1. Uro-Oncology Laparoscopic Surgery Wahjoe Djatisoesanto Department of Urology, School of medicine Airlangga University Soetomo General Hospital Surabaya

3. Introduction Minimally invasive urologic surgery is revolutionizing how physicians treat many urology diseases. Laparoscopy in particular has reduced the morbidity, and recovery time for many procedures traditionally performed through an open incision. Despite significant advances in laparoscopic technique and technologies, laparoscopic urology surgery remains technically demanding.

4. Introduction Since the first laparoscopic nephrectomy was perform by Clayman in 1990, urological laparoscopy has undergone a rapid advancement. Many of the standard operations in urology can now be performed laparoscopically. It is well accepted that laparoscopic urologic is associated with a considerable learning curve. There is still some uncertainty about relative or absolute contraindications to the laparoscopic approach.

5. Adrenal Cancer The precise role of laparoscopic adrenalectomy in malignant lesions is still controversial. The indication that this procedure appears to be gradually gaining acceptance. There are two kinds of procedure Transperitoneal laparoscopic adrenalectomy. Retroperitoneal laparoscopic adrenalectomy.

6. Indication Can be performed both in cases of primary or metastatic lesions. Organ-confined, no evidence of local invasion. No evidence of neoplastic involvement of the adrenal vein.

7. Indication In metastatic disease, if the lesion appears to be solitary and organ-confined – Curative reasons, in solitary adrenal metastasis. – Diagnostic purposes, in suspected adrenal metastasis.

8. Contraindications Severe broncopulmonary or cardiovascular diseases. Previous major surgery on the same upper-abdominal region of the adrenal lesion. The evidence of malignant lesions greater than 6 cm (transperitoneal) and greater than 10 cm (retroperitoneal) Involvement of the adrenal vascular pedicle and of the surrounding tissue.

9. Surgical technique Close collaboration with an anesthesiologist and an endocrinologist is essential-especially in cases of functional diseases. The aim of the surgical procedure is the removal of the adrenal gland en bloc. The first step is the early ligation of the main adrenal vein. No to touch the adrenal tissue directly, to avoid potential fractures and a subsequent risk of neoplastic dissemination.

10. Surgical technique A different trocar positioning and a slightly different surgical technique are emplyed on the left and right sides, according to the different surgical anatomy between the two adrenal areas.

11. Surgical technique Most of the surgeon prefer the transperitoneal approach in cases of adrenal malignancy. This is probably related to the fact that, for the most surgeon, the small working space provided by the retroperitoneoscopic approach is unsuitable for dissecting tumor.

12. Renal cell Carcinoma

13. Renal Cell Carcinoma Transperitonal Lap. Rad. Nephrectomy Extraperitoneal Lap. Rad. Nephrectomy Hand-Assisted Lap. Rad Nephrectomy Laparoscopic Partial Nephrectomy Cryoablation and other Invasive and Noninvasive Ablative Renal Procedures

14. Indications The indications continue to expand as the surgeon’s expertise grows, all patients who are a candidate for an open radical nephrectomy should be potentially considered for their suitability to a laparoscopic approach. T1 and T2 tumours, laparoscopic radical nephrectomy is emerging as a strong recommended. Laparoscopic removal of T3a and even T3b tumours have been reported.

15. Indications Walther et al (1999) pushed the ceiling even further by performing laparoscopic nephrectomy in patients as a cytoreductive procedure prior to immunotherapy.

16. Contraindications Current relative contraindications include T3 and T4 tumours together with bulky nodal disease and caval involvement. Difficult body habitus. Previous upper abdominal scar or adhesions. Patients choice after full informed consent.

17. Consent Preparation Laparoscopic surgery demands special skills and it is important to discuss with the patient. Possible risk of access injury due to the inadvertent puncture of an organ if Verres needle is used to create the pneumoperitoneum. Possible risk of inadvertent injury to another organ during the dissection of the kidney. Possible risk of bleeding from the artery and vein. The potential need to convert to the traditional open operation.

18. Oncological control Immediate adequacy – Lap. Transperitoneal Rad Nephrectomy provides an equivalent speciment to the open procedure. – An en bloc excised kidney, adrenal, perirenal fat, hilar nodes and the Gerota fascia. Seeding risk (peritoneum or port) – There is no recorded case of intraperitoneal seeding. – There is one local recurrence in a multinational study at the 5 year mark reported by Portis et al in 2002.

19. Laparoscopic versus open radical nephrectomy Portis et al

21. Complications of Laparoscopic Radical Nephrectomy (LRN), Hand-Assisted Laparoscopic Radical Nephrectomy (HALRN), and Open Radical Nephrectomy

22. Prevention of complications during laparoscopic radical nephrectomy

27. Conclusion Although long-term oncological outcomes are not available for the mayority of genitourinary malignancies treated by the laparoscopic approach, the intermediate-term data are encouraging and comparable to open surgery. Multiple factors have been associated with tumour seeding, but tumour grade and stage appear to play a mayor role. The incidence is comparable to the rate for surgical wound metastases. As a general rule, the correct application of a precise surgical technique is fundamental to preventing the majority of the complications during the laparoscopic management of renal masses.

28. Thank you