Nephrectomy Surgical Approaches

Hinmann CHAPTER 8 Surgical Approaches for Open Renal Surgery, Including Open
Radical Neph rectomy 63

Angiomyolipomas Treatment

Patients with angiomyolipomas resulting from tuberous sclerosis are at risk for hemorrhage
and impaired renal function (Bissler et al., 2016).
For many years, the threshold diameter for intervention has been more than 4 cm. Recent data
in adult patients with sporadic angiomyolipoma suggest that intervention can be delayed until
the diameter exceeds 6 cm (Kuusk et al., 2015). The International TSC Consensus Group
recommends intervention for lesions larger than 3 cm in diameter (Kingswood et al., 2016).
Lesions in TSC patients that are larger than 3 cm and enlarging appear to be at greatest risk
for bleeding. The first-line treatment for children with growing lesions (Fig. 53.13) is
with mTOR inhibitor, and embolization or surgery are second-line treatments.
Historically, a size of 4 cm or greater and being of childbearing age were used as indications
for intervention because of a concern for spontaneous hemorrhage and pain. AML less than
4 cm in size are expected to be asymptomatic and unlikely to bleed, and therefore active
surveillance is an option.

Mapping biopsy (dome, trigone, anterior, posterior, lateral kanan kiri bladder wall)

Carcinoma in situ can present as a velvet-like, reddish area, indistinguishable from

inflammation, or it may not be visible at all. For this reason biopsies from suspicious
urothelium should be taken. However, in patients with positive urine cytology, or with a
history of HG/G3 NMIBC and in tumours with non-papillary appearance, mapping biopsies
from normal-looking mucosa is recommended. To obtain representative mapping of the
bladder mucosa, biopsies should be taken from the trigone, bladder dome, right, left, anterior
and posterior bladder wall

Sumber : EAU guideline

Prostatic urethral biopsies
Involvement of the prostatic urethra and ducts in men with NMIBC has been reported. Palou
et al. showed that in 128 men with T1G3 BC, the incidence of CIS in the prostatic urethra
was 11.7% [142] (LE: 2b). The risk of prostatic urethra or duct involvement is higher if the
tumour is located at the trigone or bladder neck, in the presence of bladder CIS and multiple
tumours [143] (LE: 3b). Based on this observation, a biopsy from the prostatic urethra is
necessary in some cases (see recommendation in Section 5.14) [142, 144, 145].
Sumber : EAU guideline

CAPD insertion
New catheters have been devised to prevent obstruction (4, 5). Their intra peritoneal portions
have discs or balloons to keep the tip in the true pelvis and protect it from omental wrapping.
It also seemed logical to direct the tunnel cranially if this would make migration less likely.
After this tunnel direction was employed more frequently in our institution we had the
impression that exit infections became more frequent and difficult to treat, and began to
suspect that cranial tunnel direction facilitated exit-site contamination and impeded the
drainage of pus.