Retroperitoneal laparoscopic nephrectomy is safe and effective in obese patients: a comparative study of 55 procedures

Donor and Recipient Outcomes of Retroperitoneal Laparoscopic Donor Nephrectomy in Obese Versus Nonobese Donors: A Prospective Study

INTRODUCTION

Obese donors are increasingly accepted for living kidney donation. Obese individuals benefit the most from minimal access surgery; however, laparoscopic donor nephrectomy may be technically challenging in these individuals. Retroperitoneal laparoscopic donor nephrectomy (RLDN) in particular may be hampered by excessive perinephric fat. We performed a prospective nonrandomized controlled study comparing outcomes of RLDN in obese and nonobese kidney donors.

AIM

To compare operative parameters, donor complications, and recipient outcomes in RLDN performed in obese and nonobese donors.

MATERIALS AND METHODS

From June 2014 to April 2016, 200 donors underwent RLDN. Of these, 160 were nonobese (group I), and 40 were obese (group II). Preoperative parameters including body mass index, age, and sex, and operative parameters including total operative time, warm ischemia time, and estimated blood loss were recorded. Complications were compared using the Clavien-Dindo classification. Recipients' serum creatinine at day 7, 15, and 30 was compared between recipients who received grafts from obese and nonobese donors.

RESULTS

There were 17.5% right-sided donors in group I and 15% in group II. Operative time, warm ischemia time, blood loss, length of hospital stay, and complications were similar in the 2 groups, and there were no statistically significant differences. Serum creatinine in the recipients was similar on follow-up.

CONCLUSIONS

RLDN is safe and efficacious in obese donors. It gives all the benefits of minimal-access surgery without compromising on recipient outcomes.

Technique and outcomes of robot-assisted retroperitoneoscopic partial nephrectomy: a multicenter study

BACKGROUND

Robot-assisted retroperitoneoscopic partial nephrectomy (RARPN) may be used for posterior renal masses or with prior abdominal surgery; however, there is relatively less familiarity with RARPN.

OBJECTIVE

To demonstrate RARPN technique and outcomes.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective multicenter study of 227 consecutive RARPNs was performed at the Swedish Medical Center, the University of Michigan, and the University of California, Los Angeles, from 2006 to 2013.

SURGICAL PROCEDURE

RARPN.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We assessed positive margins and cancer recurrence. Stepwise regression was used to examine factors associated with complications, estimated blood loss (EBL), warm ischemia time (WIT), operative time (OT), and length of stay (LOS).

RESULTS AND LIMITATIONS

The median age was 60 yr (interquartile range [IQR]: 52-66), and the median body mass index (BMI) was 28.2 kg/m(2) (IQR: 25.6-32.6). Median maximum tumor diameter was 2.3 cm (IQR: 1.7-3.1). Median OT and WIT were 165 min (IQR: 134-200) and 19 min (IQR: 16-24), respectively; median EBL was 75 ml (IQR: 50-150), and median LOS was 2 d (IQR: 1-3). Twenty-eight subjects (12.3%) experienced complications, three (1.3%) had urine leaks, and three (1.3%) had pseudoaneurysms that required reintervention. There was one conversion to radical nephrectomy and three transfusions. Overall, 143 clear cell carcinomas (62.6%) composed most of the histology with eight positive margins (3.5%) and two recurrences (0.9%) with a median follow-up of 2.7 yr. In adjusted analyses, intersurgeon variation was associated with complications (odds ratio [OR]: 3.66; 95% confidence interval, 1.31-10.27; p = 0.014) and WIT (parameter estimate [PE; plus or minus standard error]: 4.84 ± 2.14; p = 0.025). Higher surgeon volume was associated with shorter WIT (PE: -0.06 ± 0.02; p = 0.002). Higher BMI was associated with longer OT (PE: 2.09 ± 0.56; p < 0.001). Longer OT was associated with longer LOS (PE: 0.01 ± 0.01; p = 0.002). Finally, there was a trend for intersurgeon variation in OT (PE: 18.5 ± 10.3; p = 0.075).

CONCLUSIONS

RARPN has acceptable morbidity and oncologic outcomes, despite intersurgeon variation in WIT and complications. Greater experience is associated with shorter WIT.

PATIENT SUMMARY

Robot-assisted retroperitoneoscopic partial nephrectomy has acceptable morbidity and oncologic outcomes, and there is intersurgeon variation in warm ischemia time and complications.

Shifting paradigms in eligibility criteria for live kidney donation: a systematic review

As the organ shortage increases, inherently the demand for donor kidneys continues to rise. Thus, live kidney donation is essential for increasing the donor pool. In order to create successful expansion, extended criteria live kidney donors should be considered. This review combines current guidelines with all available literature in this field, trying to seek and establish the optimal extended criteria. Comprehensive searches were carried out in major databases until November 2013 to search for articles regarding older age, overweight and obesity, hypertension, vascular anomalies/multiplicity, nulliparous women, and minors as donors. Of the 2079 articles found, 152 fell within the scope of the review. Five major guidelines were included and reviewed. Based on the literature search, live kidney donation in older donors (up to 70 years of age) seems to be safe as outcome is comparable to younger donors. Obese donors have comparable outcome to lean donors, in short- and mid-term follow-up. Since little literature is available proving the safety of donation of hypertensive donors, caution is advised. Vascular multiplicity poses no direct danger to the donor and women of childbearing age can be safely included as donors. Although outcome after donation in minors is shown to be comparable to adult donors, they should only be considered if no other options exist. We conclude that the analyzed factors above should not be considered as absolute contraindications for donation.

Retroperitoneoscopic nephrectomy for non-functioning kidneys related to renal stone disease

Laparoscopic nephrectomy has become the gold standard procedure for nonfunctioning or symptomatic benign kidneys due to renal calculi, obstructive, refluxive, and inflammatory nephropathies or renovascular hypertension. We aimed to investigate the effect of renal calculi as a reason of non-functioning on the progress and complication rates of the retroperitoneoscopic nephrectomy (RPN). During a 2-year period, 108 patients with benign renal conditions underwent RPN by single surgeon. Among these patients, total of 27 (Group 1) with a non-functioning kidney due to renal calculi were retrospectively compared with 27 patients (Group 2) with other benign renal conditions. The two groups were matched for age, body mass index, and previous renal surgery. We analyzed operative and post-operative findings and complications. The mean age and the BMI of the groups were similar. The operation time was significantly longer in Group 1 than Group 2 (p = 0.0001). There was no significant difference between the groups with respect to mean hemoglobin drop postoperatively (p = 0.9) and hospitalization time (p = 0.06). The perioperative and postoperative complication rates were higher in Group 1 but not statistically different from Group 2 (p = 0.19, p = 0.29, respectively). RPN for nonfunctioning calculous kidneys is more challenging procedure and is associated with prolonged operation time related to difficult dissection of dense adhesions. It can be safely performed by experienced hands with similar perioperative and postoperative complication rates as well as for other benign conditions of the kidney.

Obesity is an adverse factor on laparoscopic radical nephrectomy for t2 but not t1 renal cell carcinoma

Purpose

Laparoscopic radical nephrectomy (LRN) is more challenging with increases in body mass index (BMI). Several recent studies have shown, however, that LRN can be safely performed even in obese patients. The influence of obesity on the perioperative outcomes of LRN has not been well elucidated for large renal tumors (>7 cm), however. We estimated the impact of obesity on LRN for stage T1 and T2 renal cell carcinoma (RCC).

Materials and Methods

From January 2004 to March 2011, 266 patients underwent LRN (T1: 195, T2: 71). These patients were subdivided into the following two groups according to BMI: the nonobese group (BMI less than 25 kg/m²) and the obese group (BMI greater than 25 kg/m²). Perioperative outcomes were retrospectively compared between these two groups in T1 and T2 RCC patients.

Results

There were no significant differences in perioperative outcomes between the obese and nonobese groups of T1 RCC patients. However, in T2 RCC patients, operative time and complication rate were significantly increased in the obese group.

Conclusions

Our results suggest that LRN can be safely performed in Korean patients with T1 RCC regardless of obesity. In T2 RCC patients, however, LRN may become more difficult with increasing BMI considering a longer operation time as well as a higher complication rate. We suggest that LRN for obese patients with T2 RCC be carefully considered.

Laparoendoscopic single-site retroperitoneoscopic adrenalectomy: a matched-pair comparison with the gold standard

Background

Laparoscopic adrenalectomy has become the gold-standard for the surgical treatment of most adrenal lesions. This study evaluated the operative outcome of laparoendoscopic single-site (LESS) retroperitoneoscopic adrenalectomy (LESS-ARA) in comparison with the current standard operation procedure.

Methods

Between June and December 2009, 19 patients underwent LESS-ARA, and their outcomes were compared with a contemporary 1:2 matched-pair cohort of 38 patients who underwent standard ARA by the same surgeon. In LESS-ARA, a multichannel port was inserted through a 2.5- to 3.0-cm transverse skin incision below the tip of the 12th rib. The LESS-ARA procedure was performed using a 5-mm 30º laparoscopic camera and two standard laparoscopic instruments. The following parameters were compared between the two groups: demographics, details of the surgery, perioperative complications, postoperative visual analog pain scale score, analgesic requirement, and short-term measures of convalescence.

Results

The finding showed that LESS-ARA and standard ARA were comparable in terms of the estimated blood loss (30 vs 17.5 ml; p = 0.64), postoperative hospital stay (6 vs 6 days; p = 0.67), and postoperative complications (2 vs 3 patients; p = 1.00) for patients with similar baseline demographics and median tumor size (2.1 vs 3.0; p = 0.18) cm. The intraoperative hemodynamic values were similar in the two groups. The LESS-ARA group had a longer median operative time (55 vs 41.5 min; p = 0.0004), whereas the in-hospital use of analgesics was significantly less (5 vs 12 morphine equivalents; p = 0.03).

Conclusions

The LESS retroperitoneoscopic adrenalectomy approach is feasible and offers a superior cosmetic outcome and better pain control, with perioperative outcomes and short-term measures of convalescence similar to those of the standard approach, albeit with a longer operative time.

Initial experience with transperitoneal laparoscopic nephrectomy in an Irish hospital setting

INTRODUCTION

Laparoscopic nephrectomy has gained widespread acceptance as a treatment for both benign and malignant conditions and is becoming increasingly popular in Irish hospitals. We report a single surgeon, single centre experience with 20 consecutive laparoscopic nephrectomies comparing them to 20 open cases performed prior to the establishment of a laparoscopic service.

METHODOLOGY

A retrospective comparative analysis was carried out over an 18 month period. Transperitoneal approach was used in the laparoscopic group with renal vessels divided using an Endo GIA stapling device. Parameters examined included age, weight, indication, operative time, blood loss, tumour size, length of stay and analgesic requirements. Comparison was made with 20 open nephrectomies.

RESULTS

Mean age (p=0.26) and weight (p=0.08) were similar in both groups. Average tumour size was similar (4.98 cm [range 2.8-9] in laparoscopic group versus 6.4 cm [range 3-10], p=0.61). Mean operative blood loss was reduced in the laparoscopic group (65 ml (range 50-200) versus 351 ml (50-1740) (p=or<0.05 L.N. versus O.N.). Laparoscopic patients were discharged earlier; 3.9 days (range 3-6) versus 6.5 (range 5-11) postoperatively (p=or<0.05 L.N. versus O.N.). Analgesia requirements were reduced in terms of both total hours using PCA (25.05 hours [range 1-45] versus 41.6 hours (range 7-226)) (p=or<0.05 L.N. versus O.N.) and total morphine requirements (35.5 mg [range 2-94] versus 72.4 mg [range 18-113] [p=or<0.05 L.N. versus O.N.]). There were no complications in the laparoscopic group, while one patient developed an incisional hernia in the open group.

CONCLUSION

Laparoscopic nephrectomy is less invasive and demonstrates improved results in terms of analgesia, blood loss and reduced overall stay.

Impact of body mass index on clinical outcome and health-related quality of life following open heart surgery

The effect of increased body mass index (BMI) on survival following open heart surgery is unclear. We explored the relationship between BMI, survival following elective open heart surgery, and health-related quality of life. Our results suggest that increased BMI need not be a deterrent for undergoing open heart surgery. Patients with increased BMI can expect similar complication rates, significant gains in health-related quality of life at 1 year, and comparable intermediate survival.

Analysis of impact of body mass index on outcomes of laparoscopic renal surgery

OBJECTIVES

As the prevalence of obesity increases in the United States, it has become more important to assess its impact on surgical outcomes. We evaluated the significance of obesity on laparoscopic radical nephrectomy (LRN) and laparoscopic partial nephrectomy (LPN).

METHODS

This was a prospective database study evaluating patients who underwent either LRN or LPN from October 2002 to January 2006. Patients were divided into five groups as determined by the World Health Organization body mass index (BMI) classification: less than 25.0, 25.0 to 29.9, 30.0 to 34.9, 35.0 to 39.9, and 40.0 kg/m2 or more. Demographic (age, tumor size, American Society for Anesthesiologists score), operative (estimated blood loss, operative time, open conversion), and postoperative (complications, hospital stay, margin status) data were compared.

RESULTS

Of 239 patients who had undergone LRN or LPN during the study period, 146 underwent LRN and 85 underwent LPN. Of the 239 patients, 42% were obese. No statistical significance was determined for estimated blood loss, operative time, hospital stay, number of open conversions, or complications. However, a trend toward increased operative time and intraoperative complications was determined using linear and logistic regression analyses.

CONCLUSIONS

Laparoscopic renal surgery is safe in overweight and obese patients and may be the surgical management of choice in this subset of patients. However, obese patients should be warned that their degree of obesity may be associated with increased difficulty of surgery as reflected by a trend toward longer operative times and more intraoperative complications.

Laparoscopic Partial Nephrectomy in Obese Patients

OBJECTIVES

To report our experience with laparoscopic partial nephrectomy in obese (body mass index greater than 30 kg/m2) patients compared with a contemporary cohort of nonobese patients.

METHODS

From August 1999 to December 2004, 140 obese (group 1) and 238 nonobese (group 2) patients underwent laparoscopic partial nephrectomy at our institution. We compared the demographics, operative data, and perioperative complications of these two groups.

RESULTS

Group 1 had a significantly greater incidence of hypertension and diabetes. In groups 1 and 2, respectively, the mean estimated blood loss was 310 mL (range 50 to 1500) and 249 mL (range 50 to 2500), the mean operating time was 3.4 hours (range 2.5 to 6) and 3.4 hours (range 1.5 to 6), and the mean warm ischemia time was 31 minutes (range 15 to 51) and 32 minutes (range 12 to 60). Intraoperative complications occurred in 8 patients (5.7%) in group 1 and 20 (8%) in group 2 (P = 0.19), with a blood transfusion rate of 6% and 3%, respectively (P = 0.42). The postoperative complication rate was not significantly different between the two groups (13% versus 9%, P = 0.77). The mean hospital stay was 2.8 days (range 1 to 8) for group 1 and 3.5 days (range 1 to 32) for group 2. Retroperitoneal access was associated with a shorter operative time and hospital stay in both groups.

CONCLUSIONS

Laparoscopic partial nephrectomy was performed safely in obese patients, with a perioperative complication rate similar to that of nonobese patients. The retroperitoneal approach was associated with a shorter operative time and hospital stay in the obese and nonobese patients.

Retroperitoneoscopic Radical Nephrectomy in Obese Patients: Outcomes and Considerations

OBJECTIVE

To determine whether obesity is associated with surgical outcome in Japanese patients undergoing retroperitoneoscopic radical nephrectomy (RRN).

PATIENTS AND METHODS

Between November 1999 and March 2005, we performed 98 RRN procedures for patients with renal cell carcinoma. Patients with a body mass index (BMI) of 25.0 or more were defined as obese (group A, n=33) and those with a BMI of <25.0 were defined as non-obese (group B, n=65), in accordance with the criteria of the Japan Society for the Study of Obesity. Patient background, degree of surgical invasiveness, and period of convalescence were compared between groups A and B.

RESULTS

No statistically significant differences were observed between the groups in terms of age, gender, tumor laterality, tumor size, and time until resumption of oral intake and ambulation. However group A had a significantly longer insufflation time (172.1 vs. 137.4 min), greater blood loss (195.3 vs. 48.4 ml) and higher renal specimen weight (440.0 vs. 306.0 g) than group B.

CONCLUSION

Obesity is not a factor that affects patient eligibility for RRN, but is a risk factor for longer insufflation time and greater blood loss.

Nefrectomía radical laparoscópica

In this article, we review the different surgical approaches to carry out radical laparoscopic nephrectomy: transperitoneal approach, retroperitoneal approach and hand-assisted approach. We describe the advantages and drawbacks of each alternative and summarize the most important references in the medical literature. In spite of this being a relatively new surgical approach, less than 15 years old, it has become a standard treatment and, today, is considered as the elective surgical treatment for T1 and T2 renal tumours in many centres.

DIFFERENCES IN COMPLICATIONS AND OUTCOMES FOR OBESE PATIENTS UNDERGOING LAPAROSCOPIC RADICAL, PARTIAL OR SIMPLE NEPHRECTOMY

PURPOSE

Obesity has increased dramatically in American society during the last 2 decades. While the laparoscopic approach is common for patients requiring radical and partial nephrectomy, it is unclear if this procedure leads to worse outcomes and complications in obese patients. We determined if obese patients undergoing laparoscopic radical (RN), partial (PN) and simple (SN) nephrectomy are at risk for worse surgical outcomes or increased complications.

MATERIALS AND METHODS

We retrospectively identified patients treated with nontransplant transperitoneal laparoscopic nephrectomies from 1998 to 2003. Patients with missing body mass index (BMI), operative, postoperative or pathological information were excluded from study. Obese patients (BMI 30 or greater) were compared to nonobese patients (BMI less than 30).

RESULTS

A total of 189 patients undergoing 117 RN, 44 PN and 30 SNs met study criteria, and 29.0% of patients were obese. Overall obese patients had longer operative times (280 versus 241 minutes, p = 0.003), greater estimated surgical blood loss (230 versus 109 ml, p = 0.0001) and higher transfusion rates (6.8% versus 0.8%, p = 0.032) than nonobese patients. In subgroup analyses obese patients receiving RN and PN had longer operative times and increased blood loss. Obese and nonobese patients have similar open conversion rates, analgesic requirements, hospital stay, time to oral intake, and major and minor complication rates regardless of nephrectomy type.

CONCLUSIONS

Laparoscopic nephrectomy is associated with slightly greater operative time, estimated blood loss and transfusion rates in obese patients. Laparoscopic RN, PN and SN are safe and well tolerated in obese patients. Obesity is not a contraindication to laparoscopic renal surgery.

Comparison of Laparoscopic Radical Renal Surgery in Morbidly Obese and Non-obese Patients

BACKGROUND AND PURPOSE

Laparoscopic radical nephrectomy is rapidly becoming accepted as the preferred management of low-stage renal masses not amenable to partial nephrectomy. Minimally invasive surgery is advantageous to decrease perioperative and postoperative morbidity and allows patients to return to normal activities faster. Obesity has been a relative contraindication to this technique, and these patients have traditionally undergone open surgery. We present a review of 23 morbidly obese patients in comparison with patients who were not morbidly obese who underwent radical laparoscopic nephrectomy and nephroureterectomy at our institution.

PATIENTS AND METHODS

Hospital charts between April 2001 and October 2003 were reviewed for morbidly obese patients undergoing transperitoneal laparoscopic renal surgery who were compared with age- and sex-matched control patients who underwent laparoscopic renal surgery in the same institution for similar indications. The data were collected at the time of the surgery.

RESULTS

Twenty-three patients with a mean BMI of 42.2 kg/m2 underwent successful transperitoneal laparoscopic surgery. The mean specimen mass was 865 g, which was significantly larger than in the control group. The mean operative time was 200 minutes, which was around half an hour longer than in the matched group. The mean estimated blood loss was 243 mL, which was comparable to that of the controls. There were two perioperative complications, and the mean hospital stay was 4.5 days, 1 day longer than in the control group.

CONCLUSIONS

Laparoscopic transperitoneal renal surgery is technically more difficult in morbidly obese patients but is a feasible, effective, minimally invasive method of removing renal malignancies. It offers decreased respiratory and cardiac morbidity in this higher-risk population. This study showed a complication profile similar to that in non-obese patients.

Laparoscopic radical nephrectomy: techniques, results and oncological outcome in 125 consecutive cases

OBJECTIVES

Renal cell carcinoma is likely to become one of the most important indication for laparoscopic surgery. The laparoscopic technique combines the benefits of minimal invasive approach with established surgical principles. In our institution the laparoscopic transperitoneal approach with intact specimen removal has become the standard technique for radical nephrectomies. We report the indications, techniques and oncological outcome in a single center experience.

PATIENTS AND METHODS

Between July 1999 and March 2003 we performed laparoscopic radical nephrectomies for renal cell cancer in 125 patients. Their initial staging, complications, and postoperative course were evaluated. During this period a total of about 1800 laparoscopic cases were performed. To date 82 patients were available for follow up data and have been analyzed for oncological outcome. Patients with primary metastatic disease were excluded from this analysis.

RESULTS

123 procedures out of 125 were successful. In two cases (1.6%) conversion to open surgery was necessary due to bleeding (1 case) or bowel injury (1 case). In additional 3 cases (2.4%) intraoperative complications could be managed laparoscopically. In two cases (1.6%) postoperative bleeding lead to open revision for hemostasis. The mean tumor size was 5.1cm (range 2-14 cm); median blood loss was 210 ml (range 50-900 ml). The mean surgical time was 200 min (range 90-435), including the learning curves of five surgeons. Histological findings were pT1 in 78 (62.4%), pT2 in 12 (9.6%) and pT3 in 28 (22.4%) patients. In 7 cases (5.6%) histology did not confirm malignant disease. Positive lymph nodes were detected in 3 cases (2.4%); surgical margins were negative for tumor in all patients. Follow-up was between 3 and 50 months with an average of 23.5 months. Disease progression was observed in 3 cases after 6, 11 and 12 months. No cases of local recurrence or port metastasis occurred during observation.

CONCLUSIONS

Laparoscopic radical nephrectomy is a routine, effective treatment for patients with pT1-2N0M0 renal cell carcinoma. With more experience a tumor up to 10-12 m in size can be managed safely offering all the benefits of minimal surgery to the patients. Although no long-term follow-up is available our follow-up data up to 50 months confirm the effectiveness of laparoscopic radical nephrectomy in terms of surgical principles and oncological outcome.

Laparoscopic colorectal surgery in obese and nonobese patients: do differences in body mass indices lead to different outcomes?

BACKGROUND

The aim of this prospective study was to compare the outcome of laparoscopic colorectal surgery in obese and nonobese patients.

METHODS

All patients who underwent laparoscopic surgery for both benign and malignant disease within the past 5 years were entered into the prospective database registry. Body mass index (BMI; kg/m(2)) was used as the objective measure to indicate morbid obesity. Patients with a BMI >30 were defined as obese, and patients with a BMI <30 were defined as nonobese. The parameters analyzed included age, gender, comorbid conditions, diagnosis, procedure, duration of surgery, transfusion requirements, conversion rate, overall morbidity rate including major complications (requiring reoperation), minor complications (conservative treatment) and late-onset complications (postdischarge), stay on intensive case unit, hospitalization, and mortality. For objective evaluation, only laparoscopically completed procedures were analyzed. Statistics included Student's t test and chi-square analysis. Statistical significance was assessed at the 5% level (p < 0. 05 statistically significant).

RESULTS

A total of 589 patients were evaluated, including 95 patients in the obese group and 494 patients in the nonobese group. There was no significant difference in conversion rate (7.3% in the obese group vs 9.5% in the nonobese group, p > 0.05) so that the laparoscopic completion rate was 90.5% (n = 86) in the obese and 92.7% (n = 458) in the nonobese group. The rate of females was significantly lower among obese patients (55.8% in the obese group vs 74.2% in the nonobese group, p = 0.001). No significant differences were observed with respect to age, diagnosis, procedure, duration of surgery, and transfusion requirements (p > 0.05). In terms of morbidity, there were no significant differences related to overall complication rates with respect to BMI (23.3% in the obese group vs 24.5% in the nonobese group, p > 0.05). Major complications were more common in the obese group without showing statistical significance (12.8% in the obese group vs 6.6% in the nonobese group, p = 0.078). Conversely, minor complications were more frequently documented in the nonobese group (8.1% in the obese group vs 15.5% in the nonobese group, p = 0.080). In the postoperative course, no differences were documented in terms of return of bowel function, duration of analgesics required, oral feeding, and length of hospitalization (p > 0.05).

CONCLUSION

These data indicate that laparoscopic colorectal surgery is feasible and effective in both obese and nonobese patients. Obese patients who are thought to be at increased risk of postoperative morbidity have the similar benefit of laparoscopic surgery as nonobese patients with colorectal disease.

Laparoscopic radical nephrectomy in obese patients: outcomes and technical considerations

OBJECTIVES

To review our technique and experience with laparoscopic radical nephrectomy (LRN) in the obese patient population. Obesity has been considered a potential risk factor for poor outcomes in a variety of surgical procedures and has been considered a relative contraindication to laparoscopy. Since 1996, with increased experience and technical modifications, obesity has not been considered a contraindication for laparoscopy at our institution.

METHODS

Retrospective data were obtained for all patients who underwent LRN from January 1997 to December 2000. A body mass index (Quetelet's index) greater than 30 was used to define obese patients. Technical modifications included slightly greater insufflation pressures and a lateral shift in trocar sites. The obese laparoscopic group was compared with the nonobese laparoscopic group.

RESULTS

Of 101 patients who underwent LRN, 69 were not obese and 32 were obese. No statistically significant differences were observed in any of the analyzed operative data between the nonobese laparoscopic group and obese laparoscopic group, including a mean operative time of 220 and 242 minutes, respectively. Other factors assessed were the time to ambulation, length of hospital stay, conversion rate to an open procedure, and complication rate, which also demonstrated no statistically significant difference. Only one conversion to an open procedure was required in both the obese and the nonobese laparoscopic groups.

CONCLUSIONS

With minor technical modifications, LRN can be safely performed in obese patients. Proper trocar site selection and greater insufflation pressures were critical for success. The differences in the intraoperative and postoperative course of LRN in obese and nonobese patients were not statistically significant. Obesity should not be considered a contraindication to laparoscopic nephrectomy.

Retroperitoneoscopic radical nephrectomy in a super-obese patient (body mass index 77 kg/m2)

Although obesity was initially considered a relative contraindication for laparoscopy, the retroperitoneal approach has been reported to be safe and effective for such patients during renal and adrenal surgery. We report a case of successful retroperitoneoscopic radical nephrectomy in a super-obese patient (body mass index 77 kg/m2) with a 12-cm renal tumor. The operative time was 3 hours, and the estimated blood loss was 100 mL. The patient was discharged home 36 hours after surgery. No intraoperative or perioperative complications occurred. The pathologic examination revealed renal cell carcinoma, and all surgical margins were negative (pT2N0M0). The patient returned to normal activities 3 weeks postoperatively.

[Laparoscopic radical nephrectomy: indications, techniques, and oncological outcome]

Renal cell carcinoma is likely to become one of the most important indications for laparoscopic surgery worldwide. The laparoscopic technique combines the benefits of the minimally invasive approach with established surgical principles. In our institution the laparoscopic transperitoneal approach with intact specimen extraction has become the standard technique for radical nephrectomies. We report the indications, techniques, and oncological outcome in a single center experience in 100 cases. The mean tumor size was 5.9 cm (range: 2-11 cm), the blood loss was 220 ml, and the mean surgical time was 211 min, including the learning curves of five surgeons. Histological findings were pT1 in 66 (66%), pT2 in 11 (11%), and pT3 in 19 (19%) patients with an increasing tumor size according to the experience of the surgeons. In four cases (4%) histology did not prove malignant disease. Positive lymph nodes were detected in three cases (3%) and surgical margins were negative for tumor in all patients. To date 61 patients were available for follow-up; patients with primary metastatic disease were excluded from this analysis. Follow-up was between 1 and 30 months with an average of 12.9 months. Progressive disease occurred in two cases in patients with pT3G3 tumors. No cases of local recurrence or port metastasis occurred during observation. Laparoscopic radical nephrectomy is a routine, effective treatment for patients with renal cell carcinoma. Our follow-up data up to 30 months confirm the effectiveness of laparoscopic radical nephrectomy in terms of surgical principles and oncological outcome.

Hand-assisted laparoscopy for large renal specimens: a multi-institutional study

OBJECTIVES

To present our experience with hand-assisted laparoscopy (HAL) for larger renal specimens. One of the theoretical benefits of HAL is the ability to manage large renal specimens, which we defined as tumors greater than 7 cm, and tumors in obese patients.

METHODS

Between March 1998 and October 2000, 106 HAL radical nephrectomies were performed for enhancing renal masses, for which 95 patients had complete preoperative, intraoperative, and postoperative data. Of the 95 patients, 32 underwent HAL for large tumors (7 cm or greater) and 41 had a body mass index of 31 or greater. The demographic and outcome data of these two groups were compared with 63 patients who underwent HAL for tumors less than 7 cm and 54 patients with a body mass index of less than 31.

RESULTS

When comparing cohorts by tumor size, the only statistically significant differences were in convalescence and specimen weight. Patients with lesions 7 cm or greater required 21 days to recover compared with 18 days for patients with lesions less than 7 cm. Obese patients had statistically significantly higher American Society of Anesthesiologists classifications, longer operative times (214 versus 176 minutes), and longer convalescences (21 versus 17.5 days) compared with nonobese patients. The estimated blood loss and conversion rate was not different between the groups. Furthermore, no difference was noted between the groups in the incidence of positive margins, local recurrence, or metastatic recurrence at a mean follow-up of 12.2 months.

CONCLUSIONS

HAL provides a safe, reproducible, and minimally invasive technique to remove large renal tumors and renal tumors in the obese.