DOI:10.2214/AJR.07.2542
AJR 2007; 189:W264-W271
© American Roentgen Ray Society
CT Findings After Nephron-Sparing Surgery of Renal Tumors
Mu Sook Lee1,
Young Taik Oh1,
Woong Kyu Han2,
Koon Ho Rha2,
Young Deuk Choi2,
Sung Joon Hong2,
Seung Choul Yang2 and
Ki Whang Kim1
1 Department of Diagnostic Radiology and Research Institute of Radiological
Science, Yonsei University College of Medicine, Seodaemun-ku Shinchon-dong
134, Seoul 120-752, Republic of Korea.
2 Department of Urology, Yonsei University College of Medicine, Seoul, Republic
of Korea.
Received May 10, 2007;
accepted after revision June 7, 2007.
WEB
This is a Web exclusive article.
Address correspondence to Y. T. Oh
(oytaik{at}yumc.yonsei.ac.kr).
Abstract
OBJECTIVE. The purpose of this article is to show the CT findings of
the various postoperative changes, surgical complications, and tumor
recurrence after nephron-sparing surgery for the treatment of renal
tumors.
CONCLUSION. Familiarity with the various postoperative changes after
nephron-sparing surgery may help radiologists in differentiating these changes
from tumor recurrence or surgical complications.
Keywords: CT • kidney • nephron-sparing surgery • postoperative change • urinary system
Introduction
Radical nephrectomy has been considered the standard treatment of localized
renal cell carcinoma (RCC). Today, advances in renal imaging, improved
surgical technique, and the increasing number of incidentally detected small
RCCs and benign renal tumors have stimulated the interest in and use of
nephron-sparing surgery and partial nephrectomy
[1].
Imaging surveillance after nephron-sparing surgery is usually done with CT.
CT findings after nephron-sparing surgery are different from those after
radical nephrectomy. However, there is little in the literature describing CT
findings after nephron-sparing surgery
[2,
3]. Therefore, we aim to show
the CT findings after nephron-sparing surgery, including the postoperative
changes, tumor recurrence, and complications based on our vast retrospective
reviews of follow-up CT scans. Also, we will discuss the differential points
that help radiologists discriminate postoperative changes from tumor
recurrence or complications.
Surgical Techniques
Nephron-sparing surgery can be performed by open surgery or
laparoscopically. Before the excision of renal tumors, renal artery and renal
vascular pedicles are usually clamped to decrease bleeding and to provide a
clear surgical field. The acceptable warm ischemic time may be less than 30
minutes [4]. There are several
surgical techniques for nephron-sparing surgery: segmental polar nephrectomy,
wedge resection, transverse resection and enucleation; the method used depends
on the mass size and location
[5] (Fig.
1A,
1B,
1C,
1D,
1E,
1F,
1G,
1H,
1I,
1J,
1K,
1L,
1M). All of these techniques
involve complete excision of the renal tumor with a proper margin of normal
renal tissue [6] and
preservation of the largest possible amount of functioning renal
parenchyma.
Hilar tumors, complex tumors such as deeper infiltrating tumors that
require repair of the pelvicaliceal system, multiple tumors, and tumors with
coexisting renovascular disease are a specific and significant technical
challenge for nephron-sparing surgery
[7]. After excision of all
gross tumors, hemostasis and closure of the collecting system (if required)
can be managed by various methods, including surgical suture, electrocautery,
laser, or various hemostatic agents such as glues
[8,
9]. The parenchymal defect is
then sutured or sealed by hemostatic agents. Occasionally, the parenchymal
defect may be filled with adjacent fat or bioabsorbable agents as bolsters for
the removal of dead space and for improved hemostasis
[8]. After the reconstruction
of the kidney is finished, the vascular clamp is released to restore
circulation.
Characteristics of CT Findings After Nephron-Sparing Surgery
CT is the most important imaging technique in postoperative surveillance.
No standard protocol exists for CT follow-up; generally, the initial CT is
performed 3–6 months after surgery, and regular checkups will continue,
especially in the early years
[2]. An unenhanced scan should
be obtained to detect the presence of enhancement in the lesion of interest.
Dynamic CT is performed during the corticomedullary (early arterial) phase at
20–30 seconds and the parenchymal phase at 80–100 seconds after
contrast injection. Because most primary and recurring RCCs show early
arterial enhancement, the corticomedullary phase is important in detecting
early tumoral enhancement [2].
Postoperative changes of the kidneys and retroperitoneal spaces on CT vary
from patient to patient. To categorize these various postoperative changes, we
classify them according to their specific CT findings.
Renal Parenchymal Changes
Parenchymal changes depend mainly on surgical techniques and hemostatic
methods. The degree of complete repair of the vessel, the collecting system,
and the parenchymal defects and the duration of the postoperative period also
play a role.
Postoperative granuloma—Postoperative granulomas can be seen
as a delayed minimally enhancing lesion at the excision site. After the tumor
is excised, parenchymal defects are closed with or without bolsters. The
bolsters, such as fat and bioabsorbable agents, are spontaneously absorbed.
However, they are usually visible on the initial follow-up CT images. Some
degree of foreign body reaction occurs with the remaining bolsters or suture
material at the excision site and may form small granulomas. A previous report
has shown suture foreign body granulomas mimicking renal tumors on partial
nephrectomy sites [10]. This
case was an unusual extensive foreign body reaction resulting in a granuloma
mimicking a renal mass. Meanwhile, even in cases without the use of bolsters,
postoperative granulomas can form at the excision site because of reaction to
a suture material as a foreign body, a small amount of urine leakage, and
bleeding. These granulomas are usually smaller than 1 cm and round or ovoid.
On enhanced CT images (especially dynamic CT images), they reveal delayed
minimal enhancement, a characteristic enhancement pattern of granuloma (Fig.
2A,
2B,
2C,
2D). Their sizes decrease on
sequential CT studies.
View larger version (117K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2A —Round postoperative granuloma in 47-year-old woman after left
nephron-sparing surgery for renal cell carcinoma. On preoperative axial
corticomedullary phase CT, 3-cm-diameter solid mass (arrow) is seen
in left kidney.
|
|
View larger version (109K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2B —Round postoperative granuloma in 47-year-old woman after left
nephron-sparing surgery for renal cell carcinoma. On axial corticomedullary
phase (B) and axial parenchymal phase (C) CT performed 3 months
after nephron-sparing surgery, delayed, minimally enhancing, and round
postoperative granuloma is seen at excision site (arrow) in left
kidney.
|
|
View larger version (113K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2C —Round postoperative granuloma in 47-year-old woman after left
nephron-sparing surgery for renal cell carcinoma. On axial corticomedullary
phase (B) and axial parenchymal phase (C) CT performed 3 months
after nephron-sparing surgery, delayed, minimally enhancing, and round
postoperative granuloma is seen at excision site (arrow) in left
kidney.
|
|
View larger version (116K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2D —Round postoperative granuloma in 47-year-old woman after left
nephron-sparing surgery for renal cell carcinoma. On axial parenchymal phase
CT performed 6 months after nephron-sparing surgery, size of round
postoperative granuloma has decreased (arrow).
|
|
Fat at the excision site—Occasionally, fat can be seen in
the surgical scar [3]. Fat is
seen in the patients in whom it was used as the filling material. Fat shows as
a low-density lesion at the parenchymal defect, has negative attenuation, and
can be easily differentiated from tumor recurrence (Fig.
3A,
3B).
View larger version (100K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3A —Fat at excision site in 53-year-old woman after left
nephron-sparing surgery for renal cell carcinoma. On preoperative axial
parenchymal phase CT, 4-cm-diameter solid mass (arrow) is seen in
left kidney.
|
|
View larger version (108K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3B —Fat at excision site in 53-year-old woman after left
nephron-sparing surgery for renal cell carcinoma. On axial corticomedullary
phase CT performed 3 months after nephron-sparing surgery, low-density lesion
with negative CT attenuation (–45 H) is seen at excision site
(arrow), suggesting fat at excision site.
|
|
Linear or stellate parenchymal scar—A linear or stellate
parenchymal scar shows a narrow and elongated linear or stellate line that
runs through the renal parenchyma like a lacerated scar (Fig.
4A,
4B). These scars are usually
seen in patients with parenchymal closure without bolsters and may result from
minimal granulation tissue at the excision site. The scar is well delineated
and of low density without enhancement. The width of the scar is variable,
usually measuring less than 0.3 cm, but it may be more than 0.5 cm. The size
of the scar decreases on sequential CT studies.
View larger version (105K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 4A —Linear or stellate parenchymal scar in 33-year-old man after
right nephron-sparing surgery for angiomyolipoma. On preoperative axial
parenchymal phase CT, large fat-containing mass (arrow) is seen in
right kidney.
|
|
View larger version (115K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 4B —Linear or stellate parenchymal scar in 33-year-old man after
right nephron-sparing surgery for angiomyolipoma. On axial parenchymal phase
CT performed 3 months after nephron-sparing surgery, 2-mm-diameter, narrow
elongated linear line (arrow) that runs through renal parenchyma is
seen at surgical site in right kidney. Line shows no enhancement.
|
|
Parenchymal defect—Although the previous parenchymal changes
are seen in cases of wedge, segmental, and transverse resection, parenchymal
defects can be seen in cases of enucleation of an exophytic mass. Parenchymal
defects are sharply demarcated defects of the renal parenchyma, primarily the
cortex (Fig. 5A,
5B). Usually they show no
significant interval change on sequential CT studies.
View larger version (117K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 5A —Parenchymal defect in 44-year-old woman after right
nephron-sparing surgery. On axial corticomedullary phase CT performed 4 months
after nephron-sparing surgery, sharply demarcated renal parenchyma defect
involving mainly cortex (arrow) is seen in right kidney.
|
|
View larger version (112K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 5B —Parenchymal defect in 44-year-old woman after right
nephron-sparing surgery. On axial parenchymal phase CT performed 14 months
after nephron-sparing surgery, parenchymal defect with no significant change
(arrow) is seen in surgical site.
|
|
Other parenchymal changes—Other parenchymal changes may
occur that do not belong to the previous categories. If a confident diagnosis
is difficult to make, close follow-up or immediate biopsy should be done to
differentiate postoperative changes from early recurrence.
Retroperitoneal Space Changes
Postoperative changes are also noted in the retroperitoneal space. The
patterns of retroperitoneal space change are mainly perinephric strands (Fig.
6A,
6B), mass-like lesions (Fig.
7A,
7B,
7C), or a mixture of the two
(Fig. 8A,
8B,
8C). A mass-like lesion is
defined as a lesion that shows increased attenuation in the neighboring
perinephric fat, but with no significant enhancement or mass effect. These
retroperitoneal postoperative findings can be considered to be part of an
imaging spectrum ranging from strands to a mass-like lesion and usually show
no enhancement and a decreased extent as time passes. These changes may be due
to various factors, such as surgical damage, the presence of subclinical
leakage of blood or urine into the perinephric space after the operation, or a
degree of combined inflammation. Usually, these changes show no enhancement
and are seen to a decreased extent as time passes.
View larger version (111K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 6A —Perinephric strands in retroperitoneal space in 53-year-old
man after nephron-sparing surgery for renal cell carcinoma. On preoperative
axial parenchymal phase CT, 2-cm-diameter solid mass is seen in right kidney
(arrow).
|
|
View larger version (110K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 6B —Perinephric strands in retroperitoneal space in 53-year-old
man after nephron-sparing surgery for renal cell carcinoma. On axial
corticomedullary phase CT performed 3 months after nephron-sparing surgery,
linear strands are seen in retroperitoneal space (arrows).
|
|
View larger version (113K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 7A —Mass-like lesion in retroperitoneal space in 65-year-old man
after right nephron-sparing surgery for papillary neoplasia. On preoperative
axial unenhanced CT, 1.5-cm-diameter solid mass (arrow) is seen in
right kidney.
|
|
View larger version (119K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 7B —Mass-like lesion in retroperitoneal space in 65-year-old man
after right nephron-sparing surgery for papillary neoplasia. On axial
corticomedullary phase CT performed 6 months after nephron-sparing surgery,
mass-mimicking lesion with soft-tissue density is seen in retroperitoneal
space (arrow) with no enhancement or mass effect.
|
|
View larger version (116K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 7C —Mass-like lesion in retroperitoneal space in 65-year-old man
after right nephron-sparing surgery for papillary neoplasia. On axial
parenchymal phase CT performed 1 year after nephron-sparing surgery, extent of
mass-like lesion has decreased (arrow).
|
|
View larger version (123K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 8A —Mixture of perinephric strands and mass-like lesion in
retroperitoneal space in 47-year-old man after right nephron-sparing surgery
for renal cell carcinoma. On preoperative axial parenchymal phase CT,
1-cm-diameter solid mass (arrow) is seen in right kidney.
|
|
View larger version (115K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 8B —Mixture of perinephric strands and mass-like lesion in
retroperitoneal space in 47-year-old man after right nephron-sparing surgery
for renal cell carcinoma. On axial parenchymal phase CT performed 6 months
after nephron-sparing surgery, soft-tissue-density lesion (solid
arrow) with perinephric strands (dashed arrow) is seen in
retroperitoneal space with no enhancement.
|
|
View larger version (112K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 8C —Mixture of perinephric strands and mass-like lesion in
retroperitoneal space in 47-year-old man after right nephron-sparing surgery
for renal cell carcinoma. On axial parenchymal phase CT performed 2 years
after nephron-sparing surgery, extent of mixture of perinephric strands and
mass-like lesion in retroperitoneal space has decreased.
|
|
Postoperative retroperitoneal space changes should be differentiated from
postoperative complications such as urinoma, hematoma, or abscess because
postoperative complications require immediate management. In contrast to
postoperative changes, urinoma, hematoma, and abscess show clinical symptoms
and signs such as inflammation, infection, or bleeding. Radiologic findings of
postoperative complications are also different, displaying mass effect and
larger size.
Local Recurrence
Local recurrence occurs in two ways in the kidney treated with
nephron-sparing surgery: recurrence at the surgical site and at the
perinephric space. Local recurrence at the excision site should be
differentiated from postoperative changes. A clue for differentiation: almost
all recurrences show masses at the excision site with strong enhancement on
contrast-enhanced scans, especially in the corticomedullary phase (Fig.
9A,
9B), and an increase in size
on subsequent follow-up CT scans (Fig.
10A,
10B,
10C). These findings are not
seen in postoperative changes. Local tumor recurrence at the perinephric space
also shows masses with strong early enhancement (Fig.
11A,
11B) in contrast to
postoperative changes in the retroperitoneal space, which show no
enhancement.
View larger version (120K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 9A —Local recurrence at surgical site in 41-year-old man after
right nephron-sparing surgery for renal cell carcinoma. On preoperative axial
corticomedullary phase CT, 1-cm-diameter solid mass (arrow) is seen
in right kidney.
|
|
View larger version (121K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 9B —Local recurrence at surgical site in 41-year-old man after
right nephron-sparing surgery for renal cell carcinoma. On axial
corticomedullary phase CT performed 3 months after nephron-sparing surgery,
marked enhancing recurring nodule (arrow) is seen at excision
site.
|
|
View larger version (129K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 10A —Local recurrence at surgical site in 56-year-old woman after
right nephron-sparing surgery for renal cell carcinoma. On preoperative axial
parenchymal phase CT, 1-cm-diameter solid mass (arrow) is seen in
right kidney.
|
|
View larger version (125K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 10B —Local recurrence at surgical site in 56-year-old woman after
right nephron-sparing surgery for renal cell carcinoma. On axial
corticomedullary phase CT performed 3 months after nephron-sparing surgery,
small, strongly enhancing nodule (arrow) is seen at surgical
site.
|
|
View larger version (121K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 10C —Local recurrence at surgical site in 56-year-old woman after
right nephron-sparing surgery for renal cell carcinoma. On sequential axial
corticomedullary phase CT, size of enhancing nodule (arrow) has
increased. Nodule was found to be local recurrence.
|
|
View larger version (121K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 11A —Recurrence at perinephric space in 41-year-old man after
right nephron-sparing surgery for renal cell carcinoma. On preoperative axial
corticomedullary phase CT, 1-cm-diameter solid mass (arrow) is seen
in right kidney.
|
|
View larger version (122K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 11B —Recurrence at perinephric space in 41-year-old man after
right nephron-sparing surgery for renal cell carcinoma. On axial
corticomedullary phase CT performed 3 months after nephron-sparing surgery,
multiple enhancing recurrent nodules (arrows) are seen at perinephric
site.
|
|
Complications
Reported complication rates for nephron-sparing surgery are variable,
ranging from 4% to 37% [11,
12]. Complication rates can be
influenced by many factors, including patient status, mass size, surgeon
skill, imperative indication, and so on. Most complications can be managed by
conservative methods or, at most, endoscopy or interventional radiology
[11]. Commonly reported
complications include urinary leak or fistula, bleeding (Fig.
12A,
12B,
12C), acute renal failure, and
infection (Fig. 13A,
13B,
13C). These complications
usually occur in the early part of the postoperative period. Other
complications, including ischemic changes in the renal parenchyma (Figs.
14A,
14B,
14C and
15) and ureteral or renal
pedicle stricture (Fig. 16A,
16B), can be recognized on CT
[3].
View larger version (121K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 12A —In 74-year-old man, hematoma as complication after right
nephron-sparing surgery for renal cell carcinoma. Gross hematuria and anemia
developed 2 weeks after surgery. On preoperative axial corticomedullary phase
CT, large heterogeneously enhancing solid mass (arrow) is seen in
right kidney.
|
|
View larger version (109K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 12B —In 74-year-old man, hematoma as complication after right
nephron-sparing surgery for renal cell carcinoma. Gross hematuria and anemia
developed 2 weeks after surgery. On axial unenhanced CT performed 2 weeks
after nephron-sparing surgery, homogeneous mass (arrows) with
attenuation of 70 H is seen around surgical clips.
|
|
View larger version (135K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 12C —In 74-year-old man, hematoma as complication after right
nephron-sparing surgery for renal cell carcinoma. Gross hematuria and anemia
developed 2 weeks after surgery. Coronal reformatted unenhanced CT also shows
hyperattenuated mass, which is consistent with hematoma at surgical site
(arrows).
|
|
View larger version (114K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 13A —Abscess as complication of nephron-sparing surgery in
66-year-old man after right nephron-sparing surgery. On preoperative axial
parenchymal phase CT, 1.5-cm-diameter solid mass (arrow) is seen in
right kidney.
|
|
View larger version (122K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 13B —Abscess as complication of nephron-sparing surgery in
66-year-old man after right nephron-sparing surgery. On axial parenchymal
phase CT performed 2 weeks after nephron-sparing surgery, loculated fluid
collection with thick enhancing wall (arrows) is seen at anterior
pararenal space. This was found to be abscess.
|
|
View larger version (125K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 13C —Abscess as complication of nephron-sparing surgery in
66-year-old man after right nephron-sparing surgery. On axial parenchymal
phase CT performed 3 months after nephron-sparing surgery, postoperative
abscess has disappeared.
|
|
View larger version (124K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 14A —Ischemia as complication of nephron-sparing surgery in
39-year-old woman after left nephron-sparing surgery for cystic renal cell
carcinoma. On preoperative axial corticomedullary phase CT, cystic mass with
enhancing thick septa (arrow) is seen in left kidney.
|
|
View larger version (123K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 14B —Ischemia as complication of nephron-sparing surgery in
39-year-old woman after left nephron-sparing surgery for cystic renal cell
carcinoma. On axial parenchymal phase CT performed 1 year after
nephron-sparing surgery, parenchyma at surgical site shows decreased
enhancement and mild atrophied change (arrow) in comparison with
remnant renal parenchyma.
|
|
View larger version (133K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 14C —Ischemia as complication of nephron-sparing surgery in
39-year-old woman after left nephron-sparing surgery for cystic renal cell
carcinoma. On coronal reformatted parenchymal phase CT, ischemic change is
also seen at surgical site (arrow). Change was regarded as
postoperative ischemia.
|
|
View larger version (132K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 15 —Another case of ischemia in 45-year-old man after right
nephron-sparing surgery for renal cell carcinoma. On coronal reformatted
parenchymal phase CT, right kidney shows atrophied change and lack of
parenchymal enhancement.
|
|
View larger version (124K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 16A —Ureteral or renal pedicle stricture as complication of
nephron-sparing surgery in 55-year-old woman after left nephron-sparing
surgery for renal cell carcinoma. On preoperative coronal reformatted
parenchymal phase CT, 3-cm-diameter solid mass (arrow) is seen in
left kidney.
|
|
View larger version (131K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 16B —Ureteral or renal pedicle stricture as complication of
nephron-sparing surgery in 55-year-old woman after left nephron-sparing
surgery for renal cell carcinoma. On axial parenchymal phase CT performed 1
year after nephron-sparing surgery, renal vascular luminal narrowing
(arrow) and hydronephrosis with parenchymal atrophy are seen,
suggesting ureteral or renal pedicle stricture.
|
|
Conclusion
Nephron-sparing surgery is becoming more popular in the treatment of renal
tumors. CT is the most effective imaging technique for surveillance after this
procedure. Our article shows the various postoperative changes, tumor
recurrences, and complications of nephron-sparing surgery. Familiarity with
these findings may help the radiologist differentiate postoperative changes
from tumor recurrence or complications.
References
- Volpe A, Panzarella T, Rendon RA, Haider MA, Kondylis FI, Jewett
MA. The natural history of incidentally detected small renal masses.
Cancer 2004; 100:738
–745[CrossRef][Medline]
- Lang EK, Thomas R, Davis R, et al. Multiphasic helical CT criteria
for differentiation of recurrent neoplasm and desmoplastic reaction after
laparoscopic resection of renal mass lesions. J
Endourol 2004; 18:167
–171[CrossRef][Medline]
- Israel GM, Hecht E, Bosniak MA. CT and MR imaging of complications
of partial nephrectomy. RadioGraphics2006; 26:1419
–1429[Abstract/Free Full Text]
- Ramani AP, Ryndin I, Lynch AC, Veetil RT. Current concepts in
achieving renal hypothermia during laparoscopic partial nephrectomy.
BJU Int 2006; 97:342
–344[CrossRef][Medline]
- Novick AC. Partial nephrectomy. In: Sam D, Graham J, eds.
Glenn's urologic surgery. Philadelphia, PA: Williams
& Wilkins, 2004:30
–38
- Porpiglia F, Fiori C, Terrone C, Bollito E, Fontana D, Scarpa RM.
Assessment of surgical margins in renal cell carcinoma after nephron sparing:
a comparative study—laparoscopy vs open surgery. J
Urol 2005; 173:1098
–1101[CrossRef][Medline]
- Gill IS, Colombo JR Jr, Frank I, Moinzadeh A, Kaouk J, Desai M.
Laparoscopic partial nephrectomy for hilar tumors. J
Urol 2005; 174:850
–853; discussion 853–854[CrossRef][Medline]
- Yair Lotan JAC, Bishoff JT. Minimally invasive, nephron-sparing
interventions for renal lesions: laparoscopy and ablative techniques. In:
Robert G, Moore JTB, Loening S, Docimo SG, eds. Minimally invasive
urologic surgery. London, UK: Taylor & Francis,2005
: 527–548
- Thompson T, Ng CF, Tolley D. Renal parenchymal hemostatic aids:
glues and things. Curr Opin Urol 2003;13
: 209–214[CrossRef][Medline]
- Dogra PN, Tandon S, Ansari MS, Anupama, Chopra P. Suture foreign
body granuloma masquerading as renal neoplasm. Int Urol
Nephrol 2005; 37:27
–29[CrossRef][Medline]
- Stephenson AJ, Hakimi AA, Snyder ME, Russo P. Complications of
radical and partial nephrectomy in a large contemporary cohort. J
Urol 2004; 171:130
–134[CrossRef][Medline]
- Pasticier G, Timsit MO, Badet L, et al. Nephron-sparing surgery for
renal cell carcinoma: detailed analysis of complications over a 15-year
period. Eur Urol 2006;49
: 485–490[CrossRef][Medline]
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
Top
Abstract
Introduction
