Retroperitoneoscopic Radical Nephrectomy Research Articles

UP-1.002: Endoscopic Anatomical Study During Retroperitoneoscopic Radical Nephrectomy

UP-1.002: Endoscopic Anatomical Study During Retroperitoneoscopic Radical Nephrectomy

UP-1.037: Retroperitoneoscopic Versus Open Radical Nephrectomy in Patients with Larger Tumors (Average Diameter ≥7cm)

To report our experience with retroperitoneoscopic radical nephrectomy (RRN) and compare it with a contemporary cohort of patients who underwent open radical nephrectomy (ORN) for renal cell carcinoma (RCC) with average diameter ≥7cm.

UP-1.025: Retroperitoneoscopic versus Open Radical Nephrectomy with Report of 92 Cases

UP-1.025: Retroperitoneoscopic versus Open Radical Nephrectomy with Report of 92 Cases

Prospective comparative study between retroperitoneoscopic and hand-assisted laparoscopic approach for radical nephrectomy

No consensus has yet been established regarding the best minimally invasive access for radical ablation of renal tumors. Our objective was to prospectively compare the surgical results and oncologic management of two currently used endoscopic techniques. Over a four-year period, 50 patients with renal tumors and clinical stage T1b-T2, smaller than 12 cm, underwent a radical nephrectomy at two reference institutions, 25 underwent retroperitoneoscopic radical nephrectomy (RRN) and 25 a hand-assisted laparoscopic radical nephrectomy (HALRN). Mean follow-up of both cohorts was 50 months. Operative parameters and oncological management were compared. The mean operative time was 180 min in RRN and 108 min in HALRN (p < 0.001). The time required to access the renal pedicle in RRN was 30 min. and in HALRN 40 min., Learning curve was shorter in HALRN than RRN. Mean blood loss was 100 mL in RRN and 242 mL in HALRN. Mean incision size for specimen retrieval in RRN was 6.5 cm and in HALRN 7.5 cm. One patient with intra operative occurrence of ascites and subsequent pathological stage pT2N0M0 grade 3 operated via HALRN, had neoplasic implants in the Hand-port incision 3 months after surgery followed by death 4 months after recurrence. One patient, with pathological stage pT3N0M0 grade 3 in RRN had metastasis after 36 months. Both, RRN and HALRN techniques are accepted minimally invasive options for endoscopic radical nephrectomy with equivalent long term oncological outcome in the treatment of renal tumors.

Quality of life and perioperative outcomes after retroperitoneoscopic radical nephrectomy (RN), open RN and nephron-sparing surgery in patients with renal cell carcinoma

To prospectively evaluate health-related quality of life (HRQoL) and perioperative outcomes in patients with T1 and T2 renal cell carcinoma (RCC) after retroperitoneoscopic radical nephrectomy (RRN), open RN (ORN) or open nephron-sparing surgery (NSS). The data of 117 patients who had undergone RRN (36), ORN (37) or NSS (44) were evaluated. RRN data were obtained at Basel University Hospital, Switzerland, while the ORN and NSS data were collected at the University of Munich, Germany. Perioperative outcomes were analysed and compared. HRQoL was prospectively evaluated based on the Short Form 36 questionnaire with a mean follow-up of 22 months. Operative duration was significantly longer in the RRN group compared with the ORN and NSS groups, at a mean (sem) of 146 (42) min vs 113 (48) min and 114 (42) min (P < 0.001). In the RRN group intraoperative blood loss was lower than in the ORN and NSS groups, at a mean (sem) of 231 (153) mL vs 424 (361) mL and 494 (360) mL (P < 0.001). Morbidity rates were 13.9% for RRN, 16.2% for ORN and 20.5% for NSS, the most relevant complications being bleeding requiring transfusions in RRN and NSS patients and haemorrhage (5% of patients in each group). Creatinine values at 6 months after surgery only recovered completely in the NSS group. Patients in the ORN group had a trend towards higher mental well-being scores than patients in the RRN and NSS groups, with a mean Mental Component Summary Score of 48.3 vs 48.0 and 44.5, respectively (not statistically significant), while all patients were in similar physical condition after surgery, with a mean Physical Component Summary Scores of 48.0 (ORN), 47.4 (RRN) and 47.2 (NSS). The physical condition scores of patients in all groups were higher than scores reached by an age and sex-matched population (45.8). These real-world data show that each of the surgical techniques can be considered safe. Importantly, after surgery patients reported high QoL scores independent of the technique used.

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.

Comparison of Open and Laparoscopic Nephrectomy in Obese and Nonobese Patients: Outcomes Stratified by Body Mass Index

Laparoscopic radical nephrectomy has been accepted as the preferred management for low stage renal masses not amenable to partial nephrectomy. Early in the mid 1990s several studies suggested that obesity should be a relative contraindication to laparoscopy. We present our surgical outcomes and complications in patients undergoing open and laparoscopic nephrectomy, stratified by body mass index. We retrospectively identified 88 patients, of whom 43 underwent open nephrectomy and 45 were treated laparoscopically. All patients were stratified by body mass index to compare multiple perioperative end points and pathological outcomes of laparoscopy. Overall our data showed that compared to open nephrectomy laparoscopic nephrectomy resulted in statistically significant lower estimated blood loss (147.95 vs 640.48 cc, p <0.0002), operative time (156.11 vs 198.95 minutes, p <0.003) and hospital stay (3.7 vs 5.9 days, p <0.004). When stratified by body mass index less than 25, 25 to 29.9 and 30 kg/m(2) or greater, there was a statistically significant difference in estimated blood loss and hospital stay that was in favor of the laparoscopic approach in each body mass index category. Operative time did not show a statistical difference in the subgroups but all laparoscopic procedure times were shorter than open procedure times in each body mass index category. When patients with a body mass index of greater than 30 kg/m(2) were further subgrouped into 35 kg/m(2) or greater and 40 kg/m(2) or greater, there was a statistically significant difference in estimated blood loss and hospital stay that was again in favor of the laparoscopic method. Laparoscopic radical nephrectomy is technically more challenging as body mass index increases due to many factors but our data show that it is feasible and safe in experienced hands. Laparoscopy appears to result in perioperative outcomes that are superior to those of open nephrectomy in this high risk population with a complication profile that is equivalent to that of the open method for each stratified body mass index category.

Primary Synovial Sarcoma of the Kidney

Primary synovial sarcoma arising from the kidney is extremely rare. We report two cases with primary renal synovial sarcoma. Both were initially diagnosed as renal cell carcinoma. The first case was a 30-year-old woman who presented with right flank soreness. Ultrasonography disclosed a multiloculated cystic tumor measuring 9 x 7 cm. She underwent hand-assisted laparoscopic radical nephrectomy; there was no recurrence during 15 months of follow-up. The second case was a 49-year-old woman who presented with a palpable mass in the left upper quadrant of the abdomen of 1 month's duration. Computed tomography showed a heterogeneously enhanced tumor measuring 13 x 11 cm at the left retroperitoneum with displacement of the pancreas and the left kidney. Hand-assisted retroperitoneoscopic radical nephrectomy was performed. She had no evidence of recurrence after 27 months of follow-up. Pathology of the two cases showed histologic and immunochemical features of synovial sarcoma with coexisting spindle and epithelial cells. Physicians should be aware of the possibility of malignancy in cystic renal masses and that synovial sarcoma is one of the possibilities.

Port Site and Local Recurrence of Incidental Solitary Renal Plasmacytoma After Retroperitoneoscopic Radical Nephrectomy

Port site and local recurrences are rather rare, especially after laparoscopic excision of renal malignancies. In addition to the known risk factors, including inappropriate surgical technique and specimen removal, the tumor biology is important. Renal plasmacytomas are rare manifestations of plasma cell tumors. We report a case of port site and local tumor recurrence of a solitary renal plasmacytoma after retroperitoneoscopic radical nephrectomy without any known risk factors, other than the aggressive tumor biology itself.

Nefrectomía radical laparoscópica retroperitoneal: experiencia inicial con 50 casos

Retroperitoneal laparoscopic radical nephrectomy: Inicial experience with 50 cases PurposeLaparoscopic radical nephrectomy is preferentially performed by transperitoneal approach. Despite offering advantages the direct retroperitoneal laparoscopic approach has not found uniform acceptance due to small working space in the retroperitoneum. Retroperitoneoscopy is our preferred approach for performing radical nephrectomy for localized renal tumors. We present our technique and our experience with the first 50 retroperitoneoscopic radical nephrectomies and compare the results with other series Material and methods50 patients underwent retroperitoneoscopic radical nephrectomy for renal tumors cT1/cT2 between march 2004 to march 2007. A four ports retroperitoneal laparoscopic nephrectomy technique is performed with the patient in the full flank position. An artisanal balloon is used to create the retroperitoneal working space. The specimen is extracted intact by an extraperitoneal iliac incision. Follow up data were retrospectively reviewed ResultsMean tumor size was 5,3 cm (3 to 13 cm), surgical time was 150 min (90 to 300 min), and blood loss was 130 ml (40-1000 ml). Average hospital stay was 2,2 days (1-11 days). Complications occurred in 6 (12%) patients. Two patients (4%) presented major complications and one of then require open conversion. Four patients (8%) presented minor complications. There were two later recurrences. One local and port site recurrence in a pT 3 aN 0 M 0 renal cancer and one systemic metastases in a pT 3 N 0 M 0 urothelial cancer occurred. Both cases presented inadequately extraction ConclusionsRetroperitoneoscopy is a feasible, effective and safe alternative for the treatment of localized renal tumors. Retroperitoneoscopy should be avoided in advanced and large size renal tumors

Case Report: Retroperitoneoscopic Radical Nephrectomy for Renal-Cell Carcinoma during Twin Pregnancy

Renal-cell carcinoma (RCC) is rarely reported during pregnancy. Both the open and the laparoscopic approach to nephrectomy have been used effectively and safely in pregnant patients with RCC. We report a unique case of a 52-year-old woman found to have RCC during twin gestation who was treated with retroperitoneoscopic radical nephrectomy, one of the first such cases managed by this approach.

Oncologic Outcome of Hand-Assisted Laparoscopic Radical Nephrectomy

Objectives To evaluate and compare the oncologic outcome of hand-assisted retroperitoneoscopic radical nephrectomy (HALS) with that of open radical nephrectomy. Methods The clinical and follow-up data of 123 patients with localized renal cell carcinoma who underwent HALS were retrospectively compared with those of 70 patients who underwent open radical nephrectomy. Results No significant differences were found in operating time, complication rates, or transfusion rates between the HALS and open groups. The estimated blood loss was significantly less in the HALS group. The median follow-up period was 41.0 months for the HALS group, significantly shorter than that for the open group (74.5 months). The 3 and 5-year disease-free survival rate for the HALS and open groups was 94% and 92% and 93% and 91%, respectively. The 3 and 5-year cancer-specific survival rate for the HALS and open groups was 96% and 92% and 98% and 94%, respectively. No significant differences were found in the disease-free and cancer-specific survival rates between the two groups. In the HALS group, no significant differences were found in the disease-free survival rate between those undergoing surgery by less-experienced surgeons who had performed laparoscopic nephrectomy on 10 cases or less and those undergoing surgery by more experienced surgeons. Conclusions The oncologic outcome of HALS did not differ much from that of the open approach. Also, the experience of the surgeon did not affect the oncologic outcome. However, extended follow-up is necessary to assess the true oncologic efficacy of HALS.

Retroperitoneoscopic Radical Nephrectomy in Obese Patients: Outcomes and Considerations

Objective:To determine whether obesity is associated with surgical outcome in Japanese patients undergoing retroperitoneoscopic radical nephrectomy (RRN). Patients and Methods: Between November 1999 and March 2005, we performed 98 RRN procedures for patients with renal cell carcinoma. Patients with a body mass index (BMI) of 25.0 or more were defined as obese (group A, n = 33) and those with a BMI of <25.0 were defined as non-obese (group B, n = 65), in accordance with the criteria of the Japan Society for the Study of Obesity. Patient background, degree of surgical invasiveness, and period of convalescence were compared between groups A and B. Results: No statistically significant differences were observed between the groups in terms of age, gender, tumor laterality, tumor size, and time until resumption of oral intake and ambulation. However group A had a significantly longer insufflation time (172.1 vs. 137.4 min), greater blood loss (195.3 vs. 48.4 ml) and higher renal specimen weight (440.0 vs. 306.0 g) than group B. Conclusion: Obesity is not a factor that affects patient eligibility for RRN, but is a risk factor for longer insufflation time and greater blood loss.

Retroperitoneoscopic Versus Open Surgical Radical Nephrectomy for Large Renal Cell Carcinoma in Clinical Stage cT2 or cT3a: Quality of Life, Pain and Reconvalescence

ObjectivesTo determine whether retroperitoneoscopic radical nephrectomy for large renal cell carcinoma in stage cT2 or cT3a is a feasible, safe and effective therapy option and if it shows any advantage regarding quality of life in comparison to open procedure. Methods23 patients who underwent RPNx for tumor size greater than 7cm (group 1) were matched and compared with 25 patients, who underwent ONx (group 2) for tumor with similar size characteristics. Patient and surgical data, QoL variables and complications were statistically analyzed. ResultsThe median followup was 12 (range: 6–18) months for both groups. Group 1 had significantly (p<0.001) less blood loss, shorter hospital stay, and shorter postoperative analgesic requirements. No conversion to open surgery was neccassary, and no major complications requiring an invasive intervention occurred. Retroperitoneoscopic patients had significantly better QoL and pain scores postoperatively to 6 months (p<0.001) and they return to baseline QoL status faster (p<0.001). ConclusionsRPNx for large RCC in stage cT2 or cT3a is a safe and efficacious procedure with good short-term outcome results and significantly shorter recovery of QoL variables.

A simple kidney entrapment technique using a zipped plastic bag during retroperitoneoscopic radical nephrectomy

A simple kidney entrapment technique using a zipped plastic bag during retroperitoneoscopic radical nephrectomy

100-MINUTE RETROPERITONEOSCOPIC RADICAL NEPHRECTOMY: A NEW RETROPERITONEAL APPROACH WITH A HAND ASSISTED METHOD

A new approach for retroperitoneoscopic radical nephrectomy is introduced. The point of our surgical method is the application of a combination of hand assistance and pure laparoscopic procedures with appropriate surgical steps via the retroperitoneal approach. In our early series we had good surgical results and we completed radical nephrectomy in about 100 minutes using this procedure. A total of 20 consecutive patients with renal cell carcinoma (cT1-2) who were operated on with this surgical method were analyzed. Surgical procedures occurred in 5 steps. In step 1 the retroperitoneal space was created manually from a pararectal incision at the umbilicus level. In step 2 the lateroconal fascia was incised and the renal hilar area was exposed with hand assistance. In step 3 hilar dissection was performed by pure laparoscopic procedure with another surgical instrument inserted from the hand device. Step 4 involved the application of hand assistance again for the quick mobilization of the kidney and adrenal gland. In step 5 the intact surgical specimen was retrieved from the hand device. Mean operative time and estimated blood loss were 103 +/- 21 minutes (range 70 to 145) and 49 +/- 85 ml (range 5 to 360), respectively. Mean days to oral intake and ambulation were 1.0 and 1.1, respectively. Operative times of the steps of hilar dissection and mobilization of the kidney and adrenal were shorter than in other series performed by standard retroperitoneoscopic radical nephrectomy. Major complications were not experienced. At this point, no metastasis has been experienced. Our surgical method may have the benefits of the retroperitoneal approach and hand assistance. The retroperitoneoscopic hand assisted method may be another important option in the 3 major approaches for laparoscopic radical nephrectomy, although longer-term followup is clearly required.

INTERMEDIATE FOLLOWUP OF HAND ASSISTED LAPAROSCOPIC NEPHROURETERECTOMY FOR UROTHELIAL CARCINOMA:: FACTORS ASSOCIATED WITH OUTCOMES

We report our experience with hand assisted laparoscopic (HALS) nephroureterectomy and describe the associations of preoperative, operative and pathological factors with outcome. HALS nephroureterectomy was performed in 54 consecutive patients using modified transurethral resection of the ureteral orifice (TURUO) or a 1 port transvesical endoscopic cuff technique for the distal ureter in all except 8. Data were collected prospectively and retrospectively, and followup was distinguished for bladder, contralateral upper tract and nonurothelial (local recurrence and distant metastases) sites. The endoscopic cuff was associated with significantly shorter mean operative time than the transurethral resection of the ureteral orifice method (234 vs 295 minutes, p = 0.002) but the comparison was confounded by the effect of experience. With 28% of patients having stage II or greater tumors and 49% having high grade bladder disease, contralateral upper tract and nonurothelial recurrences developed in 55%, 11% and 25% of evaluable patients at a median followup of 25.1, 24.4 and 24.9 months, respectively, in those without recurrence. At a median followup of 25.0 months cancer specific survival was 94%, 86% and 80% at 1 to 3 years, respectively. Three-year cancer specific survival was 100% in patents with grade 1 or 2, or stage 0 or I tumors but only 57% and 36% in patients with grade 3 and stage II or IV tumors, respectively. HALS nephroureterectomy is associated with 3-year outcomes that are strongly associated with stage and grade. We prefer the endoscopic cuff method for the distal ureter because it is performed after nephrectomy, does not require patient repositioning and is expedient.

Urological Retroperitoneoscopic Surgery for Patients with Prior Intra-Abdominal Surgery

Objective: To determine whether previous intra-abdominal surgery is associated with surgical outcome in patients undergoing urological retroperitoneoscopic surgery. Patients and methods: One hundred seventeen cases of urological retroperitoneoscopic surgery, including 78 cases of retroperitoneoscopic radical nephrectomy (RN) for localized renal tumor and 39 cases of retroperitoneoscope-assisted radical nephroureterectomy (RNU) for upper urinary tract cancer, were evaluated. Thirty (38.5%) of the 78 patients who underwent RN and 13 (33.3%) of the 39 patients who underwent RNU had a history of intra-abdominal surgery. The patients were divided into two groups: those who had undergone prior intra-abdominal surgery (OP+) and those who had not (OP−). Patients’ backgrounds, degree of surgical invasiveness, and period of convalescence were compared between the OP+ and OP− groups. Results: There was no significant difference between the OP+ and OP− groups in terms of background, surgical invasiveness or convalescence, except for age in the patients who had undergone RN. Complications in the studied cases were unrelated to any history of intra-abdominal surgery. Conclusion: Previous intra-abdominal surgery is not associated with a negative outcome of urological retroperitoneoscopic surgery in patients with localized renal tumors and those with upper urinary tract cancer.

Prospective, randomized controlled study: Transperitoneal laparoscopic versus retroperitoneoscopic radical nephrectomy

ObjectivesTo evaluate the transperitoneal and retroperitoneal approaches for endoscopic radical nephrectomy in a prospective randomized manner to assess the possible differences in the outcome related to patients’ morbidity and technical difficulty for the surgeon. MethodsA total of 40 patients with Stage cT1–T2 were randomized into two equal groups: laparoscopic radical nephrectomy (LRN) and retroperitoneoscopic radical nephrectomy (RRN). The patient demographics and tumor characteristics were comparable. Two surgeons with differing experience performed an equal number of procedures in both treatment arms. The outcome was compared, and the technical difficulty for the surgeon and assistant was assessed with the European scoring system. ResultsAll procedures were completed without a need for conversion. No statistically significant differences were found between the two approaches in terms of the number and size of the trocars used, length of incision, specimen weight, pathologic stage, operative time, need for additional procedures such as adrenalectomy and/or lymph node sampling, estimated blood loss, need for blood transfusions, analgesic requirement, length of hospital stay, or the incidence of minor or major complications. All patients in the LRN group resumed oral intake on postoperative day 1, but only 75% did so in the RRN group. The technical difficulty score for either the surgeon or the assistant did not differ significantly between the two groups. Both approaches allowed complete tumor excision. The robotic assistance system (AESOP) was more difficult with RRN compared with LRN. ConclusionsThis first prospective randomized study comparing LRN and RRN did not find any real difference between the two approaches in relation to patient morbidity or the technical difficulty for the surgeon.

Retroperitoneoscopic Radical Nephrectomy with Concomitant Distal Pancreatectomy: Case Report

Whereas laparoscopic radical nephrectomy has emerged as the standard of care for most low-stage renal tumors, laparoscopic pancreatic surgery remains uncommon. We describe a retroperitoneoscopic radical nephrectomy and concomitant distal pancreatectomy for a large left renal mass with suspected involvement of the adrenal gland and the distal pancreas.