The National Institute for Health and Clinical Excellence (NICE) has issued full guidance to the NHS in England, Wales, Scotland and Northern Ireland on laparoscopic partial nephrectomy.
Indications for laparoscopic partial nephrectomy include a solid renal mass in a patient with a solitary kidney or compromised contralateral kidney, bilateral renal masses, small localised renal tumours in patients with a normal contralateral kidney.
Some small tumours may not be suitable for treatment by laparoscopic partial nephrectomy because of their position (centrally located lesions are more difficult to remove than peripheral lesions).
The standard treatment for these indications would be an open partial nephrectomy, using a flank extraperitoneal or an anterior subcostal incision to expose the kidney.
A laparoscopic partial nephrectomy is performed under general anaesthetic, using a transperitoneal or retroperitoneal approach. In the transperitoneal approach, the abdomen is insufflated with carbon dioxide and three or four small abdominal incisions are made. In the retroperitoneal approach, a small incision is made in the back and a dissecting balloon is inserted to create a retroperitoneal space. After insufflation with carbon dioxide, two or three additional small incisions are made in the back. The renal vessels are identified and either isolated using vessel loops or clamped and the kidney is mobilised to allow exposure of the lesion. A laparoscopic ultrasound probe may be used to determine the line of incision and depth of tumour involvement. Bleeding vessels are sealed or ligated with sutures and the renal capsule is then closed. The specimen is enclosed in a bag and retrieved through an expanded port.
Hand-assisted laparoscopic partial nephrectomy allows the surgeon to place one hand in the abdomen while maintaining the pneumoperitoneum required for laparoscopy. A small incision is made that is just large enough for the surgeon's hand and an airtight 'sleeve' device is used to form a seal around the incision.
M03.1 Heminephrectomy of duplex kidney
M03.2 Division of isthmus of horseshoe kidney
M03.8 Other specified partial excision of kidney
M03.9 Unspecified partial excision of kidney
Includes: Partial nephrectomy NEC
In addition to one of the above primary procedure codes one of the following approach codes must be assigned to indicate the method of approach:
Y75.2 Laparoscopic approach to abdominal cavity NEC
Y75.4 Hand assisted minimal access approach to abdominal cavity
This guidance represents the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take this guidance fully into account, and specifically any special arrangements relating to the introduction of new interventional procedures. The guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
All problems (adverse events) related to a medicine or medical device used for treatment or in a procedure should be reported to the Medicines and Healthcare products Regulatory Agency using the Yellow Card Scheme.
Commissioners and/or providers have a responsibility to implement the guidance, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties. Providers should ensure that governance structures are in place to review, authorise and monitor the introduction of new devices and procedures.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.