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===== Segmental nephrectomy (for large polar tumours) ===== * Intravenous mannitol and furosemide are administered and the renal pedicle is completely dissected, including the segmental branches. * A bulldog clamp is applied to the apical segmental artery (or basilar segmental artery for lower pole tumors) and the line of ischemia is observed. The avascular line can be further demarcated by injecting 5 mL of indigo carmine directly into the clamped artery. The line of ischemia is the optimal site for transection of the kidney and should be lightly marked with electrocautery. The apical segmental artery is ligated, then the renal pedicle is clamped en bloc with a curved Satinsky clamp. A plastic bag or sheet is placed around the kidney and filled with ice slush to cool the kidney to 20Β° C (approximately 15 minutes). The renal capsule is incised along the line of ischemia with electrocautery. Using blunt dissection, the pole of the kidney is excised. Bleeding vessels are controlled, working expeditiously and accurately. The clamp is released to check for uncontrolled bleeders. If hemostasis is adequate, collecting system repair is begun; otherwise the pedicle is reclamped and vascular control resumed. * The collecting system is inspected for injury. If the defect in the collecting system is large, a guidewire is inserted into the defect and manually guided into the ureter and bladder. A 6-Fr double-J ureteral stent is inserted over the guidewire with the proximal coil in the renal pelvis. The collecting system is closed with a running 4-0 absorbable noncutting suture. * The renal capsule is closed using Nu-Knit pledgets and horizontal mattress sutures as described earlier. Because the defect is large, we use a larger needle (e.g., XLH, GS-27) for segmental polar nephrectomies and heminephrectomies than for enucleation and wedge resections. Nephropexy should be considered if the kidney is quite mobile; however, injury to retroperitoneal nerves overlying the psoas and quadratus lumborum muscles must be avoided. The kidney is covered with perirenal fat and renal fascia and a closed suction drain is placed to monitor output postoperatively. The indwelling Foley catheter is removed when the patient is mobile and stable. Depending on the output of the closed suction drain, it can be removed 5 to 10 days postoperatively. If a ureteral stent is used, it should not be removed for 4 to 6 weeks postoperatively. After removal of the indwelling Foley catheter, if the output of the closed suction drain is increased, the transurethral indwelling Foley catheter is reinserted to reduce the intrapelvic urine pressure, which should minimize the output from the closed suction drain.
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