Laparoscopic nephrectomy: an established routine procedure

Prospective study of preoperative factors predicting intraoperative difficulty during laparoscopic transperitoneal simple nephrectomy

OBJECTIVE

To prospectively study and identify, the preoperative factors which predict intraoperative difficulty in laparoscopic transperitoneal simple nephrectomy.

PATIENTS AND METHOD

Seventy seven patients (41 males and 36 females) with mean age of 43 ± 17 years, undergoing transperitoneal laparoscopic simple nephrectomy at our institute between February 2012 to May 2013 were included in this study. Preoperative patients' characteristics recorded were: Gender of patients, history of intervention, palpable lump, BMI, urine culture, side, size of kidney, fixity of kidney on USG, perinephric fat stranding on preoperative CT scan, periureteral fat stranding, perinephric collection, enlarged hilar lymph nodes, renal vascular anomalies, differential renal function on renogram. Preoperative factors of these patients were noted and intraoperative difficulty in the surgery was scored between 1 (easiest) to 10 (most difficult or open conversion) by a single surgeon (who was a part of all studies either as operating surgeon or assistant). Using SPSS 15.0 software, multivariate and univariate analysis was done.

RESULTS

In multivariate analysis presence of pyonephrosis on preoperative evaluation and BMI < 25kg/m(2) were found to be statistically significant factors predicting intraoperative difficulty during laparoscopic simple nephrectomy. On univariate analysis following factors were associated with increased surgeon's score: Lower BMI, palpable kidney, pyonephrosis, history of renal intervention, perinephric fat stranding, right side, fixity of kidney on USG with surrounding structures.

CONCLUSION

Our findings suggest that presence of pyonephrosis as identified on preoperative imaging and a BMI of less than 25 Kg/m(2) are the most significant factors predicting intraoperative difficulty during laparoscopic simple nephrectomy.

Outcome of retroperitoneoscopic nephrectomy for benign nonfunctioning kidney: a single-center experience

OBJECTIVE

To analyze the feasibility and outcome of retroperitoneoscopic nephrectomy for benign nonfunctioning kidneys and compare it with open simple nephrectomy.

MATERIALS AND METHODS

From January 1998 to December 2006, 505 retroperitoneoscopic nephrectomies were performed. In the same time period, 112 open nephrectomies were also performed. In the retroperitoneoscopic group, the mean age was 39 years (range 15-74 years); 204 (40.4%) were men and 301 (59.6%) were women. Forty in this group had a history of surgery. Thirty-six patients had a pyonephrotic kidney; 33 of these patients had undergone percutaneous nephrostomy preoperatively. The cause of the nonfunctioning kidney was ureteropelvic junction obstruction in 198 patients, calculus disease in 193 patients, genitourinary tuberculosis in 48 patients, renal dysplasia in 19 patients, anomalous kidney in 20 patients, and renovascular hypertension in 16 patients. In 11 patients, there were other causes for the nonfunctioning kidney.

RESULTS

Retroperitoneoscopic nephrectomy was performed in 476 (94.2%) patients. Conversion to open nephrectomy was necessary in 25 patients. The mean operative time was 85 minutes (range 45-240 min) in the retroperitoneoscopic group and 70 minutes (range 35-120 min) in the open group. The mean blood loss was 110 mL (range 30-600 mL) in the retroperitoneoscopic group and 170 mL (range 70-500 mL) in the open group. Four (0.8%) patients in the retroperitoneoscopic group needed a blood transfusion, whereas 5 (4.5%) patients in the open group had a blood transfusion. The hospital stay in the retroperitoneoscopic group was 3 days (range 1-7 d) and was 5 days (range 3-12 d) in the open group.

CONCLUSIONS

Retroperitoneoscopic nephrectomy, although technically challenging, is becoming a gold standard for patients with nonfunctioning kidneys caused by benign conditions.

Hand-assisted laparoscopic nephrectomy for inflammatory renal conditions

PURPOSE

Laparoscopic surgery for large renal lesion or kidneys with chronic inflammation has proved to be technically challenging. Hand-assisted laparoscopic surgery might be useful in these complex cases, as it provides surgeons the benefits of tactile feedback, digital retraction, and facilitated dissection of the renal hilar vessels.

PATIENTS AND METHODS

Twenty-two patients undergoing hand-assisted laparoscopic (HAL) nephrectomy for benign conditions were compared with patients who underwent HAL radical nephrectomy during the same period. The demographic data, laterality, operative time, estimated blood loss, conversion rate, length of stay, histopathology findings, morbidity, and mortality were reviewed.

RESULTS

The main indications for surgery were chronic inflammation and xanthogranulomatous pyelonephritis. Twenty patients had unilateral nephrectomy (10 each on the right and left), and two patients had bilateral nephrectomy. The mean operative times for unilateral and bilateral nephrectomy were 163 minutes (range 55-261 minutes) and 265 minutes (range, 238-291 minutes), respectively. Nine patients (45%) with inflammation had complications (15% major and 30% minor). The mean length of hospitalization for patients undergoing HAL nephrectomy was 7.2 days (range 2-35 days). The patients with inflammatory pathology had longer mean operative times, higher estimated blood loss, longer hospital stay, and higher morbidity than patients undergoing radical nephrectomy.

CONCLUSION

Compared with standard laparoscopy, the hand-assisted approach has been reported to reduce operative times and increase safety. The advantages of minimally invasive surgery, such as reduced analgesia, shorter hospital stay, and faster return to normal activity, appear to be similar to those in patients undergoing a pure laparoscopic nephrectomy. Compared with radical nephrectomy for renal tumor, HAL simple nephrectomy can often be more challenging and associated with greater morbidity. For both the community urologist as well as an experienced laparoscopist, this approach is useful in handling these challenging cases.

Complications of laparoscopic urologic surgery

Laparoscopic techniques performed in the urologic setting have received great attention in the past decade. With the development of improved laparoscopic instrumentation, approaches to gonadal, renal, prostate, and bladder diseases have been successfully performed. A discussion of urologic laparoscopy (UL) with particular attention to potential complications and limitations is presented. Awareness of these evolving technologies remains critical to all surgeons with an interest in laparoscopy.

Comparison of Gas-less laparoscopy-assisted surgery, hand-assisted laparoscopic surgery and pure laparoscopic surgery for radical nephrectomy

BACKGROUND

We report our experience with Gas-less laparoscopy-assisted surgery (Gas-less LAS), hand-assisted laparoscopic surgery (HALS) and pure laparoscopic surgery (LS) for renal carcinoma and compare the characteristics and usefulness of these methods.

METHODS

Seventeen, 14 and 16 patients were subjected to Gas-less LAS, HALS and LS, respectively. The study started with Gas-less LAS and then gradually shifted to HALS and LS. We evaluated the operative and postoperative parameters for each group. The learning curve effect was evaluated based on data from the first 10 cases of each group, which were operated on by the same surgeon and operation team.

RESULTS

The learning curve of operation times in the LS group demonstrated that the operation time for this procedure is acceptable even in early-stage cases. Differences in mean operative time between the three surgical groups, excluding the conversion cases, were not statistically significant; however, there was a significant difference in blood loss volume between the groups (P </= 0.001). Operation time tended to be shorter in Gas-less LAS and the frequency of parental analgesia administration tended to be reduced in the LS group when compared to the other two groups. Of the total 47 patients treated, two cases were converted to open surgery. The major postoperative complication was one case of brain infarction in the HALS group. One patient in the LS group developed a lung metastasis 11 months after the operation.

CONCLUSION

As minimally invasive operative techniques, these three methods do not differ significantly in terms of surgical outcome; however, LS tended to be slightly superior in terms of postoperative pain control and cosmetic appearance.

Complications of contemporary radical nephrectomy: comparison of open vs. laparoscopic approach

Increasingly, laparoscopy is being employed in the treatment of urologic malignancies. This is most apparent in kidney cancer, where laparoscopic radical nephrectomy is now considered to be a gold standard. Herein, we compared early postoperative morbidity in a contemporary series of open and laparoscopic radical nephrectomies. We reviewed all patients that underwent a radical nephrectomy between October 1999 and May 2001 at our institution. We then compared open radical nephrectomy patients to those undergoing laparoscopic approaches with specific attention to early complications. A total of 74 radical nephrectomies were performed: 41 open, 18 hand-assisted and 15 pure laparoscopic nephrectomies. Overall, complication rates between the open, hand-assist and pure laparoscopic groups were similar (10%, 17% and 12%, respectively, P = 0.133). There was no statistically significant difference in ASA score (P = 0.144), pre-operative hematocrit (P = 0.575) or intra-operative blood loss (P = 0.364). The open nephrectomy group had a statistically larger average tumor size (7.4 cm vs. 4.6 cm; P = 0.005) and younger average age (57 vs. 63; P = 0.019) than the laparoscopic group. Length of hospital stay was significantly shorter in the laparoscopic group (3.6 days vs. 1.7 days; P < 0.0001). Laparoscopic radical nephrectomy has an acceptably low complication rate and compares favorably to open radical nephrectomy. The low rate of complications combined with the advantages of laparoscopic surgery favor a laparoscopic approach for the majority of patients with stage T1 and T2 tumors.

Laparoscopic nephrectomy: prediction of outcome in relation to the preoperative risk factors in two approaches

PURPOSE

The data on laparoscopic nephrectomy in Mansoura Urology & Nephrology Center were reviewed to identify the preoperative findings that may predict the need for conversion to open surgery.

PATIENTS AND METHODS

One hundred sixty-three patients were subjected to transperitoneal laparoscopic nephrectomy, while 82 underwent retroperitoneal laparoscopic nephrectomy for benign renal diseases. The preoperative demographic data and laboratory and radiologic findings of these patients were correlated with failure rate of the laparoscopic procedure.

RESULTS

The overall failure rate was 10.4% and 11% for the transperitoneal and retroperitoneal approach, respectively. Positive urine culture, renographic clearance of the removed kidney (>10 ml/min), and learning curve were independently associated with a greater risk of failure in patients undergoing transperitoneal nephrectomy. For the retroperitoneal approach, a positive urine culture, renographic clearance (> or =10 ml/min), and large kidney showed statistical significance.

CONCLUSION

Preoperative data could be used as a predictor of laparoscopic nephrectomy outcome in patients with benign renal diseases. A more experienced surgeon should be selected for risky cases, bearing in mind the greater potential for early conversion to open surgery.

Retroperitoneoscopic nephrectomy and nephroureterectomy for benign nonfunctioning kidneys: a single-center experience

OBJECTIVES

To report our experience of 185 cases of retroperitoneoscopic nephrectomy and nephroureterectomy for benign nonfunctioning kidneys with various modified techniques for differing etiologies. The feasibility, complications, and long-term outcomes are discussed.

METHODS

The present study comprised 185 patients who underwent retroperitoneoscopic nephrectomy or nephroureterectomy during a 57-month period beginning July 1995. All procedures were done using the retroperitoneoscopic approach. Thirty-two patients had a history of previous surgery, 20 patients had a percutaneous nephrostomy, and 12 patients had mild renal impairment.

RESULTS

Retroperitoneoscopic nephrectomy and nephroureterectomy were completed successfully in 167 patients. Eighteen patients required conversion to open surgery, 4 on an emergent basis and 14 electively. The mean operating time was 100 minutes (range 45 to 240), mean blood loss was 133 mL (range 30 to 1200), and mean hospital stay was 3 days (range 2 to 8). A total of 37 complications (16.2% were minor and 3.78% were major) occurred. Re-intervention was needed in 1 patient. No mortality resulted. Previous surgery, percutaneous nephrostomy, and chronic renal impairment did not affect the outcome. Apart from one incisional hernia, no long-term complications occurred.

CONCLUSIONS

Retroperitoneoscopic nephrectomy and nephroureterectomy can be performed safely and successfully with obvious advantages for benign nonfunctioning kidneys regardless of the etiology or pathogenesis, with modifications in the approach in very difficult cases. Patients with conditions often considered to be contraindications (ie, genitourinary tuberculosis, pyonephrosis, history of previous surgery, percutaneous nephrostomy, stone disease, chronic renal failure, and horseshoe kidney) can also be successfully treated by skillful dissection and modifications in the surgical technique.

Simple nephrectomy: transperitoneal approach

Transperitoneal laparoscopic nephrectomy is performed much as originally described by Clayman and associates, although preoperative embolization of the kidney is no longer routine. Some surgeons use a hand-assisted technique, especially in difficult cases or when the organ is being removed intact, as in live-donor nephrectomy.

Laparoscopic nephrectomy in patients with end-stage renal disease and autosomal dominant polycystic kidney disease

Autosomal dominant polycystic kidney disease (ADPKD) is often characterized by end-stage renal disease (ESRD) and problems including pain, hematuria, and infection. Open nephrectomy is curative; however, the morbidity of the procedure is considerable. Between 1995 and 1998, 11 laparoscopic nephrectomies were performed on nine symptomatic patients (five men and four women) with ESRD and ADPKD. Two patients underwent a staged bilateral laparoscopic nephrectomy. All patients presented with abdominal or flank pain and an abdominal mass. Other clinical problems included hypertension in eight patients, urinary tract infections in two patients, and gross hematuria in one patient. Seven patients were receiving long-term dialysis treatment, and two patients had undergone prior renal transplantation. Patients were evaluated for preoperative and postoperative pain, analgesic use, hospital course, and convalescence. The overall average operative time was 6.3 hours, with an average estimated blood loss of 153 mL. Eight nephrectomy specimens were removed by morcellation, and three specimens were removed intact through a 7- to 12-cm incision. The average hospital stay was 3 days, and the average time to normal activity was 5 weeks. With a mean follow-up of 31 months, all nine patients reported elimination of their preoperative pain based on a pain analogue score. Six major and two minor complications occurred, including blood transfusion, a vena cavotomy, splenic cyanosis, pulmonary embolism, clotted arteriovenous fistula, and brachial plexus injury. Incisional hernias occurred in two of the three patients who underwent open removal. One patient noted improvement, and two patients noted resolution of their hypertension postoperatively. Laparoscopic nephrectomy in patients with ADPKD and ESRD offers an effective alternative to open nephrectomy to manage renal-related pain. This procedure provides the benefits of minimal intraoperative blood loss, minimal postoperative pain, brief hospital stay, and rapid convalescence.

Laparoscopic nephrectomy for renal cell cancer: evaluation of efficacy and safety: a multicenter experience

OBJECTIVES

Although laparoscopic radical nephrectomy is a safe and minimally invasive alternative to open surgery, the long-term disease-free outcome of this procedure has not been reported. We evaluated our experience with the laparoscopic management of renal cell carcinoma to assess the clinical efficacy of this surgical modality.

METHODS

Between February 1991 and June 1997, 157 patients at five institutions were retrospectively identified who had clinically localized, pathologically confirmed, renal cell carcinoma and had undergone laparoscopic radical nephrectomy. Operative and clinical records were reviewed to determine morbidity, disease-free status, and cancer-specific survival. Of the patients followed up for at least 12 months (n = 101), 75% had an abdominal computed tomography scan at their last visit.

RESULTS

The mean age at surgery was 61 years (range 27 to 92) and all patients were clinical Stage T1-2,NO,MO. Fifteen patients (9.6%) had perioperative complications. During a mean follow-up of 19.2 months (range 1 to 72; 51 patients with 2 years or more of follow-up), no patient developed a laparoscopic port site or renal fossa tumor recurrence. Four patients developed metastatic disease, and 1 patient developed a local recurrence. The 5-year actuarial disease-free rate was 91%+/-4.8 (SE). At last follow-up, there were no cancer-specific mortalities.

CONCLUSIONS

The laparoscopic surgical management of localized renal cell carcinoma is feasible. Short-term results indicate that laparoscopic radical nephrectomy is not associated with an increased risk of port site or retroperitoneal recurrence. Longer follow-up is necessary to compare long-term survival and disease-free rates with those of open surgery.

Retroperitoneal laparoscopic nephrectomy

When removal of a kidney is indicated for symptomatic end-stage renal disease of benign etiology, laparoscopic nephrectomy by the retroperitoneal approach is increasingly being employed as the technique of choice at many centers. Emerging data indicate that, in select patients with T1-T3aN0M0 renal tumors < 8 cm, retroperitoneal laparoscopic radical nephrectomy may be a viable treatment option.

Retroperitoneoscopy: a laparoscopic approach for adrenal and renal surgery

OBJECTIVES

Retroperitoneoscopy has gained acceptance for urologic surgery. We assessed the safety and efficacy of this procedure for renal and adrenal surgery.

METHODS

Since December 1994, 20 patients (18 to 75 years old) have undergone laparoscopic adrenalectomy and nephrectomy, including simple nephrectomy in 8, partial nephrectomy in 1, radical nephrectomy in 2, tumorectomy with cyst excision in 1, and adrenalectomy in 8. The retroperitoneal space was created by blunt dissection with the index finger, completed by insufflation, without balloon dissection.

RESULTS

Average kidney size was 65 m (range 50 to 108), and average adrenal tumor size was 31 mm (range 20 to 40). The average operating time was 127 minutes (range 60 to 180) for nephrectomy and 84 minutes (range 45 to 140) for adrenalectomy. The average hospital stay was 3 days (range 1 to 7) for nephrectomy and 2.4 days (range 1 to 4) for adrenalectomy. Average blood loss was 65 mL for both nephrectomy and adrenalectomy. Conversion from the laparoscopic procedure to open surgery was never required. Peritoneal effraction and ureteral injury occurred in only 4 patients and 1 patient, respectively.

CONCLUSIONS

The laparoscopic retroperitoneal approach is safe and effective for simple renal nephrectomy and for excision of small adrenal tumors. Perioperative morbidity and hospital stay are reduced.

Laparoscopic adrenalectomy: review of 14 cases and comparison with open adrenalectomy

We reviewed 14 cases of laparoscopic adrenalectomy and compared the results with those of a recent series of 15 consecutive patients undergoing a traditional open adrenalectomy for a benign tumor. The laparoscopic adrenalectomy group included nine patients with primary aldosteronism, three with Cushing's syndrome, one with pheochromocytoma, and one with a nonfunctioning incidentaloma. In the patient with pheochromocytoma, a good operative field was safely obtained by a combination of pneumoperitoneum at less than 6 mm Hg insufflation pressure and the abdominal wall-lift method. In both groups, the tumors were removed successfully in all cases. Laparoscopic adrenalectomy, which required neither a large skin and muscle incision nor any resection of the ribs, offered a lower morbidity and earlier recovery in spite of the longer operation time. The most important complication observed in laparoscopic adrenalectomy was that of pneumothorax secondary to an injury of the diaphragm and pleura during the dissection of the left adrenal gland using electrocautery. However, the injury wound was small, and the pneumothorax was resolved by suturing the tear under laparoscopy. These results suggest that laparoscopic adrenalectomy is a minimally invasive alternative to traditional open adrenalectomy and thus has the potential soon to become a standard procedure for the treatment of benign adrenal tumors.