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Feasibility of Laparoscopic Partial Nephrectomy After Previous Ipsilateral Renal Procedures
Laparoscopy and Robotics Feasibility of Laparoscopic Partial Nephrectomy After Previous Ipsilateral Renal Procedures Burak Turna, Monish Aron, Rodrigo Frota, Mihir M. Desai, Jihad Kaouk, and Inderbir S. Gill OBJECTIVES
METHODS
RESULTS
CONCLUSIONS
Previous renal surgery has been considered a relative contraindication to laparoscopic partial nephrectomy (LPN) because of perirenal surgical adhesions. We present our experience with LPN in patients with previous ipsilateral renal surgery. Of 679 patients undergoing LPN for a renal mass from September 1999 to November 2006, 25 (3.7%) had undergone previous ipsilateral open or percutaneous renal procedures. The LPN technique included hilar clamping, cold tumor excision, and sutured renal reconstruction. The perioperative outcomes were retrospectively analyzed from a prospectively maintained database. Previous renal surgery included open surgery in 12 patients (nephro/pyelolithotomy in 8, pyeloplasty in 2, and partial nephrectomy in 2) and percutaneous surgery in 13 (percutaneous nephrolithotomy in 9 and renal biopsy in 4). The mean interval from previous surgery was 6.6 years (range 0.3-34). LPN (16 transperitoneal and 9 retroperitoneal) was successful in all patients. The mean tumor size was 2.5 cm (range 1-5.6), the warm ischemia time was 35.8 minutes (range 22-57), and the estimated blood loss was 215 mL (range 25-600). The mean operative time was 3 hours (range 1.5-4.5), and the hospital stay was 3.1 days (range 1-7.6). Histopathologic examination confirmed renal cell carcinoma in 19 patients (76%). No open conversions were needed, and no kidneys were lost. No intraoperative complications and 3 postoperative complications (12%) developed, including blood transfusion in 1, nausea and epistaxis in 1, and compartment syndrome requiring fasciotomy in 1 patient. The results of our study have shown that, in select patients, LPN is feasible after previous ipsilateral renal surgery. However, it can be technically challenging, and adequate previous experience with LPN is necessary. UROLOGY 72: 584 –588, 2008. © 2008 Published by Elsevier Inc.
I
n the presence of a normal contralateral kidney, the rationale for nephron-sparing surgery vs radical nephrectomy for a small renal mass is the decreased risk of progression to chronic kidney disease.1,2 Laparoscopic partial nephrectomy (LPN) was initially reserved for select patients with a small, peripheral, and exophytic tumor.3 The indications for LPN have been carefully expanded to include more complex tumors with increasing experience.4-6 Previous ipsilateral renal surgery has been considered a relative contraindication for subsequent LPN because of the likelihood of dense postoperative adhesions and distorted tissue planes, which could render hilar control and
B. Turna was supported by the Scientific and Technological Research Council of Turkey during his fellowship. From the Section of Laparoscopic and Robotic Surgery, Glickman Urological Institute, Cleveland Clinic Foundation, Cleveland, Ohio Reprint requests: Inderbir S. Gill, M.D., M.Ch., Section of Laparoscopic and Robotic Surgery, Glickman Urological Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A-100, Cleveland, OH. E-mail: [email protected] Submitted: March 29, 2007, accepted (with revisions): April 1, 2008
584
© 2008 Published by Elsevier Inc.
renal mobilization more difficult. However, a paucity of published data is available from urologic studies in this regard. We report the perioperative outcomes for 25 patients treated with LPN after previous ipsilateral renal surgery.
MATERIAL AND METHODS From September 1999 to November 2006, 679 patients underwent LPN for a renal mass at our institution. The patient data were prospectively accrued in an institutional review boardapproved LPN registry. Of the 679 patients, 25 (3.7%) had undergone previous ipsilateral renal surgery. All patients underwent preoperative spiral computed tomography with threedimensional reconstruction. Our technique of LPN has been previously described.7 For the purposes of this study, previous renal surgery was defined as any type of open or percutaneous flank surgery or procedure with the potential to cause retroperitoneal and/or perinephric fibrosis. Previous renal surgery included open surgery in 12 patients (nephro/pyelolithotomy in 8, pyeloplasty in 2, and partial nephrectomy in 2) and percutaneous surgery in 13 0090-4295/08/$34.00 doi:10.1016/j.urology.2008.04.002
Table 1. Intraoperative and postoperative data Variable
Value
Transperitoneal approach (n) Blood loss (mL) Mean Range Pelvicaliceal repair (n) Warm ischemia time (min) Mean Range Operative time (h) Mean Range FloSeal used (n) Kidney tissue excised (%) Mean Range Difficulty level for technical steps compared with standard LPN* Port placement Hilar dissection Mobilization of the kidney Deployment of vascular clamps Tumor excision Pelvicaliceal repair and renorrhaphy Intraoperative urine output (mL) Mean Range Hospital stay (d) Mean Range Interval to oral intake (d) Mean Range Interval to ambulation (d) Mean Range Convalescence (wk) Mean Range
16 (64) 215 25-600 20 (80) 35.8 22-57 3 1.5-4.5 23 (92) 26.2 10-50 Primary surgeon 1 2 2 2 3 3
Two researchers 1.92 ⫾ 0.7 4.12 ⫾ 0.3 2.96 ⫾ 0.7 2.20 ⫾ 0.7 3.72 ⫾ 0.5 3.12 ⫾ 0.3 826.5 80-2800 3.1 1-7.6 1.2 0-3 2 1-6 1.6 1-24
LPN ⫽ laparoscopic partial nephrectomy. Data in parentheses are percentages. * Subjective review by primary surgeon and 2 researchers (data presented as mean ⫾ standard deviation); see text for details.
patients (percutaneous nephrolithotomy in 9 and renal biopsy in 4). The choice of laparoscopic approach (transperitoneal or retroperitoneal) was primarily dependent on tumor location, with posterior and posteromedial tumors approached retroperitoneoscopically and anterior, anterolateral, and lateral tumors approached transperitoneally. The technical modifications for the retroperitoneal approach included avoiding the area of previous incision during the initial access, extensive digital dissection of the retroperitoneal space before balloon dilation, separate and deliberate balloon dilation initially of the cranial and then the caudal aspects of the retroperitoneal space, careful inspection of the retroperitoneal space through the balloon trocar during dilation, and insertion of the anterior secondary trocar under direct vision to avoid peritoneal entry. The technical modifications for the transperitoneal approach included initial inspection with a 1.9-mm laparoscope through a 2-mm miniport as the initial entry trocar, and meticulous lysis of any abdominal adhesions. In patients with a surgical scar in the operative field, transperitoneal access was obtained through UROLOGY 72 (3), 2008
the most geographically distant quadrant to minimize the risk of inadvertent intraabdominal injury. The LPN registry and patient charts were analyzed to obtain the demographic data, preoperative surgical history, operative details, and postoperative outcomes, including histopathologic findings, complications, and follow-up data. Technical difficulty was assessed from the detailed documentation on the operative notes. To specifically assess the difficulty of LPN after previous surgery, the degree of difficulty of each of the 6 main technical steps of LPN was evaluated on a 5-point Likert scale, ranging from 1 (easy), through 3 (moderately difficult) to 5 (extremely difficult).8 The senior author (I.S.G.) scored the steps of a standard LPN, and 2 researchers independently studied the operative notes of all reoperative LPN patients and scored each of the technical steps of LPN according to the Likert scale (see Table 1). The average of the scores of the 2 researchers was calculated. The primary surgeon independently reviewed the mean score from the 2 researchers to ensure accuracy. The patients were stratified into 2 groups depending on the type of previous surgical intervention (percutaneous vs open 585
surgery) to evaluate potential differences. Summary statistics were constructed with means or medians for continuous variables and percentages for categorical variables. Statistical comparison of the 2 subgroups was performed using the Wilcoxon rank-sum test (continuous data) and 2 test (categorical data), as appropriate. Statistical significance was set at P ⱕ .05.
RESULTS A total of 25 patients underwent LPN for a renal mass after ipsilateral renal surgery. The mean interval between the ipsilateral renal surgery and subsequent LPN was 6.6 ⫾ 9.2 years (range 0.3-34). Of the 25 patients, 18 were men and 7 were women, with a mean age of 56.9 ⫾ 10.8 years (range 40-76). The mean tumor size was 2.5 ⫾ 1.0 cm (range 1-5.6) on preoperative computed tomography. Two patients had a history of bilateral renal tumors. No patient had a solitary kidney. LPN was performed transperitoneally in 16 patients (64%) and retroperitoneally in 9 (36%). Of the 9 patients with retroperitoneoscopic LPN, 4 had previously undergone open flank surgery, and 5 had previously undergone a percutaneous renal procedure. The demographics, tumor characteristics, and previous operation data are listed in Table 2. Table 1 lists the perioperative data. LPN was performed with hilar clamping in all patients, with a mean warm ischemia time of 35.8 minutes (range 22-57). Pelvicaliceal entry and subsequent suture repair was performed in 20 patients (80%). The mean estimated blood loss was 215 mL (range 25-600), the operative time was 3 hours (range 1.5-4.5), and the hospital stay was 3.1 days (range 1-7.6). No significant difficulty was encountered during initial access to the peritoneal cavity or retroperitoneal space. No bowel or visceral injuries occurred during balloon dilation or Veress needle or trocar placement. No open conversions were needed, and no kidneys were lost. Dissection of the hilum was extremely difficult because of dense adhesions in 3 patients who had previously undergone ipsilateral open partial nephrectomy (OPN) (n ⫽ 1), open pyeloplasty (n ⫽ 1), or open pyelolithotomy (n ⫽ 1). Using the 5-point Likert scale, the primary surgeon graded the level of difficulty during a standard LPN for the following steps of the procedure: port placement (score 1), hilar dissection (score 2), mobilization of the kidney (score 2), deployment of vascular clamps (score 2), tumor excision (score 3), and renal reconstruction (score 3). For comparison, the degree of difficulty of these technical steps was also independently scored by 2 independent researchers using the same 5-point scale. The mean ⫾ standard deviation degree of difficulty for each step is listed in Table 1. Hilar dissection appeared to be the most technically challenging part of the operation, followed by tumor excision. No intraoperative complications occurred. Postoperative complications developed in 3 patients (12%). One patient required transfusion of 2 U of blood because of a decreased hematocrit. One superobese patient (body mass index 51.9 kg/m2) with an operative time of 4.5 586
Table 2. Demographic data Variable
Value
Age (y) Mean ⫾ SD Range BMI (kg/m2) Mean ⫾ SD Range ASA score Mean Range Male (n) Left side (n) Tumor size (cm) Mean ⫾ SD Range Tumor size ⱖ4 cm (n) Previous ipsilateral kidney surgery (n) Open pyelolithotomy (flank incision) Open partial nephrectomy (flank incision) Open pyeloplasty (flank incision) Percutaneous nephrolithotomy (flank) Renal biopsy (NA) Interval from previous surgery (y) Mean ⫾ SD Range Tumor location (n) Upper pole Mid-kidney Lower pole Tumor region (n) Central* Peripheral Site (n) Anterior Posterior Tumors (n) Solid Cystic Infiltrating Completely intraparenchymal
56.9 ⫾ 10.8 40-76 30 ⫾ 7.6 20-51.9 2 1-3 18 (72) 12 (48) 2.5 ⫾ (1-5.6) 4 (16) 8 (32) 2 (8) 2 (8) 9 (36) 4 (16) 6.6 ⫾ 9.2 0.3-34 10 (40) 10 (40) 5 (20) 9 (36) 16 (64) 16 (64) 9 (36) 23 (92) 2 (8) 7 (28) 1 (4)
SD ⫽ standard deviation; BMI ⫽ body mass index; ASA ⫽ American Society of Anesthesiologists; NA ⫽ not available. Data in parentheses are percentages. * Central tumors defined as those abutting central renal sinus and/or pelvicaliceal system on preoperative computed tomography scans.
hours developed left gluteal compartment syndrome requiring fasciotomy on postoperative day 2. One patient was readmitted to the hospital with unrelated nausea and epistaxis 1 week after the procedure. All 3 patients recovered without long-term sequelae. The mean time to ambulation was 2 days. Convalescence was complete in 1.6 weeks (range 1-24). Histopathologic examination confirmed renal cell carcinoma in 19 patients (76%). Negative margins for cancer were achieved in all patients, with a mean parenchymal margin width of 6 mm (range 2-15). One patient died of myocardial infarction 4 years postoperatively. At a mean follow-up of 19 months (range 2-61), the overall and cancer-specific survival rate was 96% and 100%, respectively. At last follow-up, no patient had developed port site or local recurrence or metastatic disease. The comUROLOGY 72 (3), 2008
Table 3. Comparison of surgical outcomes after LPN for patients with previous percutaneous vs open surgery Variable Patients (n) Interval from previous surgery (y) Median Range Tumor size (cm) Median Range Transperitoneal approach (n) Blood loss (mL) Median Range Pelvicaliceal repair (n) Warm ischemia time (min) Median Range Operative time (h) Median Range Hospital stay (d) Median Range Margin width (cm) Median Range Postoperative complications (n)
Percutaneous Open Surgery Surgery *P Value 13
12
3 0.3-14
3 1-34
2.2 1.6-5.6 8 (62)
2.1 1.2-4.3 8 (67)
275 50-600 10 (77)
200 25-400 10 (83)
35 25-53
34.5 22-57
3 2-4
3 1.5-4.5
3 1-6.5
2.4 1.8-7.6
0.45 0.2-1.5 1 (8)
1 0.2-1.5 2 (17)
— .7
.57 .79 .078 .69 .38
.64 .94 .25 .49
LPN ⫽ laparoscopic partial nephrectomy. Data in parentheses are percentages. * Wilcoxon rank-sum test for continuous data and 2 test for categorical data.
parative surgical outcomes after LPN for patients with previous percutaneous vs open surgery are listed in Table 3.
COMMENT Intraabdominal adhesions have been estimated to occur in 35%-90% of patients with a history of abdominal surgery.9,10 Two reports from 2002 suggested that previous abdominal surgery does not adversely affect subsequent urologic laparoscopy.11,12 However, Seifman et al.13 noted that a previously operated abdomen increased the risk of operative and major complications during transperitoneal laparoscopy. Chen et al.14 examined the feasibility and morbidity of laparoscopic renal surgery in 24 patients at high risk of intraabdominal adhesions and retroperitoneal scarring. They completed all procedures laparoscopically, with an overall complication rate of 33%, including 3 major complications. In the present series, all procedures were completed laparoscopically, despite the technical complexity of the LPN procedure. Our criteria for the choice of a laparoscopic approach for partial nephrectomy have been previously described.15 In brief, tumor location, depth, and size determine whether we use a transperitoneal or retroperitoneal approach. In this series, previous open retroperitoneal UROLOGY 72 (3), 2008
surgery typically was an indication for the transperitoneal approach for the subsequent reoperative LPN, unless the tumor location was distinctly unsuitable to the transperitoneal approach. The choice of approach is dictated primarily by surgeon experience and tumor location. Other factors include the number of tumors, number of arteries supplying the kidney, and amount of visceral fat surrounding the kidney. No access-related complications occurred in our series. A review of published studies in 2006 found that laparoscopic adhesiolysis is safe in the hands of experienced surgeons.16 In patients at risk of extensive perinephric fibrosis, a greater incidence of open conversion is likely.17 In our entire series of 679 patients, 2 patients with previous OPN underwent subsequent LPN after an interval of 1 and 3 years, respectively. This, in our experience, is the most technically challenging cohort of patients because of the extensive previous renal hilar dissection and mobilization and defatting of the kidney. Both patients had previously undergone staged bilateral OPN for bilateral renal cell carcinoma. Transperitoneal LPN for a 2- and 1.7-cm mass in each patient’s remnant kidney, respectively, was uneventful, with negative cancer margins in both patients. LPN was successful without any intraoperative complications, despite dense perihilar adhesions. Both patients were alive with normal serum creatinine levels at last follow-up. Our review of the operative notes revealed mention of technical operative difficulties in 2 additional patients. The difficulties in both were related to dense adhesions around the hilum. The relatively long warm ischemia time in the present series could be attributed to the limited mobility of the previously operated kidney. This limited mobility could potentially limit the suturing angles available to the surgeon and slow the sutured renal reconstruction. Tumor excision is also more difficult and slower because of the adherence of the perirenal fat to the renal surface around the tumor. Percutaneous surgery might be associated with less scarring than open renal surgery, which often requires complete defatting of the entire kidney, circumferential mobilization of the renal vessels, and the use of hemostatic agents and tissue sealants. Although this might true, substratification of our patients by type of previous intervention (percutaneous vs open) did not reveal a statistically significant difference between the 2 subgroups. Adherent and excessive perinephric fat adds to the technical difficulty of LPN, especially with the retroperitoneal approach. Although adherent fat was commonly encountered in this cohort of patients, it did not preclude successful LPN. However, if a surgeon has limited LPN experience, such renal lesions are best managed by other means, either OPN or probe-ablative procedures. In the present study, the technical steps of LPN were carefully re-reviewed by the primary surgeon and 2 researchers, with a special emphasis on port placement, kidney mobilization, dissection of the hilum, hilar clamp587
ing, tumor excision, and sutured reconstruction of the renal defect. Regarding technical considerations, careful planning of port placement, meticulous dissection around the hilum, use of intraoperative ultrasonography, and use of a standard protocol for tumor excision and suture repair are critical considerations for successful performance of LPN in a previously operated kidney. The initial use of the micro-laparoscope (1.9 mm) through the 2-mm miniport (alternative to Veress needle) provides establishment of the pneumoperitoneum, as well as direct visual access for safe primary port placement where intraabdominal adhesions are anticipated. In the scarred abdomen, such initial access should be obtained through a geographically distant quadrant. If adhesions involving the bowel and its mesentery are present, they should preferably be taken down “cold,” instead of using electrocautery. The surgeon should never hesitate to put in additional ports to help take down adhesions or for retraction. In a patient with previous OPN, the kidney might be completely bereft of fat and might be directly adherent to the undersurface of the abdominal wall. This needs to be remembered during renal mobilization to avoid cutting into the parenchyma. Dense adhesions around the hilum are expected, and due care is necessary. Fibrous tissue encasing the renal vessels should be handled with care. One should avoid skeletonizing the artery and vein individually and should use a laparoscopic Satinsky clamp for en bloc hilar control rather than bulldog clamps for individual renal vessels. Such kidneys could have densely adherent perinephric tissue, resulting in the likelihood of entering the subcapsular plane while defatting the kidney for LPN. Preventing such stripping of the capsule is of critical importance for sutured renorrhaphy, otherwise the parenchymal sutures will have a greater likelihood of “cut through.” Limited mobility of the operated kidney also needs to be remembered while lining up the tumor for excision and reconstruction. Our contraindications to LPN include a small renal mass with renal vein thrombus and grade 4 chronic kidney disease. However, novice laparoscopic surgeons should realize that successful LPN for complex tumors requires an in-depth understanding of the three-dimensional renal anatomy, an acute appreciation of visual cues during laparoscopy, and skilful ambidextrous handling of a variety of laparoscopic instruments. Although we have reported the feasibility of LPN after previous ipsilateral renal surgery in our hands, this does not represent the standard of care. The present study was constrained by the limitations inherent to a retrospective study. Nevertheless, all data were prospectively accrued and maintained in an institutional review board-approved database.
588
CONCLUSIONS Our results have shown that LPN after previous ipsilateral renal surgery is feasible and effective, by either a transperitoneal or a retroperitoneal approach. The procedure itself is technically challenging. In experienced hands, the perioperative outcomes and oncologic results are comparable to those after virgin LPN. Given adequate laparoscopic experience and careful patient selection, previous ipsilateral renal surgery does not necessarily constitute a contraindication to LPN. References 1. Huang WC, Levey AS, Serio AM, et al. Chronic kidney disease after nephrectomy in patients with renal cortical tumours: A retrospective cohort study. Lancet Oncol. 2006;7:735-740. 2. Lau WK, Blute ML, Weaver AL, et al. Matched comparison of radical nephrectomy vs nephron-sparing surgery in patients with unilateral renal cell carcinoma and a normal contralateral kidney. Mayo Clin Proc. 2000;75:1236-1242. 3. Janetschek G, Jeschke K, Peschel R, et al. Laparoscopic surgery for stage 1 renal cell carcinoma: Radical nephrectomy and wedge resection. Eur Urol. 2000;38:131-138. 4. Gill IS, Colombo JR Jr, Frank I, et al. Laparoscopic partial nephrectomy for hilar tumors. J Urol. 2005;174:850-853. 5. Frank I, Colombo JR Jr, Rubinstein M, et al. Laparoscopic partial nephrectomy for centrally located renal tumors. J Urol. 2006;175: 849-852. 6. Gill IS, Colombo JR Jr, Moinzadeh A, et al. Laparoscopic partial nephrectomy in solitary kidney. J Urol. 2006;175:454-458. 7. Gill IS, Desai MM, Kaouk JH, et al. Laparoscopic partial nephrectomy for renal tumor: Duplicating open surgical techniques. J Urol. 2002;167:469-476. 8. Vassiliou MC, Feldman LS, Andrew CG, et al. A global assessment tool for evaluation of intraoperative laparoscopic skills. Am J Surg. 2005;190:107-113. 9. Brill AI, Nezhat F, Nezhat CH, et al. The incidence of adhesions after prior laparotomy: A laparoscopic appraisal. Obstet Gynecol. 1995;85:269-272. 10. Weibal MA, Majno G. Peritoneal adhesion and their relation to abdominal surgery. A postmortem study. Am J Surg. 1973;126:345353. 11. Parsons JK, Jarrett TJ, Chow GK, et al. The effect of previous abdominal surgery on urological laparoscopy. J Urol. 2002;168: 2387-2390. 12. Pautler SE, Phillips JL, Walther MM. Assessment of risk for intraabdominal adhesions at laparoscopy for urological tumors. J Urol. 2002;168:2391-2394. 13. Seifman BD, Dunn RL, Wolf SJ Jr. Transperitoneal laparoscopy into the previously operated abdomen: Effect on operative time, length of stay and complications. J Urol. 2003;169:36-40. 14. Chen RN, Moore RG, Cadeddu JA, et al. Laparoscopic renal surgery in patients at high risk for intra-abdominal or retroperitoneal scarring. J Endourol. 1998;12:143-147. 15. Ng CS, Gill IS, Ramani AP, et al. Transperitoneal versus retroperitoneal laparoscopic partial nephrectomy: Patient selection and perioperative outcomes. J Urol. 2005;174:846-849. 16. Szomstein S, Lo Menzo E, Simpfendorfer C, et al. Laparoscopic lysis of adhesions. World J Surg. 2006;30:535-540. 17. Kapoor R, Vijjan V, Singh K, et al. Is laparoscopic nephrectomy the preferred approach in xanthogranulomatous pyelonephritis? Urology. 2006;68:952-955.
UROLOGY 72 (3), 2008
METHODS
RESULTS
CONCLUSIONS
Previous renal surgery has been considered a relative contraindication to laparoscopic partial nephrectomy (LPN) because of perirenal surgical adhesions. We present our experience with LPN in patients with previous ipsilateral renal surgery. Of 679 patients undergoing LPN for a renal mass from September 1999 to November 2006, 25 (3.7%) had undergone previous ipsilateral open or percutaneous renal procedures. The LPN technique included hilar clamping, cold tumor excision, and sutured renal reconstruction. The perioperative outcomes were retrospectively analyzed from a prospectively maintained database. Previous renal surgery included open surgery in 12 patients (nephro/pyelolithotomy in 8, pyeloplasty in 2, and partial nephrectomy in 2) and percutaneous surgery in 13 (percutaneous nephrolithotomy in 9 and renal biopsy in 4). The mean interval from previous surgery was 6.6 years (range 0.3-34). LPN (16 transperitoneal and 9 retroperitoneal) was successful in all patients. The mean tumor size was 2.5 cm (range 1-5.6), the warm ischemia time was 35.8 minutes (range 22-57), and the estimated blood loss was 215 mL (range 25-600). The mean operative time was 3 hours (range 1.5-4.5), and the hospital stay was 3.1 days (range 1-7.6). Histopathologic examination confirmed renal cell carcinoma in 19 patients (76%). No open conversions were needed, and no kidneys were lost. No intraoperative complications and 3 postoperative complications (12%) developed, including blood transfusion in 1, nausea and epistaxis in 1, and compartment syndrome requiring fasciotomy in 1 patient. The results of our study have shown that, in select patients, LPN is feasible after previous ipsilateral renal surgery. However, it can be technically challenging, and adequate previous experience with LPN is necessary. UROLOGY 72: 584 –588, 2008. © 2008 Published by Elsevier Inc.
I
n the presence of a normal contralateral kidney, the rationale for nephron-sparing surgery vs radical nephrectomy for a small renal mass is the decreased risk of progression to chronic kidney disease.1,2 Laparoscopic partial nephrectomy (LPN) was initially reserved for select patients with a small, peripheral, and exophytic tumor.3 The indications for LPN have been carefully expanded to include more complex tumors with increasing experience.4-6 Previous ipsilateral renal surgery has been considered a relative contraindication for subsequent LPN because of the likelihood of dense postoperative adhesions and distorted tissue planes, which could render hilar control and
B. Turna was supported by the Scientific and Technological Research Council of Turkey during his fellowship. From the Section of Laparoscopic and Robotic Surgery, Glickman Urological Institute, Cleveland Clinic Foundation, Cleveland, Ohio Reprint requests: Inderbir S. Gill, M.D., M.Ch., Section of Laparoscopic and Robotic Surgery, Glickman Urological Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A-100, Cleveland, OH. E-mail: [email protected] Submitted: March 29, 2007, accepted (with revisions): April 1, 2008
584
© 2008 Published by Elsevier Inc.
renal mobilization more difficult. However, a paucity of published data is available from urologic studies in this regard. We report the perioperative outcomes for 25 patients treated with LPN after previous ipsilateral renal surgery.
MATERIAL AND METHODS From September 1999 to November 2006, 679 patients underwent LPN for a renal mass at our institution. The patient data were prospectively accrued in an institutional review boardapproved LPN registry. Of the 679 patients, 25 (3.7%) had undergone previous ipsilateral renal surgery. All patients underwent preoperative spiral computed tomography with threedimensional reconstruction. Our technique of LPN has been previously described.7 For the purposes of this study, previous renal surgery was defined as any type of open or percutaneous flank surgery or procedure with the potential to cause retroperitoneal and/or perinephric fibrosis. Previous renal surgery included open surgery in 12 patients (nephro/pyelolithotomy in 8, pyeloplasty in 2, and partial nephrectomy in 2) and percutaneous surgery in 13 0090-4295/08/$34.00 doi:10.1016/j.urology.2008.04.002
Table 1. Intraoperative and postoperative data Variable
Value
Transperitoneal approach (n) Blood loss (mL) Mean Range Pelvicaliceal repair (n) Warm ischemia time (min) Mean Range Operative time (h) Mean Range FloSeal used (n) Kidney tissue excised (%) Mean Range Difficulty level for technical steps compared with standard LPN* Port placement Hilar dissection Mobilization of the kidney Deployment of vascular clamps Tumor excision Pelvicaliceal repair and renorrhaphy Intraoperative urine output (mL) Mean Range Hospital stay (d) Mean Range Interval to oral intake (d) Mean Range Interval to ambulation (d) Mean Range Convalescence (wk) Mean Range
16 (64) 215 25-600 20 (80) 35.8 22-57 3 1.5-4.5 23 (92) 26.2 10-50 Primary surgeon 1 2 2 2 3 3
Two researchers 1.92 ⫾ 0.7 4.12 ⫾ 0.3 2.96 ⫾ 0.7 2.20 ⫾ 0.7 3.72 ⫾ 0.5 3.12 ⫾ 0.3 826.5 80-2800 3.1 1-7.6 1.2 0-3 2 1-6 1.6 1-24
LPN ⫽ laparoscopic partial nephrectomy. Data in parentheses are percentages. * Subjective review by primary surgeon and 2 researchers (data presented as mean ⫾ standard deviation); see text for details.
patients (percutaneous nephrolithotomy in 9 and renal biopsy in 4). The choice of laparoscopic approach (transperitoneal or retroperitoneal) was primarily dependent on tumor location, with posterior and posteromedial tumors approached retroperitoneoscopically and anterior, anterolateral, and lateral tumors approached transperitoneally. The technical modifications for the retroperitoneal approach included avoiding the area of previous incision during the initial access, extensive digital dissection of the retroperitoneal space before balloon dilation, separate and deliberate balloon dilation initially of the cranial and then the caudal aspects of the retroperitoneal space, careful inspection of the retroperitoneal space through the balloon trocar during dilation, and insertion of the anterior secondary trocar under direct vision to avoid peritoneal entry. The technical modifications for the transperitoneal approach included initial inspection with a 1.9-mm laparoscope through a 2-mm miniport as the initial entry trocar, and meticulous lysis of any abdominal adhesions. In patients with a surgical scar in the operative field, transperitoneal access was obtained through UROLOGY 72 (3), 2008
the most geographically distant quadrant to minimize the risk of inadvertent intraabdominal injury. The LPN registry and patient charts were analyzed to obtain the demographic data, preoperative surgical history, operative details, and postoperative outcomes, including histopathologic findings, complications, and follow-up data. Technical difficulty was assessed from the detailed documentation on the operative notes. To specifically assess the difficulty of LPN after previous surgery, the degree of difficulty of each of the 6 main technical steps of LPN was evaluated on a 5-point Likert scale, ranging from 1 (easy), through 3 (moderately difficult) to 5 (extremely difficult).8 The senior author (I.S.G.) scored the steps of a standard LPN, and 2 researchers independently studied the operative notes of all reoperative LPN patients and scored each of the technical steps of LPN according to the Likert scale (see Table 1). The average of the scores of the 2 researchers was calculated. The primary surgeon independently reviewed the mean score from the 2 researchers to ensure accuracy. The patients were stratified into 2 groups depending on the type of previous surgical intervention (percutaneous vs open 585
surgery) to evaluate potential differences. Summary statistics were constructed with means or medians for continuous variables and percentages for categorical variables. Statistical comparison of the 2 subgroups was performed using the Wilcoxon rank-sum test (continuous data) and 2 test (categorical data), as appropriate. Statistical significance was set at P ⱕ .05.
RESULTS A total of 25 patients underwent LPN for a renal mass after ipsilateral renal surgery. The mean interval between the ipsilateral renal surgery and subsequent LPN was 6.6 ⫾ 9.2 years (range 0.3-34). Of the 25 patients, 18 were men and 7 were women, with a mean age of 56.9 ⫾ 10.8 years (range 40-76). The mean tumor size was 2.5 ⫾ 1.0 cm (range 1-5.6) on preoperative computed tomography. Two patients had a history of bilateral renal tumors. No patient had a solitary kidney. LPN was performed transperitoneally in 16 patients (64%) and retroperitoneally in 9 (36%). Of the 9 patients with retroperitoneoscopic LPN, 4 had previously undergone open flank surgery, and 5 had previously undergone a percutaneous renal procedure. The demographics, tumor characteristics, and previous operation data are listed in Table 2. Table 1 lists the perioperative data. LPN was performed with hilar clamping in all patients, with a mean warm ischemia time of 35.8 minutes (range 22-57). Pelvicaliceal entry and subsequent suture repair was performed in 20 patients (80%). The mean estimated blood loss was 215 mL (range 25-600), the operative time was 3 hours (range 1.5-4.5), and the hospital stay was 3.1 days (range 1-7.6). No significant difficulty was encountered during initial access to the peritoneal cavity or retroperitoneal space. No bowel or visceral injuries occurred during balloon dilation or Veress needle or trocar placement. No open conversions were needed, and no kidneys were lost. Dissection of the hilum was extremely difficult because of dense adhesions in 3 patients who had previously undergone ipsilateral open partial nephrectomy (OPN) (n ⫽ 1), open pyeloplasty (n ⫽ 1), or open pyelolithotomy (n ⫽ 1). Using the 5-point Likert scale, the primary surgeon graded the level of difficulty during a standard LPN for the following steps of the procedure: port placement (score 1), hilar dissection (score 2), mobilization of the kidney (score 2), deployment of vascular clamps (score 2), tumor excision (score 3), and renal reconstruction (score 3). For comparison, the degree of difficulty of these technical steps was also independently scored by 2 independent researchers using the same 5-point scale. The mean ⫾ standard deviation degree of difficulty for each step is listed in Table 1. Hilar dissection appeared to be the most technically challenging part of the operation, followed by tumor excision. No intraoperative complications occurred. Postoperative complications developed in 3 patients (12%). One patient required transfusion of 2 U of blood because of a decreased hematocrit. One superobese patient (body mass index 51.9 kg/m2) with an operative time of 4.5 586
Table 2. Demographic data Variable
Value
Age (y) Mean ⫾ SD Range BMI (kg/m2) Mean ⫾ SD Range ASA score Mean Range Male (n) Left side (n) Tumor size (cm) Mean ⫾ SD Range Tumor size ⱖ4 cm (n) Previous ipsilateral kidney surgery (n) Open pyelolithotomy (flank incision) Open partial nephrectomy (flank incision) Open pyeloplasty (flank incision) Percutaneous nephrolithotomy (flank) Renal biopsy (NA) Interval from previous surgery (y) Mean ⫾ SD Range Tumor location (n) Upper pole Mid-kidney Lower pole Tumor region (n) Central* Peripheral Site (n) Anterior Posterior Tumors (n) Solid Cystic Infiltrating Completely intraparenchymal
56.9 ⫾ 10.8 40-76 30 ⫾ 7.6 20-51.9 2 1-3 18 (72) 12 (48) 2.5 ⫾ (1-5.6) 4 (16) 8 (32) 2 (8) 2 (8) 9 (36) 4 (16) 6.6 ⫾ 9.2 0.3-34 10 (40) 10 (40) 5 (20) 9 (36) 16 (64) 16 (64) 9 (36) 23 (92) 2 (8) 7 (28) 1 (4)
SD ⫽ standard deviation; BMI ⫽ body mass index; ASA ⫽ American Society of Anesthesiologists; NA ⫽ not available. Data in parentheses are percentages. * Central tumors defined as those abutting central renal sinus and/or pelvicaliceal system on preoperative computed tomography scans.
hours developed left gluteal compartment syndrome requiring fasciotomy on postoperative day 2. One patient was readmitted to the hospital with unrelated nausea and epistaxis 1 week after the procedure. All 3 patients recovered without long-term sequelae. The mean time to ambulation was 2 days. Convalescence was complete in 1.6 weeks (range 1-24). Histopathologic examination confirmed renal cell carcinoma in 19 patients (76%). Negative margins for cancer were achieved in all patients, with a mean parenchymal margin width of 6 mm (range 2-15). One patient died of myocardial infarction 4 years postoperatively. At a mean follow-up of 19 months (range 2-61), the overall and cancer-specific survival rate was 96% and 100%, respectively. At last follow-up, no patient had developed port site or local recurrence or metastatic disease. The comUROLOGY 72 (3), 2008
Table 3. Comparison of surgical outcomes after LPN for patients with previous percutaneous vs open surgery Variable Patients (n) Interval from previous surgery (y) Median Range Tumor size (cm) Median Range Transperitoneal approach (n) Blood loss (mL) Median Range Pelvicaliceal repair (n) Warm ischemia time (min) Median Range Operative time (h) Median Range Hospital stay (d) Median Range Margin width (cm) Median Range Postoperative complications (n)
Percutaneous Open Surgery Surgery *P Value 13
12
3 0.3-14
3 1-34
2.2 1.6-5.6 8 (62)
2.1 1.2-4.3 8 (67)
275 50-600 10 (77)
200 25-400 10 (83)
35 25-53
34.5 22-57
3 2-4
3 1.5-4.5
3 1-6.5
2.4 1.8-7.6
0.45 0.2-1.5 1 (8)
1 0.2-1.5 2 (17)
— .7
.57 .79 .078 .69 .38
.64 .94 .25 .49
LPN ⫽ laparoscopic partial nephrectomy. Data in parentheses are percentages. * Wilcoxon rank-sum test for continuous data and 2 test for categorical data.
parative surgical outcomes after LPN for patients with previous percutaneous vs open surgery are listed in Table 3.
COMMENT Intraabdominal adhesions have been estimated to occur in 35%-90% of patients with a history of abdominal surgery.9,10 Two reports from 2002 suggested that previous abdominal surgery does not adversely affect subsequent urologic laparoscopy.11,12 However, Seifman et al.13 noted that a previously operated abdomen increased the risk of operative and major complications during transperitoneal laparoscopy. Chen et al.14 examined the feasibility and morbidity of laparoscopic renal surgery in 24 patients at high risk of intraabdominal adhesions and retroperitoneal scarring. They completed all procedures laparoscopically, with an overall complication rate of 33%, including 3 major complications. In the present series, all procedures were completed laparoscopically, despite the technical complexity of the LPN procedure. Our criteria for the choice of a laparoscopic approach for partial nephrectomy have been previously described.15 In brief, tumor location, depth, and size determine whether we use a transperitoneal or retroperitoneal approach. In this series, previous open retroperitoneal UROLOGY 72 (3), 2008
surgery typically was an indication for the transperitoneal approach for the subsequent reoperative LPN, unless the tumor location was distinctly unsuitable to the transperitoneal approach. The choice of approach is dictated primarily by surgeon experience and tumor location. Other factors include the number of tumors, number of arteries supplying the kidney, and amount of visceral fat surrounding the kidney. No access-related complications occurred in our series. A review of published studies in 2006 found that laparoscopic adhesiolysis is safe in the hands of experienced surgeons.16 In patients at risk of extensive perinephric fibrosis, a greater incidence of open conversion is likely.17 In our entire series of 679 patients, 2 patients with previous OPN underwent subsequent LPN after an interval of 1 and 3 years, respectively. This, in our experience, is the most technically challenging cohort of patients because of the extensive previous renal hilar dissection and mobilization and defatting of the kidney. Both patients had previously undergone staged bilateral OPN for bilateral renal cell carcinoma. Transperitoneal LPN for a 2- and 1.7-cm mass in each patient’s remnant kidney, respectively, was uneventful, with negative cancer margins in both patients. LPN was successful without any intraoperative complications, despite dense perihilar adhesions. Both patients were alive with normal serum creatinine levels at last follow-up. Our review of the operative notes revealed mention of technical operative difficulties in 2 additional patients. The difficulties in both were related to dense adhesions around the hilum. The relatively long warm ischemia time in the present series could be attributed to the limited mobility of the previously operated kidney. This limited mobility could potentially limit the suturing angles available to the surgeon and slow the sutured renal reconstruction. Tumor excision is also more difficult and slower because of the adherence of the perirenal fat to the renal surface around the tumor. Percutaneous surgery might be associated with less scarring than open renal surgery, which often requires complete defatting of the entire kidney, circumferential mobilization of the renal vessels, and the use of hemostatic agents and tissue sealants. Although this might true, substratification of our patients by type of previous intervention (percutaneous vs open) did not reveal a statistically significant difference between the 2 subgroups. Adherent and excessive perinephric fat adds to the technical difficulty of LPN, especially with the retroperitoneal approach. Although adherent fat was commonly encountered in this cohort of patients, it did not preclude successful LPN. However, if a surgeon has limited LPN experience, such renal lesions are best managed by other means, either OPN or probe-ablative procedures. In the present study, the technical steps of LPN were carefully re-reviewed by the primary surgeon and 2 researchers, with a special emphasis on port placement, kidney mobilization, dissection of the hilum, hilar clamp587
ing, tumor excision, and sutured reconstruction of the renal defect. Regarding technical considerations, careful planning of port placement, meticulous dissection around the hilum, use of intraoperative ultrasonography, and use of a standard protocol for tumor excision and suture repair are critical considerations for successful performance of LPN in a previously operated kidney. The initial use of the micro-laparoscope (1.9 mm) through the 2-mm miniport (alternative to Veress needle) provides establishment of the pneumoperitoneum, as well as direct visual access for safe primary port placement where intraabdominal adhesions are anticipated. In the scarred abdomen, such initial access should be obtained through a geographically distant quadrant. If adhesions involving the bowel and its mesentery are present, they should preferably be taken down “cold,” instead of using electrocautery. The surgeon should never hesitate to put in additional ports to help take down adhesions or for retraction. In a patient with previous OPN, the kidney might be completely bereft of fat and might be directly adherent to the undersurface of the abdominal wall. This needs to be remembered during renal mobilization to avoid cutting into the parenchyma. Dense adhesions around the hilum are expected, and due care is necessary. Fibrous tissue encasing the renal vessels should be handled with care. One should avoid skeletonizing the artery and vein individually and should use a laparoscopic Satinsky clamp for en bloc hilar control rather than bulldog clamps for individual renal vessels. Such kidneys could have densely adherent perinephric tissue, resulting in the likelihood of entering the subcapsular plane while defatting the kidney for LPN. Preventing such stripping of the capsule is of critical importance for sutured renorrhaphy, otherwise the parenchymal sutures will have a greater likelihood of “cut through.” Limited mobility of the operated kidney also needs to be remembered while lining up the tumor for excision and reconstruction. Our contraindications to LPN include a small renal mass with renal vein thrombus and grade 4 chronic kidney disease. However, novice laparoscopic surgeons should realize that successful LPN for complex tumors requires an in-depth understanding of the three-dimensional renal anatomy, an acute appreciation of visual cues during laparoscopy, and skilful ambidextrous handling of a variety of laparoscopic instruments. Although we have reported the feasibility of LPN after previous ipsilateral renal surgery in our hands, this does not represent the standard of care. The present study was constrained by the limitations inherent to a retrospective study. Nevertheless, all data were prospectively accrued and maintained in an institutional review board-approved database.
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CONCLUSIONS Our results have shown that LPN after previous ipsilateral renal surgery is feasible and effective, by either a transperitoneal or a retroperitoneal approach. The procedure itself is technically challenging. In experienced hands, the perioperative outcomes and oncologic results are comparable to those after virgin LPN. Given adequate laparoscopic experience and careful patient selection, previous ipsilateral renal surgery does not necessarily constitute a contraindication to LPN. References 1. Huang WC, Levey AS, Serio AM, et al. Chronic kidney disease after nephrectomy in patients with renal cortical tumours: A retrospective cohort study. Lancet Oncol. 2006;7:735-740. 2. Lau WK, Blute ML, Weaver AL, et al. Matched comparison of radical nephrectomy vs nephron-sparing surgery in patients with unilateral renal cell carcinoma and a normal contralateral kidney. Mayo Clin Proc. 2000;75:1236-1242. 3. Janetschek G, Jeschke K, Peschel R, et al. Laparoscopic surgery for stage 1 renal cell carcinoma: Radical nephrectomy and wedge resection. Eur Urol. 2000;38:131-138. 4. Gill IS, Colombo JR Jr, Frank I, et al. Laparoscopic partial nephrectomy for hilar tumors. J Urol. 2005;174:850-853. 5. Frank I, Colombo JR Jr, Rubinstein M, et al. Laparoscopic partial nephrectomy for centrally located renal tumors. J Urol. 2006;175: 849-852. 6. Gill IS, Colombo JR Jr, Moinzadeh A, et al. Laparoscopic partial nephrectomy in solitary kidney. J Urol. 2006;175:454-458. 7. Gill IS, Desai MM, Kaouk JH, et al. Laparoscopic partial nephrectomy for renal tumor: Duplicating open surgical techniques. J Urol. 2002;167:469-476. 8. Vassiliou MC, Feldman LS, Andrew CG, et al. A global assessment tool for evaluation of intraoperative laparoscopic skills. Am J Surg. 2005;190:107-113. 9. Brill AI, Nezhat F, Nezhat CH, et al. The incidence of adhesions after prior laparotomy: A laparoscopic appraisal. Obstet Gynecol. 1995;85:269-272. 10. Weibal MA, Majno G. Peritoneal adhesion and their relation to abdominal surgery. A postmortem study. Am J Surg. 1973;126:345353. 11. Parsons JK, Jarrett TJ, Chow GK, et al. The effect of previous abdominal surgery on urological laparoscopy. J Urol. 2002;168: 2387-2390. 12. Pautler SE, Phillips JL, Walther MM. Assessment of risk for intraabdominal adhesions at laparoscopy for urological tumors. J Urol. 2002;168:2391-2394. 13. Seifman BD, Dunn RL, Wolf SJ Jr. Transperitoneal laparoscopy into the previously operated abdomen: Effect on operative time, length of stay and complications. J Urol. 2003;169:36-40. 14. Chen RN, Moore RG, Cadeddu JA, et al. Laparoscopic renal surgery in patients at high risk for intra-abdominal or retroperitoneal scarring. J Endourol. 1998;12:143-147. 15. Ng CS, Gill IS, Ramani AP, et al. Transperitoneal versus retroperitoneal laparoscopic partial nephrectomy: Patient selection and perioperative outcomes. J Urol. 2005;174:846-849. 16. Szomstein S, Lo Menzo E, Simpfendorfer C, et al. Laparoscopic lysis of adhesions. World J Surg. 2006;30:535-540. 17. Kapoor R, Vijjan V, Singh K, et al. Is laparoscopic nephrectomy the preferred approach in xanthogranulomatous pyelonephritis? Urology. 2006;68:952-955.
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