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Commentary to “Prechemotherapy laparoscopic nephrectomy for Wilms' tumor”
Journal of Pediatric Urology (2009) 5, 420e421
Commentary to ‘‘Prechemotherapy laparoscopic nephrectomy for Wilms’ tumor’’ Jonathan Ross Cleveland Clinic, OH, USA Received 6 January 2009; accepted 10 January 2009 Available online 25 February 2009 The authors report two cases of laparoscopic nephrectomy for Wilms’ tumor performed prior to the administration of chemotherapy (only one of which is a typical Wilms’ tumor in a child). The timing of surgery is important because preoperative chemotherapy reduces tumor size and the risk of intraoperative tumor rupture. Therefore, a laparoscopic approach will generally be more challenging when performed prior to chemotherapy administration. As the authors acknowledge, this report merely demonstrates the feasibility of the operation; being a single case report it tells us nothing significant regarding the advantages, morbidity or risks. One potential advantage of a laparoscopic approach, whether before or after chemotherapy, is decreased morbidity in terms of postoperative pain and length of hospital stay. These advantages are of limited concern in small children who recover quickly in any case. And for patients with Wilms’ tumor, the total hospitalization during treatment of their disease is going to be driven primarily by the adjuvant therapy they will receive postoperatively rather than by the recovery from the operation itself. The other potential advantage of a laparoscopic approach is cosmesis. The scar of a transverse abdominal incision does become a concern to some children when they are older. And although a significant incision is still required to extract the tumor intact, a Pfannenstiel incision is significantly less apparent later in life than the traditional open surgical incision. That said, what are the potential risks of a laparoscopic approach? The authors mention the two most important: an increased risk of intraoperative tumor rupture due to loss of tactile feedback and an inadequate abdominal
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exploration, particularly lymph-node dissection. An increased risk of hemorrhage would be another concern. Both tumor rupture and inadequate lymph-node sampling significantly affect the oncological outcome for patients with Wilms’ tumor. Tumor rupture leads to upstaging and the need for adjuvant radiation therapy which would usually not otherwise be required. Inadequate lymph-node dissection leads to understaging and a higher tumor recurrence rate. The increased risks, if any, of tumor rupture and inadequate lymph-node sampling when a laparoscopic approach is applied remain undefined. But, it is troubling that no lymph nodes were present in the case report’s specimen. To perform lymph-node sampling it is sometimes necessary to dissect aggressively around the great vessels, and one wonders if there is a hesitation to undertake this dissection with a laparoscopic approach and/or if complicating hemorrhage would be more likely. So, do the advantages of quicker recovery and improved cosmesis justify a change in surgical approach? Almost certainly not, unless there is in fact no significant increased risk of hemorrhage, tumor rupture and/or inadequate staging with the laparoscopic approach. As the authors note, proving the safety of a laparoscopic approach will require studies of large numbers of patients. This raises the ethical dilemma in the meantime of subjecting patients to a laparoscopic approach when it may offer inferior oncological management. Based on the limited case reports in children and the extensive experience in adults, it seems reasonable to study the laparoscopic approach as a potential alternative to the standard of care. However, surgeons offering this approach should have a candid discussion with the family about the uncertainty regarding its safety. Furthermore, this approach
1477-5131/$36 ª 2009 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jpurol.2009.01.008
Commentary to prechemotherapy laparoscopic nephrectomy for Wilms’ tumor should only be undertaken by surgeons with extensive experience with complex laparoscopic renal surgery, and, ideally, by surgeons enrolling their patients in studies that will address these questions scientifically. Undoubtedly, whether these recommendations are followed or not, an increasing number of patients enrolled in multicenter trials
421
will have undergone laparoscopic nephrectomies. It will be important for these studies to look at the quality issues illustrated by this case report by comparing the outcomes for patients operated on through open and laparoscopic approaches, both with and without neoadjuvant chemotherapy.
Commentary to ‘‘Prechemotherapy laparoscopic nephrectomy for Wilms’ tumor’’ Jonathan Ross Cleveland Clinic, OH, USA Received 6 January 2009; accepted 10 January 2009 Available online 25 February 2009 The authors report two cases of laparoscopic nephrectomy for Wilms’ tumor performed prior to the administration of chemotherapy (only one of which is a typical Wilms’ tumor in a child). The timing of surgery is important because preoperative chemotherapy reduces tumor size and the risk of intraoperative tumor rupture. Therefore, a laparoscopic approach will generally be more challenging when performed prior to chemotherapy administration. As the authors acknowledge, this report merely demonstrates the feasibility of the operation; being a single case report it tells us nothing significant regarding the advantages, morbidity or risks. One potential advantage of a laparoscopic approach, whether before or after chemotherapy, is decreased morbidity in terms of postoperative pain and length of hospital stay. These advantages are of limited concern in small children who recover quickly in any case. And for patients with Wilms’ tumor, the total hospitalization during treatment of their disease is going to be driven primarily by the adjuvant therapy they will receive postoperatively rather than by the recovery from the operation itself. The other potential advantage of a laparoscopic approach is cosmesis. The scar of a transverse abdominal incision does become a concern to some children when they are older. And although a significant incision is still required to extract the tumor intact, a Pfannenstiel incision is significantly less apparent later in life than the traditional open surgical incision. That said, what are the potential risks of a laparoscopic approach? The authors mention the two most important: an increased risk of intraoperative tumor rupture due to loss of tactile feedback and an inadequate abdominal
E-mail address: [email protected]
exploration, particularly lymph-node dissection. An increased risk of hemorrhage would be another concern. Both tumor rupture and inadequate lymph-node sampling significantly affect the oncological outcome for patients with Wilms’ tumor. Tumor rupture leads to upstaging and the need for adjuvant radiation therapy which would usually not otherwise be required. Inadequate lymph-node dissection leads to understaging and a higher tumor recurrence rate. The increased risks, if any, of tumor rupture and inadequate lymph-node sampling when a laparoscopic approach is applied remain undefined. But, it is troubling that no lymph nodes were present in the case report’s specimen. To perform lymph-node sampling it is sometimes necessary to dissect aggressively around the great vessels, and one wonders if there is a hesitation to undertake this dissection with a laparoscopic approach and/or if complicating hemorrhage would be more likely. So, do the advantages of quicker recovery and improved cosmesis justify a change in surgical approach? Almost certainly not, unless there is in fact no significant increased risk of hemorrhage, tumor rupture and/or inadequate staging with the laparoscopic approach. As the authors note, proving the safety of a laparoscopic approach will require studies of large numbers of patients. This raises the ethical dilemma in the meantime of subjecting patients to a laparoscopic approach when it may offer inferior oncological management. Based on the limited case reports in children and the extensive experience in adults, it seems reasonable to study the laparoscopic approach as a potential alternative to the standard of care. However, surgeons offering this approach should have a candid discussion with the family about the uncertainty regarding its safety. Furthermore, this approach
1477-5131/$36 ª 2009 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jpurol.2009.01.008
Commentary to prechemotherapy laparoscopic nephrectomy for Wilms’ tumor should only be undertaken by surgeons with extensive experience with complex laparoscopic renal surgery, and, ideally, by surgeons enrolling their patients in studies that will address these questions scientifically. Undoubtedly, whether these recommendations are followed or not, an increasing number of patients enrolled in multicenter trials
421
will have undergone laparoscopic nephrectomies. It will be important for these studies to look at the quality issues illustrated by this case report by comparing the outcomes for patients operated on through open and laparoscopic approaches, both with and without neoadjuvant chemotherapy.