|Year : 2003 | Volume
| Issue : 1 | Page : 1-6
Laparoscopic radical nephrectomy: Is it ontologically safe?
Apul Goel, Ashok K Hemal
Department of Urology, All India Institute of Medical Sciences, New Delhi, India
Ashok K Hemal
Vattikuti Urology Institute, K 9, Henry Ford Hospital, 2799, West Grand Boulevard, Detroit, 48202
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objectives: Laparoscopic radical nephrectomy (LRN) is emerging as a viable alternative to open radical nephrectomy for treatment of patients with localized renal cell carcinoma (RCC). However, data regarding the oncologic effectiveness of this minimally invasive treatment option is still scarce. We review the literature regarding the oncologic efficacy of this treatment, including our own experience.
Methods: The current literature on LRN for treatment of patients with localized RCC, available on Medline, was reviewed.
Results: Although the long-term results are not known current literature suggests that LRN is as effective as open radical nephrectomy for localized RCC.
Conclusions: LRN is a safe and effective modality of treatment for patients with localized RCC. It does not pose any extra risk for port-site recurrence, local recurrence and distant metastasis over open radical nephrectomy. The survival outcomes are similar in both the techniques even at long term follow-up of 10 years.
Keywords: Laparoscopy, renal cell carcinoma, radical nephrectomy, recurrence, survival.
|How to cite this article:|
Goel A, Hemal AK. Laparoscopic radical nephrectomy: Is it ontologically safe?. Indian J Urol 2003;20:1-6
| Introduction|| |
Laparoscopic radical nephrectomy (LRN) was first performed by Clayman et al in 1991.  However, LRN for renal cell carcinoma (RCC) is still viewed as controversial.
Long-term reports about the efficacy and effectiveness of this approach are few and is still limited to a select group of patients and is being done in only selected centres worldwide. Only long-term follow-up involving a large number of patients will give the true picture about the role and indications for this approach. In this article we discuss the oncologic effectiveness of this treatment approach as per the current literature including our own experience.
| Methods|| |
The Medline was searched and all references on 'laparoscopic radical nephrectomy' for RCC were reviewed [Table 1].
| Oncologic Concern|| |
An oncologically complete removal of the tumour as accomplished in open radical nephrectomy (ORN) is also possible laparoscopically.  Early sequential control of the renal artery and vein prior to tumour manipulation, en bloc adrenalectomy, wide specimen mobilization external to Gerota fascia, avoidance of any specimen traumatization, and with documented negative surgical margins on histopathology can be achieved laparoscopically also. Regional lymphadenectomy for enlarged lymph nodes can also be performed. In a series of 100 patients treated laparoscopically the surgical margins were negative for neoplasm in all 100 specimens.  This suggests that compared with ORN, laparoscopy allows for the performance of a technically adequate dissection. With increasing experience some investigators have performed LRN for more extensive RCC like involvement of perirenal fat, level 1 renal vein thrombus and involvement of psoas muscle as well effectively.  The same group also reported an experimental study in which successful LRN was performed along with level II vena caval thrombectomy. 
| Port-Site Recurrence|| |
A critical assessment of the risk of tumour spillage at the time of laparoscopy must be studied especially because there are multiple reports documenting ovarian carcinoma and colonic adenocarcinoma port-site and abdominal wall tumour implantation. , Canis et al reported 2 recurrences after laparoscopy in 30 ovarian tumours.  A retrospective multicentre study performed by the Clinical Outcome of Surgery Therapy study group on 372 colorectal tumours treated with laparoscopy revealed 4 recurrences (1.08%) on the trajectory of the trocar and/or the abdominal wall.  These values are not very different from the 1.5% recurrence reported by the North Central Cancer Therapy Group. 
After LRN the specimen is transferred into a laparoscopic bag and then either removed intact or morcellated. The risk of port site recurrence with the intact specimen removal technique is nil if there is no tumour spillage at the time of surgery. However, if the specimen is morcellated, there is a risk of port-site recurrence although the incidence is extremely low. Till date only three cases of port-site recurrence after LRN have been reported in which the specimen was morcellated. , Other investigators still recommend morcellation, as they feel that it is safe and cosmetically more appealing than the usual 7-cm incision necessary for intact removal.  Moreover, they feel that except for tumour size all parameters like stage and grade of the tumour can be evaluated. Moreover, as there is no effective adjunctive therapy for cases with high-stage RCC that may be understaged on pre-operative CT scan, morcellation can safely be done without compromising the survival.  Pautler et al studied pre-morcellation needle biopsies and compared the histopathologic diagnosis achieved via needle biopsy prior to morcellation with that of the final morcellated specimen.  They suggested that morcellated histopathology material was adequate for diagnosis. We remove the specimen intact. There are many advantages to this approach. Firstly, it is cost reductive as the operating time is less and we save on the cost of the morcellator. Secondly, accurate tumor staging becomes possible and there is no risk of local or port-site recurrence. Moreover, the incidence of incision related morbidity and complications are not much. We have reported a large series of 242 procedures in which the specimens were removed intact following various ablative laparoscopic procedures and noted a very low incidence of complications. 
| Oncologic Adequacy in Terms of Local Recurrence, Distant Metastasis and Survival|| |
The ontological effectiveness of LRN is based on four criteria. Firstly, the kidney is removed completely without tumour transgression. The second criterion is the incidence of local recurrence on follow-up and the third criterion is distant recurrence and finally is the patient survival. Tumour seeding can occur as a result of tumour perforation and spillage of tumour cells by contaminated instruments. , However, this is very unlikely for RCC as the tumour is covered by the Gerota's fascia and therefore never in direct contact of the surrounding tissues or the instruments.
Most early-stage RCC are round and circumscribed by a pseudocapsule of compressed parenchyma and fibrous tissue rather than a true histologic capsule. Unlike upper tract transitional cell carcinoma, most RCC are not grossly infiltrative.  This explains why the incidence of local wound recurrence for T1-T2 RCC done either via open or laparoscopic approaches is very low.  Moreover, local recurrence after ORN is generally rare. Advanced stage patients with positive lymph nodes appear to be at increased risk of renal fossa recurrence. Local recurrence after radical nephrectomy is quite rare in patients with low stage T1-T2NOMO RCC. 
Various experimental studies have been done to study the effect of pneumoperitoneum and laparoscopy on tumour biology. Dorrance et al reported that the aerosols created by the gas used for insufflation led to tumour cell dissemination in the abdominal cavity but had no influence on trocar site metastasis.  However, several other studies have shown that aerosolization of tumour cells is an unlikely cause of tumour spillage. , Systemic dissemination of tumour cells during laparoscopy via the blood stream has not been demonstrated either. 
Vittimberga et al reported that the immune system is less disturbed by laparoscopy than by open surgery that may result in a better tumour defense.  Various studies have shown that following laparoscopy tumour growth is actually decreased as compared to open surgery. ,, Janetschek et al recently introduced an immunological regimen for the treatment of metastatic RCC, and for this reason, radical nephrectomy for this indication is performed by laparoscopic method even in more advanced clinical stages. 
In a series of 100 patients with a mean follow-up of 16.1 months (range 1-36 months), there were no reported local or port-site recurrences. Two patients, both with pTl NOMO tumours and dialysis-dependent renal failure. developed distant metastasis. 
Chan et al studied the cancer control in patients with RCC.  Of the 67 patients studied 46 had pathological stage TI, 8 had stage T2, 8 had stage T3a and 5 had stage T3b disease. All the surgical margins were free of tumour. The mean follow-up was 35.6 months. Eight patients died: four of them were considered disease-free as they died of other causes. They compared their results with 54 cases of ORN for organ confined disease. The mean follow-up of these patients was 44-months. Kaplan-Meier analysis of the data revealed that in the laparoscopic and open groups mean actuarial survival time was 83 and 71 months, and mean disease-free survival was 86 and 81 months, respectively which was not statistically significant (p>0.2). At 5-years for LRN and ORN the calculated disease-free rate was 95% and 86%, and the calculated actuarial survival rate were 86% and 75%, respectively. These differences were not significant on the log rank test. Since most LRN were performed more recently, mean follow-up was shorter than after ORN.
In a series of 73 cases with pathological stages T1 in 59, T3a in 6 and T3b in 3 (5 patients had benign lesions), and a mean follow-up of 13.3 months (range 1-60) not a single local recurrence or distant metastasis was seen and there were no tumour-related deaths. 
Cicco et al evaluated the carcinological risks of retroperitoneoscopic surgery for RCC. The mean follow-up was 24.76±12.76 months. The pathological stages were TI G1 in 10, TIG2 in 8, TIG3 in 7, T2G3 in 1, T2G4 in 1, T3aG2 in 1, T3aG3 in 5, T3aG4 in 3, T3bG2 in 2, T3bG1 in 1 and T3aG3M+ in 1. A local recurrence with hepatic metastasis occurred 9 months after surgery in a patient who had pT3G2 tumour and tumour-free surgical margins; this patient died 19.7 months after LRN. The patient with M+ disease at the time of diagnosis died 23.1 months after the procedure without any sign of local recurrence or trocarsite metastasis.
Cadeddu et al reported a multicentre experience of LRN in 157 patients. All patients had clinically localized RCC clinical stages T1-2, NOMO. The mean duration of followup was 19.2 months (51 patients with 2 years or more of follow-up). Four patients developed metastatic disease, and 1 patient developed a local recurrence. The 5-year actuarial disease-free rate was 91%±4.8 (SE). There were no cancer-specific mortalities. As a surrogate end point, the disease-free rate was also determined. With a total of five RCC recurrences, the 5-year actuarial cancer disease-free rates were 89% for clinical T2 and 100% for clinical T1 disease. This laparoscopic disease-free survival rate is favorable when compared with the available disease-free rates reported for ORN (e.g., 78% at 5 years for stage pT2).
Ono et al evaluated the long-term outcome of tumours less than 5-cm. One hundred and three patients underwent LRN while 46 cases underwent ORN. The laparoscopic group had a follow-up of 3 to 95 months (median 29). A total of 100 patients survived. There were 3 patients who had metastatic disease and 1 had local recurrence. The 5-year disease-free and patient survival rates were 95.1% and 95.0%, respectively. In the 46 patients who underwent ORN the median follow-up was 39 months (range 11 to 101). The 5-year disease-free and patient survival rates were 89.7% and 95.6%, respectively. There was no statistically significant difference in the disease-free or overall patient survival rates between LRN and ORN.
Dunn et al reported their 9-year experience in patients undergoing LRN. Sixty-one LRN were compared to a contemporary group of 33 patients who underwent ORN. The clinical stages were T1NOMO in 9, T2NOMO in 32 and T3bN1M1 in 1. In 3 patients with metastatic disease, nephrectomy was performed in preparation for adjunctive immunotherapy. The average follow-up was 25 months for the LRN and 27.5 months for the ORN group. RCC in 3 patients (8%) recurred in the laparoscopic group versus 3 (9%) in the open group. When stratified, patients with tumours larger than 4 to 10 cm experienced similar benefits and results as patients with tumours less than or equal to 4 cm. They did not report any instance of trocar or intraperitoneal seeding in the LRN group.
Recently, the long-term follow-up of patients treated by LRN has been reported. In this multi-centre study only patients with clinically localized RCC operated before January 1996 were studied. Thus 64 patients in whom LRN was performed were compared with 69 patients in whom ORN was done. The specimen was removed intact in 39 cases and morcellated in 25. On preoperative imaging ORN lesions were larger (6.2 cm) than LRN lesions (4.3 cm., p <0.001). Pathology reports revealed no difference in average Fuhrman grade (1.88 and 1.78, p =NS) between LRN and ORN. Median follow-up was 54 months for LRN and 69 months for ORN. Kaplan-Meier analysis with log-rank comparison revealed 5-year recurrence-free survival of 92% and 91 % for LRN and ORN, respectively (p =NS). At 5-years cancer-specific survival was 98% and 92% for LRN and ORN, respectively.
The results of LRN are equal or better than the results ORN in terms of survival. In a large recent retrospective review on 5-year cancer-specific survival after ORN for T1NO and T2NO stages revealed rates of 91% and 57% respectively. Javidan et al reported 5-year cancer-specific survival for T1NO and T2NO lesions of 95% and 88%. The results with LRN are similar to that of open approach. Even for tumours less than 4-cm the cancer-specific survival rates of 95% to 97%,  which are seen in ORN are now achieved by LRN also. With increasing expertise the indication for LRN is now being extended to selected patients with locally advanced RCC also. 
A large 10-year experience comparing LRN and ORN for RCC shows equal surgical and oncologic outcomes between two groups, even in cases of larger tumours. No difference in operating time is seen between ORN and LRN for large (T2) tumours, although estimated blood loss in significantly higher in patients undergoing ORN. Intraoperative complications are also slightly higher in ORN group. Pathologic results were nearly equivalent for T1 and T2 tumours removed laparoscopically.
| Indian Experience|| |
There is no published report in the literature from any center from India except from the authors' centre. , In the first report. 6-cases were reported to see the feasibility and efficacy of retroperitoneal approach for LRN and concluded that it is a safe option for medium-sized organ confined renal tumours. 
Subsequently, at the same center to put LRN to more rigorous test authors have performed comparison of 18 patients of LRN with ORN and concluded that LRN is comparable to ORN for RCC (TI. T2) in all aspects including oncological effectiveness. In patients undergoing LRN, patients reap all the benefits of laparoscopy such as lesser analgesic requirements. shorter hospital stay. early recuperation and excellent cosmesis. In a mean follow-up period of 17.7 months there were no local recurrences and only 1 patient with T2NOMO tumour developed distant metastasis 5 months after the surgery.  The surgical margins were negative in all the cases.
| Conclusions|| |
The laparoscopic approach for the management of localized RCC has already established its superiority over the established ORN as regards to shorter hospital stay, shorter convalescence, less analgesic requirements and better cosmesis. However, the major controversy hangs around the long-term oncological outcome of the laparoscopic approach and whether these would be equal to that of the open approach. Based on the recent 5-year followup data, in such patients LRN has been demonstrated to have clear oncologic effectiveness equivalent to ORN. Similar results have also been reiterated from Indian experience. Thus the LRN is now becoming the standard modality of treatment for the management of T1 and many T2 renal tumours.
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