Standard Laparoscopic Radical Nephrectomy Research Articles

Robotic-assisted laparoscopic radical nephrectomy using the Da Vinci Si system: how to improve surgeon autonomy. Our step-by-step technique.

Herein, we describe several steps to improve surgeon autonomy during a Left Robotic-Assisted Laparoscopic Radical Nephrectomy (RALRN), using the Da Vinci Si system. Our kidney cancer program is based on 2 community hospitals. We use the Da Vinci Si system. Access is obtained with the following trocars: Two 8mm robotic, one 8mm robotic, bariatric length (arm 3), 15mm for the assistant and 12mm for the camera. We use curved monopolar scissors in robotic arm 1, Bipolar Maryland in arm 2, Prograsp Forceps in arm 3, and we alternate throughout the surgery with EndoWrist clip appliers and the vessel sealer. Here, we described three steps and the use of 3 robotic instruments to improve surgeon autonomy. Step 1: the lower pole of the kidney was dissected and this was retracted upwards and laterally. This maneuver was performed using the 3rd robotic arm with the Prograsp Forceps. Step 2: the monopolar scissors was replaced (robotic arm 1) with the robotic EndoWrist clip applier, 10mm Hem-o-Lok. The renal artery and vein were controlled and transected by the main surgeon. Step 3: the superior, posterolateral dissection and all bleeders were carefully coagulated by the surgeon with the EndoWrist one vessel sealer. We have now performed 15 RALRN following these steps. Our results were: blood loss 300cc, console time 140min, operating room time 200min, anesthesia time 180min, hospital stay 2.5days, 1 incisional hernia, pathology: (13) RCC clear cell, (1) chromophobe and (1) papillary type 1. Tumor Stage: (5) T1b, (8) T2a, (2) T2b. We provide a concise, step-by-step technique for radical nephrectomy (RN) using the Da Vinci Si robotic system that may provide more autonomy to the surgeon, while maintaining surgical outcome equivalent to standard laparoscopic RN.

Nefrectomia Radicale Laparoendoscopic Single-site (LESS) nel Tumore Renale: Tecnica e Risultati Chirurgici Cosmetici e Valutazione del Dolore Postoperatorio

Introduction Over the last few years, many urological laparoscopic operations have been successfully performed by LESS. However, the actual role of LESS in the field of minimally invasive urologic surgery remains to be determined with controversial data about postoperative pain control and almost no results on cosmetic data. The aim of the present study is to describe the technique and report the surgical outcomes of LESS radical nephrectomy (RN) in the treatment of renal cell carcinoma with special emphasis for postoperative pain control and almost no results on cosmetic data. Materials And Methods LESS-RN was performed in 33 patients with renal tumors. The indications to perform a LESS-RN were represented by renal tumors not greater than T2, and without evidence of lymphadenopathy or renal vein involvement. Surgical procedure The Endocone (Karl Storz, Tuttlingen, Germany) was inserted through a transumbilical incision. A combination of standard laparoscopic instruments and bent grasper and scissors was used. The step sequence of LESS-RN was comparable to standard laparoscopic RN. Demographic data and perioperative and postoperative variables were recorded and analyzed. Results The mean operative time was 143.7 ∓ 24.3 min, with a mean estimated blood loss of 122.3 ∓ 34.1 mL and a mean hospital stay of 3.8 ∓ 0.8 d. The mean length of skin incision was 4.1 ∓ 0.6 cm; all patients were discharged from hospital with minimal discomfort, as demonstrated by their pain assessment scores (visual analogue scale: 1.9 ∓ 0.8). The definitive pathologic results revealed a renal cell carcinoma in all cases and a stage distribution of four T1a, 27 T1b, and 2 T2 tumors. All patients were very satisfied with the appearance of the scars, and at a median follow-up period of 13.2 ∓ 3.9 mo, all patients were alive without evidence of tumor recurrence or port-site metastasis. Conclusions LESS is a safe and feasible surgical procedure for RN in the treatment of renal cell carcinoma and has excellent cosmetic results.

A Matched-Pair Comparison of Laparoendoscopic Single-Site Surgery and Standard Laparoscopic Radical Nephrectomy by a Single Urologist

The aim of this study is to compare the perioperative outcomes after transumbilical laparoendoscopic single-site (LESS) radical nephrectomy (LESS-RN) performed by a surgeon during his learning curve of this novel procedure with the outcomes after standard laparoscopic radical nephrectomy (LRN) for patients with a solitary renal tumor. Using this information, we examined whether LESS exhibits any objective advantages over standard laparoscopy. Twenty patients who underwent LESS-RN for a solitary cT(1)N(0)M(0) renal mass (group 1) were matched and compared with 33 patients who underwent standard LRN (group 2) for tumors of similar sizes. Patient and surgical data, pathologic outcomes, and follow-up information, including patient responses regarding cosmetic satisfaction, were analyzed. The minimum duration of follow-up was 6 months for both groups. Patients in group 1 had significantly (P<0.05) quicker recoveries of bowel function, shorter postoperative analgesic time, and lower pain scores during their hospital stay. At the time of the last follow-up, all patients remained symptom free, and no evidence of recurrence was detected. Compared with that of standard LRN patients, LESS-RN patients exhibited better cosmetic satisfaction scores postoperatively at least to 6 months (P=0.013). Transumbilical LESS-RN is a feasible, safe, and efficacious procedure with favorable perioperative outcomes that results in significantly improved control of postoperative pain, more rapid recovery of bowel function, and increased cosmetic satisfaction. Additional research, including randomized controlled trials and long-term follow-ups, however, will be needed to draw solid conclusions regarding the relative efficacy of this procedure compared with standard approaches.

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.

Prospective Randomized Comparison of Laparoscopic and Hand-Assisted Laparoscopic Radical Nephrectomy

The majority of localized renal cancers are currently managed by laparoscopic radical nephrectomy, with or without the hand-assist device. In this prospective randomized study, we evaluated the patient outcomes with a standard laparoscopic radical nephrectomy (LRN) versus a hand-assisted laparoscopic radical nephrectomy (HALN). Over a 3-year period, we randomly assigned 21 patients with a localized renal mass of 10 cm or larger to a LRN group with intact specimen extraction or a HALN. The trocar size and sites, the position of the hand-assist device, and the specimen extraction sites were standardized. Patient characteristics, surgical complications, postoperative pain, and convalescence were evaluated. Twelve patients underwent LRN and 9 patients underwent HALN. Both groups had similar body mass indices (BMI), mean tumor diameter (LRN, 5.8 cm; HALN, 5.6 cm), and American Society of Anesthesiologists (ASA) scores. The HALN cohort was significantly older (mean age = 68 years) than the LRN cohort (mean age = 54 years) (P = 0.019). Perioperatively, both groups had similar mean times to oral intake and discharge (LRN 2.6 days and HALN 3 days, P = 0.6). Although both groups reported similar postoperative pain scale scores on day 1, at 1 and 3 months. Two patients in each group had complications (LRN 16% and HALN 22%). In comparing HALN and LRN, there was no difference in the majority of operative and postoperative parameters, including hospital stay and postoperative pain. However, LRN patients had a significantly shorter convalescence with quicker return to normal activities and work than the HALN group. Part of the delay in long-term convalescence parameters may be due to the older patients in the HALN cohort.

Comparison of Laparoscopic Radical Nephrectomy with Open Radical Nephrectomy

Purpose: Laparoscopic surgery has become the standard surgical method within the urological community. This study was undertaken to evaluate the safety and efficacy of a standard laparoscopic radical nephrectomy (LRN) compared to an open radical nephrectomy (ORN) at a single medical center. Materials and Methods: Between January 2003 and March 2006, laparoscopic radical nephrectomies for renal cell cancer were performed in 30 patients and the results of the laparoscopic radical nephrectomy were compared with those of the open counterpart. Surgical results, such as the operation time, estimated blood loss (EBL), transfusion rate, narcotic analgesic requirement, hospital stay, complications and pathologic results, were retrospectively reviewed and analyzed using the Student's t-test. Results: There were no significant differences in the demographic data between the two groups. The pathological reports showed a clear cell type in 59 cases and a chromophobe type in 1 case. For the LRN and ORN groups, the mean operation times were 208 (120-320) vs. 206 min. (115-300) (p>0.05), EBL of 135 (100-200) vs. 318ml (100-2,000) (p=0.02), transfusion rates of 6.6 vs. 30%, narcotic analgesic requirements of 160 vs. 255mg diclofenac sodium, hospital stays of 6.7 vs. 10.5 days (p=0.04) and intraoperative complications in 0/30 (0%) vs. 2/30 cases (7%), respectively. The pathological surgical margins were all negative. The surgical and pathological parameters of the LRN group showed no significant differences to those of the ORN group, with the exception of the EBL and hospital stay. Conclusions: Laparoscopic radical nephrectomy resulted in less blood loss, a shorter hospital stay and earlier rapid recovery than an open radical nephrectomy. In our opinion, laparoscopic surgery could be a standard surgical treatment in renal cell cancer. (Korean J Urol 2007;48:259-264)

Laparoscopic Radical Nephrectomy for Renal Tumor: Comparison with Hand-assisted and Open Radical Nephrectomy

Purpose: We wanted to evaluate the safety and efficacy of standard laparoscopic radical nephrectomy (LRN) as compared to hand-assisted laparoscopic radical nephrectomy (HALS) and open radical nephrectomy (ORN) when the three different procedures were all performed by a single experienced surgeon. Materials and Methods: Between May 2000 and September 2005, 62 consecutive patients with renal tumor underwent LRN (16 patients), HALS (18 patients), or ORN (32 patients) by a single surgeon who had performed more than 100 laparoscopic surgeries. The surgical results such as the operation time, estimated blood loss (EBL), transfusion rate, narcotic analgesia requirement, hospital stay and complications, and pathologic results were reviewed retrospectively. Results: The LRNs and HALSs were successfully performed for all patients without open conversion. The final pathologic reports showed renal cell carcinomas in 65 cases and oncocytoma in 1 case. There were no significant differences of demographic data between the three groups. For the LRN, HALS, and ORN patients, the mean tumor size was 2.8cm (1.3-8.5), 4.5cm (1.5-13.5) and 5.6cm (1.0-12.5), respectively, the mean weight of the removed kidney was 200.6g (63-375), 214.5g (122-444.3) and 367.0g (122-823), respectively, the mean operation time was 174.8 min. (125-232), 196.4 min. (150-350) and 157.7 min. (110-265), respectively, the EBL was 140ml (50400), 108ml (50-600) and 297ml (50-700), respectively, the transfusion rate was 0%, 5.6% and 15.6%, respectively, the narcotic analgesia requirement was 20mg, 15mg and 43mg of morphine sulfate, respectively, the postoperative hospital stay was 4.8 days, 5.2 days and 10.5 days respectively, and the number of complication was 1/16 cases (6.3%), 1/18 cases (5.6%) and 4/32 cases (12.5%) respectively. The surgical and pathological parameters of LRN showed no significant difference compared to those of the HALS. Conclusions: LRN for renal tumors was less invasive than ORN and it showed similar surgical results to HALS. Therefore standard laparoscopic radical nephrectomy is considered to be an effective and safe treatment modality for renal tumors. (Korean J Urol 2006;47:1046-1051)

Comparison of Hand Assisted Versus Standard Laparoscopic Radical Nephrectomy for Suspected Renal Cell Carcinoma

We compared standard and hand assisted laparoscopic radical nephrectomy for suspected renal cell carcinoma. We retrospectively reviewed 22 hand assisted and 16 standard laparoscopic radical nephrectomies performed for suspected renal cell carcinoma. Operative and recovery data were collected prospectively and from medical records as part of an institutional review board approved protocol. Patients completed pain, activity and the 12-item short form health related quality of life surveys preoperatively and postoperatively. Although patients undergoing hand assisted laparoscopic nephrectomy had larger tumors (mean 6.3 versus 4.1 cm., p = 0.009), tended toward greater corrected mean specimen weight (658 versus 482 gm., p = 0.111) and had greater medical co-morbidity (p = 0.0228), mean operative time for hand assisted laparoscopic procedures was significantly shorter (205 versus 270 minutes, p = 0.0004). With experience mean operative time decreased for standard but not for hand assisted laparoscopy (293 to 232 minutes, p = 0.0445, versus 206 to 204, p = 0.6162). Procedure type, surgeon experience and adrenal sparing were the only significant predictors of operative time. There was no difference in the groups in terms of the complication rate, hospital cost or stay, return to activity or overall pain score, or in the difference in preoperative and postoperative 12-item short form scores. Hand assisted laparoscopic nephrectomy tended to be associated with more abdominal pain early in convalescence and more wound complications but not significantly so. Hand assisted laparoscopic radical nephrectomy offers recovery, morbidity and cost that are comparable to those of standard laparoscopy. The benefits of the technique include shorter operative times, no need for specimen morcellation and direct manual control of the operative field. It is particularly useful early in surgeon experience, for large specimens or when patient co-morbidities require a rapid procedure.

Comparison of Hand Assisted Versus Standard Laparoscopic Radical Nephrectomy for Suspected Renal Cell Carcinoma

Comparison of Hand Assisted Versus Standard Laparoscopic Radical Nephrectomy for Suspected Renal Cell Carcinoma