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ORIGINAL ARTICLE
Year : 2002  |  Volume : 19  |  Issue : 1  |  Page : 38-41
 

Retroperitoneoscopic radical nephrectomy for renal cell carcinoma


Department of Urology, All India Institute of Medical Sciences, New Delhi, India

Correspondence Address:
Narmada P Gupta
Department of Urology, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


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Keywords: Renal Cancer: Renal Cell Carcinoma; Laparoscopy; Retroperitoneoscopy; Radical Nephrectomy


How to cite this article:
Gupta NP, Hemal AK, Aron M. Retroperitoneoscopic radical nephrectomy for renal cell carcinoma. Indian J Urol 2002;19:38-41

How to cite this URL:
Gupta NP, Hemal AK, Aron M. Retroperitoneoscopic radical nephrectomy for renal cell carcinoma. Indian J Urol [serial online] 2002 [cited 2019 Jul 16];19:38-41. Available from: http://www.indianjurol.com/text.asp?2002/19/1/38/20289



   Introduction Top


Laparoscopy affords less postoperative pain, more rapid convalescence and an optimal cosmetic result compared with traditional incisional surgery. [1] Therapeutic urologic laparoscopy can be performed either transperitoneally or retroperitoneally. Retroperitoneoscopy seems to offer cer­tain advantages over transperitoneal laparoscopy in urol­ogy [2],[3] as it affords direct access to the retroperitoneally located genitourinary organs without the need for perito­neal entry or colonic mobilization. The potential for intra­peritoneal organ injury is minimized. [2] The possibility of bacterial contamination of the potential cavity is elimi­nated, postoperative hematoma or urinoma are confined to the retroperitoneum [2] and the risk of future adhesive ob­struction is minimized.

Initially described by Bartel in 1969, [4] retroperitoneoscopy was until recently considered cumbersome because of the limited working space and lack of well-defined anatomical landmarks. Wick-ham [5] reported the first retroperitoneoscopic ureterolithotomy in 1979 and Clayman's group from St. Louis performed the first retroperitoneoscopic nephrectomy for renal oncocytoma in 1990. [6] However, retroperitoneoscopy never caught on in a big way until Gaur [7] demonstrated the elegant technique of atraumatic balloon dissection of the retroperitoneum.

Offered at only a few centers worldwide, laparoscopic radical nephrectomy is almost exclusively performed by the transperitoneal approach, [8],[9],[10],[11],[12],[13] because of the greater working space afforded by the peritoneal cavity. Recently, however, there have been some reports of retroperi­toneoscopic radical nephrectomy for renal cancer. [13],[14],[15],[16],[17] Herein, we present our initial experience with retro­peritoneoscopic radical nephrectomy for renal cell carci­noma, and define its indications, technique, feasibility and efficacy. This is the first such report in the Indian litera­ture.


   Patients and Methods Top


Between April and December 1998, we treated six cases of renal cell carcinoma with retroperitoneoscopic radical nephrectomy. The inclusion criteria for these patients were a) organ confined disease, b) tumor size <8 cm in largest dimension, c) no significant co-morbid illness and, d) in­formed consent. All patients were staged pre-operatively with contrast-enhanced computed tomography (CECT) scan.

Position, Retroperitoneal Access, and Port Placement

All procedures were done under endotracheal anesthesia and with a catheter in the bladder. The patients were placed in the standard flank position, with the diseased side up. Three ports of 10 mm and one of 5 mm were used for all cases. The primary port was placed 2 cm below the tip of the 12 th rib in the posterior axillary line. A 2 cm incision for the primary port was made and deepened down to the retroperitoneal space, which was then developed pos­teriorly, towards both poles, and medially, using finger dissection. [18],[19] Subsequently, either an Origin (Origin Medsystems, Munlo Park, CA) transparent balloon or an indigenous balloon [18],[19],[20] was inserted into the extraperitoneal space outside the fascia of Gerota. The balloon was in­flated with 500-800 ml of air (transparent balloon) or sa­line (indigenous balloon) and maintained for 3-5 minutes so as to create adequate space in the retroperitoneum and secure hemostasis. The advantage of the Origin balloon is that adequacy of the retroperitoneal space all the way up to the diaphragm can be confirmed by introducing the laparoscope into the transparent shaft of this balloon de­vice, while a disadvantage especially in developing coun­tries is the high cost of this device. The advantage of the indigenous balloon is the negligible cost, while a disad­vantage is the inability to check the retroperitoneal space through the balloon. At times, it was necessary to deflate and then reintroduce the balloon into a more cephalad po­sition for adequate dissection. Then the balloon was re­moved and a 10 mm cannula (primary port) introduced into the retroperitoneal space. We prefer to use a cannula with a subfascial retention balloon (Hasson's cannula) since it reduces the incidence of surgical emphysema and inadvertent gas-leak from the retroperitoneum. This can­nula was stabilized with 2 pre-placed sutures of 1-0 ny­lon, which included the parietal musculature and the thoracolumbar fascia in order to prevent surgical emphy­sema and accidental dislodgement during the procedure. A carbon-dioxide pneumo-retroperitoneum was estab­lished through this cannula and pressure maintained at 14 mmHg. The laparoscope was introduced through the can­nula and the retroperitoneum inspected. Additional ports were introduced by the closed technique, under laparoscopic guidance. The second port was introduced in the anterior axillary line at the same horizontal level as the primary port. The third port of 10 mm was placed at the lateral border of the ipsilateral psoas at the same hori­zontal level as the primary port. The fourth port (5 mm) was introduced in the mid-axillary line midway between the costal margin and the iliac crest.

Dissection and Radical Nephrectomy

The psoas major muscle was easily identified and it was traced up to the vicinity of the renal hilum that was iden­tified by looking for pulsation in the gutter medial to the medial margin of the psoas. Blunt dissection in this area with a blunt dissector or a sucker tip exposed the great vessels and the renal pedicle. A hilar window was created around the renal pedicle and enlarged by blunt dissection, both towards the kidney and the great vessels, so that ad­equate length of the renal vessels was bared. The renal artery was first cleared and 6 clips were applied on it, whereafter it was divided between three clips on either side. If the renal vein did not become flat after this step an attempt was made to look for an accessory renal artery which is usually present in such instances. Subsequently, the renal vein was similarly clipped and divided. Medium­size clips are adequate for the renal artery: however, the renal vein usually requires large clips or an endostapler (if available). The kidney was mobilized outside the fascia of Gerota, taking care not to violate its integrity at any point. For upper pole tumors, the adrenal was also included in the dissection. In such cases, special care is required to prevent avulsion of the adrenal vein during dissection and traction, and it is preferable to clip and divide this vessel at an early stage. Once the whole kidney was mobilized, the ureter was clipped and divided and the specimen was now free in the retroperitoneum. Subsequently an inci­sion was made between the primary port and the third port and the specimen delivered intact through this without morcellation. A suction drain was introduced through the 5 mm port-site and the port-sites and incised wound closed in layers.


   Results Top


The procedure was completed successfully in 4 patients while 2 patients required conversion to open surgery [Ta­ble 1]. In the successful patients the mean operating time and blood loss respectively were 156 minutes and 275 ml while that in the converted patients were 142 minutes and 450 ml. The parenteral pethidine requirement in the suc­cessful patients averaged 162 mg, while that in the con­verted patients averaged 450 mg. Mean duration to resumption of oral intake in the successful cases was 1.25 days while that in converted cases was 3.5 days. Hospital stay averaged 3 days in the successful cases and 7 days in the converted patients.

In I patient the reason for conversion was the presence of nodes in the renal hilum that prevented adequate expo­sure of the pedicle for clipping. On exploration these nodes were removed and sent for histopathology where they were found to be reactive in nature. In the other patient we had unexpected gas leak from a malfunctioning port. which prevented adequate pneumo-retroperitoneum for this com­plex and painstaking dissection. With increasing experi­ence such conversions will probably not be required. In all patients, there was agreement between the clinical stage and pathological stage with the exception of patient no. 4 where the reactive nodes were missed at CECT. The op­erative specimen in all cases revealed no breach in the integrity of the fascia of Gerota.

Follow-up data is available on these patients over 1-9 months (mean 6.1 months). 5 patients have no evidence of disease while 1 (patient no.]) has developed multiple cannon-ball secondaries in the chest, suggesting the pres­ence of micro-metastases at the time of retroperitoneo­scopic extirpation. This is an occurrence over which the urologist has no control.


   Discussion Top


Offered at only a few centers worldwide. laparoscopic radical nephrectomy [Table 2] is almost exclusively per­formed by the transperitoneal approach. [8],[9],[10],[11],[12],[13] Recently, how­ever, there have been some reports of retroperitoneoscopic radical nephrectomy for renal cancer. [13],[14],[15],[16],[17] The retroperi­toneoscopic approach to a retroperitoneal organ has in­herent appeal, yet the transperitoneal approach is more common because of the greater working space afforded by the peritoneal cavity. Laparoscopic radical nephrec­tomy is a viable treatment option for a small or medium sized (<8 cm) renal tumor. without lymphatic. venous or perirenal involvement. [8]

This preliminary study was conducted to assess the safety and technical feasibility of retroperitoneoscopic radical nephrectomy at our institution and to define the operative technique. A completely retroperitoneoscopic approach is eminently feasible and a transperitoneal ap­proach will probably be required only for larger tumors. It is important to stay outside the fascia of Gerota and go straight for the pedicle so that none of the principles of renal cancer surgery are compromised. In fact, it has been our observation that the delineation of the anatomy of the retroperitoneum, in some aspects, is superior with laparo­scopy than even with open surgery because of the magni­fied view provided by the laparoscope. As our experience increases, our threshold for conversion will also increase and the success rate is likely to go up.

If there is difficulty in identifying landmarks in the retro­peritoneum, one must first identify the psoas both by pal­pation from outside and under laparoscopic vision from inside. This is a constant landmark and always easy to locate. The psoas is then crossed from laterally to medial in a cephalad direction to identify the pulsation at the re­nal hilum. [17] Another useful and constant landmark is the fibers of the diaphragm, but they are only seen if the bal­loon dissection has been cephalad enough to reach the dia­phragm. The triflange (or fan) retractor is an invaluable aid for this procedure. It is useful to retract not only the peritoneum, but also the renal surface during hilar dissec­tion. We have used multiple clips to control the main re­nal vessels. It is important to apply this "chain of steel" on the main renal vessels to reduce the risk of subsequent slippage and potentially fatal hemorrhage. A faster option (if available) would be the use of staplers, which would apply two staggered rows of staples and divide the vessel between the staples. A very important consideration in hilar control is to always look for an accessory renal artery if the renal vein does not collapse after the clipping of the main renal artery. During clipping of the renal vein, one must be careful not to tent up the inferior vena cava.

There is controversy regarding the advisability of speci­men morcellation during laparoscopic radical nephrec­tomy. The advantage is the ease of retrieval by suction while an obvious disadvantage is the loss of precise pathologic tumor staging and the risk of tumor seeding, apart from increased operating time required for morcel­lation. In a recent study, Shalhav and associates [21] found that no patient with low stage (T3a or lower) renal cancer is understaged by pre-operative CECT and hence there management based on clinical staging alone is adequate, thus obviating the need for pathological staging after laparoscopic surgery. On this basis they concluded that specimen morcellation is an acceptable procedure. In an­other recent report, Barrett et al [10] presented 66 successful transperitoneal radical nephrectomies with specimen mor­cellation. At a mean follow-up of 21.4 months they did not find any instance of port-site recurrence, retroperito­neal recurrence or distant metastases. However, like sev­eral other authors, [9],[13],[17] we have preferred to remove the specimen intact through a small incision with an aim to obtain accurate pathologic data for prognostication and further treatment planning.

The results in this pilot study have shown that retroperi­toneoscopic nephrectomy is technically feasible and safe in patients with medium-sized organ-confined renal tumors. However, because of the complex dissection in­volved, only those urologists who already have experi­ence with retroperitoneoscopy for benign disease should undertake it. As experience increases, the success rate is likely to increase and the operating times reduce, and it might become the procedure of choice for such selected patients in the next millennium.


   Acknowledgement Top


We are thankful to Dr. Inderbir S.Gill, Head, Section of Laparoscopic and Minimally Invasive Surgery, Depart­ment of Urology, Cleveland Clinic Foundation for help in starting retroperitoneoscopic radical nephrectomy at our center. We are also grateful to the faculty and residents of our department for their support and help during the plan­ning and performance of these procedures.

 
   References Top

1.Kerbl K, Clayman RV, McDougall EM et al. Transperitoneal ne­phrectomy for benign disease of the kidney: a comparison of laparoscopic and open surgical technique. Urology 1994; 43: 607.  Back to cited text no. 1    
2.Gill IS, Grune MT, Munch LC. Access technique for retroperi­toneoscopy. J Urol 1996; 156: 1120.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Clayman RV, McDougall EM, Kerbl K et al. Laparoscopic nephrec­tomy : transabdominal vs. retroperitoneal. J Endourol 1993; 7: S 139.  Back to cited text no. 3    
4.Bartel M. Die retroperitoneoscopie : Eine endoskopische methode zur inspection and bioptischem untersuchung des retroperitonealen raumes. Zentralbl Chir 1969; 94: 377.  Back to cited text no. 4  [PUBMED]  
5.Wickham JEA (ed.). The surgical management of renal lithiasis. In: Urinary Calculus Disease. New York, Churchill Livingstone 1979; 145-198.  Back to cited text no. 5    
6.Clayman RV, Kavoussi LR, Soper NJ et al. Laparoscopic nephrec­tomy : Initial case report. J Urol 1991; 146: 278.  Back to cited text no. 6    
7.Gaur DD. Laparoscopic operative retroperitoneoscopy. J Urol 1992; 148: 1137.  Back to cited text no. 7  [PUBMED]  
8.Clayman R, Elbahnasy A. Elashry 0 et al. Laparoscopic vs. open radical/total nephrectomy for renal cell carcinoma (abstract no. 1280). J Urol 1997; 157: 328.  Back to cited text no. 8    
9.Laparoscopic radical nephrectomy for renal tumor: the Washington university experience. J Urol 1996; 155: 1180-1185.  Back to cited text no. 9    
10.Barrett PH, Fentie DD, Taranger LA. Laparoscopic radical nephrec­tomy with morcellation for renal cell carcinoma: the Saskatoon experience. Urology 1998: 52: 23-28.  Back to cited text no. 10    
11.Cadeddu JA, Ono Y, Clayman RV, Barrett PH, Janetschek G, Fentie DD, McDougall EM, Moore RG, Kinukawa T, Elbahnasy AM, Nelson JB, Kavoussi LR. Laparoscopic nephrectomy for renal cell cancer: evaluation of efficacy and safety: a multicenter experience. Urology 1998; 52: 773-777.  Back to cited text no. 11  [PUBMED]  [FULLTEXT]
12.Rassweiler J, Fornara P, Weber Metal. Laparoscopic nephrectomy: the experience of the laparoscopy working group of the German urologic association. J Urol 1998; 160: 18-21.  Back to cited text no. 12    
13.Ono Y. Katoh N, Kinukawa T, Matsuura O. Ohshima S. Laparo­scopic radical nephrectomy: the Nagoya experience. J Urol 1997: 158: 719-723.  Back to cited text no. 13    
14.Gasman D. Saint F, Barthelemy Y. Antiphon P, Chopin D, Abbou CC. Retroperitoneoscopy: a laparoscopic approach for adrenal and renal surgery. Urology 1996; 47: 801-806.  Back to cited text no. 14    
15.Gill IS, Grune MT. Pomeroy BD. Retroperitoneoscopic radical ne­phrectomy for renal tumors in end stage kidneys (abstract no. P6­15). JEndourol 1997: 11: S127.  Back to cited text no. 15    
16.Ono Y, Katoh N. Kinukawa T et al. Laparoscopic radical nephrec­tomy via the retroperitoneal approach (abstract no. V-38). J Urol 1996: 155: 297A.  Back to cited text no. 16    
17.Gill IS. Retroperitoneal laparoscopic nephrectomy. Urol Clin N Amer 1998; 25: 343-360.  Back to cited text no. 17    
18.Hemal AK. Gupta NP, Rajeev TP, Aron M, Bhowmik D. Jain R. Retroperitoneoscpic management of infected cysts in adult poly­cystic kidney disease. Urol Int (In Press).  Back to cited text no. 18    
19.Hemal AK, Aron M, Gupta NP, Seth A. Wadhwa SN. Retroperi­toneoscopie management of recalcitrant renal, giant adrenal and complex peripelvic cysts and nonfunctioning congenital anoma­lous kidneys. Br J Urol (In Press).  Back to cited text no. 19    
20.Hemal AK. Gupta NP, Wadhwa SN. Modified cost-reductive retroperitoneoscopic nephrectomy and nephroureterectomy in chil­dren : a pilot study. Br J Urol (In Press).  Back to cited text no. 20    
21.Shalhav AL. Leibovitch I, Lev R, Hoenig DM, Ramon J. Is laparoscopic radical nephrectomy with specimen morcellation ac­ceptable cancer surgery ? J Endourol 1998; 12: 255-257.  Back to cited text no. 21    




 

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    Introduction
    Patients and Methods
    Results
    Discussion
    Acknowledgement
    References

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