|Year : 2004 | Volume
| Issue : 2 | Page : 154-159
Laparoscopic radical nephrectomy: Our initial experience
Pradeep Bansal, Anant Kumar, Aneesh Shrivastava, Devendra Kumar, Anil Mandhani, Mahendra Bhandari
Department of Urology, SGPGIMS, Lucknow, India
Department of Urology, SGPGIMS, Raebareli Road, Lucknow - 226 014
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objectives: The objective of the current study was to report our initial experience of transperitoneal laparoscopic radical nephrectomy with intact specimen extraction and to compare it with a similar cohort of patients who underwent conventional open surgical procedure to assess the feasibility and advantage of laparoscopy in renal tumor surgery.
Methods: Twenty patients (13 men and 7 women) with mean age of 55 years underwent transperitoneal laparoscopic radical nephrectomy. The kidney was dissected laparoscopically together with the adrenal gland, perirenal fat and Gerota's fascia. Intact specimen was removed through a small incision. Intra-operative and postoperative problems were analyzed and compared with the 16 comparable renal tumors operated by open procedures during the same period.
Results: Of the 20 patients, 16 kidneys could be successfully removed laparoscopically. Four patients needed early conversion to open either due to technical problem in dissecting the hilar area because of larger tumor size or due to bleeding. Mean operating time was 3.5 hours and mean estimated blood loss was 290 ml. Two had intraoperative complications, one with splenic tear due to retraction injury and the other with bleeding from adrenal vein avulsion. Laparoscopy costed about rupees 4.5 to 5 thousand more than open surgery while the incision length was 5 to 11 cm depending on the tumor size (mean 7 cm) as compared to 20-28 cm (mean 25 cm) in open surgery. Pathological tumor stage was T1NOMO in 16, T2NOMO in 1 patient treated laparoscopically, which were comparable to that of the conventional open group. Postoperative hospital stay was 3-7 days (mean 5 days) when compared to 5-12 days (mean 7 days) in the open group. Convalescence period was between 12 and 34 days (mean 19 days). No metastatic disease, local recurrence and seeding at the port site were observed during the follow-up period of 1-23 months (mean 12 months).
Conclusions: Laparoscopic radical nephrectomy, although technically demanding and more expensive, is a viable option for managing localized renal tumors. It imparts lesser morbidity, better cosmesis and early convalescence to the patient.
Keywords: Laparoscopy, carcinoma, radical nephrectomy, open surgery.
|How to cite this article:|
Bansal P, Kumar A, Shrivastava A, Kumar D, Mandhani A, Bhandari M. Laparoscopic radical nephrectomy: Our initial experience. Indian J Urol 2004;20:154-9
|How to cite this URL:|
Bansal P, Kumar A, Shrivastava A, Kumar D, Mandhani A, Bhandari M. Laparoscopic radical nephrectomy: Our initial experience. Indian J Urol [serial online] 2004 [cited 2020 May 28];20:154-9. Available from: http://www.indianjurol.com/text.asp?2004/20/2/154/21533
| Introduction|| |
Laparoscopic nephrectomy for benign renal disease has found widespread acceptance since the initial success by Clayman et al in 1990.  Since then, laparoscopic removal of kidney for both benign and malignant disease has rapidly gained worldwide acceptance. It is currently being performed either by transperitoneal ,, or retroperitoneal approach. ,
Comparison between laparoscopic and traditional open total/radical nephrectomy have consistently demonstrated the advantages of laparoscopic approach in all the parameters i.e. peri operative morbidity, blood loss, postoperative narcotic requirements, length of hospitalization, cosmesis and duration of convalescence. ,,,
Fear concerning tumor spillage, trocar site implantation and oncological effectiveness .has generated controversy on the role of laparoscopy in oncology. ,, Others have shown the feasibility and short-term success of laparoscopic radical nephrectomy for renal cell carcinoma without port site recurrence or distant metastasis. ,,,,, Recently long term oncological effectiveness equivalent to traditional nephrectomy have been reported , .
Herein, we present our initial experience of laparoscopic radical nephrectomy and, in addition, we compare results with those who underwent open radical nephrectomy during the same period to evaluate the efficacy of the laparoscopic procedure.
| Patients and Methods|| |
Between November 2000 and November 2002, 13 men and 7 women (mean age 55 years, range 24-68 years) underwent laparoscopic radical nephrectomy. All patients were assessed by computed tomography (CT) of the abdomen, chest X-ray, renal and liver function tests. The inclusion criteria for laparoscopic radical nephrectomy were T1 or T2 disease on preoperative staging and general well being of the patient to tolerate prolonged anesthesia. Laparoscopic radical nephrectomies were carried out using the transperitoneal approach. During the same period 29 patients were treated by conventional open radical cal nephrectomy and the results of open and laparoscopic procedure were retrospectively compared. Out of these, 16 patients had a clinical stage and general condition comparable to those who underwent laparoscopic nephrectomy and these were included for comparative analysis. We compared all parameters, including information on long-term recovery, between the 2 groups of patients.
Laparoscopic technique: Port placement: Pneumoperitoneum was created by veress needle in all except 3 patients where it was done by open method (due to previous operated scar). An 11 mm camera port was placed either sub-umbilically or para-rectally. Four ports technique was used for both the left sided [Figure - 1] and the right sided tumor [Figure - 2]. Dissection of the kidney: During right nephrectomy, the ascending colon and duodenum were reflected medially. Liver retraction was required to expose upper part of kidney. The ureter was dissected about 5-7 cm below the level of the lower pole of the kidney and was clipped and cut. The junction of the renal vein with the inferior vena cava (IVC) was defined and then the renal vein was dissected all around. The renal artery was identified behind the renal vein. The renal vein was transected using the Endo-GIA stapler (USA Surgical Norwalk, CT) or hemolock clip and for the renal artery hemolock clips were used. The kidney was mobilized outside Gerota's fascia. For left nephrectomy, following mobilization of the colon, the ureter was identified and transected. The junction of the gonadal and the adrenal vein with the renal vein was defined and cut between the clips (300 mm). By lifting the renal vein the lumbar vein was identified and cut between the clips. The renal artery was identified and dissected similar to the right sided nephrectomy. The rest of the procedure was similar to that on the right side. Kidney extraction was performed by a 5-11 cm incision (mean 7) extending from one of the major port site or by pfannenstiel incision and the specimen was retrieved intact manually.
| Results|| |
Twenty patients with the age range of 24 to 68 years (mean 55 years) underwent transperitoneal laparoscopic radical nephrectomy. Eight patients had disease on the right side and 12 on the left side. The preoperative staging was TI NOMO in 17 and T2NOMO disease in 3 patients [Table - 1].
All patients underwent transperitoneal laparoscopic radical nephrectomy, and the procedure was performed successfully in 16 patients. In 4 patients early conversion was required. In two patients hilar dissection was difficult due to the narrow space as a result of tumor bulge in the hilum. In one patient, hemorrhage from the renal vein injury at the junction of IVC precluded further dissection due to poor visualization. In the fourth patient there was a 12-14 cm large vascular tumor adherent to the mesentery of the colon, and during bowel mobilization there was uncontrollable bleeding from the mesenteric vessels [Table - 2].
Two patients with transitional cell carcinoma (TCC) of the renal pelvis underwent radical nephroureterectomy with excision of bladder cuff. Here the kidney was mobilized outside the gerota's fascia following initial vascular control. Kidney along with the dissected ureter was pushed into the pelvis. Nephroureterectomy specimen enbloc with the cuff of bladder was removed using a 7-8 cm Pfannenstiel incision. Two patients underwent concomitant laparoscopic cholecystecomy with the addition of one port on right and two on the left side.
There were 2 intraoperative complications, bleeding from the injured spleen due to improper retraction, and bleeding from an injured adrenal vein during dissection at the renal vein area. Both were managed laparoscopically by applying surgicel and clipping the adrenal vein [Table - 2]. In all cases except the four in whom open conversion was done, the specimen could be retrieved by a 5-11 cm incision (mean 7 cm). Operative time ranged from 2.5 to 6 hours (mean 3.5 hours). Overall estimated blood loss was between 100 to 700 ml (mean 290 ml). Postoperative analgesia was given for the first postoperative day (Injection Tramadol 50 mg 8 hourly) and only six patients required additional analgesics on the subsequent postoperative days. Adequacy of analgesia was assessed by patient satisfaction. The mean analgesic requirement was 297 mg of tramadol. [Table - 3].
In the early postoperative period, one patient had prolonged ileus and another had prolonged drainage of sero-sanguinous fluid for 4-5 days and one patient had wound infection [Table - 2]. All were managed conservatively. Postoperative hospital stay was between 4 and 11 days (mean 5 days), and convalescence was achieved between 12 -34 days (mean 19 days) [Table - 3].
All sixteen specimens were removed intact. Final pathological analysis revealed renal cell carcinoma in 18 and TCC of the renal pelvis in two patients. Thirteen patients had pT1N0M0 and 6 had pT2NOMO and one patient had pT2N1M1 [Table - 2]. The follow-up period was between 1 and 23 months (mean 12 months). No patient had distant metastatic disease, local recurrence or seeding at the port sites.
Sixteen patients who had similar stage disease underwent open radical nephrectomy [Table - 1]. Incision length was 20 - 28 cm (mean 25 cm) depending upon the body habitus and the size of the tumor. Operative time was between 1.9-4.2 hours (mean 3.1 hours), and the blood loss was between 90 to 570 ml. (mean 230ml). The mean operative time (p=0.3) and blood loss (p=0.21) were not much different from that of laparoscopically treated patients [Table 3]. Blood transfusion was required in one case from each group. Major complications(6.25%) included renal vein injury and minor complications (31.25%) included serosal tear of the duodenum during mobilization,  prolonged paralytic ileus,  wound infection  and all were managed conservatively [Table - 2]. All patients required postoperative analgesia; the average dosage was 500 mg of tramadol. Open procedure was 4500 to 5000 rupees cheaper compare to the laparoscopic group. Treatment cost was estimated by calculating the total hospital stay, operative charge, expenses incurred on consumable and the cost of medicines.
Postoperative hospital stay was 6-14 days (mean 7 days) while the mean time to convalescence was 34 days. Pathologically all had renal cell cancer with stage comparable to laparoscopic group [Table - 3].
| Discussion|| |
Since the first reported use of laparoscopy in urology in 1991,  laparoscopic nephrectomy has being gaining momentum as an adequate mode of primary renal cancer therapy in the appropriately selected patients. Initial series, even in the early years of the learning curve, consistently revealed that laparoscopic nephrectomy is as effective as open surgical extirpation and it was better tolerated than open surgery. ,
In a direct comparison of the two approaches, Mc Dougall et al  reported comparative data of seventeen laparoscopic and 12 open radical nephrectomy patients. There was significantly less postoperative pain, and earlier discharge from the hospital (4.5 v/s. 8.4 days) and earlier full recovery (3.5 v/s. 5.1 weeks). In our early experiences also, the need for analgesia (297 v/s. 500 mg of tramadol), the postoperative hospital stay (5 v/s. 7 days) and the period of full convalescence (19 v/s. 34 days) were significantly less for the laparoscopic procedure than the open radical nephrectomy. However, the estimated blood loss was more (290 v/s. 230 ml) for laparoscopy as compare to open surgery but it was not much different from the reported loss of mean of 289 ml for laparoscopy and 309 ml for open radical nephrectomy by David Y C et al.  While Yoshinari 0 et al observed significantly more blood loss with open radical nephrectomy as compared to laparoscopic procedure (513 v/s. 255 ml). 
Laparoscopic nephrectomy often takes more operative time. However the impact of experience underlies the importance of the learning curve to achieve acceptable operative time. McDougall et al  reported in 1996, the initial operative time of 6.9 hours, which decreased 5.5 hours in later series. Similarly Higashihara et al retrospectively reported a significantly decreased in operative time with experience and was similar to time of open radical nephrectomy.  In the present series likewise operative time has decreased by nearly half when comparing the first and last ten patients (initial 4.5 -6 hours to 2.5-4.2 hours). Our mean laparoscopic operating time was not much different from the open radical nephrectomy (3.5 v/s. 3.1)
In the present series, laparoscopic complications are similar to the 34% rate reported by Gill et al (16). Though major complications were not different from the open radical nephrectomy (10% v/s. 6.25%), however minor complications rate was higher for the open group (20% v/s. 31.25%) [Table - 3].
Intact specimen extraction using laparoscopic sac with an incision of 5 to 6 cm is quite common. , We preferred manual extraction of the intact specimen over lap sac due to its cost effectiveness. The removal of an intact specimen through 5-11 cm muscle splitting and muscle cutting incision, results in only minimal trauma to the patient. The advantage of specimen being removed intact minimizes the risk of tumor spillage or metastatic implantation with complete tissue availability for histopathological evaluation. The time-consuming placement and costly morcellation of the specimen in a lap sac can be omitted.
Reports of port site tumor recurrence have raised concern about the safety of laparoscopy for treating malignancy.  To date only two cases of port site metastasis have been reported following laparoscopic radical nephrectomy. , In our series there was no incidence of port site metastasis on a mean follow-up of twelve months. Our series is limited by a short follow-up and hence it would be premature to comment on survival, However a recent large series (11) reported, five year recurrence free survival of 92% v/s. 91 % (p =0.583), 5 year cancer specific survival of 98% v/s. 92% (p=0.124%), and overall survival of 81 % v/s. 89% (p=0.260) for laparoscopic and open radical nephrectomy, respectively. Economically also laparoscopic nephrectomy is not a costly procedure as compared to open technique rather it is more economical in long-term considering the shorter hospital stay, less analgesic requirement and most importantly early convalescence (19 vs. 34 days) with return to early normal and productive life. Increased cost (Rupees 4500 to 5000 more than open) for laparoscopic procedure may be attributable to initial longer operating time and use of more expensive instrumentation, which is mostly disposable.
| Conclusions|| |
Laparoscopic radical nephrectomy, although technically more demanding and expensive than open radical nephrectomy, is a viable alternative for managing localized renal tumors. In comparison with standard open radical nephrectomy, this procedure requires longer operative time and significant learning curve, however patients continue to benefit from an improved postoperative course with less pain and a quicker recovery while providing similar efficacy at a short follow up. Longer follow up would tell us the disease-free status compared with that of open surgery.
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[Figure - 1], [Figure - 2]
[Table - 1], [Table - 2], [Table - 3]