscopic transperitoneal nephroureterectomy. Results: Operative time was 220 min. Blood losses were negligible. Length of hospitalization was 4 days. No Complications occurred. Hemoglobin at discharge was 12.1 g/dl. Creatinine at discharge was 1.0 mg/dl. Final pathology confirmed upper urinary tract transitional cell carcinoma of the medium-lower calyx, 2 cm in size, Ta, G2, R0. Conclusions: Although robotics is gaining broader diffusion due to intrinsic advantages, nephroureterectomy remains feasible and safe via a pure laparoscopic approach. Pure laparoscopic approach could represent the ideal indication in case of complex anatomy. Indeed, typical anatomical landmarks of nephrectomy can be altered in such cases. The possibility of a fast “port-hopping” is the most interesting peculiarity of pure laparoscopic approach, allowing for optic/instruments exchange by the operating surgeon. Vascular stapler is a viable instrument for resecting the isthmus of a horseshoe kidney in a bloodless field. In our experience, the 60 mm one with its higher moment of force performed better.
