THE LONG-TERM OUTCOME OF LAPAROSCOPIC RADICAL NEPHRECTOMY FOR SMALL RENAL CELL CARCINOMA

Initial Experiences of Laparoscopic Nephrectomy in a Tertiary Oncology Center: An Analysis of 142 Cases

INTRODUCTION

Kidney tumors have an important place among urological malignancies. The increased utilization of imaging methods has led to a rise in renal cell carcinoma (RCC) diagnoses, albeit with declining mortality rates, particularly in developed countries. Radical nephrectomy remains the gold standard treatment. The aim of this study was to share a tertiary oncology hospital's initial experiences with laparoscopic nephrectomy.

MATERIALS AND METHODS

This retrospective study analyzes data from patients who underwent laparoscopic nephrectomy, focusing on demographic characteristics, tumor features, and operative outcomes. Information regarding age, gender, tumor size, operative details, and pathology results was collected and analyzed.

RESULTS

One hundred forty-two patients were included in the study; 69 (48.60%) were female and 73 (51.40%) were male. The mean age of the patients was 57.11 ± 12.6 years, with tumors primarily located on the left kidney (52.80%). The mean tumor size was 53.01 ± 24.01 mm. Intraoperative complications included the need for conversion to open surgery in five cases and vascular, pneumothorax, or duodenal injuries in a subset of patients. However, postoperative complications, such as sepsis or mortality, were not observed.

DISCUSSION

Despite an initial learning curve associated with longer operation times, laparoscopic techniques offer benefits, including reduced blood loss, faster recovery, and improved cosmetic outcomes. Histologically, clear cell RCC was the most common tumor type encountered. This study underscores the safety and efficacy of laparoscopic radical nephrectomy, advocating for its widespread adoption while emphasizing the importance of surgeon experience and patient selection in optimizing outcomes.

The role of open radical nephrectomy in contemporary management of renal cell carcinoma

Radical nephrectomy (RN) remains a cornerstone of the management of localised renal cell carcinoma (RCC). RN involves the en bloc removal of the kidney along with perinephric fat enclosed within Gerota's fascia. Key principles of open RN include appropriate incision for adequate exposure, dissection and visualisation of the renal hilum, and early ligation of the renal artery and subsequently renal vein. Regional lymph node dissection (LND) facilitates local staging but its therapeutic role remains controversial. LND is recommended in patients with high risk clinically localised disease, but its benefit in low risk node-negative and clinically node-positive patients is unclear. Concomitant adrenalectomy should be reserved for patients with large tumours with radiographic evidence of adrenal involvement. Despite a recent downtrend in utilisation of open RN due to nephron-sparing and minimally invasive alternatives, there remains a vital role for open RN in the management of RCC in three domains. Firstly, open RN is important to the management of large, complex tumours which would be at high risk of complications if treated with partial nephrectomy (PN). Secondly, open RN plays a crucial role in cytoreductive nephrectomy (CN) for metastatic RCC, in which the laparoscopic approach achieves similar results but is associated with a high reoperation rate. Finally, open RN is the current standard of care in the management of inferior vena caval (IVC) tumour thrombus. Management of tumour thrombus requires a multidisciplinary approach and varies with cranial extent of thrombus. Higher level thrombus may require hepatic mobilisation and circulatory support, whilst the presence of bland thrombus may warrant post-operative filter insertion or ligation of the IVC.

An Easy and Effective Method to Locate Renal Vein During Retroperitoneal Laparoscopic Radical Nephrectomy: Single-Center Experience

Background

There are few studies that address how to quickly locate the renal vein after processing the renal artery during retroperitoneal laparoscopic radical nephrectomy (RLRN) for renal cell carcinoma (RCC). This study aimed to evaluate the feasibility of an easy and effective method to locate the renal vein in RLRN.

Material/Methods

Between September 2016 and October 2017, a total of 44 consecutive cases of RLRN were performed. All the surgeries used the proposed study method to locate the renal vein, in which surgeons located the renal artery following the medial arcuate ligament on the posterior abdominal wall, then the surgeon directly searched for the renal vein caudally relative to renal artery when performing left nephrectomy, but cranially when performing right nephrectomy.

Results

Among the 44 enrolled RLRN patients, there were 28 left nephrectomies and 16 right nephrectomies. We found the renal vein in most cases successfully by our proposed method. The renal vein was located caudally relative to the renal artery in 27 cases of the left kidney (96.4%), and was located cranially in 14 cases of the right kidney (87.5%). The mean operative time was 135.0±27.8 minutes. No intraoperative complications occurred. Postoperative complications (fever) developed in 5 patients. Pathological examination revealed: clear cell carcinoma in 34 cases (77.3%), chromophobe renal cell carcinoma (RCC) in 5 cases (11.4%), papillary RCC in 3 cases (6.8%), multilocular cystic RCC in 1 case (2.3%), and oxyphil cell adenoma in 1 case (2.3%).

Conclusions

Our proposed method to search for the renal vein might be a safe and feasible procedure to accelerate the process of handling the renal pedicle and of great practical significance in RLRN surgery.

Utility of anteroposterior diameter ratio of tumor and abdomen for laparoscopic approach for radical nephrectomy in large renal masses

INTRODUCTION

Laparoscopic radical nephrectomy (LRN) is now increasingly done for tumors larger than 10 cm. Despite selection of favorable cases, LRN may not be successful due to lack of adequate working space with large tumors. We describe a new feature on Contrast Enhanced Computed Tomography (CECT) abdomen to predict feasibility of LRN for large renal masses between 10 and 15 cm.

METHODS

From January 2005 to December 2015, renal tumors between 10 and 15 cm were selected retrospectively for LRN. Patients with retroperitoneal lymphadenopathy, Inferior vena cava (IVC) thrombus and involvement of adjacent organs were excluded. Anteroposterior (AP) diameter ratio of renal tumor and abdomen (APROTA) was calculated by dividing the maximum AP diameter of tumor along with normal renal parenchyma, by the AP diameter of abdomen on CECT. The patients were stratified into two groups: Group A (successful LRN) and Group B (conversion to open surgery) and outcomes were compared. The reasons for conversion were also noted.

RESULTS

Of 29 patients, 16 (55.2%) had successful LRN (Group A), while 13 (44.8%) had conversion to open surgery (group B). The median tumor size in Group A was 11.3 ± 1.8 cm and in Group B was 13.6 ± 1.26 cm. Eleven of 13 patients had conversion due to large tumor size causing failure to progress. Two conversions were due to bleeding and injury to the colon each. There was a significant difference in the APROTA in group A and B [0.43 ± 0.09 in group A and 0.64 ± 0.14 in group B (p = 0.0001)].

CONCLUSIONS

Patients with APROTA of more than 0.65 are unlikely to have successful outcome with LRN.

Laparoscopic Versus Open Radical Nephrectomy for Renal Cell Carcinoma: a Systematic Review and Meta-Analysis

BACKGROUND

The aim of this study is to summarize and quantify the current evidence on the therapeutic efficacy of laparoscopic radical nephrectomy (LRN) compared with open radical nephrectomy (ORN) in patients with renal cell carcinoma (RCC) in a meta-analysis.

METHODS

Data were collected by searching Pubmed, Embase, Web of Science, and ScienceDirect for reports published up to September 26, 2016. Studies that reported data on comparisons of therapeutic efficacy of LRN and ORN were included. The fixed-effects model was used in this meta-analysis if there was no evidence of heterogeneity; otherwise, the random-effects model was used.

RESULTS

Thirty-seven articles were included in the meta-analysis. The meta-analysis showed that the overall mortality was significantly lower in the LRN group than that in the ORN group (odds ratio [OR] =0.77, 95% confidence interval [CI]: 0.62-0.95). However, there was no statistically significant difference in cancer-specific mortality (OR=0.77, 95% CI: 0.55-1.07), local tumor recurrence (OR=0.86, 95% CI: 0.65-1.14), and intraoperative complications (OR=1.27, 95% CI: 0.83-1.94). The risk of postoperative complications was significantly lower in the LRN group (OR=0.71, 95% CI: 0.65-0.78). In addition, LRN has been shown to offer superior perioperative results to ORN, including shorter hospital stay days, time to start oral intake, and convalescence time, and less estimated blood loss, blood transfusion rate, and anesthetic consumption.

CONCLUSION

LRN was associated with better surgical outcomes as assessed by overall mortality and postoperative complications compared with ORN. LRN has also been shown to offer superior perioperative results to ORN.

Clinical outcomes following laparoscopic management of pT3 renal masses: A large, multi-institutional cohort

INTRODUCTION

We described the clinical and oncological outcomes of patients treated by laparoscopic surgery for non-metastatic pT3 renal cell carcinoma (RCC).

METHODS

We queried a multi-institutional database for patients diagnosed with non-metastatic pathological T3 RCC from 13 Canadian centres treated laparoscopically (radical or partial nephrectomy) between 2008 and 2014. Clinical and pathological outcomes were evaluated. Progression was defined as the development of recurrence or metastatic disease. Log-rank testing and Kaplan-Meier statistical methods assessed for differences and estimated progression-free survival (PFS).

RESULTS

In total, 176 patients were identified with a median age of 64 years. The median tumour size was 7.0 cm. Pre-clinical stage was cT1 to cT4 in 39%, 28%, 30% and 3%, respectively. The median blood loss was 150 mL (range: 0-6000) and the median operative time was 124 minutes (range: 60-360). Most lesions were clear cell RCC (80%). After a median follow-up of 17.6 months (range: 0.2-75.0), disease progression occurred in 26% (46/176) of patients, consisting of local recurrence in 7% (3/46), and metastatic disease in 93% (43/46). The 3-year PFS was 67%, with a median PFS of 49 months. Of those who progressed, the median time to progression was 10.3 months.

CONCLUSIONS

This study is the largest cohort of pT3 RCC patients treated laparoscopically in the literature and suggests that for properly selected patients, laparoscopic management of locally advanced renal masses yields acceptable short-term oncological outcomes.

Fast access and early ligation of the renal pedicle significantly facilitates retroperitoneal laparoscopic radical nephrectomy procedures: modified laparoscopic radical nephrectomy

Background

The objective of this study was to develop a modified retroperitoneal laparoscopic nephrectomy and compare its results with the previous technique.

Methods

One hundred retroperitoneal laparoscopic nephrectomies were performed from February 2007 to October 2011. The previous technique was performed in 60 cases (Group 1). The modified technique (n = 40) included fast access to the renal pedicle according to several anatomic landmarks and early ligation of renal vessels (Group 2). The mean operation time, mean blood loss, duration of hospital stay conversion rate and complication rate were compared between the groups.

Results

No significant differences were detected regarding mean patient age, mean body mass index, and tumor size between the two groups (P >0.05). The mean operation time was 59.5 ± 20.0 and 39.5 ± 17.5 minutes, respectively, in Groups 1 and 2 (P <0.001). The mean intraoperative blood loss was 147 ± 35 and 100 ± 25 ml, respectively, in Groups 1 and 2 (P <0.001). No significant differences were detected regarding the conversion rate and the complication rate between the two groups (P >0.05).

Conclusions

Early ligature using fast access to the renal vessels during retroperitoneal laparoscopic radical nephrectomy contributed to less operation time and intraoperative blood loss compared with the previous technique. In addition, the modified technique permits the procedure to be performed following the principles of open radical nephrectomy.

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.

A Feasible Technique for Transient Vascular Occlusion by Using a Vessel Loop and Hem-o-Lok Clips in Laparoscopic Partial Nephrectomy

PURPOSE

We introduce our transient vascular occlusion technique that uses a vessel loop and Hem-o-Lok clips in laparoscopic partial nephrectomy.

MATERIALS AND METHODS

From March 2009 to March 2011, 15 consecutive patients underwent laparoscopic partial nephrectomy. All operations were performed by a single surgeon using the transperitoneal approach. The transient vascular occlusion technique was as follows. After dissection of renal vessels, the vessel loop is winded twice around the vessel. Both distal portions of the vessel loop are clipped with a Hem-o-Lok clip. When vascular occlusion is required, an additional Hem-o-Lok clip is applied to the proximal portion of the vessel loop by pulling the distal portion. When no longer needed, the vessel loop is simply cut.

RESULTS

All operations were performed successfully without open conversion. The mean tumor size was 2.5 cm (range, 1.1-3.5 cm). There were 8 cases of renal cell carcinoma and 7 cases of angiomyolipoma. All cases of renal cell carcinoma had a negative surgical margin. The mean operative time and the mean warm ischemic time were 176 minutes (range, 104-283 minutes) and 26.1 minutes (range, 18-34 minutes), respectively. There were no cases of uncontrollable intraoperative bleeding and no postoperative complications.

CONCLUSIONS

The transient vascular occlusion technique with a vessel loop and Hem-o-Lok clips is a feasible technique with simplicity, effectiveness, and safety. It is an acceptable alternative to standard vascular occlusion techniques, such as laparoscopic bulldog or Satinsky clamps.

[Operative treatment of renal cell carcinoma]

Renal cell carcinoma represents the fifth most frequent malignant tumor in humans. At the time of diagnosis, 20% of the patients already manifest metastases. A further 20-30% of the patients develop systemic metastases in the postoperative course. Despite continued advances in pharmacological treatment options, cancer surgery tailored to the individual tumor findings constitutes the only curative treatment option.

Laparoscopic versus Open Radical Nephrectomy in T2 Renal Cell Carcinoma: Long-Term Oncologic Outcomes

Purpose

Laparoscopic radical nephrectomy (LRN) has become the standard technique for radical nephrectomies for T1 renal tumors (7 cm or less). We extended our experience with LRN to T2 renal tumors (greater than 7 cm) and compared the efficacy and long-term oncologic outcomes with those of open radical nephrectomy (ORN) for T2 clear renal cell carcinoma (RCC) in the same period.

Materials and Methods

We retrospectively analyzed the data from 33 patients who underwent LRN and 35 patients who underwent ORN in our institution from January 2003 to June 2006 for T2N0M0 RCC. We compared long-term oncologic outcomes between the two groups.

Results

The median follow-up periods were 60.0 months (range, 48.0-77.0 months) and 65.6 months (range, 56.0-77.0 months) in the LRN and ORN groups, respectively. There were no statistically significant differences between the two groups in the patients' demographic data. There were no significant differences in the 5-year overall survival rate, the cancer-specific survival rate, or the recurrence-free survival rate.

Conclusions

Our results suggest that LRN for the management of T2 RCC is feasible and efficacious and that the long-term oncologic outcomes of LRN are comparable to those of ORN.

Laparoendoscopic single-site radical nephrectomy: a comparison with conventional laparoscopy

PURPOSE

To study the feasibility and safety of laparoendoscopic single-site (LESS) radical nephrectomy, we compared the operative results with conventional laparoscopic radical nephrectomy.

PATIENTS AND METHODS

Ten patients underwent LESS radical nephrectomy for renal tumors (group 1). Two types of single-port devices, a SILS port and a homemade single-port device that was made using a surgical glove and a wound retractor, were used through a 4-cm periumbilical incision. The operative results of LESS radical nephrectomy matched those of 12 patients who underwent conventional laparoscopic radical nephrectomy (group 2). For comparing the 2 groups, the Mann-Whitney U test and the Fisher exact test were used.

RESULTS

LESS surgeries were completed successfully, without conversion to conventional laparoscopic or open surgery. The patients' characteristics did not differ significantly between the two groups. The mean operative times in groups 1 and 2 were 127.7 ± 22.3 minutes and 126.1 ± 43.1 minutes, respectively (P = 0.235). The mean estimated blood loss was 185.7 ± 121.9 mL and 324.0 ± 187.0 mL, respectively (P = 0.65). The complication rates were 10% and 17%, respectively (P = 0.658). The mean times to postoperative initiation of ambulation and initiation of oral intake were not different in the two groups (1.1 vs 1.0 days, P = 0.269; 1.0 vs 1.0 day, P = 1.0). The mean lengths of hospital stay were 6.5 and 6.1 days (P = 0.435). The mean tumor sizes were 4.0 cm and 5.2 cm (P = 0.345).

CONCLUSIONS

LESS radical nephrectomy is technically feasible and comparable to conventional laparoscopy. Long-term follow-up and technical development, however, are needed for assessing the cancer-control effect and facilitating the minimal invasiveness of the surgery.

Hand-Assisted Laparoscopic Radical Nephrectomy: Comparison with Conventional Open Radical Nephrectomy

PURPOSE

To compare the outcomes of hand-assisted laparoscopic radical nephrectomy (HALRN) with those of open radical nephrectomy (ORN) for renal-cell carcinoma (RCC).

PATIENTS AND METHODS

A total of 130 patients with stage T(1) or T(2) RCC with a maximum diameter < 10 cm underwent radical nephrectomy by HALRN (n = 63) or ORN (n = 67). Data from these two groups were reviewed retrospectively.

RESULTS

Although the maximum tumor size treated by HALRN was significantly less than that treated by ORN, there were no significant differences in the remaining features of the two groups. One HALRN was converted to open surgery. The mean operative time for HALRN (273 minutes) was significantly longer than that for ORN (189 minutes), whereas the mean estimated blood loss (315 v 381 mL). There were significant differences in measures of postoperative recovery, including time to walking (1.4 days for HALRN v 2.2 days for ORN), time to oral intake (1.8 v 3.3 days), and time to grant of permission for hospital discharge (7.4 v 10.2 days). Postoperative complications were observed in one and four patients in the HALRN and ORN groups, respectively. There were no significant differences in the recurrence-free and cancer-specific survival rates in the two groups.

CONCLUSIONS

Despite the longer operative time, HALRN represents an effective, safe, and less-invasive treatment option for RCC. If performed for the proper indications, HALRN could achieve cancer control similar to that available with ORN.

Controlled Survival Study of the Effects of Tisseel or a Combination of FloSeal and Tisseel on Major Vascular Injury and Major Collecting-System Injury during Partial Nephrectomy in a Porcine Model

PURPOSE

We report the results of a controlled survival study in a porcine model investigating Tisseel or a combination of FloSeal and Tisseel in dealing with vascular and collecting-system injury during partial nephrectomy.

MATERIALS AND METHODS

We performed an open right lower-pole partial nephrectomy on 15 large female pigs. The defect was repaired using standard open techniques (N = 5; controls), Tisseel only (N = 6; group I), or FloSeal followed by Tisseel (N = 4; group II). A Jackson-Pratt drain was placed. Nephrectomy and retrograde pyelography were performed at 1 week.

RESULTS

Operative times were shorter in both study groups, achieving statistical significance in group I (P = 0.008). Warm-ischemia times were significantly improved in both study groups (P = 0.029 and P = 0.00005 in groups I and II, respectively). Time to hemostasis was significantly shorter in group II only (P = 0.002) but approached significance in Group I as well (P = 0.09). Estimated blood loss was not significantly different from the controls in either group. When Tisseel was placed alone after hilar control, hematoma formation under the Tisseel was noted on release of the hilar clamp. After 1 week, there was one urinoma and three urine leaks in the control group. In group I, there was one urinoma and four urine leaks, and there was only one urine leak and no urinomas in group II. There were no hematomas in any of the groups.

CONCLUSIONS

Tisseel alone is not adequate for either hemostasis or management of major collecting-system injury. FloSeal capped with Tisseel appears sufficient to control major vascular and collecting-system injuries without adjunctive surgical measures. A proposed technique for laparoscopic partial nephrectomy without reconstructive techniques is presented that warrants clinical study.

Laparoscopic vs open partial nephrectomy in consecutive patients: the Cornell experience

OBJECTIVE

To compare a contemporary series of laparoscopic partial nephrectomy (LPN) and open partial nephrectomy (OPN) at one institution, to evaluate the size and types of tumour in each group and the early outcome after each procedure, as LPN is replacing open radical nephrectomy as the standard of care for uncomplicated renal tumours but partial nephrectomy remains significantly more difficult laparoscopically, especially if the goal is to duplicate the open surgical technique.

PATIENTS AND METHODS

We retrospectively analysed the records of all patients who underwent partial nephrectomy at our institution from January 2000 to April 2004, identifying 66 who had LPN and compared them with 59 who had OPN (mean age at LPN and OPN, 62.1 and 64.2 years, respectively; 70% men in each group). Variables analysed included operative time, blood loss, creatinine levels before and after partial nephrectomy, time to resuming clear liquids and regular diet, length of stay, tumour size, tumour pathological type and complications. Groups were compared using Student's t-test, with P < 0.05 taken to indicate significance.

RESULTS

Of those having LPN, 59% had right-sided tumours, vs 53% in the OPN group; the respective mean tumour size was 2.2 and 3.4 cm, the mean operative duration 144 and 239 min (both P < 0.001), and the mean estimated blood loss 236 and 363 mL (P = 0.09). Seven patients in the OPN group had obligatory partial nephrectomy for either a solitary kidney (two) or azotaemia (five). No patient in the LPN group required an obligatory partial nephrectomy. Serum creatinine levels were measured before and 1 and 2 days after surgery, and were 88, 88 and 97 micromol/L for the LPN group, and 97, 106 and 106 micromol/L for the OPN group. Clear fluids were started a mean of 41 h after surgery, a regular diet resumed 76 h after and discharge was 129 h after surgery in the OPN group; the respective values for the LPN group were 24 h (P = 0.01), 49 h (P = 0.2) and 82 h (P < 0.001). Complications were similar in both groups but the pathological subtypes differed.

CONCLUSIONS

LPN offers early functional advantages over OPN in terms of earlier resumption of diet and slightly earlier discharge. However, the two groups of patients were clearly not evenly matched for size nor pathological subtypes, with larger, malignant subtypes more predominant in the OPN group. These results suggest that while LPN is a safe, effective treatment for small renal tumours, obligatory partial nephrectomy or large tumours continue to be performed using open techniques with good results.

Long-Term Outcome of Hand-Assisted Laparoscopic Radical Nephrectomy for Localized Stage T1/T2 Renal-Cell Carcinoma

PURPOSE

To evaluate the efficacy of hand-assisted laparoscopic radical nephrectomy (HALRN) in patients with localized stage T(1)/T(2) renal-cell carcinoma, we analyzed the clinical results of our patients treated in this way.

PATIENTS AND METHODS

From March 1999 to March 2003, a total of 96 patients aged 28 to 86 years (mean 61 years) with clinical stage T(1)/T(2)N(0)M(0), pathologically confirmed renal-cell carcinoma underwent HALRN. The outcomes were compared with those of open radical nephrectomy, which was performed in 86 patients from November 1991 to February 1999 in our institution. Kaplan-Meier analysis was used to analyze survival.

RESULTS

Ten patients (10.4%) had perioperative complications. During a mean follow-up of 25 months (range 6-54 months), no patients died of the cancer, although three patients had metastatic disease. The 4-year disease- free and overall survival rates were 88% and 100%, respectively. Seventy-eight patients who underwent open radical nephrectomy were followed for 38 to 156 months (median 86 months). Seventy-three survived without any recurrent disease, five survived with metastasis, and no patient died of metastatic disease. The 4-year disease-free and overall survival rates were 93% and 100%, respectively.

CONCLUSIONS

Hand-assisted laparoscopic surgical management of T(1)/T(2) renal-cell carcinoma is feasible and safe. At our institution, HALRN confers long-term oncologic effectiveness equivalent to that of open radical nephrectomy.

Laparoscopic Radical Nephrectomy: Long-Term Outcomes

BACKGROUND

Although more than a decade of experience with laparoscopic radical nephrectomy indicates it is an alternative to open surgery for localized renal-cell carcinoma (RCC), the long-term oncologic effectiveness of this procedure remains to be established.

MATERIALS AND METHODS

A thorough MEDLINE and PubMed literature research on long-term outcomes of laparoscopic radical nephrectomy was performed, and all pertinent articles were reviewed in detail. This review was formulated on the current cancer indication, the oncologic basis, the oncologic efficacy, and the longterm oncologic effectiveness of the procedure, including laparoscopic cytoreductive nephrectomy, with regard to metastasis, port-site tumor recurrence, and the relation to laparoscopic partial nephrectomy. Furthermore, the authors' previous report on the intermediate-term efficacy of laparoscopic radical nephrectomy was updated.

RESULTS

With increasing experience, the indications for laparoscopic radical nephrectomy continue to expand. There were many reports of intermediate-term, two reports of long-term, and our up-to-date outcomes analyzing the management of localized RCC that showed effective cancer control with no statistically significant difference between laparoscopic and open radical nephrectomy in the true 5- and 10-year survival analysis.

CONCLUSION

Long-term data, critical in the evaluation of any treatment for cancer, are currently available with respect to laparoscopic radical nephrectomy for localized RCC.

Early Ligature of Renal Artery during Radical Laparoscopic Transperitoneal Nephrectomy: Description of Standard Technique and Direct Access

PURPOSE

We compared two techniques of early ligature of the renal artery during transperitoneal laparoscopic radical nephrectomy: a standard technique and a direct approach to the artery.

PATIENTS AND METHODS

Of 100 patients undergoing transperitoneal laparoscopic radical nephrectomy at our institution, in the last 70, we used early renal-artery ligature. Of these, the standard technique after exposure of the vascular pedicle was used in 45 patients (group A), and ligature with a direct access to the renal artery was attempted in 25 patients (group B).

RESULTS

No statistical differences were noted between the two groups in terms of age, lesion size, operative time, estimated blood loss, or intraoperative and postoperative complications. There were no recurrences of disease by CT evaluation in either group during follow-up (range 1-46 months).

CONCLUSIONS

Transperitoneal laparoscopic radical nephrectomy with direct access to renal artery for early ligature is technically difficult but feasible and safe.

Oncological outcome of 100 laparoscopic radical nephrectomies for clinically localized renal cell carcinoma

BACKGROUND

Laparoscopic renal surgery is now accepted within the urological community and its indication is extended to oncological operation. The oncological outcome and survival of patients undergoing laparoscopic radical nephrectomy for clinically localized renal cell carcinoma were evaluated.

METHODS

From October 1998 to July 2003, 100 patients underwent laparoscopic radical nephrectomy for clinically localized renal cell carcinoma. All operations were performed by transperitoneal approach with early vascular control. Perioperative events and pathological data were recorded prospectively. Patients were followed up by clinical examination, chest radiograph, ultrasonography and/or computed tomography where appropriate.

RESULTS

The median age of patients was 61 years. Median operating time was 120 min and blood loss was 100 mL. There were five open conversions. There was no perioperative mortality but 11 patients had complications. Resection margins were clear in all but one patient. The median tumour size was 4.6 cm. The median follow-up time was 30 months. All patients survived up to the date of review. No patient developed port-site recurrence but two patients had recurrence at the renal bed 1 year after the operation. Five patients developed distant metastases involving liver, lung and bone.

CONCLUSION

Laparoscopic radical nephrectomy is a safe and efficacious treatment option for clinically localized renal cell carcinoma. The intermediate-term oncological outcome appears favourable.

Laparoscopically assisted vaginal extraction of the kidney after laparoscopic radical nephrectomy

BACKGROUND

Gynecologists have long used a vaginal incision for surgical treatment of pelvic pathology. More recently, however, laparoscopy has allowed gynecologists and other specialists to replace laparotomy with minimally invasive surgical techniques. The combination of laparoscopic and vaginal approaches has increased the surgical armamentarium of both the gynecologist and the urologist.

CASE

A gynecologist found a renal cell carcinoma in a 52-year-old woman. The Urology and Gynecol-ogy Departments of the Kaiser Permanente (KP) Hawaii Region (KP Hawaii) planned a combined minimally invasive surgical procedure that became Hawaii's first reported retroperitoneal radical nephrectomy followed by laparoscopically assisted vaginal extraction of an intact kidney.

CONCLUSION

Collaboration between laparoscopic surgeons in the Departments of Urology and Gynecology has allowed us to share surgical techniques and approaches to perform minimally invasive surgery instead of using more morbid large incisions of the abdomen or flank as required previously.

Extraperitoneal laparoscopic retroperitoneal lymph node dissection in supine position after chemotherapy for advanced testicular carcinoma

AIM

To evaluate the feasibility and usefulness of extraperitoneal laparoscopic retroperitoneal lymph node dissection (RPLND) in the supine position after chemotherapy for advanced testicular carcinoma.

METHODS

Three patients with advanced testicular cancer underwent chemotherapy. Although serum markers were decreased compared with the normal range, residual masses requiring surgical resection were recognized by computed tomography scanning. We applied extraperitoneal laparoscopic RPLND. The patients were placed in the supine position and the first trocar was inserted two finger widths medial to the anterior iliac spine. The retroperitoneal space was dilated using a preperitoneal distention balloon. Two more ports were inserted into the retroperitoneal space and surgery proceeded thereafter.

RESULTS

The residual tumors were completely resected by laparoscopy. The procedure required 250-310 min and the bleeding volume was below 50 mL. Although the histopathological findings consisted only of necrosis in all of the patients, one patient recurred at the same place.

CONCLUSIONS

Extraperitoneal laparoscopic RPLND in the supine position for residual tumors after chemotherapy is technically feasible and useful in terms of postoperative recovery. With regard to cancer control, further evaluation should be necessary.

Early experience of laparoscopic radical nephrectomy for T3b renal cell carcinoma

We report our experience with laparoscopic radical nephrectomy for a 79-year-old man who had renal cell carcinoma (RCC) with a renal vein thrombus. For the transaction of the renal vein with the thrombus, we used an endoscopic gastrointestinal anastomosis stapler. The operating time was 4 h and blood loss was 400 mL. The patient could walk and drink on the first postoperative day. He recovered normal activity 30 days postoperatively. There were no intraoperative and postoperative complications. The present report demonstrates the feasibility of laparoscopic radical nephrectomy in patients with T3b RCC who suffer from tumor thrombus in the renal vein.

Routine vascular control using the Hem-o-lok clip in laparoscopic nephrectomy: animal study and clinical application

BACKGROUND AND PURPOSE

During laparoscopic nephrectomy (LPN), a stapling device is often used for vascular control, especially of the renal vein. Herein, we report our experience using a polymer clip (Hem-o-lok) for routine control of the vessels during LPN in the animal and clinical setting.

PATIENTS AND METHODS

Fifty ablative and fifteen live-donor nephrectomies were performed in domestic pigs. Hem-o-lok clips (10 mm; Weck Closure System, Research Triangle Park, NC) were routinely used for vascular control. In addition, from January 2001 to July 2002, 46 patients underwent hand-assisted laparoscopic (HAL) (N=40) or laparoscopic (N=6) nephrectomy for renal disease or donor nephrectomy. Venous control was achieved solely by the Hem-o-lok clips where at least two clips were applied on the patient side. Arterial control was obtained by the Hem-o-lok clips either alone or in combination with the metal clips. The technical difficulty in obtaining vascular control, transfusion requirement, and clinical outcome were evaluated.

RESULTS

In the animal study (total 65 nephrectomies), individual vascular control was obtained by the Hem-o-lok clip in all cases except two, where vascular injury during dissection necessitated endoscopic stapling of renal hilum or open conversion. The warm ischemic time for animal donor kidney harvest was uniformly <2 minutes. In the clinical study, arterial control was obtained mostly by a combination of Hem-o-lok and metal clips. Venous control using the Hem-o-lok was successful in all 46 cases without any slipping of clips or uncontrolled bleeding. The mean operating time was 148 minutes. No open conversion was required. The transfusion rate was 6.5% (N=3), with none of the transfusions being related to inadequacy of vascular control using the Hem-o-lok. Major complications included deep vein thrombosis and postoperative retroperitoneal hemorrhage (same patient) and acute respiratory distress syndrome (N = 1). The mean postoperative stay was 5.2 days (range 1-20 days).

CONCLUSION

The Hem-o-lok is a reliable and economical device for vascular control in laparoscopic renal surgery.

Small renal oncocytoma with central cystic degeneration

A case of a small renal oncocytoma with central cystic degeneration, 15 mm in diameter, is reported. Contrast-enhanced computed tomography showed the tumor contained a central hypoattenuating region and had an irregular, heterogeneously enhanced wall. Magnetic resonance images showed a well-circumscribed lesion and the T(1)-weighted image indicated medium signal intensity, whereas the T(2)-weighted image indicated slight hypointensity. Both T(1)- and T(2)-weighted images showed central hyperintensity. Our preoperative diagnosis was renal cell carcinoma originating in a renal cyst wall or cystic renal cell carcinoma. Nephrectomy was performed because frozen-section examination did not completely rule out malignancy. The final pathological diagnosis of the entire surgical specimen was renal oncocytoma with cystic degeneration. To our knowledge, this is the 14th case of renal oncocytoma with central cystic degeneration reported in the published works. We discuss herein the variant forms of oncocytoma and difficulties with their preoperative diagnosis, especially when the tumor is small.

Hand-Assisted Laparoscopic Nephroureterectomy for Upper Urinary-Tract Transitional-Cell Carcinoma

Hand-assisted laparoscopic nephroureterectomy with laparoscopic, cystoscopic, or open management of the distal ureter and bladder cuff allow anyone from the novice to the advanced laparoscopic surgeon to perform en-bloc resection of the kidney, ureter, and bladder cuff without compromising oncologic principles. Patients receive significant benefits in the form of less pain, shorter hospital stay, and rapid convalescence. As more urologic surgeons develop skills with this procedure, a more critical analysis of early and long-term results will be possible. As operative times decrease, hand-assisted laparoscopic nephroureterectomy may become the procedure of choice for upper-tract transitional-cell carcinoma. The techniques and early results are described.

Hand-Assisted Retroperitoneoscopic Radical Nephrectomy and Nephroureterectomy

In laparoscopic operations for renal tumor and upper urinary-tract transitional-cell carcinoma (TCC), three approaches - the transperitoneal, retroperitoneal, and transperitoneal hand-assisted - have been reported. We have performed hand-assisted retroperitoneoscopic radical nephrectomy (RN) since 1999 and nephroureterectomy (NU) since 2000. The surgical techniques and the operative results of 95 cases of RN and 54 cases of NU are described and analyzed. These procedures were effective and safe for renal tumors and upper urinary-tract TCC.

Which Is the Real Gold Standard for Small-Volume Renal Tumors? Radical Nephrectomy versus Nephron-Sparing Surgery

BACKGROUND AND PURPOSE

Until recently, the gold standard for treatment of localized renal-cell carcinoma with a normal contralateral unit was deemed to be a formal radical nephrectomy. Advocates of nephron-sparing surgery have recently challenged this concept; we wished to evaluate the evidence to determine which treatment is objectively superior for patients with renal tumors up to 4 cm.

MATERIALS AND METHODS

MEDLINE, CANCERLIT, and EMBASE computer literature searches were performed to identify peer-reviewed papers pertaining to radical nephrectomy (RN), nephron-sparing surgery (NSS), or comparisons of these methods for tumors as large as 4 cm in maximum diameter. Review of the bibliographies of recovered articles and data in recent textbooks were used to supplement the computerized searches. There were a total of 797 cases in the RN group and 1211 in the NSS group. The parameters specifically evaluated were evidence of local recurrence, disease progression, and death within 33 months, this period being chosen primarily because it was the shortest follow-up in the studies evaluated. The data were then subjected to rigorous statistical analysis. Laparoscopic radical nephrectomy (LRN) and laparoscopic nephron-sparing surgery (LNSS) articles were also reviewed; however, current follow-up periods were considered too short to draw a statistically significant conclusion.

RESULTS

Disease-specific survival rates (P=0.001; Mann-Whitney test) as well as the incidence of metastases (P<0.05; Mann-Whitney test) were significantly better in the NSS group. The incidence of local recurrence (P=0.22; Mann-Whitney test) was not significantly different. It should be borne in mind that there are different follow-up periods for each study, and this may have had an impact on the results.

CONCLUSION

Nephron-sparing surgery seems to be as effective as RN in patients with renal cell tumours up to 4 cm, although only a large randomized controlled trial with long follow-up periods would provide a definite answer.

Retroperitoneal Laparoscopic Radical Nephrectomy: Experience of 23 Cases

INTRODUCTION

Retroperitoneal laparoscopic radical nephrectomy has recently been performed in several institutions for renal cancer. We report our experience with this type of operation and discuss the anatomy of perirenal fascial structures.

PATIENTS AND METHODS

From July 2000 to May 2002, we performed retroperitoneal laparoscopic radical nephrectomy in 23 patients. We began this operation with longitudinal cutting of two layers of the posterior renal fasciae, and removed specimens without any fascial structure.

RESULTS

Mean operative time was 203 min (range 129-314 min) with an average estimated blood loss of 113 ml (range 0-837 ml). There was 1 patient who required open conversion due to uncontrollable hemorrhage, but no complication was observed.

CONCLUSIONS

Retroperitoneal laparoscopic radical nephrectomy is a safe and reliable method when the anatomy of the perirenal fasciae is clearly understood. Long-term follow-up of patients undergoing this procedure is warranted to its effect on the prognosis of renal cancer.

Hand-assisted laparoscopic nephrectomy for stage T1 and large stage T2 renal tumors

BACKGROUND AND PURPOSE

Standard laparoscopic nephrectomy (LN) has been shown to be as effective oncologically as open surgery for both stage T1 and stage T2 renal tumors. While much has been published regarding the increasing indications for laparoscopic nephrectomy, there is little in the literature regarding the advantages of hand-assisted laparoscopy (HAL) for the treatment of large (>7-cm) stage T2 renal tumors. To our knowledge, this study is the first to directly compare the results in pathologic stage T1 and stage T2 tumors. Our aim was to assess whether HAL nephrectomy for these larger tumors maintains the same advantages enjoyed by HAL for the smaller ones (<7 cm).

PATIENTS AND METHODS

One hundred HAL renal extirpative procedures were performed over a 3-year period. Of these, 60 were radical nephrectomies for malignant disease, of which 50 tumors were stage T1 and 10 stage T2. Standard HAL nephrectomy was performed through a vertical midline or paramedian incision, and the specimen was sent for histologic examination and tumor staging. We retrospectively analyzed our charts to determine if HAL nephrectomy for T2 tumors was as advantageous as for T1 tumors. We collected data on patient age, ASA score, average tumor size, estimated blood loss, operative time, conversion rate, rate of complications, and length of hospital stay. Follow-up ranged from 4 to 26 months with a mean of 11 months.

RESULTS

The mean size was 4.68 and 9.22 cm for stage T1 and T2 tumors, respectively. Intraoperatively, stage T2 tumors were associated with less blood loss than were T1 tumors (105 mL v 190 mL). Operative times were equivalent, at 190 and 185 minutes for stage T1 and T2, respectively. No open conversions were required in the T2 group v four (8.7%) in the T1 group. Three of these open conversions were seen in the first 25 HAL cases. No complications or conversions were seen in the stage T2 patients. Of note, the majority of the operations for stage T2 disease were performed after the learning curve had been surpassed.

CONCLUSION

The HAL nephrectomy maintains the benefits associated with standard LN. Stage T1 and T2 tumors are equally amenable to HAL nephrectomy, enjoying the same perioperative advantages. The larger size of the higher-stage tumors does not appear to hinder intact organ removal via a 7-cm hand incision. For the novice laparoscopist, we recommend approaching smaller tumors first with HAL nephrectomy, as there is a learning curve. As surgical expertise with HAL nephrectomy increases, larger tumors (stage T2) can be removed safely and expeditiously with little blood loss and a low complication rate. In the short term, patients with stage T2 cancers appear to enjoy the same disease-free survival rate as those with tumors of lower stage. Longer-term follow-up is clearly needed; however, we anticipate the same excellent results as have been demonstrated by others performing conventional radical LN.

Pathologic sampling of laparoscopically morcellated kidneys: a mathematical model

BACKGROUND AND PURPOSE

Kidney morcellation permits tissue removal through a port site; however, standard methods of histopathologic examination of the numerous specimen fragments thus produced have not been established. We developed a model to guide pathologic evaluation of the morcellated kidney.

MATERIALS AND METHODS

A mathematical model was created to determine the quantity of morcellated tissue needed to establish a diagnosis. Inputs into the equation included estimated lesion size, total specimen volume, and the desired certainty of identifying at least a portion of the lesion on pathologic analysis. Nomograms were calculated to illustrate the model and provide clinically relevant guidelines.

RESULTS

The hypergeometric distribution was used to develop the formula: P = 1 - (1 - k/N)(n), where k/N represents the fraction of total specimen with tumor, n is the amount of specimen that must be sampled to yield a diagnosis, and P is the probability of encountering the tumor in the sampled tissue. The model provided nomograms that were feasible and would guide a practical approach to the pathologic analysis of laparoscopically morcellated specimens.

CONCLUSIONS

The increasing application of laparoscopy to the removal of solid organs with suspected tumors has raised several important issues. Morcellation of these specimens precludes traditional pathologic examination and necessitates an alternative method of specimen sampling and diagnosis. We describe a novel, systematic model to assist in the histopathologic examination of morcellated specimens. Issues of pathologic staging remain unresolved, but this sampling system provides a nonarbitrary framework to help arrive at a histologic diagnosis.