|Year : 2002 | Volume
| Issue : 1 | Page : 38-41
Retroperitoneoscopic radical nephrectomy for renal cell carcinoma
Narmada P Gupta, Ashok K Hemal, Monish Aron
Department of Urology, All India Institute of Medical Sciences, New Delhi, India
Narmada P Gupta
Department of Urology, All India Institute of Medical Sciences, New Delhi - 110 029
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
| Introduction|| |
Laparoscopy affords less postoperative pain, more rapid convalescence and an optimal cosmetic result compared with traditional incisional surgery.  Therapeutic urologic laparoscopy can be performed either transperitoneally or retroperitoneally. Retroperitoneoscopy seems to offer certain advantages over transperitoneal laparoscopy in urology , 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.  The possibility of bacterial contamination of the potential cavity is eliminated, postoperative hematoma or urinoma are confined to the retroperitoneum  and the risk of future adhesive obstruction is minimized.
Initially described by Bartel in 1969,  retroperitoneoscopy was until recently considered cumbersome because of the limited working space and lack of well-defined anatomical landmarks. Wick-ham  reported the first retroperitoneoscopic ureterolithotomy in 1979 and Clayman's group from St. Louis performed the first retroperitoneoscopic nephrectomy for renal oncocytoma in 1990.  However, retroperitoneoscopy never caught on in a big way until Gaur  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, ,,,,, 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. ,,,, 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|| |
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. , Subsequently, either an Origin (Origin Medsystems, Munlo Park, CA) transparent balloon or an indigenous balloon ,, 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|| |
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|| |
Offered at only a few centers worldwide. laparoscopic radical nephrectomy [Table 2] is almost exclusively performed by the transperitoneal approach. ,,,,, Recently, however, there have been some reports of retroperitoneoscopic radical nephrectomy for renal cancer. ,,,, 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. 
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.  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  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  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, ,, 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|| |
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|| |
|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. |
|2.||Gill IS, Grune MT, Munch LC. Access technique for retroperitoneoscopy. J Urol 1996; 156: 1120. [PUBMED] [FULLTEXT]|
|3.||Clayman RV, McDougall EM, Kerbl K et al. Laparoscopic nephrectomy : transabdominal vs. retroperitoneal. J Endourol 1993; 7: S 139. |
|4.||Bartel M. Die retroperitoneoscopie : Eine endoskopische methode zur inspection and bioptischem untersuchung des retroperitonealen raumes. Zentralbl Chir 1969; 94: 377. [PUBMED] |
|5.||Wickham JEA (ed.). The surgical management of renal lithiasis. In: Urinary Calculus Disease. New York, Churchill Livingstone 1979; 145-198. |
|6.||Clayman RV, Kavoussi LR, Soper NJ et al. Laparoscopic nephrectomy : Initial case report. J Urol 1991; 146: 278. |
|7.||Gaur DD. Laparoscopic operative retroperitoneoscopy. J Urol 1992; 148: 1137. [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. |
|9.||Laparoscopic radical nephrectomy for renal tumor: the Washington university experience. J Urol 1996; 155: 1180-1185. |
|10.||Barrett PH, Fentie DD, Taranger LA. Laparoscopic radical nephrectomy with morcellation for renal cell carcinoma: the Saskatoon experience. Urology 1998: 52: 23-28. |
|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. [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. |
|13.||Ono Y. Katoh N, Kinukawa T, Matsuura O. Ohshima S. Laparoscopic radical nephrectomy: the Nagoya experience. J Urol 1997: 158: 719-723. |
|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. |
|15.||Gill IS, Grune MT. Pomeroy BD. Retroperitoneoscopic radical nephrectomy for renal tumors in end stage kidneys (abstract no. P615). JEndourol 1997: 11: S127. |
|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. |
|17.||Gill IS. Retroperitoneal laparoscopic nephrectomy. Urol Clin N Amer 1998; 25: 343-360. |
|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). |
|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). |
|20.||Hemal AK. Gupta NP, Wadhwa SN. Modified cost-reductive retroperitoneoscopic nephrectomy and nephroureterectomy in children : a pilot study. Br J Urol (In Press). |
|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. |