Complications Of Laparoscopic Nephrectomy Research Articles

Feasibility of E-PASS score to predict postoperative complications in laparoscopic nephrectomy.

To evaluate the usefulness of E-PASS score to predict postoperative complications after laparoscopic nephrectomy. Between 2008 and 2020, 424 patients (179 patients: simple nephrectomy, 158 patients: radical nephrectomy, 87 patients: donor nephrectomy) who underwent laparoscopic nephrectomy in our clinic, were included in the study. Patient groups separated according to the presence of postoperative complications were compared retrospectively regarding demographic, clinical, intraoperative, and postoperative data, comorbidities, and E-PASS scores (PRS, SSS, and CRS). The relationship between postoperative complications and E-PASS scores was examined. Postoperative complications occurred in 43 (10.1%) of the patients. Age, previous abdominal/retroperitoneal surgery, radical nephrectomy rate of surgeries, operation time, amount of bleeding, need for blood transfusion, rate of conversion from laparoscopic surgery to open surgery, hospitalization time, E-PASS PRS, SSS, and CRS were statistically significantly higher in the group with postoperative complications. The cutoff value of the E-PASS CRS was -0.2996 to predict the development of postoperative complications (AUC = 0.706; 95% CI 0.629-0.783; p < 0.001). According to multivariate analysis, presence of previous abdominal/retroperitoneal surgery (OR 2.977; 95% CI 1.502-5.899; p = 0.002), laparoscopic radical nephrectomy (OR 2.518; 95% CI 1.224-5.179; p = 0.012), conversion from laparoscopic surgery to open surgery (OR 4.869; 95% CI 1.046-22.669; p = 0.044) and E-PASS CRS > -0.2996 (OR 2.816; 95% CI 1.321-6.004; p = 0.007) were found to be independent risk factors predicting postoperative complications. The E-PASS scoring system is an effective and convenient system for predicting postoperative complications after laparoscopic nephrectomy.

Complications of laparoscopic nephrectomy – determining risk factors for complications and conversion to open surgery after an experience of 402 cases

Complications of laparoscopic nephrectomy – determining risk factors for complications and conversion to open surgery after an experience of 402 cases

Chylous Ascites as a Complication of Laparoscopic Nephrectomy

Chylous ascites is a rare complication after major retroperitoneal surgery. Recently chylous ascites has developed more often after laparoscopic nephrectomy since that is increasingly done for various indications at many centers. We reviewed our cases of chylous ascites after laparoscopic nephrectomy. Between January 2002 and December 2008 we performed 622 transperitoneal laparoscopic nephrectomies. We retrospectively analyzed factors related to chylous ascites as a complication of laparoscopic nephrectomy. The overall incidence of chylous ascites was 5.1% (32 of 622 cases), including 4 severe refractory cases (0.6%). The difference in incidence by operation type was not statistically different (p = 0.251). Chylous ascites developed more often after left than right nephrectomy (7.3% or 25 of 343 cases vs 2.5% or 7 of 279, p = 0.010). In patients with radical nephrectomy and nephroureterectomy the incidence was higher in those who did vs did not undergo lymphadenectomy (13.9% or 10 of 72 vs 4.0% or 11 of 275, p = 0.027). Only 1 patient underwent explorative laparotomy due to persistent severe chylous ascites despite 8-week conservative management. The other cases were successfully managed conservatively by total parenteral nutrition and a low fat diet. Chylous ascites is not a rare complication after laparoscopic nephrectomy and most cases can be managed conservatively. To prospectively prevent this complication we recommend meticulous clipping of all perihilar and retroperitoneal fibrous fatty tissue during major vessel dissection, especially for left nephrectomy or extensive lymphadenectomy.

Obesity and Morbid Obesity are Associated With a Greater Conversion Rate to Open Surgery for Standard but Not Hand Assisted Laparoscopic Radical Nephrectomy

We noted that the impact of obesity on renal laparoscopy may vary with the specific surgical approach. Patients who underwent standard and hand assisted laparoscopic radical nephrectomy at our institution were categorized by body mass index as nonobese--body mass index less than 30, obese--30 to 39.9 and morbidly obese--40 kg/m(2) or greater. We assessed the association of intraoperative and postoperative outcomes with body mass index for standard and hand assisted laparoscopic radical nephrectomy. Of 350 patients who underwent standard (196) or hand assisted (154) laparoscopic radical nephrectomy 36% were obese and 12% were morbidly obese. Patients who underwent hand assisted laparoscopic radical nephrectomy had a greater body mass index, more frequent assignment of American Society of Anesthesiologists score 3 or 4 and larger masses than those who underwent standard laparoscopic radical nephrectomy. Despite this fact conversion to open surgery from hand assisted laparoscopic radical nephrectomy did not occur, while such conversion occurred in the standard laparoscopic radical nephrectomy group in 0.8% of nonobese, 3.0% of obese and 17% of morbidly obese patients (association with body mass index p = 0.003). Operative time, intraoperative and postoperative complications, and hospitalization duration did not vary with body mass index. On multivariate analysis only body mass index and not age, gender, American Society of Anesthesiologists score, prior abdominal surgery or tumor size was associated with an increasing likelihood of conversion to open surgery (p = 0.04), and only in the standard laparoscopic radical nephrectomy group. Although obesity and morbid obesity are associated with more frequent conversion to open surgery during standard laparoscopic radical nephrectomy, such conversion did not occur during hand assisted laparoscopic radical nephrectomy. This advantage of hand assisted laparoscopic radical nephrectomy should be considered when planning laparoscopic radical nephrectomy in obese and morbidly obese patients.

Outcome and Complications of Laparoscopic Nephrectomy in Patients with Previous Renal Surgery

The aim of this study was to evaluate the technical difficulties, limitations, outcome, and complications of laparoscopic nephrectomy in patients with previous ipsilateral renal surgery. Eighteen patients with a history of epsilateral renal surgery underwent laparoscopic simple nephrectomy for benign renal disease at our center between November 2001 and March 2005. All patients were informed about the details of the laparoscopic procedure, and an informed consent was obtained that included the possibility of an emergency laparotomy. All procedures performed were carried out through a transperitoneal approach. A separate table with a laparotomy set was available in the room and ready for open conversion. The procedure was completed in 13 patients. Excluding the cases converted to open surgery, the operative time ranged from 120 to 210 minutes, with a mean of 170 +/- 32.9. The intraoperative blood loss ranged from 30 to 400 cc, with a mean blood loss of 100. Complications included minor visceral injury (liver) in 1 patient, minor bleeding in 2, major bleeding (open conversion) in 1, technical failure (open conversion) in 4, postoperative bleeding (reexploration) in 1, and postoperative renal bed collection in 1. Laparoscopic nephrectomy is an alternative to the open nephrectomy for the removal of nonfunctioning kidneys in benign diseases and results in less morbidity and a shorter hospital stay. A higher conversion to open and complication rate should be expected in patients with previous open or endoscopic renal surgery and postinflammatory conditions.

Laparoscopic nephrectomy for benign non functioning kidneys

Laparoscopic nephrectomy has been established as the standard of care for the management of benign non-functioning kidneys and has gained worldwide popularity over the past decade. In this article, we have reviewed the current literature to elucidate the indications, contraindications, surgical techniques, results and complications of laparoscopic nephrectomy.

THE USE OF STAB INCISIONS FOR INSTRUMENT ACCESS IN LAPAROSCOPIC UROLOGICAL PROCEDURES

Traditional laparoscopic procedures use expensive cannulas to facilitate the insertion and removal of laparoscopic instruments. We report our experience with limited access stab incisions for the insertion of instruments into the peritoneal cavity during laparoscopic urological procedures to minimize the use of disposable cannulas. All patients undergoing laparoscopic urologic procedures using stab incisions, as performed by us, from November 1999 through March 2003 were included. Procedures included nephrectomy, partial nephrectomy, varicocelectomy, nephroureterectomy, orchiopexy and adrenal procedures. A single cannula was used for telescope access. In select cases additional cannulas were used for unique instruments or specimen manipulation/extraction. Abdominal wall stab incisions were used for the remaining instruments. Stab incisions were closed with a Steri-Strip (3M Healthcare, St. Paul, Minnesota) at the skin level only. A total of 53 procedures were performed during the study period. Pneumoperitoneum was maintained in all cases. There were no complications associated with the use of stab incisions. A total of 105 cannulas were saved using our technique. At a cost to the patient of dollars 140 per cannula the overall cost saving was dollars 14,700 with an average saving of dollars 277 per case. Laparoscopic urological procedures can be performed effectively and safely with stab incisions for instrument access. There are significant cost savings related to the elimination of cannulas. We believe that our technique of stab incisions for instrument access is equivalent to the traditional cannula approach and should be used when possible.

Complications of Pediatric Urological Laparoscopy: Mistakes and Risks

We evaluate the results and complications of laparoscopic urological procedures in children. In a 3-year period 4,350 laparoscopic procedures were performed at 8 Italian centers of pediatric surgery. We analyzed only the data of urological procedures for a total of 701 laparoscopic operations on patients 1 month to 14 years old. The indications for surgery were cryptorchidism in 414 cases, varicoceles in 159, ambiguous genitalia in 37, total nephrectomy in 34, partial nephrectomy in 4, adrenalectomy in 3 and other diagnostic procedures in 50. We adopted a retroperitoneoscopic approach in 72 cases (10.3%) and a laparoscopic approach in 629 (89.7%). Patient records were analyzed to search for any complication that may have occurred during the laparoscopic procedure and assess how they were managed. We recorded 19 complications (2.7%) in our series, of which 6 required conversion to open surgery and 13 did not. There was no mortality. At a maximum followup of 4 years all children were alive and had no problems related to the laparoscopic complications. Our study shows that pediatric laparoscopic urological surgery has an acceptable rate of complications with no mortality. We believe that routine use of open laparoscopy in pediatric patients is a key factor to help avoid complications. Most complications can be avoided with surgeon and team experience, together with proper compliance with the indications for surgery.

Comparison of Hand Assisted and Standard Laparoscopic Radical Nephroureterectomy for the Management of Localized Transitional Cell Carcinoma

Hand assisted laparoscopy affords the surgeon tactile sensation and blunt dissection, which are currently limited using the standard laparoscopic technique. Therefore, we compared standard and hand assisted laparoscopic radical nephroureterectomy for localized upper tract transitional cell carcinoma. The medical records of 27 patients who underwent standard (11) or hand assisted (16) laparoscopic radical nephroureterectomy between April 1998 and January 2001 were retrospectively reviewed. The parameters of efficacy, efficiency, safety and convalescence were compared. Mean patient age was 64 and 66 years (p = 0.72) in the standard and hand assisted groups, and the mean American Society of Anesthesiologists score was 2.5 and 2.7 (p = 0.64), respectively. All standard and 15 of the 16 hand assisted (94%) procedures were successfully completed via laparoscopy. Total operative time was more than 1 hour shorter for hand assisted than for laparoscopic radical nephroureterectomy (4.9 versus 6.1 hours, p = 0.055). Mean estimated blood loss was similar in the standard and hand assisted groups (190 and 201 ml., p = 0.78). In each group 1 patient required blood transfusion. Mean specimen weight was significantly higher in hand assisted cases (576 versus 335 gm., p = 0.036). Mean time to oral intake was similar in patients who underwent standard and hand assisted laparoscopic radical nephroureterectomy (13 and 20 hours, respectively, p = 0.45). The mean analgesic requirement was also similar (29 and 33 mg. morphine sulfate, respectively, p = 0.83). Mean hospital stay in uncomplicated cases was similar for standard and hand assisted surgery (2.9 and 2.5 days, respectively). Overall hospital stay in the 2 cohorts was also similar (3.3 and 4.5 days, respectively, p = 0.59). Four patients per group experienced postoperative complications. There were no deaths in the standard group but 1 patient (6%) in the hand assisted group died postoperatively. Mean time to partial and complete convalescence in the standard and hand assisted groups was 2.4 and 5.2, and 3.5 and 8.0 weeks, while mean followup was 27.4 and 9.6 months, respectively. Compared with standard laparoscopy hand assisted laparoscopy decreases operative time without significantly altering short-term parameters of convalescence. However, long-term convalescence after hand assisted laparoscopic radical nephroureterectomy is 1 to 3 weeks longer (p = 0.27). Longer followup in the hand assisted cohort is necessary to determine whether there are any differences in the 2 methods in regard to cancer control.

COMPLICATIONS OF LAPAROSCOPIC PROCEDURES AFTER CONCENTRATED TRAINING IN UROLOGICAL LAPAROSCOPY

To increase the safety and efficiency of laparoscopic surgery clinical training programs have been developed to increase the skill and efficiency of urological trainees. We evaluated the impact of dedicated laparoscopy training on the rate and type of complications after trainees entered clinical practice. Data were obtained from 13 centers where laparoscopy was performed by a single surgeon with at least 12 months of training in urological laparoscopy before clinical practice. Data included training experience, laparoscopic procedures performed after commencing clinical practice and associated complications. Procedures were classified as easy, moderate and difficult. During training each surgeon participated in a mean of 71 cases. In clinical practice a total of 738 laparoscopic cases were performed with the group reporting an overall complication rate of 11.9%. The rate was unchanged when the initial 20, 30 and 40 cases per surgeon were compared with all subsequent cases (12%, 11.9% and 12% versus 11.8 to 12%, respectively). The re-intervention rate was 1.1%. The complication rate increased with case difficulty. Overall and early complication rates attributable to laparoscopic technique in the initial 20, 30 and 40 cases were identical. The most common complications were neuropathy in 13 patients, urine leakage/urinoma in 9, transfusion in 7 and ileus in 5. The complication rate of surgeons who completed at least 12 months of laparoscopy training did not differ according to initial versus subsequent surgical experience. Intensive training seems to decrease the impact of the learning curve for laparoscopy.

A 3 TROCAR TECHNIQUE FOR TRANSPERITONEAL LAPAROSCOPIC NEPHRECTOMY

Additional trocars and retractor instruments may enhance the risk of iatrogenic injuries during laparoscopic nephrectomy. We describe a modified technique of laparoscopic nephrectomy requiring only 3 ports of entry and no extra instruments instead of the 5 ports, 2 of which are used for retractors, usually required. With the patient in full flank position a 10 mm. trocar is inserted between the umbilicus and subcostal margin, a 5 mm. trocar is placed subcostal in the midclavicular line and a 12 mm. trocar is inserted over the iliac crest in the anterior axillary line. The first step is incision of the line of Toldt and medial reflection of the colon. During the second step of vascular controls the posterosuperior attachments of the kidney are left untouched, keeping the renal vessels stretched, with no need for an extra instrument. The third step consists of severing the remaining posterior and superior attachments of the kidney followed by specimen retrieval. A total of 14 consecutive patients underwent laparoscopic nephrectomy with this technique. All 14 procedures were completed without an additional port. There were no intraoperative or postoperative complications, except 1 abdominal wall hematoma. Mean operating time was 120 minutes (range 70 to 230) and mean hospital stay was 5 days (range 3 to 7). Transperitoneal laparoscopic nephrectomy with laparoscopic access limited to 3 trocars is a reliable and safe technique.

THE ROLE OF COMPUTERIZED TOMOGRAPHY IN THE EVALUATION OF COMPLICATIONS AFTER LAPAROSCOPIC UROLOGICAL SURGERY

Radiographic evaluation may be necessary to assess the possible complications of laparoscopic procedures. We undertook a retrospective review to determine the indications for and findings of computerized tomography (CT) in symptomatic patients after urologic laparoscopic surgery. Of 400 laparoscopic urological procedures performed between July 1993 and September 1996, 20 patients (5%) had postoperative symptomatology that could not be explained by physical exam or routine clinical studies. An abdominal CT scan was obtained (1 to 120 days after the procedure) to help determine a diagnosis. CT findings were correlated with the indication for the study and clinical followup. The indications for CT were unexplained pain, fever, leukocytosis or falling hematocrit. Thirteen patients had significant findings related to their surgery that were identified by CT. In 2 cases, we identified pathology unrelated to the surgery. Therefore, CT identified a symptom-related diagnosis in 75% of patients (15 of 20). Each scan for decreasing hematocrit demonstrated a hematoma. In all patients with unexplained fever or leukocytosis, CT revealed the cause. CT evaluation of atypical postoperative pain demonstrated a pathological cause in 58% (7 of 12). Percutaneous or laparoscopic surgical intervention was required in 4 of 20 patients. In 8 patients scanned by postoperative day 6, intraperitoneal or retroperitoneal gas was identified in 3 who had an abdominal incision made for intact specimen removal and in 1 with a perforated ulcer. CT after urologic laparoscopy is indicated in patients with significant clinical findings in whom routine examination and tests are not diagnostic. CT can reliably identify postoperative bleeding, urinary leak or obstruction and can also detect nonurinary pathology.

Complications of laparoscopic nephrectomy in 185 patients: a multi-institutional review.

We document the incidence of complications associated with laparoscopic nephrectomy in a multi-institutional study. The study included the initial 185 patients undergoing laparoscopic nephrectomy at 5 centers in the United States between June 1990 and July 1993. A total of 30 patients (16%) had 34 complications. There was no mortality. Access-related complications included 2 cases of hernia formation at the trocar site, 1 abdominal wall hematoma and 1 trocar injury to a hydronephrotic kidney. Intraoperative complications included 5 cases of vascular injury, 1 splenic laceration and 1 pneumothorax. Postoperative complications involved the gastrointestinal tract in 6 cases, cardiovascular system in 6, genitourinary tract in 4, respiratory system in 4 and musculoskeletal system in 2. Miscellaneous complications occurred in 3 patients. Open surgical intervention was required electively in 8 patients and on an emergency basis in 2. The incidence of complications decreased with experience: 71% occurred during the initial 20 cases at each institution. In our early experience the complication rate for laparoscopic nephrectomy was 12% in patients with benign renal disease and 34% in those with renal cancer. Based on this collective experience, recommendations for prevention, recognition and treatment of complications are made.

Complications of Laparoscopic Nephrectomy in 185 Patients: A Multi-Institutional Review

Purpose We document the incidence of complications associated with laparoscopic nephrectomy in a multi-institutional study. Materials and Methods The study included the initial 185 patients undergoing laparoscopic nephrectomy at 5 centers in the United States between June 1990 and July 1993. Results A total of 30 patients (16 percent) had 34 complications. There was no mortality. Access-related complications included 2 cases of hernia formation at the trocar site, 1 abdominal wall hematoma and 1 trocar injury to a hydronephrotic kidney. Intraoperative complications included 5 cases of vascular injury, 1 splenic laceration and 1 pneumothorax. Postoperative complications involved the gastrointestinal tract in 6 cases, cardiovascular system in 6, genitourinary tract in 4, respiratory system in 4 and musculoskeletal system in 2. Miscellaneous complications occurred in 3 patients. Open surgical intervention was required electively in 8 patients and on an emergency basis in 2. The incidence of complications decreased with experience: 71 percent occurred during the initial 20 cases at each institution. Conclusions In our early experience the complication rate for laparoscopic nephrectomy was 12 percent in patients with benign renal disease and 34 percent in those with renal cancer. Based on this collective experience, recommendations for prevention, recognition and treatment of complications are made.