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Background: The need to enlarge one of laparoscopic holes for specimen retrieval at the end of a laparoscopic nephrectomy, suggested us to use this final access for the entire procedure. We describe our technique placing trocars directly on the fascia once the skin and the subcutaneous layers were prepared., Material and Methods: A 10 consecutive patients series operated by Single Incision Laparoscopic Nephrectomy (SILN) is presented. With a 5 cm mean skin incision, the fascia was prepared and 3/4 trocars inserted separately directly on the fascia. Surgical strategy followed the standard technique, except for the use of articulating instruments and 5 mm optic. Demographics, Body Mass Index (BMI), operative time, blood loss, perioperative complications, transfusions, hemoglobin decrease, analgesic requirement, length of stay, final pathology were recorded. Postoperative and prior-to-discharge Video Analogue Scale Pain (VAS) evaluation were also collected, together with the limitations inherent to the instruments placing and parallel driving during the procedure., Results: SILN was successfully completed in all but one cases. The mean operative time was 169 min (mean blood loss 113 ml). Without major perioperative complications, the patients were discharged early (mean 5.3 days). Four patients had a BMI > 30. For specimen retrieval (neoplasms) two trocars holes were joined. One patient required analgesics; the mean post-operative and prior-to-discharge VAS scores were 5.7 and 1.4, respectively. Pathology examination confirmed 4 pyelonephritic kidneys, 4 renal carcinoma and 2 upper-urinary tract carcinoma., Conclusion: SILN is feasible, safe, with favourable perioperative and short-term outcomes. It's technically more challenging than standard laparoscopy requiring advanced surgical skills.

Introduction: Haemostasis remains the greatest challenge during laparoscopic partial nephrectomy. We describe the use of the Vivostat system helping effective haemostasis during laparoscopic partial nephrectomy (LPN)., Patients and Method: Twenty-eight patients underwent LPN. Autologous fibrin sealant was prepared with the Vivostat system and applied to the resection bed. This system is an automated medical device for the preparation of an autologous fibrin sealant from the patient's blood. Pre and postoperative clinical parameters and laboratory values were evaluated, for acute and delayed bleeding., Results: Median patient's age was 58 years (range, 25-75). All patients underwent LPN for renal tumors (mean size 2.5 cm; range 0.9-4.5 cm). Six resection were performed without vessels clamping, and 22 were realized with selective arterial Bulldog clamping. Haemostasis was achieved by a cellulose bolster (80%), by stitches (67%) and by sealant application after declamping (100%) (mean amount applied: 5.1 ml). The mean warm ischemia time was 26 minutes (range, 16-45) for 22 interventions. Mean blood loss was 128 cc (range, 20-500). Pre-operative and post-operative creatinine values (mean, 0.91 vs. 1 ng/mi) did not differ significantly; whereas mean Hb levels slightly decreases after surgery (mean, 14.7 vs. 12.5 g/dl). Mean operative time was 131 minutes (range, 60-190). All but one had negative surgical margins. One intraoperative bleeding occurred needing blood transfusion (1 unit). Postoperatively, we observed only 1 perirenal hematoma treated conservatively requiring blood transfusion., Conclusions: In this study, an effective haemostasis was achieved and maintained after kidney reperfusion. These data support the previous finding with the same system and encourage its use in LPN.

Nephron-sparing surgery is the reference standard for the management of a small renal masses, especially in patients with a solitary kidney or bilateral renal tumors. The rationale for elective partial nephrectomy is based on the risk of developing kidney failure and the significant percentage of benign lesions on final histopathologic examination. Recent studies have demonstrated comparable survival and recurrence rates with partial and radical nephrectomy for renal tumors of 4 cm or less, and it is well demonstrated that radical nephrectomy is a significant risk factor for the development of chronic kidney disease. The latest evidences indicate that the outcomes are similar after partial nephrectomy for selected tumors 4 to 7 cm in size. The laparoscopic partial nephrectomy showed functional and oncologic outcomes comparable to those after open partial nephrectomy. Nevertheless, laparoscopic partial nephrectomy is a technically demanding procedure. With increasing experience and technical refinements, the complications rates have decreased substantially. Simultaneously, the indications of laparoscopic partial nephrectomy are being carefully extended to include more complex tumors. The purpose of this paper was to underline the evolution of, and expanding indications for, a nephron-sparing approach also for renal masses between 4 and 7 centimeters and a normal contralateral kidney, presuming a careful and sensible patient selection. This option should be reserved only to experienced centers.

We report a case of post traumatic thrombosis of the renal artery with renal infarction and associated liver injury. Conservative treatment was initially planned in consideration of the delayed diagnosis (> 3 hours), but the patient subsequently developed hypertension not controllable with anti-hypertensive drugs. He underwent laparoscopy with nephrectomy and liver injury repair. Hypertension resolved after nephrectomy without further medical treatment. Laparoscopic nephrectomy is not a standard procedure for renal trauma but it could be an option in selected patients.