Prospective randomized comparison of transperitoneal versus retroperitoneal laparoscopic radical nephrectomy

PURPOSE: We report on a prospective randomized comparison of transperitoneal versus retroperitoneal laparoscopic radical nephrectomy for renal tumor. MATERIALS AND METHODS: Between June 1999 and June 2001, 102 consecutive eligible patients with a computerized tomography identified renal tumor were prospectively randomized to undergo either a transperitoneal (group 1, 50 patients) or retroperitoneal (group 2, 52 patients) laparoscopic radical nephrectomy with intact specimen extraction. Exclusion criteria for the study included body mass index greater than 35 or a history of prior major abdominal surgery in the quadrant of interest. Both groups were matched regarding age (63 versus 65 years, p = 0.69), BMI (29 versus 28, p = 0.89), American Society of Anesthesiologists class (2.7 versus 2.8, p = 0.37), laterality (right side 46% versus 48%, p = 0.85) and mean tumor size (5.3 versus 5.0 cm, p = 0.73). RESULTS: All 102 procedures were technically successful without the need for open conversion. Compared to the transperitoneal approach, the retroperitoneal approach was associated with a shorter time to renal artery control (91 versus 34 minutes, p <0.0001), shorter time to renal vein control (98 versus 45 minutes, p <0.0001) and shorter total operative time (207 versus 150 minutes, p = 0.001). However, the transperitoneal and retroperitoneal approaches were similar in terms of estimated blood loss (180 versus 242 cc, p = 0.13), hospital stay (43 versus 45 hours, p = 0.55), intraoperative complications (10% versus 7.7%, p = 0.30), postoperative complications (20% versus 13.5%, p = 0.14) and postoperative analgesia requirements (27 versus 26 mg MSO4 equivalent p = 0.13). Pathology revealed renal cell carcinoma in 84% and 75% of cases, respectively, with no positive surgical margin in any case. CONCLUSIONS: Laparoscopic radical nephrectomy can be performed efficiently and effectively with the transperitoneal or the retroperitoneal approach. While renal hilar control and total operative time may be quicker with retroperitoneoscopy, the approaches are similar in terms of other patient outcomes evaluated.     

后腹腔镜下根治性肾切除术完整标本取出切口的随机对照研究

目的 探讨后腹腔镜下根治性肾切除术完整取出标本的适宜切口.方法 因肾癌需实施后腹腔镜下根治性肾切除术的连续性住院病例119例,按随机数字表随机分为2组,腹部切口组60例,腰部切口组59例.手术均由同一组医生实施,完整标本取出均由同一位医生完成.统计分析2组手术时间、标本取出时间、切口长度、标本质量、术后下床活动时间、术后胃肠功能恢复时间、术后住院日、术后止痛剂用量、并发症发生率等方面的差异.结果 2组患者性别、年龄、体质指数、肾脏最大横径、肿瘤分期等比较差异均无统计学意义(P＞0.05).2组手术时间分别为(99±14)、(115±12)min(P=0.000),切口长度分别为(4.9±0.3)、(5.3±0.4)cm(P=0.000),标本取出时间分别为(14±2)、(24±6)min(P=0.000),术后止痛剂用量分别为(35±27)、(52±29)mg(P=0.002),下床活动时间分别为(20±2)、(21±4)h(P=0.016),组间比较差异均有统计学意义;2组胃肠功能恢复时间分别为(21±3)、(20±4)h(P=0.457),术后住院日分别为(6±1)、(6±1)d(P=0.476),标本质量分别为(469±181)、(459±169)g(P=0.776),组间比较差异均无统计学意义.119例切口均甲级愈合,无切口液化、感染病例.89例获随访,随访时间6～18个月,中位时间12个月,未见切口疝、肿瘤切口种植病例.结论后腹腔镜下根治性肾切除术完整取出标本时,腹部切口具有切口小、损伤少、手术时间短、术后恢复快、疼痛轻等优点,是完整取出标本较为合适的路径.

Abstract：

Objective To investigate the appropriate incision for intact specimen extraction during retroperitoneoscopic radical nephrectomy. Methods One hundred and nineteen patients in need of retroperitoneoscopic radical nephrectomy were randomized into two groups. One group of 60 patients received intact specimen extraction through a muscle-splitting abdominal incision. The second group of 59 patients received intact specimen extraction through a muscle-cutting lumbar incision. All procedures were performed by the same team of surgeons, and the intact specimens were extracted by the same surgeon. Standard operative features were measured and recorded (operative time, the time of specimen extraction, incision length, specimen weight, the time to get out of bed, the recovery time of gastrointestinal function, postoperative hospital stay, analgesia requirement, and complication rate). Results The two groups were matched in regard to patient age, body mass index, the maximum diameter of the kidney, and the stage of TNM (each P>0.05). There were significant differences between the abdominal incision group and lumbar incision group in terms of operative time (99±14 min vs 115±12 min; P=0.000), incision length (4.9±0.3 cm vs 5.3±0.4 cm; P=0.000), the time of specimen extraction (14±2 min vs 24±6 min; P=0.000), analgesia requirement (35±27 mg vs 52±29 mg; P=0.002), the time to get out of bed (20±2 h vs 21±4 h; P=0.016). The differences were not significant between the 2 groups in terms of the recovery time of gastrointestinal function (21±3 h vs 20±4 h; P=0.457), hospital stay (6±1 d vs 6±1 d; P=0.476), and specimen weight (469±181 g vs 459±169 g; P=0.776). There was no complication of incision in the 2 groups at 12 months′ follow-up (rang, 6 to 18 months). Conclusion A muscle-splitting abdominal incision for intact specimen extraction is more appropriate than a lumbar incision during retroperitoneoscopic radical nephrectomy, with small incision, little injury, short operative time, quick recovery, and less pain.     

Prospective, randomized comparison of transperitoneal versus retroperitoneal laparoscopic adrenalectomy

PURPOSE: We report a prospective, randomized comparison of transperitoneal laparoscopic adrenalectomy (TLA) vs retroperitoneal laparoscopic adrenalectomy (RLA) for adrenal lesions with long-term followup. MATERIALS AND METHODS: Between December 1997 and November 1999, 57 consecutive eligible patients with surgical adrenal disease were prospectively randomized to undergo TLA (25) or RLA (32). Study exclusion criteria were patient age greater than 80 years, body mass index greater than 40, bilateral adrenalectomy and significant prior abdominal surgery in the quadrant of interest. Mean followup was 5.96 years in the 2 groups. RESULTS: The groups were matched in regard to patient age (p = 0.84), body mass index (p = 0.43), American Society of Anesthesiologists class (p = 0.81) and laterality (p = 0.12). Median adrenal mass size was 2.7 cm (range 1 to 9) in the TLA group and 2.6 cm (range 0.5 to 6) in the RLA group (p = 0.83). TLA was comparable to RLA in terms of operative time (130 vs 126.5 minutes, p = 0.64), estimated blood loss (p = 0.92), specimen weight (p = 0.81), analgesic requirements (p = 0.25), hospital stay (p = 0.56) and the complication rate (p = 0.58). One case per group was electively converted to open surgery. Pathology data on the intact extracted specimens were similar between the groups. Averaged convalescence was 4.7 weeks in the TLA group and 2.3 weeks in the RLA group (p = 0.02). During a mean followup of 6 years 2 patients in the TLA group had a late complication (port site hernia). Mortality occurred in 5 patients, including 1 with TLA and 4 with RLA, during the 6-year followup. CONCLUSIONS: For most benign adrenal lesions requiring surgery laparoscopic adrenalectomy can be performed safely and effectively by the transperitoneal or the retroperitoneal approach.     

经腹腔与腹膜后腹腔镜肾癌根治术疗效比较

目的比较经腹腔与经腹膜后入路腹腔镜肾癌根治术的临床效果。方法分析2010年4月至2012年2月间在北京大学第一医院接受腹腔镜肾癌根治术的141例患者资料,其中经腹腔入路组61例、经腹膜后腔入路组80例,比较两种手术入路患者在手术时间、出血量、术后住院日等方面的差异。结果所有141例手术均在腹腔镜下完成。对于经腹腔入路组和经腹膜后腔组,平均手术时间分别为192.1及147.2min（P=0.000）;平均术后住院日分别为5.8d及7.2d（P=0.000）;平均肿瘤长径分别为5.6cm及4.3cm（P=0.001）。在术中出血量、并发症及输血情况等方面无显著性差异。结论经腹腹腔镜和经后腹膜腹腔镜肾癌根治术围手术期均有良好效果,经腹腔入路适合治疗体积较大的肿瘤,术后恢复快,而经腹膜后腔入路具有手术时间短的优势。     

Laparoscopic radical nephrectomy: retroperitoneal versus transperitoneal approach

Laparoscopic radical nephrectomy can be efficaciously performed by either the transperitoneal or the retroperitoneal laparoscopic approach. The primary indication for selecting one approach over another has historically depended on the individual surgeon's experience and training. With either technique, laparoscopy adheres to established surgical oncologic principles of wide specimen mobilization and early vascular control. This article reviews the history, contraindications, anatomic considerations, patient preparation, and surgical technique of these two laparoscopic approaches. A salient summary of the worldwide experience with these procedures is presented, as well as a brief synopsis of controversial arguments favoring specimen morcellation versus intact extraction.     

Transperitoneal versus retroperitoneal laparoscopic radical nephrectomy: A comparative study

Objectives:   To compare perioperative outcome of transperitoneal and retroperitoneal approaches during laparoscopic radical nephrectomy (LRN) and to identify selection criteria for each approach.
Methods:   Over a 7-year period, 100 consecutive patients (median age 62 years, range 20–80) underwent LRN for a renal tumor with clinical stage T1a–T3a. The first choice approach was retroperitoneal. The transperitoneal approach was chosen in selected cases based on tumor characteristics. Thirty-three patients underwent the transperitoneal approach, and 67 had the retroperitoneal approach. Perioperative parameters including operative time, blood loss and complications and pathology data were retrospectively analyzed.
Results:   Overall, 33 transperitoneal laparoscopic radical nephrectomies (TLRN) and 67 retroperitoneal laparoscopic radical nephrectomies (RLRN) were carried out. There was a statistically significant difference between the two groups in terms of size (5.3 vs 3.0 cm, P  < 0.0001) and clinical T stage (higher in the TLRN group, P  < 0.0001) of the tumors. Intraoperative complications included bradycardia, pneumothorax, renal vein injury, and renal artery injury in the TLRN group, and pneumothorax in the RLRN group. There were no differences in terms of operative time, blood loss and tumor grade between the two groups.
Conclusions:   Retroperitoneal and transperitoneal approaches yielded excellent surgical outcomes. The transperitoneal approach should be chosen based on tumor size and location to minimize vascular injury.     

腹腔镜下根治性肾切除手术技巧和105例经验

目的 探讨经腹腔入路腹腔镜下根治性肾切除(LRN)的手术操作技巧. 方法 对2008年12月至2010年12月收治的105例肾肿瘤患者采用经腹腔入路行LRN.肿瘤位于左肾51例,右肾54例,直径(5.8 ±2.4)cm.术前肿瘤分期为T1N0M048例,T2N0M0 51例,T3aN0M06例.术中均以生殖静脉为标志寻找肾动、静脉并依次结扎,完整切除标本后经耻骨上Pfannensteil切口取出. 结果 105例均成功施行经腹腔“生殖静脉标志法”LRN,28例肾上极肿瘤切除同侧肾上腺,16例加行区域淋巴结清扫.无中转开放手术者,无肝、脾、肠管等重要脏器损伤.手术时间44～78 min,平均(55±11)min.术中出血量35～600 ml,平均(85±26)ml.术后住院时间4～11 d,平均(6±2)d.主要并发症有血管损伤3例,膈肌损伤1例,淋巴漏2例.术后临床病理分期为T1N0M044例,T1N1M01例,T2 N0 M0 47例,T2N1M0 1例,T3aN0M0 7例,T3aN1M0 1例,T4N0M0 2例,良性病变2例.术后随访9～33个月,平均18个月,出现切口疝1例,局部复发1例,死于肺转移1例. 结论 经腹途径“生殖静脉标志法”LRN可准确定位、迅速结扎肾蒂大血管,术中无严重副损伤,术后恢复快、并发症少.Pfannensteil切口创伤小,符合美学要求.     

Hand-assisted laparoscopic radical nephrectomy: comparison of the transperitoneal and retroperitoneal approaches

Transperitoneal and retroperitoneal approaches have been introduced to perform hand-assisted laparoscopic radical nephrectomy. The efficacy and convalescence of both approaches were compared. Of 26 patients with renal cell carcinoma, 14 patients were treated by the transperitoneal approach and 12 by the retroperitoneal approach at the same institution. The mean operative time by transperitoneal approach was significantly shorter than retroperitoneal approach (236.4 and 280.0 minutes, respectively, P < 0.05), but there is a steeper learning in retroperitoneal approach. A significant increase in operative time was required with an increase in specimen weight (r = 0.591, P < 0.05). There were no differences in patient demographic, operative, and convalescence data between the both groups. Hand-assisted laparoscopic radical nephrectomy is safe by either the transperitoneal or the retroperitoneal approach. Making enough retroperitoneal space for the hand and instrument enables us to use the retroperitoneal approach readily. Patients with abundant fatty tissues around the kidney should be treated by the transperitoneal approach.     

经腹腔与腹膜后行腹腔镜肾癌根治术的比较

目的:比较经腹腔和腹膜后方式行腹腔镜肾癌根治术的优缺点。方法:随机将60例肾癌患者分别经腹腔或腹膜后方式行腹腔镜下肾癌根治术,比较两组术中、术后的情况。结果:与经腹腔方式比较,腹膜后方式处理肾动脉平均时间、处理肾静脉平均时间、总的手术平均时间较短。但经腹膜和腹膜后方式在估计出血量、术后住院时间、术中并发症和术后并发症发生率上无明显差异。结论:腹腔镜下经腹腔或腹膜后方式行肾癌根治术均有效,但后者在处理肾门和总的手术时间方面更快。     

Hand-assisted retroperitoneoscopic radical nephrectomy: Initial experience

OBJECTIVES: To report our initial experience of hand-assisted retroperitoneoscopic radical nephrectomy for stage T1 renal tumors. METHODS: The clinical data on 22 consecutive patients who had undergone hand-assisted retroperitoneoscopic radical nephrectomy and 22 who had undergone open radical nephrectomy were reviewed. The operation was performed with a hand placed retroperitoneally through a pararectal longitudal 7-7.5 cm incision using a LAP DISC. RESULTS: The total operating time was between 2.3 and 5.8 h (mean: 3.4 h). The estimated blood loss was between 15 and 650 mL (mean: 170 mL). The complication rate was 9% (2/22). No conversions to open procedure occurred. In comparison to open radical nephrectomy, the operating time was similar (3.4 vs 3.9 h) whereas the estimated blood loss was significantly less in this procedure (170 vs 495 mL). During the convalescence period the patients revealed significantly less postoperative pain, shorter intervals to resuming oral intake and more rapid return to normal activities compared to the open radical nephrectomy patients. CONCLUSION: Hand-assisted retroperitoneoscopic radical nephrectomy is an effective and safe procedure for T1 renal tumors.     

Task-specific bench model training versus basic laparoscopic skills training for laparoscopic radical prostatectomy: a randomized controlled study

Background

Performing a laparoscopic urethrovesical anastomosis (LUA) after a radical prostatectomy is technically challenging for the novice laparoscopic surgeon. We developed a low-fidelity urethrovesical model (UVM) to allow a urologist to practise this critical step. The aim of our study was to compare the effect of task-specific bench model training (anastomotic suturing on the UVM) with that of basic laparoscopic suturing on intracorporeal urethrovesical anastomosis performance.

Methods

We recruited 28 senior surgical residents, fellows or staff surgeons for this prospective, single-blinded, randomized controlled study. We randomly assigned participants to an intervention group practising LUA on the UVM or to a control group practising basic laparoscopic suturing and knot-tying on a foam pad. After practising, we videotaped participants performing 5 intra-corporeal interrupted sutures on a foam pad and a LUA on the UVM. A blinded expert scored the videotaped performance using a laparoscopic suturing checklist (CL) and a global rating scale (GRS), and timed the performance.

Results

On the foam pad suturing task, the group that trained on the UVM had significantly higher CL scores (10.9 v. 8.1, p = 0.017). On the LUA task, the group that trained on the UVM had significantly higher CL scores (10.9 v. 8.1, p = 0.017), GRS (29.6 v. 22.8, p = 0.005) and shorter times (27.6 v. 38.3 min, p = 0.004) than the control group.

Conclusion

Our task-specific bench model was shown to be superior to basic laparoscopic suturing drills on a foam pad.     

后腹腔镜与开放肾癌根治性手术的回顾性比较

目的回顾性比较后腹腔镜下肾癌根治术与开放性肾癌根治术的临床疗效。方法回顾性分析68例后腹腔镜肾癌根治性手术及52例开放肾癌根治性手术患者的临床资料，比较两种术式在手术时间、术中估计出血量、术后镇痛药物使用剂量、胃肠道功能恢复时间、下床活动时间及术后住院时间等方面的差异。结果后腹腔镜组与开放手术组患者在性别、年龄、肿瘤位置、肿瘤大小及肿瘤分级上的差别无统计学意义。所有手术均获成功，均未输血。后腹腔镜组平均手术时间（138．4±36．2）min较开放组手术时间（112．3±32．5）min长，但二者之间差异无统计学意义。开放组术中估计出血量（298．1±19．5）ml，后腹腔镜组估计出血量（123．6±24．6）ml，二者差异有统计学意义。后腹腔镜组在镇痛药用量、胃肠道功能恢复时间、下床活动时间及术后住院日等方面均明显优于开放组（P〈0．05）。术后随访3个月至3年，两组均无肿瘤复发，未见操作通道部位或后腹腔内种植。结论与传统开放手术相比，后腹腔镜肾癌根治性手术具有出血少、创伤小、患者痛苦少、恢复快、住院时间短等特点。     

Hand-assisted retroperitoneoscopic radical nephrectomy and nephroureterectomy

In laparoscopic operations for renal tumor and upper urinary-tract transitional-cell carcinoma (TCC), three approaches - the transperitoneal, retroperitoneal, and transperitoneal hand-assisted - have been reported. We have performed hand-assisted retroperitoneoscopic radical nephrectomy (RN) since 1999 and nephroureterectomy (NU) since 2000. The surgical techniques and the operative results of 95 cases of RN and 54 cases of NU are described and analyzed. These procedures were effective and safe for renal tumors and upper urinary-tract TCC.     

腹腔镜下与开放性根治性肾切除术的前瞻性随机对照研究

目的 比较腹腔镜下与开放性根治性肾切除术治疗肾癌的疗效.方法 2006年1月至2009年7月T1～T2肾癌患者62例,随机分为2组,每组31例.分别行腹腔镜下及开放性根治性肾切除术,比较2组住院时间、手术时间、切口长度、术中出血量、并发症、术后局部复发率、远处转移率及死亡率.取第一类误差α=0.05,第二类误差β=0.10,2种术式术后住院时间均值相差2 d,差异有统计学意义.结果 2组患者术后住院时间分别为(5.4±1.3)及(8.1±2.2)d,中位切口长度分别为8及15 cm,中位术中出血量分别为100及200 ml,差异均有统计学意义(P<0.05).2组手术时间、术后并发症发生率、淋巴结清扫数、局部复发率、远处转移率、死亡率比较差异均无统计学意义(P>0.05).结论 腹腔镜下根治性肾切除术较开放性根治性肾切除术手术创伤小、住院时间短.     

后腹腔镜下根治性肾切除术治疗肾癌的疗效观察

目的评价后腹腔镜下根治性肾切除术的临床疗效。方法回顾性分析后腹腔镜下根治性肾切除术（A组）及开放性根治性肾切除术（B组）患者的临床资料。A组76例,男49例,女27例。年龄26～75岁,平均53岁。肾肿瘤位于左侧42例,右侧34例;肾上极36例,中极23例,下极17例。肿瘤平均直径5．4（2．0～10．2）cm,肿瘤分期T1 65例,T2 11例。病程5 d～17个月。B组73例,男45例,女28例。年龄18～79岁,平均56岁。肾肿瘤位于左侧35例,右侧38例;肾上极28例,中极21例,下极24例。肿瘤平均直径5．9（2．4～11．7）cm,肿瘤分期T1 54例,T2 19例。病程2 d～24个月。患者均行B超、IVU、逆行造影以及CT和（或）MRI检查确定肿瘤大小、位置、分期、是否有瘤栓和淋巴结转移等。2组患者的年龄、性别、美国麻醉师协会评分（ASA评分）、体重指数（body mass index,BMI）、肿瘤大小、患侧、Fuhrman分级比较,差异均无统计学意义（P值均〉0．05）。比较2组手术时间、术中出血量、术后肠功能恢复时间（以患者术后排气时间计算）、止痛药物（双氯芬酸钠）用量、并发症、住院总天数、随访时间、局部复发、切口种植转移等指标。结果A组平均手术时间69（50～175）min,平均术中出血量77（15～500）ml。平均术后肠功能恢复时间1（1～2）d,术后切口感染者5例,出现切口侧下腹部皮肤感觉过敏者6例,无严重并发症出现。平均术后止痛药物用量50（50～100）mg。平均术后住院6（5～10）d。B组平均手术时间121（80～220）min。平均术中出血量273（120～800）ml。平均术后肠功能恢复时间2（1～3）d,术后出现切口感染者9例,出现切口侧下腹部皮肤感觉过敏者45例,无严重并发症出现。平均术后止痛药物用量125（100～150）mg。平均术后住院11（7～15）d。A组手术时间、术中出血量、术后肠功能恢复时间、术后止痛药物用量、术后并发症、术后住院总天数方面明显优于开放手术组（P值均〈0．01）。A组平均随访36．3（12～70）个月,未见局部复发和远处转移者;B组平均随访39．8（12～75）个月,术后15个月失访1例,余均无局部复发,2例T2患者因肾癌肝转移分别于术后18个月和22个月死亡。2组5年无瘤生存率分别为98．1％和96．9％（P〉0．05）。结论后腹腔镜下根治性肾切除术具有微创、安全、可靠等特点。对于T1～T2 N0M0肾癌患者,后腹腔镜下根治性肾切除术的疗效与开放手术相当。