RE: PORT SITE TUMOR RECURRENCES OF RENAL CELL CARCINOMA AFTER VIDEOLAPAROSCOPIC RADICAL NEPHRECTOMY

Laparoscopic Surgery in Urologic Oncology

Background

Techniques in genitourinary oncologic surgery have evolved over the past several years, shifting from traditional open approaches toward minimally invasive routes by laparoscopy.

Methods

We reviewed the literature on laparoscopic surgery for genitourinary cancer, with emphasis on contemporary indications, complications, and oncologic outcome of laparoscopic surgery for urologic malignancies.

Results

All urologic oncology procedures have been performed laparoscopically. Laparoscopic radical nephrectomy is becoming the preferred approach for managing kidney cancer. The initial experience with nephroureterectomy is encouraging. Laparoscopic radical prostatectomy is rapidly becoming the standard in Europe and is the procedure of choice in many centers in the United States.

Conclusions

When following the open oncologic principles for the surgical treatment of malignancies, laparoscopy offers similar oncologic clinical outcomes, less morbidity, improved operative precision, and reduced convalescence time.

Port-site metastasis as a primary complication following retroperitoneal laparoscopic radical resection of renal pelvis carcinoma or nephron-sparing surgery: A report of three cases and review of the literature

The present study reports the clinical data of two patients with renal pelvis carcinoma and one patient with renal carcinoma who developed port-site metastasis following retroperitoneal laparoscopic surgery. The current study aimed to identify the cause and prognosis of the occurrence of port-site metastasis subsequent to laparoscopic radical resection of renal pelvis carcinoma and nephron-sparing surgery. Post-operative pathology confirmed the presence of high-grade urothelial cell carcinoma in two patients and Fuhrman grade 3 renal clear cell carcinoma in one patient. Port-site metastasis was initially detected 1–7 months post-surgery. The two patients with renal pelvis carcinoma succumbed to the disease 2 and 4 months following the identification of the port-site metastasis, respectively, whereas the patient with renal carcinoma survived with no disease progression during the targeted therapy period. The occurrence of port-site metastasis may be attributed to systemic and local factors. Measures to reduce the development of this complication include strict compliance with the operating guidelines for tumor surgery, avoidance of air leakage at the port-site, complete removal of the specimen with an impermeable bag, irrigation of the laparoscopic instruments and incisional wound with povidone-iodine when necessary, and enhancement of the body's immunity. Close post-operative follow-up observation for signs of recurrence or metastasis is essential, and systemic chemotherapy may be required in patients with high-grade renal pelvis carcinoma and renal carcinoma in order to prolong life expectancy.

Port site metastasis after surgery for renal cell carcinoma: harbinger of future metastasis

PURPOSE

Port site metastasis is a rare occurrence after minimally invasive treatment for renal cell carcinoma. However, its prognostic implications are unclear because reports in the literature are heterogeneous in detail and followup. We clarify the significance of port site metastasis in cancer specific survival and broaden our understanding of this phenomenon.

MATERIALS AND METHODS

A MEDLINE® search for published studies of renal cell carcinoma port site metastasis was performed. Contributing factors to port site metastasis, stage, Fuhrman grade, pathology, port site metastasis treatment method, followup protocol and long-term outcomes were collected. The corresponding authors of each publication were contacted to fill in details and provide long-term outcomes. We added 1 case from our recent experience.

RESULTS

A total of 16 cases from 12 authors (including ourselves) were found. Of the 12 authors 8 were available for correspondence and 9 cases were updated. Eventual outcomes were available for 11 of the 16 cases and survival curves showed poor prognosis with a 31.8% overall 1-year survival rate. Of the 16 cases 12 were radical nephrectomy and 4 were partial nephrectomy, and 13 involved multiple metastases in addition to the port site metastasis. Nine of the cases had no identifiable technical reason for port site metastasis formation such as specimen morcellation, absence of entrapment or tumor rupture. These tumors were uniformly aggressive, Fuhrman grade 3 or higher.

CONCLUSIONS

Port site metastasis after minimally invasive surgery for renal cell carcinoma is a rare occurrence with a poor prognosis. In most cases port site metastasis is not an isolated metastasis but instead is a harbinger of progressive disease. While technical factors can have a role in port site metastasis formation, it appears that biological factors like high tumor grade also contribute.

Camera-port site metastasis of a renal-cell carcinoma after robot-assisted partial nephrectomy

BACKGROUND AND PURPOSE

Port-site metastasis (PSM) is a rare complication of laparoscopic intervention in urologic malignancies. Of the greater than 50 reported cases of PSM in the urologic oncology literature, only 9 have occurred after surgery for renal-cell carcinoma (RCC). We report a 10th instance of RCC metastasis-in this case to the camera-port site after robot-assisted partial nephrectomy (RAPN). To our knowledge, this case is the first reported PSM of RCC after RAPN.

PATIENT AND METHODS

A 68-year-old man underwent an uncomplicated right RAPN for a 4-cm right renal mass (stage T1aN0M0). Five months later, he was found to have metastatic disease with an isolated peritoneal recurrence at the camera-port site. Biopsy of the lesion confirmed RCC, and the lesion was surgically resected. A comprehensive MEDLINE search for all published studies of port-site recurrences after laparoscopic renal surgery for RCC was performed.

RESULTS

Nine cases of PSM after successful laparoscopic radical or partial nephrectomy for locally confined RCC have been reported. Proposed etiologic factors for port-site recurrence include biologic aggressiveness of the tumor, patient immunosuppression, local wound factors, and technique-related factors. We report an unusual case of PSM to a camera port that was not used for specimen manipulation or extraction.

CONCLUSION

PSM after laparoscopic renal surgery for RCC is a rare occurrence. Our case, in which PSM occurred without specimen bag rupture or extraction through the port in question, highlights the importance of local and systemic factors in contributing to PSM occurrence. We also demonstrate that when PSM is the only site of disease recurrence, it can be successfully managed with minimally invasive surgical resection.

The role of laparoscopy and robotic surgery in the management of small renal masses

Increased utilization of cross-sectional abdominal imaging has led to a significant increase in the incidence of small renal masses. There is a growing body of literature suggesting that these lesions have a low malignant potential, thus supporting surveillance as a therapeutic option, particularly in the elderly population. Over the last decade, there has been an explosion of minimally invasive techniques for managing these lesions, including laparoscopic nephrectomy, laparoscopic partial nephrectomy, cryotherapy, radiofrequency ablation and, more recently, robotic-assisted surgery. The aim of this article is to review recent literature and assess the role of laparoscopic and robotic-assisted surgery in the management of small renal masses.

Localized renal cell carcinoma management: an update

OBJECTIVE

To review the current modalities of treatment for localized renal cell carcinoma.

MATERIALS AND METHODS

A literature search for keywords: renal cell carcinoma, radical nephrectomy, nephron sparing surgery, minimally invasive surgery, and cryoablation was performed for the years 2000 through 2008. The most relevant publications were examined.

RESULTS

New epidemiologic data and current treatment of renal cancer were covered. Concerning the treatment of clinically localized disease, the literature supports the standardization of partial nephrectomy and laparoscopic approaches as therapeutic options with better functional results and oncologic success comparable to standard radical resection. Promising initial results are now available for minimally invasive therapies, such as cryotherapy and radiofrequency ablation. Active surveillance has been reported with acceptable results, including for those who are poor surgical candidates.

CONCLUSIONS

This review covers current advances in radical and conservative treatments of localized kidney cancer. The current status of nephron-sparing surgery, ablative therapies, and active surveillance based on natural history has resulted in great progress in the management of localized renal cell carcinoma.

Complications of laparoscopic surgery for renal masses: prevention, management, and comparison with the open experience

CONTEXT

The initial excitement about the laparoscopic treatment of renal masses has been tempered by concerns related to increased operative time, technical complexity, and the suitability of laparoscopic approaches to oncologic surgery.

OBJECTIVE

To provide a comprehensive review of intraoperative and postoperative complications and their prevention and management during laparoscopic surgery of renal tumors.

EVIDENCE ACQUISITION

A literature review of the Medline and Google Scholar databases was performed, searching for renal cell carcinoma, renal mass, laparoscopy, laparoscopic radical nephrectomy, open radical nephrectomy, laparoscopic partial nephrectomy, open partial nephrectomy, laparoscopic cryoablation, laparoscopic radiofrequency ablation, complications, intra-operative, and post-operative. English-language articles published between 1990 and 2008 were reviewed.

EVIDENCE SYNTHESIS

Laparoscopic radical nephrectomy (LRN), whether transperitoneal or retroperitoneal, can be performed safely. The overall complication rate is low and does not significantly differ from that of the open experience. Laparoscopic partial nephrectomy (LPN), in contrast, is a technically challenging procedure. Although the intermediate oncologic outcomes are comparable to those of the open experience, there are concerns related to warm ischemia time, and there is a risk of major complications such as urinary leakage and hemorrhage requiring transfusion. Laparoscopic-assisted ablative therapies (cryotherapy and radiofrequency) are being performed more commonly for the treatment of small exophytic renal lesions with a low complication rate and intermediate oncologic outcomes similar to LRN and LPN.

CONCLUSIONS

Complications associated with the laparoscopic management of renal masses vary among the different procedures and with surgeon experience. The rate of complication appears to be similar to that of open surgery.

Port site metastases

PURPOSE OF REVIEW

The aim of this article is to provide an overview of the incidence, pathophysiology, risk factors and possible methods of reducing the risk of port site metastases following uro-oncological procedures.

RECENT FINDINGS

To our knowledge, 28 cases of port site metastasis have been reported in the urologic literature. There has been an increased interest in the use of intraperitoneal instillation of various tumoricidals in order to reduce the risk of port site seeding.

SUMMARY

The risk of port site metastases remains low, provided that surgeons rigorously adhere to the principles of oncological surgery.

Case Report: Port-Site Metastasis after Laparoscopic Radical Nephrectomy for Renal-Cell Carcinoma

A 65-year-old man with a 5.5 x 3.2-cm stage T(2)N(0)M(0) grade III renal-cell carcinoma suffered a port-site metastasis 8 months after laparoscopic radical nephrectomy with specimen removal in an organ-retrieval bag. This case underlines the need to be conversant with, and care to avoid, risk factors for this complication.

Laparoscopic specimen extraction: morcellation

OBJECTIVES

To review our experience with intact extraction and morecellation of nephrectomy specimen, and the advantages and disadvantages of morcellation indicated by current reports.

PATIENTS AND METHODS

In a previous study, 56 consecutive patients undergoing radical and simple transperitoneal laparoscopic nephrectomy were prospectively evaluated. Morcellation specimens (33) were extracted at the umbilical or lateral port sites and intact specimens (23) through an infraumbilical incision. Data were obtained on pathology, narcotic requirements, hospital stay, complications, estimated blood loss, size of renal mass based on preoperative imaging, specimen weight and extraction incision length.

RESULTS

The mean incision length was 1.2 cm in the morcellation group and 7.1 cm in the intact group (P< 0.001). There were no significant differences in pain or recovery between the groups. In two cases of tumor nephrectomy, microscopic invasion of the perinephric adipose tissue in the intact specimen group were up-staged from clinical T1 to pT3a disease; there was no change in patient treatment based on this information.

CONCLUSIONS

With proper technique, morcellation is safe for extracting renal tumours. The specimen can be evaluated for histology but not for pathological staging, limiting its use with transitional cell carcinoma. Port-site seeding is rare, and does not appear to be more frequent than with open nephrectomy. Although morcellation is cosmetically more desirable, there was no significant advantage in operating time, pain or duration of hospital stay. The choice od extraction method depends on the surgeon's preference and patient choice.

Tumor seeding in urological laparoscopy: an international survey

PURPOSE

During the last 10 years laparoscopy has been applied to treat most urological pathology including malignancies. There has been concern regarding peritoneal dissemination and port site metastases. We undertook a survey to assess the incidence of this occurrence.

MATERIALS AND METHODS

A total of 50 international urology departments with experts in laparoscopic urological surgery were contacted for this study. Each site was asked to complete a 2-page survey regarding the volume of laparoscopic urological procedures and port site recurrences.

RESULTS

Nineteen sites elected to participate. A total of 18750 laparoscopic procedures were performed, of which 10912 were for cancer. These included 2604 radical nephrectomies, 559 nephroureterectomies, 555 partial nephrectomies, 27 segmental ureterectomies, 3665 radical prostatectomies, 1869 pelvic lymph node dissections, 479 retroperitoneal lymph node dissections, 336 adrenalectomies and 108 procedures listed as other. Tumor seeding was reported in 13 cases (0.1%), including 3 nephroureterectomies for transitional cell carcinoma, 4 nephrectomies (incidental transitional cell carcinoma), 4 adrenalectomies for metastases, 1 retroperitoneal lymph node dissection for testicular cancer and 1 pelvic lymph node dissection for cancer of the penis. Port seeding occurred in 10 cases (0.09%) and peritoneal spread in 3 cases (0.03%).

CONCLUSIONS

The incidence of tumor seeding after laparoscopic oncological surgery is rare and does not appear greater than what has been historically reported for open surgery. Tumor seeding seems to be most commonly related to the removal of high grade tumors and deviation from oncological surgical principles.

Changing Concepts in the Surgical Management of Renal Cell Carcinoma

The foundations of the generally accepted principles underlying the surgical management of renal cell carcinoma (RCC) were best annunciated in 1969 by Robson in his classic description of the radical nephrectomy [J Urol 1969;101;297]. Since then, much has changed in our understanding of the basic biology and genetics of kidney cancer, advances in renal imaging and clinical staging have led to the increased detection of incidental, lower stage, organ-confined tumors more amendable to expanded surgical options, surgical techniques themselves have evolved, and surgical equipment technology has advanced to make possible new methods of managing renal tumors in situ. Thus, the management of both localized and metastatic RCC has changed dramatically in the last 20 years, predicated on these major advancements in renal imaging, surgical techniques, and the development of effective immunotherapies for advanced disease. In this review, the evolution in thinking regarding the tenets of the radical nephrectomy will be examined, including the necessity for removal of the entire kidney, the possibility of sparing the adrenal gland, when and how extensive a lymphadenectomy should be performed, the development of laparoscopic and percutaneous nephron-sparing surgery using ablative technologies, and the role of nephrectomy and metastasectomy in patients with metastatic RCC. Here, we review current concepts and outcomes on the surgical management of RCC to help elucidate some of these changes, from the evolution of open to laparoscopic to percutaneous, from radical to partial to ablative approaches.

Port site metastases in urological laparoscopic surgery

PURPOSE

Laparoscopic surgery is rapidly gaining widespread acceptance among urologists, including extensive application in malignant conditions. However, untoward occurrences of port site metastases have not eluded to urological applications. This up-to-date review on port site metastases in urology delineates possible contributing factors and describes techniques to prevent it.

MATERIALS AND METHODS

We comprehensively reviewed published experimental and clinical studies with special emphasis on the incidence, pathophysiology and prevention of port site metastases.

RESULTS

Nine cases of port site metastases after urological laparoscopy have been described in clinical and experimental studies. Etiological factors include natural malignant disease behavior, host immune status, local wound factors, laparoscopy related factors such as aerosolization of tumor cells (the use of gas, type of gas, insufflation and desufflation, and pneumoperitoneum) and sufficient technical experience of the surgeons and operating team (adequate laparoscopic equipment, skill, minimal handling of the tumor, surgical manipulation and wound contamination during instruments change, organ morcellation and specimen removal).

CONCLUSIONS

Port site metastases is a multifactorial phenomenon with an as yet undetermined incidence. The problem is influenced to some extent by surgeon and operating team experience and, therefore, it could be partially prevented. The suggested preventive steps are avoiding laparoscopic surgery when there are ascites, trocar fixation to prevent dislodgment, avoiding gas leakage along and around the trocar, sufficient technical readiness of the operating team (adequate laparoscopic equipment and technique, minimal handling and avoiding tumor boundary violation of the tumor), using a bag for specimen removal, placing drainage when needed before desufflation, povidone-iodine irrigation of instruments, trocars and port site wounds, and suturing 10 mm. and larger trocar wounds.

Single-center comparison of purely laparoscopic, hand-assisted laparoscopic, and open radical nephrectomy in patients at high anesthetic risk

BACKGROUND AND PURPOSE

The laparoscopic approach for management of high-risk patients with renal-cell carcinoma (RCC) may reduce perioperative and postoperative morbidity. The aim of this study was to compare the outcome of purely laparoscopic radical nephrectomy (LRN), hand-assisted laparoscopic radical nephrectomy (HALRN), and open radical nephrectomy (ORN) for renal tumors in a population of patients at high risk for perioperative complications.

PATIENTS AND METHODS

All patients undergoing radical nephrectomy for presumed RCC between August 1999 and August 2001 at Vanderbilt University Medical Center and having an American Society of Anesthesiologists (ASA) score of >/=3 were reviewed. Patients with known metastasis, local invasion, caval thrombi, or additional simultaneous surgical procedures were excluded from analysis. Thirteen patients underwent LRN, eight patients underwent HALRN, and 26 underwent ORN. The patient demographics were similar in the three groups. The groups were compared with regard to intraoperative and postoperative parameters. Statistical analysis was done using chi-square testing for categorical variables and analysis of variance (ANOVA) for continuous variables. Differences in outcomes were examined using ANOVA and Dunnett's T for pairwise comparisons.

RESULTS

The ASA 4 patients had significantly longer hospital stays and total hospital costs than the ASA 3 patients. The mean operative time in the ASA 3 patients was similar in the three groups: 2.8 hours, 2.8 hours, and 2.5 hours for the LRN, HALRN, and ORN patients, respectively. Both the LRN patients (22.9 mg of morphine sulfate equivalent) and the HALRN patients (42.1 mg) required less pain medication than the open surgery patients (97.7 mg). When the total hospital costs were compared, LRN was less costly than HALRN ($6089 v $7678; P = 0.57) and open surgery ($6089 v $7694; P = 0.04). The complication rate in the LRN, HALRN, and ORN group was 0%, 25%, and 27%, respectively, although the differences were not statistically different (P = 0.12).

CONCLUSIONS

Both LRN and HALRN can be performed safely in patients with significant comorbid conditions. Careful preoperative preparation, intraoperative monitoring, and awareness of laparoscopy-induced oliguria can preclude inadvertent overhydration, hemodilution, and congestive heart failure. Both LRN and HALRN result in less pain medication requirement and faster return to oral intake than ORN, and LRN results in fewer perioperative complications than HALRN or ORN in patients at high perioperative risk. The LRN technique has a 21% lower total cost than both HALRN and ORN.