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LAPAROSCOPIC PARTIAL NEPHRECTOMY
MINIMALLY INVASIVE SURGERY OF THE KIDNEY: A PROBLEM-ORIENTED APPROACH
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LAPAROSCOPIC PARTIAL NEPHRECTOMY The European Experience Jens J. Rassweiler, MD, Claude Abbou, MD, Gunter Janetschek, MD, and Klaus Jeschke, MD
Traditionally, partial nephrectomy for renal has not become a widespread procedure. Excell carcinoma was performed only for tu- pertise has concentrated in centers that are increasingly becoming active throughout the mors occurring in a solitary kidney or when 5, 15, 29, 41, 45, 46. 57 Nevertheless, even the patient presented with bilateral among laparoscopic surgeons, the indications disease.". 2x Because of the favorable results for radical nephrectomy are still under deobtained in terms of patient survival, tumor bate. Only 37 of 482 nephrectomies reported control, and complication rates, the indicain a recently published German multicenter tions for nephron-sparing surgery were exstudy were performed for renal m a l i g n a n ~ y . ~ ~ tended to include patients with small tumors During the last 3 years, there has been an 26, 27, 34, 39, and a normal contralateral kidney.20* increasing number of reports of laparoscopic 4n, iiSmall renal cell carcinomas are usually of radical nephrectomy using different technical lower stage and have a better prognosis. Owapproaches, such as transperitoneal lapaing to the widespread use of diagnostic ultras2 and r o s ~ o p y , 55 ~ ~retroperitoneoscopy,l2. , sound and CT, an increasing number of such hand-assisted and gasless laparo~copy.~' lesions are detected in~identally;~,53 and interBased on their favorable experience with est in nephron-sparing surgery and other orlaparoscopic radical nephrectomy and with gan-preserving approaches, such as cryotherpartial nephrectomy for benign renal disorapy3' or high-energy focused u l t r a ~ o u n d , ~ ~ ders,", 23, 24* 51 the authors now perform nephcan be expected to grow. ron-sparing surgery for small renal cell carciClayman and colleague^'^ pioneered laparnoma as an alternative to the open technique. oscopic nephrectomy when they removed a renal oncocytoma in 1990. Almost 1 year, later Coptcoat and c o - w o r k e r ~ 'used ~ the same OPERATIVE TECHNIQUE technique for radical extirpation of a T2 renal cell carcinoma. Despite the enthusiasm of The operative technique has been modified these pioneering surgeons, laparoscopic surwithin the last years. Two of the authors (GJ gery, especially laparoscopic nephrectomy,
From the Department of Urology, Klinikum Heilbronn, University of Heidelberg, Germany OR), the Department of Urology, HBpital Henri Mondor, Creteil, France (CA), the Department of Urology, University of Innsbruck, (GJ), and the Department of Urology, Landeskrankenhaus Klagenfurt (KJ), Austria.
UROLOGIC CLINICS OF NORTH AMERICA VOLUME 27 * NUMBER 4 * NOVEMBER 2000
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Table 1. LAPAROSCOPIC PARTIAL NEPHRECTOMY FOR RENAL CELL CARCINOMA-PATIENT DATA Criteria
Participating centers Creteil-Paris Innsbruck Heilbronn Klagenfurt Total number of patients Transperitoneal approach Retroperitoneal approach Patient characteristics Ratio male/female Mean age Ratio left/right kidney Localization of tumor Upper pole Middle Lower pole
Number
18 16 10 9 53 15 38 34/19 61.5 (range, 39-80) 28 / 25 15 24 24
and KJ) prefer the transperitoneal approach, and two (JR and CA) prefer the retroperitoneal approach (Table 1). The main operative steps are summarized in the following sections.
All patients undergo similar preoperative preparation as in open surgery, including a mild bowel cathartic. An indwelling bladder catheter is routinely placed. Under general anesthesia, a nasogastric tube is inserted. The patient is placed in a flank (retroperitoneoscopy) 45" lateral decubitus position on the relevant side (left or right renal tumor).
Transperitoneal Laparoscopic Approach Pneumoperitoneum is attained after insertion of a Veress needle placed lateral to the rectus abdominis muscle paraumbilically with the patient in the lateral decubitus position. Trocars are inserted through the anterior abdominal wall as depicted in Figure 1. The laparoscope is passed through port I and used to inspect the trocar insertions intra-abdominally for ports I1 and 111. After inspection of the intra-abdominal contents, either the as-
Figure 1. Transperitoneal laparoscopic partial nephrectorny. A, Positioning of the patient and site of trocars. illustration continued on opposite page
LAPAROSCOPIC PARTIAL NEPHRECTOMY
cending (right kidney) or descending (left kidney) colon is mobilized through a laterocolic incision of the peritoneum (along the white line of Toldt). Because the respective colon is free to fall off medially (Fig. lB), one or two additional ports (port IV, V) can be created through the newly exposed retroperitoneum. Tumors on the ventral surface of the right kidney are most readily accessible after exclusive incision of the peritoneum (Fig. 1C). Next, Gerota's fascia is dissected off the renal surface in the region where the tumor is located. When the tumor is located on the dorsal aspect of the kidney, the layer between
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Gerota's fascia and the lumbar aponeurosis is dissected. Subsequently, the kidney can be rotated medially nearly 180". After this maneuver, the tumor is directly accessible. Identification of the lumbar ureter is essential to avoid injury.
RetroperitoneoscopicApproach A 15- to 18-mm incision is made in the lumbar (Petit's) triangle (trigonum lumbale) between the 12th rib and the iliac crest, bounded by the lateral edges of the latissimus dorsi and external oblique muscles. A tunnel
Figure 1 (Continued). 8, Laterocolic incision along the white line of Toldt. C, Exposure of the retroperitoneum, ideal for ventrally located tumors.
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B
\
Psoas muscle
Retrorenal fascia (Gerota)
M. obliquus externus
/
Petit triangle
I
M. latissimus dorsi
Figure 2 (Continued). B, Finger dissection of the retroperitoneal space. C, Site of trocars.
Wedge Resection (Partial Nephrectomy)
The principles of wedge resection are identical in both approaches and are similar in the open technique. A 5-mm margin of healthy parenchyma around the tumor is the mini-
mum required for a safe resection. For oncologic and technical reasons, in all centers, laparoscopic wedge resection is restricted to tumors no larger than 5 cm in diameter and to tumors protruding from the renal surface (Fig. 3 ) with an average size of 2.4 cm (range, 1.0-5).
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Figure 3. Retroperitoneoscopic wedge resection. A, Computer tomography of a 3.5 cm lesion at the lower pole of a lefl solitary kidney. B, Nuclear magnetic imaging of the renal tumor. C, Endoscopic view with the tumor still surrounded by perirenal fat. Illustration continued on opposite page
LAPAROSCOPIC PARTIAL NEPHRECTOMY
Figure 3 (Continued). D, Removal of the perirenal fat at the base of the tumor. f, Step-by-step excision of the tumor with bipolar coagulation. F; Careful blunt dissection of the tumor along the renal pyramids to the medulla. Illustration continued on following page
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Figure 3 (Continued). G, Entrapment of the specimen in the organ bag (Extraction Bag, Karl Stow, Kuttlingen. Germany). H, Introduction of the fibrin glue coated cellulose (Tachocomb, Nycomed, Munich, Germany). I, Sealing of the cut surface with the fixed cellulose.
LAPAROSCOPIC PARTIAL NEPHRECTOMY
During wedge resection of the kidney, major hemorrhage may occur at any time; therefore, adequate hemostasis is of crucial importance. In open surgery, cold ischemia is used. Hypothermia is achieved by external cooling with ice in combination with temporary clamping of the pedicle. For technical reasons, this method cannot be applied in laparoscopy. Only warm ischemia is possible, restricting considerably the time of occlusion of the renal artery. Meticulous step-by-step dissection and hemostasis make laparoscopic wedge resection a time-consuming procedure, and prolonged warm ischemia time carries the risk of irreversible damage to the renal parenchyma. Different techniques of hemostasis have been applied. Temporary Ischemia With a Tourniquet Around the Renal Artery This technique requires an optimal visual field to the tumor because the wedge resection must be carried out in a reasonable time (15-20 minutes). The resection plane is mainly controlled by fibrin glue, a hemostatic gauze covered with fibrin (i.e., Tachocomb, Nycorned, Munich, Germany), or a heat-activated tissue adhesive (gelatin resorcinol formaldehyde glue). Wedge Resection Without Ischemia For this technique a bipolar coagulation forceps is used almost exclusively for simultaneous dissection and hemostasis (Fig. 3). Occasionally, the authors have used monopolar electrocautery, the blade of the harmonic scalpel, and a neodymium: YAG laser. In the authors' hands (all four centers), bipolar coagulation forceps have proved to be most efficient for surgery on the renal parenchyma. The scissors of the harmonic scalpel (Ultracision, Ethicon, Hamburg, Germany) and the Rotoresect (Karl Storz, Tuttlingen, Germany) for vaporization and dissection have proved to be promising in anecdotal clinical cases (Fig. 4). Sealing the Cut Surface Additional application of oxidized regenerated cellulose under pressure, fibrin-coated hemostyptic gauze (Tachcomb, Munich, Germany), has been effective for control of major bleeding. Occasionally, cauterization of the cut surface with an argon beam coagulator
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has been effective. One of the authors (CA) prefers to cover the cut surface with a cellulose mesh impregnated with gelatin resorcinol formaldehyde glue. Intraoperative biopsy specimens of the base of resection are assessed by frozen section. Cautious retrieval of the resected renal tumor is facilitated by use of a small-sized organ bag (i.e., LapSac, Cook Urological, Spencer, IN; Extraction bag, Karl Storz, Tuttlingen, Germany) to preclude tumor seeding (see Fig. 3).", The operative field is drained for 2 days.
PATIENTS AND TUMORS
Since June 1994, a total of 53 patients (34 males and 19 females) have been treated by laparoscopic partial nephrectomy at four European centers (Table 1).Fifteen tumors were located at the upper pole, 24 at the mid part, and 24 at the lower pole of the kidney. The average tumor size was 2.3 cm in diameter (range, 1.1-5).
OPERATIVE DATA AND COMPLICATIONS
According to the preference of the surgeons, a transperitoneal approach was used in 15 cases and a retroperitoneal approach in 38 (Table 1).The operating time averaged 191 minutes (range, 90-320). The mean estimated blood loss was 725 mL (range, 20-1500). Pneumothorax developed in one patient after extensive use of the argon beam coagulator with rising retroperitoneal pressure. There were four conversions to open surgery (8%). In two cases, conversion occurred because of significant intraoperative bleeding. In two other patients, the tumor could not be exposed adequately owing to its location at the ventral surface of the upper pole. At one center (JR), intraoperative laparoscopic ultrasound is not available. Two other cases of massive bleeding were stopped conservatively by compression and fibrin glue. A total of six patients (12%) required reintervention owing to bleeding ( n = 1)and urinoma ( n = 5). In two cases, nephrectomy was performed for treatment of bleeding and persistant urinoma. The other cases of urinoma were managed by percutaneous drainage or an indwelling stent. The mean postoperative hospital stay was 5.4 days (Table 2).
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Figure 4. Techniques of laparoscopic wedge resection. A, Bipolar coagulation (Karl Storz, Tuttlingen, Germany). B,Harmonic blade (Ultracision, Ethicon, Hamburg). C,Blunt dissection with suction device along the renal pyramids (Karl Storz, Tuttlingen, Germany).
LAPAROSCOPIC PARTIAL NEPHRECTOMY Table 2. RESULTS OF LAPAROSCOPIC PARTIAL NEPHRECTOMY FOR RENAL CELL CARCINOMA Criteria
Duration of procedure (minutes) Estimated blood loss (rnL) Complications Intraoperative Bleeding Postoperative Bleeding Urinorna Conversions Bleeding Technical problems Reintervention Percutaneous drainage Indwelling stent Open revision Nephrectomy Postoperative stay (days) Follow-up (months) Median observation time Regional relapse Distant metastases No evidence of disease'
190.9 range (90.0-320.0) 725 (range, 20-1500)
4 (8%) 1(2%) 5 (IOY") 4 (8%) 2 (4%) 2 (4%) 6 (12%) 2 (4%) 1 (2%) 2 (4%) 1 (2%)
5.4 (range, 3--28) 24 (range, 6 3 6 ) None None 37
HISTOLOGY
Histology showed 37 (69%) renal cell carcinomas (14 grade 1, 22 grade 2, 1 grade 3), 15 (28%) benign tumors (2 angiomyolipomas, 3 oncocytomas, 7 multilocular cysts, 3 adenomas), and 1 malignant lymphoma (Table 3). The latter patient was treated by subsequent polychemotherapy. FOLLOW-UP DATA
The cumulative overall disease-free survival rate after 3 years is 100% for the 37 pT1 Table 3. LAPAROSCOPIC PARTIAL NEPHRECTOMY FOR RENAL CELL CARCINOMA-FINAL HISTOLOGY
Renal cell carcinoma (pT1) Grade 1 Grade 2 Grade 3 Benign renal tumors Angiomyoliporna Oncocytorna Multilocular cyst Aden om a Other tumors Malignant lymphoma
renal cell tumors (see Table 2). Longer followup is necessary.
Number
'Only for the 37 renal cell carcinomas, stage T1.
Criteria
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Number 14 22 1 2 3 7 3
1
DISCUSSION Therapeutic Concepts in the Management of Small Renal Cell Carcinoma For most urologists, radical nephrectomy represents the treatment of choice for localized renal cell carcinoma regardless of the size, stage, and localization of the tumor; however, some centers have demonstrated the long-term efficacy of nephron-sparing surgery for small renal cell cancers with similar survival and low local recurrence rates.20, 26, 34, 39, 40, 55 These good results of tumor excision have occurred in cases of solitary kidneys or bilateral tumors, an imperative indication for nephron-sparing surgery.28The upper limit for wedge resection of a small renal cell carcinoma in a patient with a normal contralateral kidney, a selective indication was initially determined to be a tumor 2.5 cm in longitudinal diameterz6; however, other clinicians focus on the existence of multifocal tumors with an incidence of 4.8% 31, 32, 33 According to the indication to 19.7%.25, (selective versus imperative), tumor size, and pathologic stage, local recurrence rates ranging from 0.7% to 25% have been reported.20, 34, 39, 40, 55 Nevertheless, because of the increasing incidental detection of small peripheral renal cell tumors by diagnostic ultrasound, nephron-sparing surgery has become popular among urologists. Recently, the 4cm cut-off size of the lesion as an important selection criterion for substratification for nephron-sparing surgery has been shown in a series of 485 patientsz0 ~~l~of L~~~~~~~~~~in the Management of Renal Cell Carcinoma Laparoscopic radical nephrectomy in more than 500 cases has resulted in comparable long-term survival in early series in major centers worldwide for renal tumors up to a size of 5 cm (Table 4). The procedure is increasingly accepted as a minimally invasive option in the management of T1 tumors, even by experienced uro-oncologic surgeons who do not perform laparoscopy (A. Novick, per-
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Table 4. LAPAROSCOPIC RADICAL NEPHRECTOMY-WORLDWIDE
EXPERIENCE
~~
Study
Number
Stage
McDougall et al, 199629 Cicco et al, 199812 Gill et al, 1998IR Ono et al, 199842
17 21 42 60
pTl-pT3 pTl-pT2 pTl-pT2 pTl-pT2
Cadeddu et al, 19985
157
Rassweiler et al, 1999?* NA
=
26
Access
Transperitoneal Retroperitoneal Retroperitoneal Transperitoneal Retroperitoneal pTl-pT3 Transperitoneal Retroperitoneal pTl-pT3 Transperitoneal Retroperitoneal
Operating Room Hospital 5-Year Time Stay (mlnutes) (days) Complications Survival 400 131 199 330
4.5 4.6 2.1 5.2
18% NA 10Y" NA
NA NA NA 96%
NA
NA
6%
89%
235
7.4
13%
91%
not available.
sonal comm~nication).~ Many centers performing laparoscopy are trying to extend the indications for this technique in the management of localized renal cell carcinoma. Although some groups have treated larger tumors by laparoscopy,'8, 42 the authors use laparoscopy and retroperitoneoscopy for nephron-sparing surgery.
There are two main problems of laparoscopic wedge resection for small renal cell carcinoma-hemostasis and the risk of tumor cell spillage.
tion has proved more useful than other technologies, such as the argon beam coagulator or harmonic scalpel. In contrast to laparoscopic radical nephrectomy, currently there is no standard technique for laparoscopic partial nephrectomy. The only reason for immediate conversion to open surgery has been uncontrollable bleeding from the resection site (4%). New techniques for bloodless transurethral resection (i.e., CoCut; Rotoresect Holmium laser) may improve this critical part of the operation. Some surgeons perform a hand-assisted laparoscopic approach for partial nephrectomy using a pneumosleeve for introduction of the surgeon's hand without loss of the pneumop e r i t ~ n e u m They . ~ ~ report that the main advantage of this technique is the possibility of manual compression of the kidney to control bleeding after excision of the tumor. The authors have used the hand-assisted approach for radical n e p h r e ~ t o m yand ~ ~ for removal of the intact specimen after living-donor nephrectomy. Manual assistance was problematic for various reasons. The technique of dissection was difficult to standardize and differed from the precise dissection technique of laparoscopy and retroperitoneoscopy. Because of the side difference, the surgeon cannot always introduce his or her nondominant hand, which may increase the technical difficulty of dissection rather than improving it. Other than in the case of living-donor nephrectomy, the removed specimen is small, discouraging a large (8-10 cm) additional, albeit, muscle-splitting incision.
Adequate Hernostasis
Tumor Cell Spillage
Hemostasis must be adequate during excision of the tumor. The use of bipolar coagula-
The second problem concerns seeding of tumor cells. Tumor seeding most frequently
Advantages of Laparoscopic Partial Nephrectomy If proved to be technically safe and to have identical oncologic impact, laparoscopic or retroperitoneoscopic tumor excision will provide significant advantages over the open surgical approach. As is true adrenalectomy in open surgery a small lesion is removed via a relatively large incision. Laparoscopy or retroperitoneoscopy could significantly reduce postoperative morbidity.50 A malignant tumor could be detected microscopically in 72% of the authors' cases only (see Table 3). If open radical nephrectomy were performed, the remaining 15 patients would have either lost a kidney or sustained the trauma of a supracostal incision. Technical Problems of Laparoscopic Partial Nephrectomy
LAPAROSCOPIC PARTIAL NEPHRECTOMY
occurs at the port site where the specimen has been retrieved. Only a single case of port metastasis has been reported after laparoscopic radical n e p h r e ~ t o m y ,whereas ~ four cases of tumor seeding can be found in the literature after laparoscopic nephroureterectomy for upper tract transitional cell carcinoma.', 4, 52, 41 Cases of tumor seeding after laparoscopic cholecystectomy or ovarian cyst resection should not be considered because the gall bladder or ovarian carcinoma was found incidentally in these cases, and specimens were removed without the use of an organ sack. The authors have studied a variety of organ entrapment bags.48Only a few fulfill criteria for safe removal of malignant tissue, such as the LapSac (Cook, Spencer, IN) or Extraction bag (Karl Storz, Tuttlingen, Germany). To date, the authors have not seen any cases of tumor seeding after laparoscopic radical nephrectomy or laparoscopic partial nephre~tomy.~, In contrast to laparoscopic radical nephrectomy, in which the tumor is totally covered by the perirenal fat and usually remains untouched during dissection, the nephron-sparing approach theoretically has a higher risk of tumor cell spillage. Tumor seeding occurs almost exclusively as a result of tumor perforation and spillage of tumor cells by contaminated instruments. Aerolization by the CO, pressure is an unlikely cause. Systemic dissemination of tumor cells via the blood stream during laparoscopy could not be demonstrated. The effect of local factors, such as mechanical protection by the mesothelial cells and chemical protection by substances such as hyaluronic acid and heparinlike substances, is decreased with peritoneal injury, which may promote the ingrowth of spilled tumor cells.24This observation explains why recurrences are most commonly seen at laparotomy incisions, anastomoses, peritoneal lesions, and port 30
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When laparoscopic and open tumor excision are performed under excellent vision in a careful manner using safety margins, tumor seeding can be avoided, as proved by the results of open wedge resection. If seeding occurs, it may be clinically irrelevant owing to the low grade of the excised tumors. Based on an optimal technique of hemostasis, laparoscopic partial resection can be considered safe for the removal of small renal cell carcinoma. Postoperative Complications
The most frequent complication is postoperative urinary leakage (lo%), which may occur after any type of partial nephrectomy owing to late necrosis of the coagulated or sutured cut surface. Campbell and co-workers6 observed urinary fistula in 45 patients (17%) in a series of 259 open partial nephrectomies despite adequate reconstruction of the collecting system. The use of fibrin gluecoated (resorcinol formaldehyde glued cellulose) may reduce the rate of urinary leakage.20, 24, 51 The laparoscopic technique is not associated with a higher rate of postoperative complications and reinterventions. Most urinomas can be drained percutaneously and managed by placement of an indwelling ureteral stent.
Alternative Techniques
A variety of alternative minimally invasive techniques have been developed and studied in experimental and preliminary clinical trials (Table 5). Beside laparoscopic radical nephrectomy, no technique has a significant level of evidence to support it,16 and even laparoscopic radical nephrectomy has not been studied in a phase I11 trial. Laparoscopic, percuta-
Table 5. MINIMALLY INVASIVE MANAGEMENT OF SMALL RENAL CELL CARCINOMA-ALTERNATIVES Clinical Studies' Technique
Animal Studies
Experimental
Phase I
Phase Ila
Phase Ilb
Laparoscopic radical nephrectomy Laparoscopic partial nephrectomy Laparoscopic cryosurgery Focal ultrasound Interstitial laser Interstitial radiofrequency therapy Interstitial photon radiotherapy
Yes Yes Yes Yes Yes Yes Yes
Yes Yes Yes Yes Yes Yes No
Yes Yes Yes No No No No
Yes Yes Yes No No No No
Yes No No No No No No
'No phase I11 studies performed.
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neous, and noninvasive extracorporeal approaches can be distinguished. Although the early results of laparoscopic cryotherapy are promising,37taking the studies on prostate cancer into account, long-term results are needed for final assessment of this technique.” The main problem is the degree of complete tissue necrosis in the area of the ice ball.’O. ll. 37, 43, 5h Other alternatives include the percutaneous interstitial laser, thermorods, and radiofrequency or photon radiation therapy.7,22, Some of these techniques have been used for the treatment of benign prostatic hyperplasia or prostate cancer. Except for anecdotal palliative applications, substantial clinical experience does not exist. The ideal method to treat small renal tumors would be totally noninvasive, such as the use extracorporeal high-intensity focal ultrasound (HIFU). Early clinical series of HIFU for the management of localized prostatic carcinoma are promising9,58; however, they also show the limitations of this technology.8 Recently, a different energy source and an applicator of focused ultrasound has been developed.35,36 This device enables focusing of renal tumors, and early clinical studies are underway. The main problem when using all of these techniques is determining exactly when during the treatment the entire carcinoma has been destroyed. No imaging technique can provide this information. Moreover, despite the fascinating concept of noninvasive detection and almost simultaneous destruction of neoplasms, one must take into consideration the fact that open nephron-sparing surgery for renal cell cancer has reached a high standard against which all of the novel minimally invasive techniques including laparoscopic partial resection must be compared. Careful selection of the best treatment is crucial because renal cell cancer represents an aggressive type of tumor. Perspectives
Despite the authors’ preliminary success, the techniques described herein are still in a developmental phase and should only be performed in centers providing advanced laparoscopic expertise. It is hoped that the techniques will be shown to be safe and reproducible. Access can be achieved through either the transperitoneal or retroperitoneal approach; however, the final technique of wedge
resection has not yet been determined. Bipolar coagulation can be advantageous but will not prevent intraoperative bleeding during excision of the tumor. SUMMARY
Laparoscopic partial nephrectomy is technically difficult but oncologically effective. The operation should be performed in centers with expertise. Hemostasis can be achieved using bipolar coagulation and fibrin gluecoated cellulose. Further studies will determine whether less invasive alternatives (focused ultrasound, cryotherapy) will meet the high standard of open (or laparoscopic) nephron-sparing surgery for small renal cell carcinoma. References 1. Andersen JR, Steven K: Implantation metastasis after laparoscopic biopsy of bladder cancer. J Urol 153: 1047, 1995 2. Aso Y, Homma Y: A survey on incidental renal cell carcinoma in Japan. J Urol 147 340, 1992 3. Bangma CH, Kirkels WJ, Chada S, et al: Cutaneous metastasis following laparoscopic lymphadenectomy for prostatic carcinoma. J Urol 153: 1635, 1995 4. Barrett PH, Fentie DD, Taranger L: Laparoscopic radical nephrectomy with morcellation [abstract]. J Endourol 11(S128), P6, 1997 5. Cadeddu JA, On0 Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety. A multi-center experience. Urology 52773, 1998 6. Campbell SC, Novick AC, Streem SB, et al: Complications of nephron sparing surgery for renal tumors. J Urol 151: 1177, 1994 7. Chan D, Koniaris L, Magee C, et al: Feasibility of ablating normal renal parenchyma by intracavitary photon radiation energy in a canine model [abstract]. J Endourol 13:A13, 1999 8. Chan D, Pant B, Pacheco R, et al: Power requirements for renal ablation using high intensity focused ultrasound (HIFU) in a rabbit model [abstract]. J Endourol 13:A13, 1999 9. Chaussy C, Thuroff S: Localized prostate cancer treated by transrectal high intensive ultrasound (HIFU): Outcome of 170 patients after 3 years [abstract]. J Endourol 13: A96, 1999 10. Chen RN, Bishoff J, Jackman SV, et al: Doppler ultrasound and CT evaluation of the kidney following cryosurgical ablation in a porcine model [abstract].J Endourol 13: A13, 1999 11. Chin JL, Pautler S, Freeman C, et al: Critical appraisal of results from salvage cryoablation for prostate cancer in 90 radiation failures [abstract]. J Endourol 13: A97, 1999 12. Cicco A, Joual A, Hoznek A, et al: Radical nephrectomy by retroperitoneal laparoscopic approach versus open surgery [abstract]. J Urol 159: 154 A, 1998
LAPAROSCOPIC PARTIAL NEPHRECTOMY 13. Clayman RV, Kavoussi LR, Soper NJ, et al: Laparoscopic nephrectomy: Initial case report. J Urol 146: 278, 1991 14. Coptcoat MJ, Rassweiler J, Wickham JEA, et al: Laparoscopic nephrectomy for renal cell carcinoma [abstract no. D-66). I n Proceedings of the Third International Congress for Minimal Invasive Therapy, Boston, November 10-12, 1991 15. Coptcoat MJ, Joyce A, Rassweiler J, et al: Laparoscopic nephrectomy: The Kings and Mannheim clinical experience [abstract]. J Urol 147 433 A, 1992 16. Coptcoat MJ, Joyce A, Rassweiler J, et al: EAU-guidelines of laparoscopy in urology. (in press) 17. de Kernion J: Laparoscopic radical nephrectomycontra. Presented at the Annual Conference of the American Urological Association, Dallas, May 1999 18. Gill IS, Soble J, Gyung TS, et al: Retroperitoneoscopic radical nephrectomy i n 41 patients: Expanding indications and impact of specimen size [abstract]. J Endourol 12: S103, 1998 19. Coldstein AE, Abeshouse BS: Partial resections of the kidney: A report of 6 cases and a review of the literature. J Urol 38: 15, 1937 20. Hafez KS, Fergany AF, Novick AC: Nephron sparing surgery for localized renal cell carcinoma: Impact of tumor size on patient survival, tumor recurrence and TNM staging. J Urol 162: 1930, 1999 21. Hoznek A, Salomon L, Antipon P, et al: Partial nephrectomy with retroperitoneal laparoscopy. J Urol 162: 1922, 1999 22. Huidobero C, Larson T, Platz C, et al: Ablation of the prostate using thermal rods [abstract]. J Endourol 13: A97, 1999 23. Janetschek G, Seibold J, Radmayr C, et al: Laparoscopic heminephrectoureterctomy in pediatric patients. J Urol 158: 1928, 1997 24. Janetschek G, Daffner P, Peschel R, et al: Laparoscopic nephron sparing surgery for small renal cell carcinoma. J Urol 159: 1152, 1998 25. Johnsen JA, Hellsten S: Lymphatogenous spread of renal cell carcinoma: An autopsy study. J Urol 157 450, 1997 26. Levy DA, Slaton JW Swanson DA, et al: Stage specific guidelines for survival after radical nephrectomy for local renal cell carcinoma. J Urol 159: 1163, 1998 27. Licht MR, Novick AC: Nephron sparing surgery for renal cell carcinoma. J Urol 149: 1, 1993 28. Marberger M, Pugh RC, Auvert J, et al: Conservative surgery of the renal carcinoma: The EIRSS experience. Br J Urol 53: 528, 1981 29. McDougall EM, Clayman RV, Elashry OM: Laparoscopic radical nephrectomy for renal tumor: The Washington University experience. J Urol 155: 1180, 1996 30. Mickisch G, Tschada R, Rassweiler J, et al: Das lokale Rezidiv nach Nierentumoroperation. Akterelle Urologie 21: 77, 1990 31. Moch H. Gasser TC. Urreiola C. et al: Metastastic behaviour of renal cell c a k e r : An analysis of 871 autopsies [abstract]. J Urol 1 5 7 66A, 1997 32. Mukamel E, Konichezky M, Engelstein D, et al: Incidental small renal tumors accompanying clinical overt renal cell carcinoma. J Urol 140: 22, 1988 33. Nissenkorn I, Bemheim J: Multicentricity in renal cell carcinoma. J Urol 153: 620, 1995 34. Kletscher BA, Quian J, Bostwick DG, et al: Prospective analysis of multifocality in renal cell carcinoma: Influence of histological pattern, grade, number, size, volume and deoxyribonucleic ploidy. J Urol 153: 904, 1995
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35. Kohrmann KU, Michel MS, Rassweiler JJ, et al: Shock waves-focused ultrasound. In Smith A, Badlani G, Bagley D, et al (eds): Smiths Textbook of Endourology. St. Louis, Quality Medical, 1996, pp 661-679 36. Kohrmann KU, Michel MS, Alken P: New possibilities for therapeutic applications of extracorporeal acoustic energy [abstract]. J Endourol 13: A14, 1999 37. Meraney AM, Gill IS, Sung GT, et al: Histology of renal tumors 3 4 months postcryoablation [abstract]. J Endourol 13: A14, 1999 38. Nakada SY, Jerde TJ, Lee FT, et al: Efficacy of cryotherapy and nephrectomy in treating implanted VX2 carcinoma in a rabbit kidney [abstract]. J Endourol 13: A14, 1999 39. Polascik TJ, Pound CR, Meng MV, et al: Partial nephrectomy: Technique, complications and pathological findings. J Urol 154: 1312, 1995 40. Provet T, Tessler A, Brown J, et al: Partial nephrectomy for renal cell carcinoma: Indications, results and implications. J Urol 145: 472, 1991 41. Ono Y, Sahashi M. Yamada S, et al: Laparoscopic nephrectomy without morcellation for renal cell carcinoma: Report of initial 2 cases. J Urol 150: 1222, 1993 42. On0 Y, Kinukawa T, Hattori R, et al: Long-term result of laparoscopic radical nephrectomy [abstract]. J Endourol 12: S103, 1998 43. Orihuela E, van Somenberg E, Motamedi M, et al: Effect of warm arterial bloode flow and multiple cryotherapy probes on cryotherapy of renal cell carcinoma [abstract]. J Endourol 13: A13, 1999 44. Pate1 VR, Leveillee RJ, Herron A, et al: "Wet" radiofrequency ablation of the rabbit kidney using the liquid electrode: Acute and chronic observations [abstract]. J Endourol 13: A14, 1999 45. Rassweiler JJ, Henkel TO, Potempa DM, et al: The technique of transperitoneal laparoscopic nephrectomy, adrenalectomy and nephroureterectomy. Eur Urol 22425, 1993 46. Rassweiler J, Coptcoat MJ: Laparoscopic surgery of the kidney and adrenal gland. 01Janetschek G, Rassweiler J, Griffith D (eds): Laparoscopic Surgery in Urology. New York, Thieme Stuttgart, 1996, p p 139155 47. Rassweiler J, Merkle W: Urologische Sonographie New York, Thieme Stuttgart, 1997 48. Rassweiler J, Stock C, Frede T, et al: Organ retrieval systems for endoscopic nephrectomy: A comparative study. J Endourol 12: 325, 1998 49. Rassweiler J, Fornara P, Weber M, et al: Laparoscopic nephrectomy: The experience of the laparoscopic working group of the German Urological Association. J Urol 1 6 0 18, 1998 50. Rassweiler J, Frede T, Henkel TO, et al: Nephrectomy: A comparative study between the transperitoneal and retroperitoneal laparoscopic versus the open approach. Eur Urol 13: 489, 1998 51. Rassweiler JJ, Seemann 0, Frede T, et al: Retroperitoneoscopy: Experience with 200 cases. J Urol 160: 1265, 1998 52. Rassweiler J, Coptcoat M, Frede T Laparoscopic radical nephrectomy and nephroureterectomy for treatment of renal cell and transitional cell carcinoma: Current status. Urol Integr Invest 4: 225, 1999 53. Ritchie AW, d e Kernion JB: Incidental renal neoplasms: Incidence in Los Angeles County, treatment and prognosis. Frog Clin Biol Res 269: 347, 1988 54. Shalhav AL, Leibovitch I, Lev R, et al: Is laparoscopic
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radical nephrectomy with specimen morcellation acceptable cancer surgery. J Endourol 12: 255, 1998 55. Steinbach F, Stockle M, Muller SC, et al: Conservative surgery of renal tumors in 140 patients: 21 years of experience. J Urol 148: 24, 1992 56. Sung GT, Gill IS, Hsu THS, et al: Effect of intentional cryoinjury to the renal collecting system [abstract]. J Endourol 13: A13, 1999 57. Tschada RK, Rassweiler JJ, Schmeller N, et al: Laparo-
scopic radical nephrectomy-the German experience [abstract]. J Urol 153: 479A, 1995 58. Vallancien G, Guillonneau B, Desgrandchamps F, et al: Local control of prostate cancer with HIFU Preliminary results of the European study [abstract]. J Endourol 13: A96, 1999 59. Wolf S, Moon TD, Madisom WI, et al: Hand-assisted laparoscopic nephrectomy: Comparison to standard laparoscopic nephrectomy. J Urol 160: 22, 1998
Address reprint requests to Jens Rassweiler, MD Urologische Klinik Am Gesundbrunnen 20 D-74074 Heilbronn Germany e-mail: [email protected]
0094-0143/00 $15.00
+
.OO
LAPAROSCOPIC PARTIAL NEPHRECTOMY The European Experience Jens J. Rassweiler, MD, Claude Abbou, MD, Gunter Janetschek, MD, and Klaus Jeschke, MD
Traditionally, partial nephrectomy for renal has not become a widespread procedure. Excell carcinoma was performed only for tu- pertise has concentrated in centers that are increasingly becoming active throughout the mors occurring in a solitary kidney or when 5, 15, 29, 41, 45, 46. 57 Nevertheless, even the patient presented with bilateral among laparoscopic surgeons, the indications disease.". 2x Because of the favorable results for radical nephrectomy are still under deobtained in terms of patient survival, tumor bate. Only 37 of 482 nephrectomies reported control, and complication rates, the indicain a recently published German multicenter tions for nephron-sparing surgery were exstudy were performed for renal m a l i g n a n ~ y . ~ ~ tended to include patients with small tumors During the last 3 years, there has been an 26, 27, 34, 39, and a normal contralateral kidney.20* increasing number of reports of laparoscopic 4n, iiSmall renal cell carcinomas are usually of radical nephrectomy using different technical lower stage and have a better prognosis. Owapproaches, such as transperitoneal lapaing to the widespread use of diagnostic ultras2 and r o s ~ o p y , 55 ~ ~retroperitoneoscopy,l2. , sound and CT, an increasing number of such hand-assisted and gasless laparo~copy.~' lesions are detected in~identally;~,53 and interBased on their favorable experience with est in nephron-sparing surgery and other orlaparoscopic radical nephrectomy and with gan-preserving approaches, such as cryotherpartial nephrectomy for benign renal disorapy3' or high-energy focused u l t r a ~ o u n d , ~ ~ ders,", 23, 24* 51 the authors now perform nephcan be expected to grow. ron-sparing surgery for small renal cell carciClayman and colleague^'^ pioneered laparnoma as an alternative to the open technique. oscopic nephrectomy when they removed a renal oncocytoma in 1990. Almost 1 year, later Coptcoat and c o - w o r k e r ~ 'used ~ the same OPERATIVE TECHNIQUE technique for radical extirpation of a T2 renal cell carcinoma. Despite the enthusiasm of The operative technique has been modified these pioneering surgeons, laparoscopic surwithin the last years. Two of the authors (GJ gery, especially laparoscopic nephrectomy,
From the Department of Urology, Klinikum Heilbronn, University of Heidelberg, Germany OR), the Department of Urology, HBpital Henri Mondor, Creteil, France (CA), the Department of Urology, University of Innsbruck, (GJ), and the Department of Urology, Landeskrankenhaus Klagenfurt (KJ), Austria.
UROLOGIC CLINICS OF NORTH AMERICA VOLUME 27 * NUMBER 4 * NOVEMBER 2000
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Table 1. LAPAROSCOPIC PARTIAL NEPHRECTOMY FOR RENAL CELL CARCINOMA-PATIENT DATA Criteria
Participating centers Creteil-Paris Innsbruck Heilbronn Klagenfurt Total number of patients Transperitoneal approach Retroperitoneal approach Patient characteristics Ratio male/female Mean age Ratio left/right kidney Localization of tumor Upper pole Middle Lower pole
Number
18 16 10 9 53 15 38 34/19 61.5 (range, 39-80) 28 / 25 15 24 24
and KJ) prefer the transperitoneal approach, and two (JR and CA) prefer the retroperitoneal approach (Table 1). The main operative steps are summarized in the following sections.
All patients undergo similar preoperative preparation as in open surgery, including a mild bowel cathartic. An indwelling bladder catheter is routinely placed. Under general anesthesia, a nasogastric tube is inserted. The patient is placed in a flank (retroperitoneoscopy) 45" lateral decubitus position on the relevant side (left or right renal tumor).
Transperitoneal Laparoscopic Approach Pneumoperitoneum is attained after insertion of a Veress needle placed lateral to the rectus abdominis muscle paraumbilically with the patient in the lateral decubitus position. Trocars are inserted through the anterior abdominal wall as depicted in Figure 1. The laparoscope is passed through port I and used to inspect the trocar insertions intra-abdominally for ports I1 and 111. After inspection of the intra-abdominal contents, either the as-
Figure 1. Transperitoneal laparoscopic partial nephrectorny. A, Positioning of the patient and site of trocars. illustration continued on opposite page
LAPAROSCOPIC PARTIAL NEPHRECTOMY
cending (right kidney) or descending (left kidney) colon is mobilized through a laterocolic incision of the peritoneum (along the white line of Toldt). Because the respective colon is free to fall off medially (Fig. lB), one or two additional ports (port IV, V) can be created through the newly exposed retroperitoneum. Tumors on the ventral surface of the right kidney are most readily accessible after exclusive incision of the peritoneum (Fig. 1C). Next, Gerota's fascia is dissected off the renal surface in the region where the tumor is located. When the tumor is located on the dorsal aspect of the kidney, the layer between
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Gerota's fascia and the lumbar aponeurosis is dissected. Subsequently, the kidney can be rotated medially nearly 180". After this maneuver, the tumor is directly accessible. Identification of the lumbar ureter is essential to avoid injury.
RetroperitoneoscopicApproach A 15- to 18-mm incision is made in the lumbar (Petit's) triangle (trigonum lumbale) between the 12th rib and the iliac crest, bounded by the lateral edges of the latissimus dorsi and external oblique muscles. A tunnel
Figure 1 (Continued). 8, Laterocolic incision along the white line of Toldt. C, Exposure of the retroperitoneum, ideal for ventrally located tumors.
LAPAROSCOPIC PARTIAL NEPHRECTOMY
725
B
\
Psoas muscle
Retrorenal fascia (Gerota)
M. obliquus externus
/
Petit triangle
I
M. latissimus dorsi
Figure 2 (Continued). B, Finger dissection of the retroperitoneal space. C, Site of trocars.
Wedge Resection (Partial Nephrectomy)
The principles of wedge resection are identical in both approaches and are similar in the open technique. A 5-mm margin of healthy parenchyma around the tumor is the mini-
mum required for a safe resection. For oncologic and technical reasons, in all centers, laparoscopic wedge resection is restricted to tumors no larger than 5 cm in diameter and to tumors protruding from the renal surface (Fig. 3 ) with an average size of 2.4 cm (range, 1.0-5).
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Figure 3. Retroperitoneoscopic wedge resection. A, Computer tomography of a 3.5 cm lesion at the lower pole of a lefl solitary kidney. B, Nuclear magnetic imaging of the renal tumor. C, Endoscopic view with the tumor still surrounded by perirenal fat. Illustration continued on opposite page
LAPAROSCOPIC PARTIAL NEPHRECTOMY
Figure 3 (Continued). D, Removal of the perirenal fat at the base of the tumor. f, Step-by-step excision of the tumor with bipolar coagulation. F; Careful blunt dissection of the tumor along the renal pyramids to the medulla. Illustration continued on following page
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Figure 3 (Continued). G, Entrapment of the specimen in the organ bag (Extraction Bag, Karl Stow, Kuttlingen. Germany). H, Introduction of the fibrin glue coated cellulose (Tachocomb, Nycomed, Munich, Germany). I, Sealing of the cut surface with the fixed cellulose.
LAPAROSCOPIC PARTIAL NEPHRECTOMY
During wedge resection of the kidney, major hemorrhage may occur at any time; therefore, adequate hemostasis is of crucial importance. In open surgery, cold ischemia is used. Hypothermia is achieved by external cooling with ice in combination with temporary clamping of the pedicle. For technical reasons, this method cannot be applied in laparoscopy. Only warm ischemia is possible, restricting considerably the time of occlusion of the renal artery. Meticulous step-by-step dissection and hemostasis make laparoscopic wedge resection a time-consuming procedure, and prolonged warm ischemia time carries the risk of irreversible damage to the renal parenchyma. Different techniques of hemostasis have been applied. Temporary Ischemia With a Tourniquet Around the Renal Artery This technique requires an optimal visual field to the tumor because the wedge resection must be carried out in a reasonable time (15-20 minutes). The resection plane is mainly controlled by fibrin glue, a hemostatic gauze covered with fibrin (i.e., Tachocomb, Nycorned, Munich, Germany), or a heat-activated tissue adhesive (gelatin resorcinol formaldehyde glue). Wedge Resection Without Ischemia For this technique a bipolar coagulation forceps is used almost exclusively for simultaneous dissection and hemostasis (Fig. 3). Occasionally, the authors have used monopolar electrocautery, the blade of the harmonic scalpel, and a neodymium: YAG laser. In the authors' hands (all four centers), bipolar coagulation forceps have proved to be most efficient for surgery on the renal parenchyma. The scissors of the harmonic scalpel (Ultracision, Ethicon, Hamburg, Germany) and the Rotoresect (Karl Storz, Tuttlingen, Germany) for vaporization and dissection have proved to be promising in anecdotal clinical cases (Fig. 4). Sealing the Cut Surface Additional application of oxidized regenerated cellulose under pressure, fibrin-coated hemostyptic gauze (Tachcomb, Munich, Germany), has been effective for control of major bleeding. Occasionally, cauterization of the cut surface with an argon beam coagulator
729
has been effective. One of the authors (CA) prefers to cover the cut surface with a cellulose mesh impregnated with gelatin resorcinol formaldehyde glue. Intraoperative biopsy specimens of the base of resection are assessed by frozen section. Cautious retrieval of the resected renal tumor is facilitated by use of a small-sized organ bag (i.e., LapSac, Cook Urological, Spencer, IN; Extraction bag, Karl Storz, Tuttlingen, Germany) to preclude tumor seeding (see Fig. 3).", The operative field is drained for 2 days.
PATIENTS AND TUMORS
Since June 1994, a total of 53 patients (34 males and 19 females) have been treated by laparoscopic partial nephrectomy at four European centers (Table 1).Fifteen tumors were located at the upper pole, 24 at the mid part, and 24 at the lower pole of the kidney. The average tumor size was 2.3 cm in diameter (range, 1.1-5).
OPERATIVE DATA AND COMPLICATIONS
According to the preference of the surgeons, a transperitoneal approach was used in 15 cases and a retroperitoneal approach in 38 (Table 1).The operating time averaged 191 minutes (range, 90-320). The mean estimated blood loss was 725 mL (range, 20-1500). Pneumothorax developed in one patient after extensive use of the argon beam coagulator with rising retroperitoneal pressure. There were four conversions to open surgery (8%). In two cases, conversion occurred because of significant intraoperative bleeding. In two other patients, the tumor could not be exposed adequately owing to its location at the ventral surface of the upper pole. At one center (JR), intraoperative laparoscopic ultrasound is not available. Two other cases of massive bleeding were stopped conservatively by compression and fibrin glue. A total of six patients (12%) required reintervention owing to bleeding ( n = 1)and urinoma ( n = 5). In two cases, nephrectomy was performed for treatment of bleeding and persistant urinoma. The other cases of urinoma were managed by percutaneous drainage or an indwelling stent. The mean postoperative hospital stay was 5.4 days (Table 2).
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Figure 4. Techniques of laparoscopic wedge resection. A, Bipolar coagulation (Karl Storz, Tuttlingen, Germany). B,Harmonic blade (Ultracision, Ethicon, Hamburg). C,Blunt dissection with suction device along the renal pyramids (Karl Storz, Tuttlingen, Germany).
LAPAROSCOPIC PARTIAL NEPHRECTOMY Table 2. RESULTS OF LAPAROSCOPIC PARTIAL NEPHRECTOMY FOR RENAL CELL CARCINOMA Criteria
Duration of procedure (minutes) Estimated blood loss (rnL) Complications Intraoperative Bleeding Postoperative Bleeding Urinorna Conversions Bleeding Technical problems Reintervention Percutaneous drainage Indwelling stent Open revision Nephrectomy Postoperative stay (days) Follow-up (months) Median observation time Regional relapse Distant metastases No evidence of disease'
190.9 range (90.0-320.0) 725 (range, 20-1500)
4 (8%) 1(2%) 5 (IOY") 4 (8%) 2 (4%) 2 (4%) 6 (12%) 2 (4%) 1 (2%) 2 (4%) 1 (2%)
5.4 (range, 3--28) 24 (range, 6 3 6 ) None None 37
HISTOLOGY
Histology showed 37 (69%) renal cell carcinomas (14 grade 1, 22 grade 2, 1 grade 3), 15 (28%) benign tumors (2 angiomyolipomas, 3 oncocytomas, 7 multilocular cysts, 3 adenomas), and 1 malignant lymphoma (Table 3). The latter patient was treated by subsequent polychemotherapy. FOLLOW-UP DATA
The cumulative overall disease-free survival rate after 3 years is 100% for the 37 pT1 Table 3. LAPAROSCOPIC PARTIAL NEPHRECTOMY FOR RENAL CELL CARCINOMA-FINAL HISTOLOGY
Renal cell carcinoma (pT1) Grade 1 Grade 2 Grade 3 Benign renal tumors Angiomyoliporna Oncocytorna Multilocular cyst Aden om a Other tumors Malignant lymphoma
renal cell tumors (see Table 2). Longer followup is necessary.
Number
'Only for the 37 renal cell carcinomas, stage T1.
Criteria
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Number 14 22 1 2 3 7 3
1
DISCUSSION Therapeutic Concepts in the Management of Small Renal Cell Carcinoma For most urologists, radical nephrectomy represents the treatment of choice for localized renal cell carcinoma regardless of the size, stage, and localization of the tumor; however, some centers have demonstrated the long-term efficacy of nephron-sparing surgery for small renal cell cancers with similar survival and low local recurrence rates.20, 26, 34, 39, 40, 55 These good results of tumor excision have occurred in cases of solitary kidneys or bilateral tumors, an imperative indication for nephron-sparing surgery.28The upper limit for wedge resection of a small renal cell carcinoma in a patient with a normal contralateral kidney, a selective indication was initially determined to be a tumor 2.5 cm in longitudinal diameterz6; however, other clinicians focus on the existence of multifocal tumors with an incidence of 4.8% 31, 32, 33 According to the indication to 19.7%.25, (selective versus imperative), tumor size, and pathologic stage, local recurrence rates ranging from 0.7% to 25% have been reported.20, 34, 39, 40, 55 Nevertheless, because of the increasing incidental detection of small peripheral renal cell tumors by diagnostic ultrasound, nephron-sparing surgery has become popular among urologists. Recently, the 4cm cut-off size of the lesion as an important selection criterion for substratification for nephron-sparing surgery has been shown in a series of 485 patientsz0 ~~l~of L~~~~~~~~~~in the Management of Renal Cell Carcinoma Laparoscopic radical nephrectomy in more than 500 cases has resulted in comparable long-term survival in early series in major centers worldwide for renal tumors up to a size of 5 cm (Table 4). The procedure is increasingly accepted as a minimally invasive option in the management of T1 tumors, even by experienced uro-oncologic surgeons who do not perform laparoscopy (A. Novick, per-
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RASSWEILER et al
Table 4. LAPAROSCOPIC RADICAL NEPHRECTOMY-WORLDWIDE
EXPERIENCE
~~
Study
Number
Stage
McDougall et al, 199629 Cicco et al, 199812 Gill et al, 1998IR Ono et al, 199842
17 21 42 60
pTl-pT3 pTl-pT2 pTl-pT2 pTl-pT2
Cadeddu et al, 19985
157
Rassweiler et al, 1999?* NA
=
26
Access
Transperitoneal Retroperitoneal Retroperitoneal Transperitoneal Retroperitoneal pTl-pT3 Transperitoneal Retroperitoneal pTl-pT3 Transperitoneal Retroperitoneal
Operating Room Hospital 5-Year Time Stay (mlnutes) (days) Complications Survival 400 131 199 330
4.5 4.6 2.1 5.2
18% NA 10Y" NA
NA NA NA 96%
NA
NA
6%
89%
235
7.4
13%
91%
not available.
sonal comm~nication).~ Many centers performing laparoscopy are trying to extend the indications for this technique in the management of localized renal cell carcinoma. Although some groups have treated larger tumors by laparoscopy,'8, 42 the authors use laparoscopy and retroperitoneoscopy for nephron-sparing surgery.
There are two main problems of laparoscopic wedge resection for small renal cell carcinoma-hemostasis and the risk of tumor cell spillage.
tion has proved more useful than other technologies, such as the argon beam coagulator or harmonic scalpel. In contrast to laparoscopic radical nephrectomy, currently there is no standard technique for laparoscopic partial nephrectomy. The only reason for immediate conversion to open surgery has been uncontrollable bleeding from the resection site (4%). New techniques for bloodless transurethral resection (i.e., CoCut; Rotoresect Holmium laser) may improve this critical part of the operation. Some surgeons perform a hand-assisted laparoscopic approach for partial nephrectomy using a pneumosleeve for introduction of the surgeon's hand without loss of the pneumop e r i t ~ n e u m They . ~ ~ report that the main advantage of this technique is the possibility of manual compression of the kidney to control bleeding after excision of the tumor. The authors have used the hand-assisted approach for radical n e p h r e ~ t o m yand ~ ~ for removal of the intact specimen after living-donor nephrectomy. Manual assistance was problematic for various reasons. The technique of dissection was difficult to standardize and differed from the precise dissection technique of laparoscopy and retroperitoneoscopy. Because of the side difference, the surgeon cannot always introduce his or her nondominant hand, which may increase the technical difficulty of dissection rather than improving it. Other than in the case of living-donor nephrectomy, the removed specimen is small, discouraging a large (8-10 cm) additional, albeit, muscle-splitting incision.
Adequate Hernostasis
Tumor Cell Spillage
Hemostasis must be adequate during excision of the tumor. The use of bipolar coagula-
The second problem concerns seeding of tumor cells. Tumor seeding most frequently
Advantages of Laparoscopic Partial Nephrectomy If proved to be technically safe and to have identical oncologic impact, laparoscopic or retroperitoneoscopic tumor excision will provide significant advantages over the open surgical approach. As is true adrenalectomy in open surgery a small lesion is removed via a relatively large incision. Laparoscopy or retroperitoneoscopy could significantly reduce postoperative morbidity.50 A malignant tumor could be detected microscopically in 72% of the authors' cases only (see Table 3). If open radical nephrectomy were performed, the remaining 15 patients would have either lost a kidney or sustained the trauma of a supracostal incision. Technical Problems of Laparoscopic Partial Nephrectomy
LAPAROSCOPIC PARTIAL NEPHRECTOMY
occurs at the port site where the specimen has been retrieved. Only a single case of port metastasis has been reported after laparoscopic radical n e p h r e ~ t o m y ,whereas ~ four cases of tumor seeding can be found in the literature after laparoscopic nephroureterectomy for upper tract transitional cell carcinoma.', 4, 52, 41 Cases of tumor seeding after laparoscopic cholecystectomy or ovarian cyst resection should not be considered because the gall bladder or ovarian carcinoma was found incidentally in these cases, and specimens were removed without the use of an organ sack. The authors have studied a variety of organ entrapment bags.48Only a few fulfill criteria for safe removal of malignant tissue, such as the LapSac (Cook, Spencer, IN) or Extraction bag (Karl Storz, Tuttlingen, Germany). To date, the authors have not seen any cases of tumor seeding after laparoscopic radical nephrectomy or laparoscopic partial nephre~tomy.~, In contrast to laparoscopic radical nephrectomy, in which the tumor is totally covered by the perirenal fat and usually remains untouched during dissection, the nephron-sparing approach theoretically has a higher risk of tumor cell spillage. Tumor seeding occurs almost exclusively as a result of tumor perforation and spillage of tumor cells by contaminated instruments. Aerolization by the CO, pressure is an unlikely cause. Systemic dissemination of tumor cells via the blood stream during laparoscopy could not be demonstrated. The effect of local factors, such as mechanical protection by the mesothelial cells and chemical protection by substances such as hyaluronic acid and heparinlike substances, is decreased with peritoneal injury, which may promote the ingrowth of spilled tumor cells.24This observation explains why recurrences are most commonly seen at laparotomy incisions, anastomoses, peritoneal lesions, and port 30
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When laparoscopic and open tumor excision are performed under excellent vision in a careful manner using safety margins, tumor seeding can be avoided, as proved by the results of open wedge resection. If seeding occurs, it may be clinically irrelevant owing to the low grade of the excised tumors. Based on an optimal technique of hemostasis, laparoscopic partial resection can be considered safe for the removal of small renal cell carcinoma. Postoperative Complications
The most frequent complication is postoperative urinary leakage (lo%), which may occur after any type of partial nephrectomy owing to late necrosis of the coagulated or sutured cut surface. Campbell and co-workers6 observed urinary fistula in 45 patients (17%) in a series of 259 open partial nephrectomies despite adequate reconstruction of the collecting system. The use of fibrin gluecoated (resorcinol formaldehyde glued cellulose) may reduce the rate of urinary leakage.20, 24, 51 The laparoscopic technique is not associated with a higher rate of postoperative complications and reinterventions. Most urinomas can be drained percutaneously and managed by placement of an indwelling ureteral stent.
Alternative Techniques
A variety of alternative minimally invasive techniques have been developed and studied in experimental and preliminary clinical trials (Table 5). Beside laparoscopic radical nephrectomy, no technique has a significant level of evidence to support it,16 and even laparoscopic radical nephrectomy has not been studied in a phase I11 trial. Laparoscopic, percuta-
Table 5. MINIMALLY INVASIVE MANAGEMENT OF SMALL RENAL CELL CARCINOMA-ALTERNATIVES Clinical Studies' Technique
Animal Studies
Experimental
Phase I
Phase Ila
Phase Ilb
Laparoscopic radical nephrectomy Laparoscopic partial nephrectomy Laparoscopic cryosurgery Focal ultrasound Interstitial laser Interstitial radiofrequency therapy Interstitial photon radiotherapy
Yes Yes Yes Yes Yes Yes Yes
Yes Yes Yes Yes Yes Yes No
Yes Yes Yes No No No No
Yes Yes Yes No No No No
Yes No No No No No No
'No phase I11 studies performed.
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neous, and noninvasive extracorporeal approaches can be distinguished. Although the early results of laparoscopic cryotherapy are promising,37taking the studies on prostate cancer into account, long-term results are needed for final assessment of this technique.” The main problem is the degree of complete tissue necrosis in the area of the ice ball.’O. ll. 37, 43, 5h Other alternatives include the percutaneous interstitial laser, thermorods, and radiofrequency or photon radiation therapy.7,22, Some of these techniques have been used for the treatment of benign prostatic hyperplasia or prostate cancer. Except for anecdotal palliative applications, substantial clinical experience does not exist. The ideal method to treat small renal tumors would be totally noninvasive, such as the use extracorporeal high-intensity focal ultrasound (HIFU). Early clinical series of HIFU for the management of localized prostatic carcinoma are promising9,58; however, they also show the limitations of this technology.8 Recently, a different energy source and an applicator of focused ultrasound has been developed.35,36 This device enables focusing of renal tumors, and early clinical studies are underway. The main problem when using all of these techniques is determining exactly when during the treatment the entire carcinoma has been destroyed. No imaging technique can provide this information. Moreover, despite the fascinating concept of noninvasive detection and almost simultaneous destruction of neoplasms, one must take into consideration the fact that open nephron-sparing surgery for renal cell cancer has reached a high standard against which all of the novel minimally invasive techniques including laparoscopic partial resection must be compared. Careful selection of the best treatment is crucial because renal cell cancer represents an aggressive type of tumor. Perspectives
Despite the authors’ preliminary success, the techniques described herein are still in a developmental phase and should only be performed in centers providing advanced laparoscopic expertise. It is hoped that the techniques will be shown to be safe and reproducible. Access can be achieved through either the transperitoneal or retroperitoneal approach; however, the final technique of wedge
resection has not yet been determined. Bipolar coagulation can be advantageous but will not prevent intraoperative bleeding during excision of the tumor. SUMMARY
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Address reprint requests to Jens Rassweiler, MD Urologische Klinik Am Gesundbrunnen 20 D-74074 Heilbronn Germany e-mail: [email protected]