Retroperitoneoscopic nephrectomy and nephroureterectomy for benign nonfunctioning kidneys: a single-center experience

ADULT UROLOGY

RETROPERITONEOSCOPIC NEPHRECTOMY AND NEPHROURETERECTOMY FOR BENIGN NONFUNCTIONING KIDNEYS: A SINGLE-CENTER EXPERIENCE A. K. HEMAL, N. P. GUPTA, S. N. WADHWA, A. GOEL,

AND

R. KUMAR

ABSTRACT Objectives. To report our experience of 185 cases of retroperitoneoscopic nephrectomy and nephroureterectomy for benign nonfunctioning kidneys with various modified techniques for differing etiologies. The feasibility, complications, and long-term outcomes are discussed. Methods. The present study comprised 185 patients who underwent retroperitoneoscopic nephrectomy or nephroureterectomy during a 57-month period beginning July 1995. All procedures were done using the retroperitoneoscopic approach. Thirty-two patients had a history of previous surgery, 20 patients had a percutaneous nephrostomy, and 12 patients had mild renal impairment. Results. Retroperitoneoscopic nephrectomy and nephroureterectomy were completed successfully in 167 patients. Eighteen patients required conversion to open surgery, 4 on an emergent basis and 14 electively. The mean operating time was 100 minutes (range 45 to 240), mean blood loss was 133 mL (range 30 to 1200), and mean hospital stay was 3 days (range 2 to 8). A total of 37 complications (16.2% were minor and 3.78% were major) occurred. Re-intervention was needed in 1 patient. No mortality resulted. Previous surgery, percutaneous nephrostomy, and chronic renal impairment did not affect the outcome. Apart from one incisional hernia, no long-term complications occurred. Conclusions. Retroperitoneoscopic nephrectomy and nephroureterectomy can be performed safely and successfully with obvious advantages for benign nonfunctioning kidneys regardless of the etiology or pathogenesis, with modifications in the approach in very difficult cases. Patients with conditions often considered to be contraindications (ie, genitourinary tuberculosis, pyonephrosis, history of previous surgery, percutaneous nephrostomy, stone disease, chronic renal failure, and horseshoe kidney) can also be successfully treated by skillful dissection and modifications in the surgical technique. UROLOGY 57: 644–649, 2001. © 2001, Elsevier Science Inc.

A

fter the initial description by Clayman et al.1 in 1990, laparoscopic nephrectomy has established itself in the field of urology. Laparoscopic nephrectomy either by the transperitoneal or retroperitoneal route affords less postoperative pain, a more rapid convalescence, and an optimal cosmetic result compared with the traditional open surgery.2– 4 Retroperitoneoscopy has certain distinct advantages over transperitoneal access.5 Although it was first reported in 1969,6 retroperitoneoscopy did not become popular until Gaur’s demonstration of the elegant technique of atrauFrom the Department of Urology, All India Institute of Medical Sciences, New Delhi, India Reprint requests: Professor A. K. Hemal, Department of Urology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India Submitted: June 27, 2000, accepted (with revisions): November 7, 2000

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© 2001, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED

matic balloon dissection of the retroperitoneum.7–9 The past few years have witnessed the emergence of retroperitoneoscopic nephrectomy as a better alternative than open surgery.4,6,10 Urologic programs worldwide have started reporting their experience with retroperitoneoscopy.2,3 We present our experience with retroperitoneoscopic nephrectomy with various modified techniques for the kidney that is nonfunctioning or poorly functioning secondary to a variety of reasons. This is the largest series to date of retroperitoneoscopic nephrectomy from a single center and includes a wide range of etiologies for benign nonfunctioning kidneys. MATERIAL AND METHODS During July 1995 to April 2000, retroperitoneoscopic nephrectomy and nephroureterectomy were performed for the 0090-4295/01/$20.00 PII S0090-4295(00)01059-1

nonfunctioning and very poorly functioning (creatinine clearance less than 5 mL/min) kidney secondary to various benign diseases. Patient characteristics, etiology, and intraoperative, perioperative, and postoperative data are described in Table I. Of the 185 patients, 32 had history of previous surgery. Sixteen of the operations were either retroperitoneal surgery or pelvic surgery on the same side as the nephrectomy, and the other 16 had undergone intra-abdominal surgery. The status of the contralateral kidney was normal in all except 12 patients who had mild renal impairment. The present series also included 20 patients who had a percutaneous nephrostomy placed 6 weeks to 8 months before nephrectomy to assess the salvageability of kidney. Since the creatinine clearance did not improve (less than 5 mL/min), these patients underwent retroperitoneoscopic nephrectomy.

SURGICAL TECHNIQUE The construction technique for our homemade balloon for early filling and emptying and our technique to create the retroperitoneal space have been described previously.11,12 Retroperitoneoscopic nephrectomy and nephroureterectomy were performed primarily using three or four ports and very rarely a fifth port. The primary port was usually placed just below and posterior to the tip of the twelfth rib by a closed technique. Subsequent ports were placed as shown in Figure 1. The spatial anatomy of the port placement varied with the space available between the rib and iliac crest, body habitus, and position of the target organ in the retroperitoneum. The specific modifications in different situations are as follows: 1. Hydronephrotic and giant hydronephrotic kidney: subsequent to the creation of the retroperitoneal space, the kidney was mobilized all around, as the tense hydronephrotic sac helps in the identification of the perirenal plane.11 Once adequately dissected, the kidney can be deflated and, in the case of a giant hydronephrotic kidney, extracorporeal retraction can be done13 to facilitate additional dissection. 2. Congenital anomalous kidneys: angiography for vascular mapping is not essential in these cases, and we did not do it in any of our patients. For the horseshoe and iliac kidney, after creation of the retroperitoneal space, the position is tilted 45° semilateral, with the diseased side up. In these patients, the port placement may change, and one port is required in the anterior axillary line and another medial to the anterior superior iliac spine.12 The vessels that may be coming up to the kidney at various places can be seen well under endoscopic vision and controlled with clips and divided. The isthmus can be divided intracorporeally or extracorporeally. A pelvic kidney can be dealt with similarly. However, kidneys located very medially in the pelvis often pose a problem using the retroperitoneal access. We had to convert to open surgery in 2 patients and suggest a transperitoneal approach instead. Three-dimensional computed tomography can help diagnose this problem preoperatively. 3. Genitourinary tuberculosis and inflammatory conditions: making the retroperitoneal space is difficult, and we found hydraulic distension of the balloon to work better than pneumatic distension. The procedure begins with control of the hilar vessels outside Gerota’s fascia and subsequent dissection of the kidney either within or outside the fascia depending on the degree of the perinephric adhesions. A direct approach to the hilum without dissecting the kidney is crucial to minimize oozing. 4. Patients with percutaneous nephrostomy: after creation of the initial space, division of the percutaneous nephrostomy tract in the retroperitoneum is helpful, as it allows the kidney to be pushed forward. This helps in creating a larger retroperitoneal space. 5. Hypoplastic kidneys, renovascular hypertension, and so forth: these are simple cases with minimal perinephric adUROLOGY 57 (4), 2001

hesion, and adequate space can be created under Gerota’s fascia. The kidney can be mobilized first and followed by hilar dissection. These are ideal cases for beginners.

RESULTS During a 4-year, 6-month period, 185 patients at our center underwent retroperitoneoscopic nephrectomy (n ⫽ 154) or nephroureterectomy (n ⫽ 31) for benign nonfunctioning kidneys. Retroperitoneoscopic nephrectomy and nephroureterectomy were successfully completed in 167 of the 185 patients, with 18 (9.72%) requiring conversion to open surgery. Fourteen of the conversions occurred during our first 100 cases and four conversions occurred in the last 85 cases. In 4 cases, all in our first 100 cases, the conversion was due to a major complication encountered at the time of surgery (Table II). One patient had an injury to the renal vein during insertion of the trocar. In another patient with stone disease and dense perinephric adhesions, an injury to the colon occurred during the dissection with the diathermy hook. On conversion to open surgery, the rent was closed primarily and the procedure completed without any further complications. The third patient required conversion because after completion of the dissection, during intact retrieval of the kidney, the vascular clip applied to the renal vein slipped off, leading to rapid bleeding. The vessel was easily controlled after open exploration. In the fourth patient, injury to the gonadal vein occurred during mobilization. This could not be adequately controlled endoscopically and required emergent conversion to open surgery. Two patients required conversion because of a rent in the peritoneum during dissection, with subsequent dissipation of the pneumoretroperitoneum. In the other 12 patients, conversion was done electively because of a lack of progress in the dissection. All these patients had dense perinephric adhesions, including 1 case of xanthogranulomatous pyelonephritis and 2 cases of tuberculosis. The 12 cases were spread evenly throughout our experience and were related more to the underlying pathologic features than to the expertise of the operating surgeon. The operating time in the successful cases varied from 45 to 240 minutes (average 100), and the mean blood loss was 133 mL (range 30 to 1200). Four patients required blood transfusions. The hospital stay varied from 2 to 8 days (average 3). Seven major complications (3.78%) occurred, four of which required conversion to open surgery, as described above. The other three included one port site hernia, one gonadal vein injury controlled endoscopically, and 1 patient who developed a retroperitoneal collection. Five of these complications occurred in our first 100 cases, with the remaining two in the last 85. The patient with a 645

7 2 14–70 33.22 5/4 2/7 1 —

60–170 103.57

90–120 101.42

2–4 3.2 2

53 14

19–68 42.2 39/28 37/30 7

2

55–240 109.6

40–800 150.4

2–6 3.0 7

2–7 3.6 2

50–1200 250.0

70–200 123.0

1

13–43 34.33 8/4 9/3 1

9 3

1

18–35 26.2 3/2 2/3 —

5 —

—

25–38 31.5 0/2 1/1 —

2 —

2–3 2.5 1

75–150 101.25

2–3 2.6 2

3–4 3.5

75–150 30–70 108.3 50

110–125 85–120 90–110 118.75 98.3 100

—

13–30 22.6 2/3 3/2 —

5 —

4–7 5.5

100 100

120–180 150

—

20 20 1/1 2/0 —

2 —

3–5 3.66

50–400 183.3

90–180 123.3

—

38–45 42 2/1 2/1 1

— 3

2 2

70 70

140 140

—

0/1 1/0 —

24

— 1

1

15–20 17.5 2/0 2/0 —

2 —

RVH

1

15–61 29.2 4/1 4/1 —

— 5

VUR

60–120 60–135 120–140 100 97.5 126.25

1

24–58 37.3 2/1 1/2 —

— 3

Total

45–240 99.91

12

4–70 34.77 113/72 98/87 20

185

3–6 4

2–4 2.6

3–4 3.5

3–7 4.5 1

2–8 3.02 18 (9.72%)

50–300 100–200 30–100 100–150 30–1200 125 166.6 65 116.25 133.14

80–120 95

1

5–32 21.25 3/1 1/3 —

4 —

KEY: UPJO ⫽ ureteroplevic junction obstruction; RVH ⫽ renovascular hypertension; VUR ⫽ vesicoureteral reflux; RPN ⫽ retroperitoneoscopic nephrectomy; NUT ⫽ nephroureterectomy; M/F ⫽ male/female; R/L ⫽ right/left side.

RPN (n ⫽ 154) 65 NUT (n ⫽ 31) — Age (yr) Range 4–65 Mean 31.2 M/F (n) 42/23 R/L (n) 31/34 Nephrostomy 10 (n) Renal 4 impairment (n) Operative time (min) Range 45–180 Mean 92.1 Blood loss (mL) Range 40–800 Mean 107.2 Hospital stay (days) Range 2–8 Mean 3.2 Conversion (n) 3

Iliac Pelvic Horseshoe Kidney Kidney Ectopic Obstructive Ectopic Unknown Stone Genitourinary Ureteral Kidney ⴙ ⴙ UPJO ⴙ UPJO ⴙ Stone ⴙ Stone Ureterocele Megaureter Ureter Dysplasia Cause UPJO Disease Tuberculosis Stricture UPJO

Nonfunctioning Kidney Etiology

TABLE I. Patient data

TABLE II. Complications and conversions First 100 Cases

FIGURE 1. Basic port placement. I indicates the primary port; optional ports are indicated by black circles.

Complications (n) Intraoperative Major Trocar injury Colon injury Gonadal vein injury Slipped vein clip Minor Peritoneal rent Emphysema Puncture/spill Postoperative Major Retroperitoneal collection Port site hernia Minor Wound infection Ileus Fever Conversions (n) Complication induced Nonprogressive dissection

1 1 2 1

Next 85 Cases

(1) (1) (1) (1)

0 0 0 0

8 (2) 2 3

4 1 1

0 0

1 1

3 2 2

2 1 1

6 8

0 4

Numbers in parentheses indicate number of conversions.

retroperitoneal collection required re-exploration for drainage of the collection but subsequently recovered completely. Apart from the hernia, no long-term sequelae were found. Thirty minor complications occurred (16.2%), including two that required conversion to open surgery (Table II). All the major intraoperative complications occurred in the first 100 cases, as did the larger number of minor complications. The occurrence of postoperative minor complications were relatively evenly distributed; the two postoperative major complications— unrelated to the surgeon’s experience— occurred during the last 85 cases. COMMENT Progress in any field of surgery today depends on the development of minimally invasive techniques. This is clearly illustrated by the rapid developments in the field of laparoscopic urologic surgery.1,2,14 –20 Between the two techniques of laparoscopy, retroperitoneoscopy has the inherent advantage of directly approaching the retroperitoneal genitourinary organs.3,21–23 Gill et al.3 in a survey of 36 urologic laparoscopy centers in 1998 concluded that retroperitoneoscopy is rapidly gaining acceptance worldwide, with 51% retroperitoneoscopic cases compared with 24% in 1993. Most of the single-center series on retroperitoneoscopic nephrectomy in the published reports have been small, and the large ones have been a combination of multicenter experience.2,14 –19,23 UROLOGY 57 (4), 2001

Although these series are, without doubt, critical to document the feasibility, pitfalls, and current trends in laparoscopic surgery, it has been well established that increasing experience leads to a decreased incidence in complications and higher success rates.2,21,23,24 It has even been suggested that laparoscopic surgery be limited initially to specific centers with well-developed training programs.23 The current series is the largest singlecenter experience of retroperitoneoscopic nephrectomy and nephroureterectomy. Moreover, it covers a wide range of indications for the technique. It includes the initial learning curve and demonstrates the changes in technique with increasing experience. Our 185 patients had a variety of causes for nonfunctioning kidneys, including ureteropelvic junction obstruction, stone disease, genitourinary tuberculosis, ureteral strictures, renovascular hypertension, and vesicoureteral reflux. Congenitally anomalous kidneys, including horseshoe and pelvic kidneys, were also included. These cover almost all the causes for nonfunctioning kidneys and demonstrate the adequacy of the procedure in all cases. It is important to properly site the trocars to enable adequate mobility of the instruments within the retroperitoneum. Modifications had to be made in a substantial number of cases. We have been using one of three techniques depending on the degree of the adhesions. In cases in which the 647

adhesions were few, we mobilized the kidney, followed by control of the hilum. In more difficult cases, we first controlled the hilum inside the fascia, followed by kidney dissection. In cases with dense adhesions such as occur in patients with previous surgery, genitourinary tuberculosis, and pyonephrosis, the hilum was approached directly, outside the fascia, followed by kidney dissection inside or outside the fascia. The ureter was always tackled at the end. We were able to successfully complete the procedure in 167 of the patients. The success rate of 90% compares well with other series2,14 –19,23 of retroperitoneoscopic nephrectomy. The operative time of 100 minutes was lower than most series,2,14 –19,23 highlighting the advantages of experience in the procedure. The reduction in operative time could also be because of our removal of the intact organ through the extracorporeal retraction port, by extending the first port, or by joining two ports. This avoids the time spent in capturing the specimen in an organ bag and morcellating it. The blood loss of 133 mL and hospital stay of 3 days were similar to the data reported and indicate the benefits of minimally invasive procedures over conventional open surgery. Eighteen of our patients required conversion to open surgery, 14 electively and 4 because of major intraoperative complications. The conversions per se were not considered a complication if performed because of a lack of progress in the dissection.23,24 This is an inherent limitation of the procedure and occurred in 12 of our cases. We have subsequently modified the technique in patients with extensive perinephric adhesions and find that, using the hilum-first approach, we are able to successfully complete cases that earlier would have resulted in conversion. In 6 cases, the conversion occurred because of complications. Seven major complications occurred, five intraoperatively, four of which required urgent conversion. Nephrectomy is considered a “difficult” procedure,24 and vascular injuries are the most common major complications reported,2,3,21,23 with an incidence of up to 3%. Visceral injuries follow closely in terms of incidence.3 In 1 case, an injury to the renal vein occurred during secondary trocar placement. Proper positioning of the trocar under laparovision and use of an open technique, especially by beginners, to place the first trocar help avoid this problem. Visceral injury usually occurs because of the use of monopolar cautery with poor insulation and can be avoided by using blunt dissection and limited cautery application. Even with the major complications, the outcome was as planned and caused no additional disadvantage to the patient who would otherwise have undergone open surgery anyway. 648

Although a common problem, with increasing experience, we have successfully managed peritoneal rents without conversion. We now tilt the patient further to the contralateral side, place an intravenous cannula or angiocatheter in the peritoneum to allow the egress of the gas and also retract the peritoneal rent medially and cover it with a triflanged retractor. This allows adequate development of the pneumoretroperitoneum for successful completion of the procedure. Peritoneoscopy is usually performed at the end of the procedure to rule out any visceral injury. The puncture of the distended kidney during dissection causes leakage of the contents into the operative field. However, it is one of the advantages of retroperitoneoscopy that this spillage is confined to the retroperitoneum and does not extend within the peritoneum. The space is thoroughly lavaged at the end of the procedure, and no long-term complications have occurred from the spillage. Balloon rupture during space creation has already been tackled by the use of a double glove as described by us previously.11,12 Subcutaneous emphysema can be avoided by careful placement of the first port using a trocar-sealing balloon below the parietes or by placing sutures through the entire abdominal wall to prevent extravasation of carbon dioxide between the layers. In none of our patients was the emphysema significant enough to cause hypercarbia or necessitate conversion. CONCLUSIONS This single-center series of 185 cases of retroperitoneoscopic nephrectomy and nephroureterectomy demonstrates the feasibility of the technique in a wide range of conditions and establishes the indications for it. With slight modifications, the procedure can be successfully performed in most cases. Major complications are not common and in most cases do not affect the long-term outcome of the patients. Minor complications are often not significant enough to either hamper the successful completion of the procedure or alter the long-term prognosis. REFERENCES 1. Clayman RV, Kavoussi LR, Soper NJ, et al: Laparoscopic nephrectomy: initial case report. J Urol 146: 278 –282, 1991. 2. Rassweiler J, Fornara P, Weber M, et al: Laparoscopic nephrectomy: the experience of the laparoscopy working group of the German Urologic Association. J Urol 160: 18 –21, 1998. 3. Gill IS, Clayman RV, Albala DM, et al: Retroperitoneal and pelvic extraperitoneal laparoscopy: an international perspective. Urology 52: 566 –571, 1998. 4. Kerbl K, Clayman RV, McDougall EM, et al: Transperitoneal nephrectomy for benign disease of the kidney: a comUROLOGY 57 (4), 2001

parison of laparoscopic and open surgical technique. Urology 43: 607– 613, 1994. 5. Gill IS, Grune MT, and Munch LC: Access technique for retroperitoneoscopy. J Urol 156: 1120 –1124, 1996. 6. Bartel M: Retroperitoneoscopy: an endoscopic method for inspection and bioptic examination of the retroperitoneal space. Zentralbl Chir 22; 94(12): 377–383, 1969. 7. Wickham JEA (Ed): The surgical treatment of renal lithiasis, in Urinary Calculus Disease. New York, Churchill Livingstone, 1979, p 145–178. 8. Kerbl KL, Figenshau RS, Clayman RV, et al: Retroperitoneal laparoscopic nephrectomy: laboratory and initial clinical experience. J Endourol 7: 23–26, 1993. 9. Gaur DD: Laparoscopic operative retroperitoneoscopy: use of a new device. J Urol 148: 1137–1139, 1992. 10. McDougall EM, and Clayman RV: Laparoscopic nephrectomy for benign disease: comparison of the transperitoneal and retroperitoneal approaches. J Endourol 10: 45– 49, 1996. 11. Hemal AK, Wadhwa SN, Kumar M, et al: Transperitoneal and retroperitoneal laparoscopic nephrectomy for giant hydronephrosis. J Urol 162: 35–39, 1999. 12. Hemal AK, Aron M, Gupta NP, et al: The role of retroperitoneoscopy in the management of renal and adrenal pathology. Br J Urol 83: 929 –936, 1999. 13. Hemal AK, and Kumar M: Extracorporeal renal retraction and adjunct during retroperitoneoscopic renal surgery. Br J Urol Int 83: 136 –137, 1999. 14. McDougall EM, Clayman RV, and Fadden PT: Retroperitoneoscopy: the Washington University Medical School experience. Urology 43: 446 – 452, 1994. 15. Eraky I, El-Kappany H, Shamma MA, et al: Laparo-

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scopic nephrectomy: an established routine procedure. J Endourol 8: 275–278, 1994. 16. Yamada S, Ono Y, Katoh N, et al: Efficacy of a retroperitoneal approach in a laparoscopic nephrectomy for benign renal disease (abstract). J Endourol 9: 560, 1995. 17. Valla JS, Guilloneau B, Montupet P, et al: Retroperitoneal laparoscopic nephrectomy in children. Eur Urol 30: 490 – 493, 1996. 18. Doublet JD, Barreto HS, Degremont AC, et al: Retroperitoneal nephrectomy: comparison of laparoscopy with open surgery. World J Surg 20: 713–716, 1996. 19. Gill IS, Das S, Munch LC, et al: Retroperitoneoscopy and pelvic extraperitoneoscopy: 124 cases (abstract). J Endourol 10: S186, 1996. 20. Rassweiler J, Henkel TO, Potempa DM, et al: The technique of transperitoneal laparoscopic nephrectomy, adrenalectomy and nephroureterectomy. Eur Urol 23: 425– 430, 1993. 21. Gill IS, Kavoussi LR, Clayman RV, et al: Complications of laparoscopic nephrectomy in 185 patients: a multi-institutional review. J Urol 154: 479 – 483, 1995. 22. Pearle MS, and Nakada SY: Laparoscopic nephrectomy: retroperitoneal approach. Semin Laparosc Surg 3: 75– 83, 1996. 23. Fahlenkamp D, Rassweiler J, Fornara P, et al: Complications of laparoscopic procedures in urology: experience with 2407 procedures at 4 German centers. J Urol 162: 765– 770, 1999. 24. Rassweiler JJ, Seemann O, Frede T, et al: Retroperitoneoscopy: experience with 200 cases. J Urol 160: 1265–1269, 1998.

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