Sequential bilateral minimum incision endoscopic radical nephrectomy in dialysis patients with bilateral renal cell carcinomas

Since 1998, we have performed minimum incision endoscopic surgery (MIES) for renal cell carcinoma (RCC). For seven dialysis patients with bilateral RCC, we have performed sequential bilateral MIES radical nephrectomy. It was carried out by retroperitoneal approach through a single minimum incision that narrowly permitted extraction of the specimen using endoscopy and direct stereovision, without trocar ports, without gas insufflation and without the insertion of the hands of operators into the operative field. Although six of the seven patients had multiple complications in addition to chronic renal failure (CRF), bilateral kidneys were successfully removed by sequential MIES radical nephrectomy without major operative complication. Postoperative recovery was prompt with all patients resuming oral feeding and walking by the second postoperative day. Sequential bilateral MIES radical nephrectomy, leaving the peritoneal cavity intact and without imposing circulatory stress caused by gas insufflation, is a feasible treatment for bilateral RCCs in dialysis patients.     

Hand-assisted laparoscopic nephrectomy for renal masses >9.5 cm: series comparison with open radical nephrectomy

OBJECTIVE: To assess the feasibility of hand-assisted laparoscopic nephrectomy (HALN) for large renal masses (stage T2, mean size 9.7 cm) and compare outcomes with a similar cohort undergoing open radical nephrectomy (ORN). METHODS: A nonrandomized comparison of 19 consecutive patients who underwent nephrectomy for renal masses >or=7 cm was performed. The HALN group was compared to the ORN group regarding demographic parameters and perioperative data, including blood loss, operating time, narcotic usage, hematocrit change, return to standard oral intake, length of hospital stay, and complications. Data collected prospectively and statistics used 2-tailed t-test analysis. RESULTS: Patients underwent either ORN (mean tumor size 12.3 cm) or HALN (mean tumor size 9.7cm). Tumors up to 14 cm (n = 2) and pT3b, with renal vein thrombosis (n = 2), could be safely excised with HALN. There were no differences between the HALN and ORN groups regarding any demographic parameter. Blood loss, operating time, length of stay, parenteral narcotic use, and time to tolerating regular diet were all less statistically significant in the HALN group as compared to the ORN group (P < 0.05). Tumors >15 cm necessitated ORN. CONCLUSIONS: HALN is technically feasible even for tumors with mean size >9.5 cm. There is a significant advantage to HALN over ORN regarding the intraoperative and postoperative morbidity. Tumors >or=15 cm should, in most cases, be performed with an open approach.     

Metastatic renal cell cancer after laparoscopic radical nephrectomy: long-term follow-up

OBJECTIVE: To assess the risk of metastatic disease in longer-term follow-up of patients undergoing laparoscopic radical nephrectomy with morcellation for renal cell carcinoma (RCC). PATIENTS AND METHODS: We present the findings at follow-up at 13.5 to 70 months (mean 33.4 months) of 57 previously reported patients. Three, all of whom initially had clinical stage N0M0 disease, were found to have metastases. One, who had a clinical stage T3 grade III/IV tumor, developed an asymptomatic recurrence in the renal fossa with associated chest metastasis 14 months postoperatively. The second, who had a clinical stage T2 grade II/IV tumor, developed painful bony lesions and a chest metastasis 20 months postoperatively. The third patient, with a clinical stage T3 grade IV/IV tumor, was found to have a solitary port-side abdominal-wall recurrence with no other evidence of metastatic disease at 25 months. CONCLUSIONS: Longer-term follow-up has demonstrated a 5% (3/57) rate of metastases after laparoscopic radical nephrectomy. In two of these patients, the course was consistent with the natural history of RCC; however, the third had a port-site recurrence. Thus, it behooves us to be meticulous with our technique and to follow patients closely after laparoscopic nephrectomy. Several suggestions are made to reduce the likelihood of port-site recurrence.     

The experience of laparoscopic radical nephrectomy for renal tumors

We evaluate the safety and feasibility of laparoscopic radical nephrectomy for renal tumors. Between September 1993 and October 2001, 18 patients with renal tumors underwent laparoscopic radical nephrectomy. The mean patient age was 57.1 years ranging from 36 to 78. Clinical stage was T1N0 in all patients. The mean tumor diameter was 4.0 cm ranging from 1.8 to 7.0. Laparoscopic radical nephrectomy was performed by using the transperitoneal anterior approach on 11 patients and retroperitoneal approach on 7 patients. The specimen was removed through an extended stab wound after blunt segmentation of renal parenchyma in a specimen bag (LapSac). The mean operative time was 405 (270-550) and 453 (325-635) min for the transperitoneal approach and retroperitoneal approach respectively, and the mean blood loss was 281 (52-700) and 223 (10-850) ml, respectively. There was an intraoperative complication of minor splenic injury in 2 patients receiving the transperitoneal approach, which was conservatively managed. Histopathology revealed renal cell carcinoma in 17 patients and renal oncocytoma in one patient. There was no recurrence with a mean follow-up of 28.9 months. Compared with 13 patients who underwent open radical nephrectomy during the same period, laparoscopic nephrectomy has a longer operative time (424 versus 214 min, p < 0.001), equal blood loss (259 versus 210 ml, p = 0.59), quicker resumption of ambulation (1.8 versus 2.5 days, p = 0.016) and food intake (1.4 versus 2.2 days, p = 0.003), shorter postoperative hospital stay (10.9 versus 18 days, p = 0.0016), and a tendency of less frequent analgesic requirements (1.9 versus 4.7 times, p = 0.09). Laparoscopic radical nephrectomy is a safe and useful surgery for renal tumors providing minimal invasiveness.     

Long-term followup after laparoscopic radical nephrectomy

PURPOSE: Laparoscopic radical nephrectomy has been shown to be less morbid than traditional open radical nephrectomy. The long-term oncological effectiveness of laparoscopic radical nephrectomy remains to be established. MATERIALS AND METHODS: At 3 centers patients undergoing laparoscopic radical nephrectomy before November 1, 1996 with pathologically confirmed renal cell carcinoma were identified. A representative group of patients undergoing open radical nephrectomy for clinical T1, T2 lesions was also identified. Staging, operative details and postoperative course were reviewed. Followup consisted of review of clinical, laboratory and radiological records. Kaplan-Meier analysis was performed. RESULTS: The study included 64 patients treated with laparoscopic and 69 treated with open radical nephrectomy with respective average ages of 60.6 and 61.3 years at surgery. On preoperative imaging open lesions were larger (6.2 cm., range 2.5 to 15) than laparoscopic radical nephrectomy lesions (4.3 cm., range 2 to 10, p <0.001). Pathology reports revealed no difference in specimen weight (425 and 495 gm., p = 0.146) or average Fuhrman grade (1.88 and 1.78, p = 0.476) between laparoscopic and open radical nephrectomy, respectively. Median followup was 54 months (range 0 to 94) for laparoscopic and 69 months (range 8 to 114) for open radical nephrectomy. Kaplan-Meier analysis with log rank comparison revealed 5-year recurrence-free survival of 92% and 91% for laparoscopic and open radical nephrectomy, respectively (p = 0.583). At 5 years cancer specific survival was 98% and 92% (p = 0.124), and nonspecific survival was 81% and 89% (p = 0.260) for laparoscopic and open radical nephrectomy, respectively. CONCLUSIONS: Laparoscopic radical nephrectomy confers long-term oncological effectiveness equivalent to traditional open radical nephrectomy.     

两种取肾切口在后腹腔镜肾癌根治术中应用分析

目的 探讨经后腹腔镜肾癌根治术的临床效果及两种取肾切口的效果评价.方法 回顾性分析本院28例经后腹腔镜肾癌根治术患者的临床资料,所有手术均为同一手术组完成,IUPU法建立腹膜后腔操作通道,于腹腔镜下肾周筋膜内游离肾脏后内侧、输尿管并向上游离肾蒂,结扎锁阻断肾血管并剪断,充分游离肾脏,完整切除.根据取肾切口不同分为两组:腰部切口取肾组18例,腹部小切口取肾组10例.对其术后肠道功能恢复时间、术后下床活动时间、留置引流管时间、术后住院时间,术后疼痛评分以及切口美容满意度进行比较.结果 所有手术均成功,后腹腔镜下完整肾切除手术时间为40～90 min;术中出血量50～200mL,平均100mL;两种不同取肾切口组在术后肠道功能恢复时间、术后下床活动时间、留置引流管的时间、术后住院时间方面比较差异均无统计学意义(P＞0.05);两组术后疼痛评分分别为(4.11±1.02)和(3.20±0.92),组间比较差异有统计学意义(P＜0.05);腹部小切口组满意度(90％)高于腰部切口组(77.8％),但组间比较差异无统计学意义(P＞0.05).结论 后腹腔镜肾癌根治术具有微创、出血少、术后恢复快等优点,是一种安全可靠的手术方法.腹部小切口取肾患者刀口疼痛轻,切口美容满意度高是一种可行的手术路径.     

腹股沟斜切口在后腹腔镜肾癌根治术中的应用

目的 总结腹股沟斜切口在后腹腔镜肾癌根治术中的应用体会.方法 选择我院2009年4月至2011年8月开展的后腹腔镜肾癌根治术202例,根据手术标本取出切口的不同分为实验组和对照组,实验组78例采用腹股沟斜切口取出标本,对照组124例采用腰部斜切口.对其手术时间、术中出血量、患者住院时间、切口并发症以及美容满意度进行比较.结果 本组202例后腹腔镜肾癌根治术均全部成功,未出现死亡和重大并发症.实验组和对照组手术时间、术中出血量差异无统计学意义;两组术后需镇痛治疗、切口感染、切口脂肪液化、切口疝、切口膨出、腰腹部不对称病例分别为2例和23例(P＜0.05)、1 例和12例(P＜0.05)、0例和6例(P＜0.05)、0例和3例(P＜0.05)、0例和2例(P＜0.05)、0例和14例(P＜0.05);两组平均住院时间分别为(5.2±2.3)d和(6.8±3.4)d(P＜0.05);实验组美容满意度明显高于对照组.结论 对于后腹腔镜肾癌根治术,腹股沟斜切口用于手术标本的取出具有创伤小、切口并发症少、患者美容满意度高等优点,值得临床广泛推广.     

Safe retroperitoneoscopic radical nephrectomy with small incision for renal cell carcinoma

PURPOSE: Retroperitoneoscopic radical nephrectomy (RRN) has been performed at Yokohama City University Medical Center since May 2002. Three surgeons have become skilled in performing RRN without major complications. We investigated the outcomes of the surgery and attempt to clarify whether the technique we adopted is suitable to perform this procedure safely. PATIENTS AND METHODS: Between May 2002 and June 2003, 14 patients suspected of renal cell carcinoma underwent retroperitoneoscopic radical nephrectomy at Yokohama City University Medical Center. The surgical procedure is shown below. In a lateral position, a lumbar oblique incision 6 cm long is made to approach the retroperitoneal space. Under direct vision, the ureter is dissected and Gerota's fascia is dissected from the peritoneum and the psoas muscle to signalize the subsequent dissection line. After the dissection, hand port device was attached to the skin and three 12 mm trocars were placed. The subsequent procedures are performed by retroperitoneoscopic surgery with carbon dioxide insufflation. The isolated kidney was removed through the incision that was made initially. We investigated the outcomes of this procedure. RESULTS: The mean surgical duration was 244.4 minutes and mean blood loss was 217.9 ml. Conversion to open surgery was required in one case due to bleeding and in one case due to incomplete management of a small artery. Blood transfusion was not required in any case. There were no major complications during the perioperative period. CONCLUSIONS: The three operators have become skilled in performing RRN safely with this technique.     

经腹腹腔镜肾癌根治术的临床分析

目的:探讨经腹腹腔镜肾癌根治术的临床应用价值。方法:选择肾癌患者196例,肿瘤直径3.5～8.2cm;左侧87例,右侧109例,86例肿瘤直径大于5.0cm,均行经腹腹腔镜肾癌根治术。结果:194例成功完成腹腔镜手术,2例中转开腹。手术时间60～180min,平均110min。术后无严重并发症发生,术后住院5～10d,平均7.2d。结论:经腹腹腔镜肾癌根治术安全有效,患者创伤小,康复快,具有良好的临床应用前景。     

A matched-cohort comparison of laparoscopic cryoablation and laparoscopic partial nephrectomy for treating renal masses

OBJECTIVE: To compare the surgical outcomes of elderly patients with renal masses treated with laparoscopic partial nephrectomy (LPN) or laparoscopic cryoablation (LCA). PATIENTS AND METHODS: All 15 patients who had LCA at the authors' institution between May 2003 and July 2005 were included, and compared with a matched cohort of 15 patients selected by patient age and tumour size, from a pre-existing database of 104 patients who had LPN from July 2002 to July 2005. The two groups were compared for gender, number of comorbidities, American Society of Anesthesiologists status (ASA), body mass index (BMI), baseline renal function and haematocrit, location and size of lesion, length of stay, operative time, estimated blood loss (EBL), transfusion rate, number and type of complications, conversion rate, and postoperative renal function and haematocrit. RESULTS: The two groups were similar in age, sex, BMI, ASA, baseline renal function, haematocrit, size and side of tumour, the percentage of exophytic tumours, and the likelihood of more than one comorbidity. Surgical outcomes between the groups were also relatively similar. The length of stay, creatinine and haematocrit levels after surgery did not differ between the groups. The LPN group had a significantly longer operation (248 vs 152 min, P < 0.001) and higher EBL (222 vs 59 mL, P = 0.007) than the LCA group, but only one patient required a transfusion and there was no discernible difference in discharge haematocrit values. No recurrences were detected in either group, with a similar mean follow-up of 9.8 and 11.9 months, respectively. CONCLUSION: Although this matched-cohort comparison showed that LPN had a higher mean EBL, a longer operation and higher relative risk of open conversion, the overall clinical outcome was similar in terms of complication rates, length of stay and changes in creatinine and haematocrit after surgery. In this small retrospective evaluation, there was similar morbidity, treatment outcome and short-term efficacy with LCA and LPN. At present, although still experimental, LCA is a good choice for elderly patients with comorbidities precluding blood loss or renal ischaemia. However, in experienced hands, LPN is a preferred option for most elderly patients and should be considered when contemplating definitive treatment of renal masses.