RESUMO
PURPOSE: By evaluating the technical challenges encountered during 123 laparoscopic nephrectomies, we have been able to modify the surgical technique to allow general urologists to effectively perform the procedure with minimal complications. DESIGN AND METHOD: A retrospective chart review was performed on 123 patients who consecutively underwent laparoscopic nephrectomy or nephroureterectomy. Using a modified dissection approach to the hilum and en bloc ligation of the renal pedicle with a vascular stapler, a new standard of laparoscopic nephrectomy was developed at our institution. In 30 cases, the conventional technique was used, whereas in 93 cases the en bloc technique was used. Operating time, blood loss, transfusion requirements, intra- and postoperative complications, and the incidence of arteriovenous fistula (AVF) were documented. Follow-up included serial clinical evaluation and computed tomography angiogram at 3 months and repeated at 3-monthly intervals where indicated. RESULTS: Operative and postoperative parameters were improved in the en bloc group compared with the conventional group. In the en bloc group, the average operating time was 56 minutes and the average blood loss was 32 mL. No patients required a blood transfusion and only two cases required conversion to open nephrectomy. No late vascular complications related to this method were observed with a mean follow-up of 28 months. There were no perioperative deaths. Postoperative complications were self-limiting and no patients developed postnephrectomy AVF. CONCLUSION: The results of using the en bloc ligation technique for laparoscopic nephrectomy have been favorable in terms of operating time, risk to the patient, and surgeon's surgical preference. The risk of AVF formation after en bloc ligation of the renal pedicle and ligation by the conventional method appears to be equal based on the clinical follow-up and radiological evaluation. Therefore, long-term radiological follow-up is not mandatory in most cases.
