COMPARISON OF RETROPERITONEOSCOPIC NEPHRECTOMY WITH OPEN SURGERY FOR TUBERCULOUS NONFUNCTIONING KIDNEYS

0022-5347/00/1641-0032/0 THE JOURNAL OF UROLOGY® Copyright © 2000 by AMERICAN UROLOGICAL ASSOCIATION, INC.®

Vol. 164, 32–35, July 2000 Printed in U.S.A.

COMPARISON OF RETROPERITONEOSCOPIC NEPHRECTOMY WITH OPEN SURGERY FOR TUBERCULOUS NONFUNCTIONING KIDNEYS ASHOK K. HEMAL, NARMADA P. GUPTA

AND

RAJEEV KUMAR

From the Department of Urology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India

ABSTRACT

Purpose: We describe, define and evaluate the role of retroperitoneoscopic nephrectomy for tuberculous nonfunctioning kidneys, and compare the results with those of open nephrectomy in similar cases in a nonrandomized study. Materials and Methods: Beginning in July 1994, 9 patients underwent retroperitoneoscopic nephrectomy for tuberculous nonfunctioning kidneys at our center. Data obtained from the records of these patients were compared with those of 9 who underwent open nephrectomy for a similar indication during the same period. Retroperitoneoscopic nephrectomy was initially performed by kidney dissection followed by ligation of the hilar vessels. The technique was subsequently modified and the vessels controlled before dissecting the kidney. Various parameters were compared and statistical analysis was done. Results: The 2 groups were similar in regard to patient age, gender and side of disease. Retroperitoneoscopic nephrectomy was successful in 7 of the 9 patients. Although 2 of our initial patients required conversion to open surgery, the remaining 7 successfully underwent retroperitoneoscopic nephrectomy after modifying the technique. Mean operative time was slightly greater in the retroperitoneoscopy than in the open surgery group (103.3 versus 92.2 minutes). Mean blood loss was less in the retroperitoneoscopy group (101.4 versus 123.3 ml.), mean hospital stay plus or minus standard deviation was significantly shorter (3.2 ⫾ 0.83 versus 8.88 ⫾ 3.37 days) and mean time to return to work was significantly less (3 versus 7 weeks). Mean analgesic requirement for opioids and diclofenac sodium was also lower in the retroperitoneoscopic nephrectomy group (0 versus 1.44 ⫾ 0.72 and 3.8 ⫾ 1.3 versus 4.3 ⫾ 1.2 doses, respectively). Minor complications developed in only 2 retroperitoneoscopy cases. Conclusions: Tuberculosis has been considered a contraindication to retroperitoneoscopic nephrectomy due to a high conversion rate. However, we believe that our modified technique of retroperitoneoscopic nephrectomy is a viable option for managing tuberculous nonfunctioning kidneys. The conversion rate is lower than previously reported. Comparing our results with those of open nephrectomy shows that retroperitoneoscopic nephrectomy is beneficial in all respects except for slightly longer operative time. Because of the benefits of minimally invasive surgery, this approach should be considered in such cases. KEY WORDS: kidney, nephrectomy, laparoscopy, tuberculosis

With an incidence of 8 to 10 million new cases yearly1 tuberculosis continues to be a major public health problem. Of all cases of extrapulmonary tuberculosis 20% are urogenital.1 Advanced renal tuberculosis may lead to nonfunctioning hydronephrotic kidneys, caseation and calcification.1 In rare cases it may spread to surrounding structures, resulting in complex fistulas.2 In such cases it is impossible to eradicate the infection without ablative surgery.3 After the initial description of Clayman et al laparoscopic nephrectomy became an established technique for removing kidneys with benign diseases.4 –12 The development by Gaur of retroperitoneal dissection by the balloon technique led to the increasing use of retroperitoneoscopic surgery.13 Tuberculous nonfunctioning kidneys continue to be a technical challenge and a relative contraindication to retroperitoneoscopic surgery due to dense perinephric adhesions and a high conversion rate.10, 14 We analyzed our data on 9 patients who underwent the retroperitoneoscopic technique and compared them to the results of open nephrectomy in similar patients.

lous nonfunctioning kidneys at our center. All patients had a normally functioning contralateral kidney with normal parameters. Of the patients 3 in the retroperitoneoscopy and 1 in the open nephrectomy group had stricture of the contralateral ureter with mild back pressure changes. In 1 retroperitoneoscopy and 3 open nephrectomy cases percutaneous nephrostomy was done on the diseased side 6 weeks before nephrectomy with no improvement in renal function on that side. One patient in the open nephrectomy group had undergone pyelolithotomy for stone disease on the same side 10 years before nephrectomy. Preoperatively tuberculosis was suspected based on symptoms and confirmed by a positive urine smear for acid-fast bacilli, urine polymerase chain reaction for acid-fast bacilli, excretory urography and cystography or histopathological evaluation of bladder biopsy. All patients received antituberculous treatment before surgery for 6 weeks to 1 year. The standard regimen consisted of 4 drugs in the initial 2 months followed by 2 for 6 to 10 months. The initial drugs were 5 mg./kg. isoniazid orally once daily, 10 mg./kg. rifampicin orally once daily, 25 mg./kg. pyrazinamide orally in 2 divided doses daily and 15 mg./kg. ethambutol orally once daily. In the remaining months isoniazid and rifampicin were administered daily in the described doses. The duration of medication that our patients received var-

MATERIAL AND METHODS

Beginning in July 1994, 18 patients underwent retroperitoneal laparoscopic (9) or open (9) nephrectomy for tubercuAccepted for publication February 18, 2000. 32

33

RETROPERITONEOSCOPIC NEPHRECTOMY FOR TUBERCULOUS KIDNEYS Comparative data on retroperitoneoscopic versus open nephrectomy Retroperitoneoscopy No. pts. Mean age (range) No. men/No. women No. lt./rt. side affected Mean mins. operative time (range) Mean ml. blood loss (range) Mean days hospitalized (range) Mean wks. to return to work (range) No. analgesic doses: Opioids Nonsteroidal anti-inflammatory drugs No. elective conversions to open surgery No. complications Major Minor

9 33.2

(14–70) 6/3 7:2 103.57 (60–170) 101.42 (90–120) 3.2 (2–4) 3 (2–5) 0 3.8 2 0 2

Open Surgery 9 35.2

(18–70) 4/5 6:3 92.22 (50–140) 123.33 (60–250) 8.88 (3–15) 7 (5–11)

p Value (Wilcoxon rank sum test) Not Not Not Not Not

significant significant significant significant significant ⬍0.05 ⬍0.01

⬍0.01 Not significant

1.44 4.3 — 1 3

ied since all were referred to us by different primary physicians who had already started them on the drugs at various times. We ensured a minimum of 6 weeks of antituberculous treatment before surgery as well as a minimum of 12 months of treatment overall.15 Severely diseased kidneys with less than 10% relative function on a diethylenetriaminepentaacetic acid scan or less than 5 ml. per minute creatinine clearance on nephrostomy drainage were considered nonfunctioning and scheduled for nephrectomy.

50 to 75 mg. diclofenac sodium intramuscularly on the day of surgery. Additional analgesics were given based on patient requirements. Conventional open nephrectomy was performed using the standard flank approach. These patients received 2 doses of diclofenac sodium and 1 of 1 mg./kg. pethidine intramuscularly on the day of surgery. Subsequent analgesics were administered based on individual need.

OPERATIVE TECHNIQUE

We compared 9 cases of retroperitoneoscopic nephrectomy with 9 cases of open nephrectomy. Statistical analysis was done using the Wilcoxon rank sum test. Of the 9 patients who underwent retroperitoneoscopic nephrectomy 2 (22%) required elective conversion to open surgery due to nonprogress and excessive renal oozing (see table). These 2 cases represent our initial attempts to treat tuberculous nonfunctioning kidneys via laparoscopy. In each patient renal dissection was done first. Dense perinephric adhesions and bleeding were observed, and when significant progress was not made, we decided to convert to elective open surgery. No complications resulted from the laparoscopic attempt in these 2 cases. Two other patients had a small contracted bladder with severe urinary frequency and urgency. In addition to nephrectomy, they required augmentation cystoplasty and 1 also needed a Double-J* stent for contralateral ureteral narrowing. After retroperitoneoscopic nephrectomy the patients were repositioned, and low midline and Pfannensteil incisions were made in 1 each. Colocystoplasty was performed after removing the nephroureterectomy specimen from this lower incision. Hospital stay and analgesic requirement data for these 2 patients were not included in our analysis since they also underwent augmentation. No patient required any blood transfusion. The 2 minor complications were inadvertent renal puncture and leakage of caseous material during dissection. The analgesic requirement was 3 to 6 doses (mean 3.8) of injectable diclofenac sodium in each patient. Mean hospital stay in the 5 evaluable cases was 3.2 days (range 2 to 4) and mean time to return to work was 3 weeks (range 2 to 5). Of the 9 patients who underwent open nephrectomy 3 had minor postoperative complications (see table). Chest and wound infections developed in 1 and 2 cases, respectively. One patient had a major complication involving an incisional hernia at the operative site. No patient required blood transfusion. All patients received a dose of pethidine intramuscularly on the night of surgery with additional doses of pethidine and diclofenac sodium as required. An average of 1.44 (range 1 to 3) and 4.3 (range 3 to 6) doses of pethidine and diclofenac were administered, respectively. Mean hospital

The patient was placed in the lateral decubitus position with a minimal kidney bridge to achieve a wider space between the subcostal and iliac crest regions. The primary port was placed by a previously described technique.16 The retroperitoneal space was created using a balloon fashioned from 2 fingers of a sterile No. 7.5 or 8 surgical glove with 1 finger intussuccepted inside the other and tied over a 16 to 22Fr catheter. Care was taken to advance the catheter tip to the bottom of the finger balloon, which helps in early and prompt filling as well as in subsequent deflation of saline after the retroperitoneal space is created.16, 17 Then 2 or 3 additional ports were inserted under video endoscopic guidance. In our initial few cases we placed the balloon inside Gerota’s fascia and the space was created within the fascia. The kidney was dissected first, beginning posteriorly and progressively dissecting around it. The hilum was then approached from the posterior aspect, and the vessels were clipped and divided. In 1 case using this technique we observed significant oozing from the dissected kidney and converted to open surgery. We then modified our approach by reaching the hilum directly as step 1 and controlling the vessels. Kidney dissection was begun after the hilum was approached. Because of significant difficulty with perinephric dissection of the kidneys, we further modified our technique in subsequent cases. The balloon is now placed in the retroperitoneum just below the thoracolumbar fascia and outside of Gerota’s fascia. The hilum is approached directly from the posterior aspect and the vessels are individually identified and clipped. This approach is similar to the technique described by Gill.9 After controlling the hilum the kidney is dissected, mostly outside of Gerota’s fascia, and separated free. When feasible, dissection is brought back within Gerota’s fascia. Staying outside the fascia helps because scarring and adhesions are less in this area than within the fascia. The ureter is usually dissected as low as possible and nephroureterectomy is performed when there is evidence of disease in the ureter. In all cases the specimen was removed intact and without morcellation by extending a port. All wounds were closed in 2 layers after placing a drain. All patients received 2 doses of

RESULTS

* Medical Engineering Corp., New York, New York.

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RETROPERITONEOSCOPIC NEPHRECTOMY FOR TUBERCULOUS KIDNEYS

stay was 8.8 days (range 3 to 15) and mean time to return to work was 7 weeks (range 5 to 11). Histopathological evaluation confirmed the diagnosis in all cases. Findings included tuberculous pyelonephritis with caseation, perinephritis and tuberculous pyonephrosis. Two patients with hydroureteronephrosis had ureteral strictures with tuberculous ureteritis. DISCUSSION

Tuberculosis is a major public health problem in developing nations. Despite a decrease in the incidence in the early 1980s, there has been a resurgence and up to 8% of cases of pulmonary tuberculosis progress to urogenital tuberculosis.1 Renal tuberculosis is associated with significant parenchymal and perirenal fibrosis. Parenchymal lesions caseate and extend into the surrounding areas, leading to a nonfunctioning adherent kidney. Narrow areas of the urinary tract, such as the ureteropelvic and ureterovesical junctions, are especially prone to stricture with hydropyonephrosis.1 In advanced cases of urogenital tuberculosis with nonfunctioning kidneys it may be impossible to eradicate the infection without nephrectomy, and up to 50% cases of renal tuberculosis may require such a radical procedure.3, 18, 19 The diagnosis is based on the symptoms of frequency, dysuria and hematuria, and urine examination for mycobacteria, urinary polymerase chain reaction for mycobacteria and excretory urography.19 Since its first description by Clayman et al, laparoscopic surgery has made tremendous progress in urology.4 The retroperitoneoscopic technique was further refined by Gaur et al with the introduction of retroperitoneal dissection using the balloon technique.6, 13 Compared to conventional open surgery laparoscopic procedures increase patient comfort and cosmesis, and decrease convalescence.4, 20, 21 Even for laparoscopic procedures the retroperitoneal route has been shown to have better results than the transperitoneal route.21, 22 The drawback of retroperitoneoscopic surgery is a small working space. Time and experience are required for a surgeon to become oriented to the view presented by retroperitoneoscopy. Of the benign renal conditions amenable to retroperitoneoscopic nephrectomy tuberculosis has been considered a relative contraindication10, 14 with a conversion rate approaching 80%. The main reason for this situation is the dense perinephric inflammation and adhesions that develop in tuberculous kidneys, which preclude a clean field of dissection.10 We had similar problems in our initial 2 cases in which we electively converted to open surgery due to a lack of progress and bleeding. We realized that this problem was due to our attempt to dissect the kidney before controlling the hilum. In our subsequent 7 cases we modified the technique and now place the balloon outside of Gerota’s fascia, as described by Gill.9 Since this area has few adhesions, we directly approach the hilum and control the renal vessels. Subsequently we mobilize the kidney, staying outside the fascia as required. When adequate space is available, the fascia is opened and dissection is continued within it. Initially controlling the vessels and staying outside of the fascia minimize bleeding and assist in dissection. Using this technique we successfully completed all of our subsequent 7 cases. While our conversion rate of 22% is higher than that reported for nephrectomy for other benign conditions,8, 10, 11, 18, 23 it is not as high as earlier believed and is also likely to decrease by adherence to our modified operating technique. To demonstrate the advantages of this technique we compared our data objectively with those of open surgery for similar indications. The 2 groups were comparable in terms of age, sex and renal parameters. A greater number of patients had a percutaneous nephrostomy catheter indwelling in the open nephrectomy group but only 1 patient had nephrostomy in the retroperitoneoscopic nephrectomy group.

Mean operative time for retroperitoneoscopic nephrectomy was 104 minutes (range 60 to 170), which was not statistically different from the mean of 92 minutes (range 50 to 140) in the open nephrectomy group, and is also much lower than that reported in the literature (145 to 192 minutes).8, 10, 11 This decreased time may be partially due to our retrieval of the specimen intact instead of after morcellation. Similarly blood loss was comparable for retroperitoneoscopic and open nephrectomy (mean 102 ml., range 90 to 120 and 123, range 60 to 250, respectively). These data are also similar to those reported in major series in the literature.8, 10 –12, 18 The other major concern when performing retroperitoneoscopy is the incidence of complications. In a multicenter review of 200 cases Rassweiler et al noted a 7.5% incidence of complications in difficult cases including nephrectomy.11 Gill et al reviewed the data on the initial 185 cases of laparoscopic urological surgery at 5 centers, and noted an incidence of 16% (12% in benign cases and 34% for malignancy).21 Similar data have been reported by others at major laparoscopy centers.10, 18, 23 It has also been adequately shown that the complication rate decreases as the number of operations performed increases.10, 11, 21 We had problems in 2 cases of retroperitoneoscopy in which inadvertent renal puncture during dissection led to the leakage of caseous material. This problem did not result in any significant difficulty and the wound was washed with saline at the end of the procedure. Each patient was followed for more than 6 months with no untoward results. These cases represent a 22% incidence of minor complications. None of our patients had any major complications. On the other hand, in the open nephrectomy group 3 patients had minor complications involving wound and chest infection, and 1 had an incisional hernia. The major advantage of laparoscopy is shorter convalescence with less requirement for postoperative analgesia. The latter advantage was manifested in our study by the significantly lower analgesia requirements in the retroperitoneoscopic than open nephrectomy group. No patient who underwent retroperitoneoscopic nephrectomy required opioid analgesics, while 1 to 3 doses (mean 1.44) were required in the open nephrectomy group. The requirement of injectable diclofenac sodium in the retroperitoneoscopic nephrectomy group was also lower but not statistically significant. The other objective indicator of early recovery is duration of hospital stay, which was significantly shorter for retroperitoneoscopic than for open nephrectomy (mean 3.2 days, range 2 to 4 versus 8.8, 3 to 15). Similarly, return to work was more rapid in the retroperitoneoscopy group. These data also correlate with those for laparoscopic nephrectomy performed for other benign conditions8, 10 and are less than those of Rassweiler et al.24 CONCLUSIONS

The retroperitoneoscopic approach to nephrectomy for tuberculous nonfunctioning kidneys is a viable alternative to open surgery. Operative time, blood loss, analgesic requirement and hospital stay are similar to those of laparoscopic surgery for other benign renal conditions. Although the conversion rate is higher in the initial cases, it progressively decreases with experience as well as with use of the modified dissection technique. Tuberculous nonfunctioning kidneys should no longer be considered a contraindication to retroperitoneoscopic nephrectomy. REFERENCES

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