Disasters in renal cancer surgery: How to avoid them

14th Meeting of the EAU Section of Oncological Urology (ESOU) Disasters in renal cancer surgery: How to avoid them V. Pansadoro, Rome (IT) With the advent of laparoscopic and robotic surgery the whole scenario of kidney surgery has completely changed. When we speak about disasters we have to distinguish between those due to laparoscopic access from those related to the actual kidney surgery. The open access is by definition the safest but is slightly more time consuming, especially in obese patients. On the other end with the direct access a lesion of the small or large bowel is a possibility which should be avoided. The clampless Enucleation is more and more popular but, especially in large tumors, it is mandatory to prepare and pass a vessel loop on the renal artery. For large tumors located on anterior third of the right kidneys also the renal vein needs to be prepared with a vessel loop. A lesion of a branch of the renal vein, at this level, is equivalent to a hole in the cava! The main problem of laparoscopic and robotic assisted partial nephrectomy is to avoid excessive bleeding which could hinder a tumorectomy done without positive margins. The Padua score can be very useful especially at the beginning of the learning curve helping avoiding the more difficult and complex cases. The excessive Warm Ischemia Time (WIT) should be avoided at any cost since over 20’ the damage to the kidney is substantial and every minute counts. Bleeding could be intra-operative but also post-operative due to a artero-venous fistula or a pseudo aneurism. For this late bleeding the collaboration with the interventional radiologist is the optimal solution. In case of an important intraoperative bleeding from the site of the resection a conversion is always a possible solution in the patient’s interest. It is better a conversion than excessive bleeding or incomplete resection of the tumor. It is obvious that conversions happen more frequently at the beginning of the learning curve! Furthermore there are complications due to damage to nearby structures like spleen, pancreas and the diaphragm all of which can be taken care by the experienced urologist. In case of a single kidney the indications, surgical technique, WIT and amount of kidney parenchyma removed with the tumor are even more delicate due to absence of the other kidney. I like to conclude this short overview with a sentence of Inderbir Gill published on the Journal of Urology in 2010. “Despite these excellent results nevertheless LPN remains an advanced procedure requiring complete comfort in the minimally invasive environment” I would suggest to keep this sentence in mind when the less experienced surgeon has to face a complex case.

Eur Urol Suppl 2017; 16(2):106