RETROPERITONEOSCOPIC RADICAL AND PARTIAL NEPHRECTOMY IN THE PATIENT WITH CIRRHOSIS

0022-5347/05/1734-1094/0 THE JOURNAL OF UROLOGY® Copyright © 2005 by AMERICAN UROLOGICAL ASSOCIATION

Vol. 173, 1094 –1097, April 2005 Printed in U.S.A.

DOI: 10.1097/01.ju.0000148362.47315.1a

Oncology: Renal/Upper Tract/Bladder RETROPERITONEOSCOPIC RADICAL AND PARTIAL NEPHRECTOMY IN THE PATIENT WITH CIRRHOSIS WILLIAM K. JOHNSTON, III,* JEFFREY S. MONTGOMERY

AND

J. STUART WOLF, JR.†

From the Department of Urology, University of Michigan, Ann Arbor, Michigan

ABSTRACT

Purpose: In patients with cirrhosis and a renal mass options may be limited by medical disease and the surgical difficulties associated with portal hypertension. We describe a retrospective review of patients with cirrhosis with renal masses who underwent radical or partial nephrectomy through a retroperitoneoscopic approach. Materials and Methods: Ten consecutive patients, including 4 men and 6 women, with cirrhosis, of whom 2 had undergone liver transplantation, underwent radical (7) or partial (3) nephrectomy for a total of 5 right and 5 left renal neoplasms via the retroperitoneoscopic approach at our institution from March 2002 to February 2004. Recovery data were prospectively obtained and other information was gathered retrospectively from the medical record. Results: Average patient age was 58 years and average American Society of Anesthesiology score was 2.8. Average renal tumor size for radical and partial nephrectomy was 4.6 (range 2.9 to 7) and 1.8 cm (range 1.3 to 2.3), respectively. Operative time was 140 to 315 minutes (median 172) and estimated blood loss was 100 to 5,000 ml (median 225). One patient required open conversion due to hemorrhage from left portosystemic venous communications. Mean postoperative hospitalization was 1.5 days (range 1 to 6). Conclusions: Although retroperitoneoscopic surgery avoids many surgical dangers associated with portal hypertension and it is our preferred approach to renal surgery in patients with cirrhosis, significant portosystemic venous communications exist in the retroperitoneum, especially on the left side, and they still lead to substantial blood loss in some patients. KEY WORDS: kidney, laparoscopy, nephrectomy, liver cirrhosis, portal hypertension

Transperitoneal laparoscopic and retroperitoneoscopic approaches to nephrectomy are effective and well established techniques.1, 2 Current investigations focus on increasing the general availability of the techniques, refining and standardizing certain steps, and broadening use to marginal cases. To this end we reviewed our experience with the retroperitoneoscopic approach to renal surgery in patients with cirrhosis. In patients with cirrhosis and a renal mass surgical options may be limited by medical disease and difficulties associated with portal hypertension. Among associated comorbidities the fragile and engorged portal system, and associated portosystemic venous communications can make surgical hemostasis difficult. Mansour et al reported bleeding complications in 30% of patients with portal hypertension and coagulopathy while undergoing abdominal surgery.3 As a result, many urologists have been reluctant to offer a surgical approach to patients with cirrhosis who have renal malignancy. These patients are attractive candidates for such minimally invasive options as cryotherapy and radiofrequency ablation. These 2 techniques are limited by tumor

size and location, and long-term success has yet to be determined.4 – 8 Accordingly some surgeons advocate surveillance for suspicious renal masses with serial radiological examination in medically unfit patients to avoid surgical morbidity.9, 10 When surveillance fails, as indicated by renal mass growth, active treatment may be necessary. In addition, patients with advanced liver disease are often under evaluation for liver transplantation and nonextirpative management of a renal mass suspicious for neoplasm may render a patient ineligible for transplantation. In the patient with cirrhosis transabdominal nephrectomy can be challenging due to ascites, an engorged portal venous system and dilated portosystemic venous communications. Retroperitoneal nephrectomy avoids some of these deterrents and it may result in a safer surgical approach and better outcome. To even more advantage a retroperitoneoscopic approach, as opposed to an open surgical retroperitoneal approach, provides the added benefit of improved visualization and possible tamponade of dilated varices while working in a pressurized working space. In addition, patients receive all of the advantages of minimally invasive surgery, such as a short hospital stay, decreased postoperative pain, improved cosmetic outcome and shorter recovery time.11 We describe a retrospective review of 10 consecutive patients with cirrhosis who had renal masses and underwent radical or partial nephrectomy through a retroperitoneoscopic approach.

Submitted for publication June 28, 2004. * Current address: Feinberg School of Medicine, Northwestern University, Laparoscopy and Minimally Invasive Urology, Evanston Northwestern Hospital, 1000 Central St., Suite 720, Evanston, Illinois 60201 (e-mail: [email protected]). † Correspondence: University of Michigan, Michigan Urologic Center, 1500 East Medical Center Dr., Ann Arbor, Michigan 48109-0330 (e-mail: [email protected]). 1094

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Patients. Ten consecutive patients, including 4 men and 6 women, who had a history of cirrhosis underwent radical (7) or partial (3) nephrectomy for a total of 5 right and 5 left renal neoplasms via the retroperitoneoscopic approach at our institution from March 2002 to February 2004. Two patients had previously undergone liver transplantation and, although they were greatly improved over the pre-transplant state, they were considered at high risk for transabdominal surgery. All renal masses were characterized by computerized tomography (CT) and all patients had clinical stage T1 disease. Two patients had previously been followed radiographically for the renal mass and growth of the mass prompted active treatment. Retroperitoneoscopic operative procedure. Preoperative intravenous antibiotics are administered and sequential compressive devices are placed on the lower extremities prior to general anesthesia induction. An oral gastric tube is placed for the duration of the case and a urethral catheter is inserted prior to placing the patient in the lateral decubitus position on a bean bag. The kidney rest is raised, the bed is flexed, an axillary roll is inserted and the extremities are padded and positioned appropriately. A 15 mm incision is made 1 finger breadth below the 12th rib. The retroperitoneum is entered by blunt dissection down to the lumbodorsal fascia, which is opened by clamp insertion. Digital blunt dissection is done to expand the space posterior to the kidney along the psoas muscle. A balloon dilator directed along the psoas muscle posterior to the kidney is used to expand the retroperitoneal space. A 12 mm balloon port is used for camera placement and the retroperitoneal space is insufflated to 15 mm Hg with CO2. A 5 mm port is positioned 2 finger breaths caudal and medial to the initial port. A 10 mm port is placed medial to the tip of the 11th rib with care taken to avoid the peritoneum. Finally, a 12 mm port is placed at the junction of the 12th rib and the spinous musculature. Radical nephrectomy. The kidney within Gerota’s fascia is lifted anterior off of the psoas muscle and the renal pedicle is identified, usually in direct line with the most posterior 12 mm port. The renal artery is identified using blunt and hook dissection. The artery is secured with clips and incised, and then the renal vein is isolated and secured with a vascular stapler. The remaining posterior dissection is completed from the inferior to superior specimen pole. The adrenal gland is dissected off of or taken with the specimen depending on renal mass location. The kidney is carefully released from the peritoneum anterior. A laparoscopic fan retractor used to bluntly stroke the anterior aspect of the specimen away from the peritoneum, as integrated with hook dissection, often aides in this dissection. The lower pole of the specimen is released and the ureter is identified, isolated and divided. The specimen is placed in an entrapment bag for morcellation. The primary port site is enlarged to approximately 3 cm and the area is draped to allow manual morcellation under

direct vision using ring forceps.12 Care is taken to avoid grasping the entrapment bag. The laparoscope may be introduced through an adjacent port to proctor morcellation. The process typically requires approximately 5 to 10 minutes depending on specimen size.12 The lumbodorsal fascia of the primary port site is then closed in a series of figure-of-8 sutures using a Carter-Thomason device and zero polyglycolic acid sutures. Partial nephrectomy. The renal hilum is prepared as describe for radical nephrectomy. The kidney is mobilized as needed to expose the tumor. Gerota’s fascia is entered adjacent to the suspected tumor. Intraoperative ultrasound confirms the location and depth of the renal mass. The renal capsule is scored around the mass with hook cautery. If the tumor penetrates greater than 0.5 cm deep, or entry into the collecting system or renal sinus is anticipated, the renal hilum is clamped with laparoscopic bulldog clamps and cold excision of the mass is completed with care taken to circumscribe the mass with a margin of benign tissue. If the collecting system or renal sinus is entered, the base of the resection site is closed with a running suture of 2-zero polyglycolic acid. FloSeal (Baxter, Deerfield, Illinois) is applied and a rolled Surgicel (Johnson and Johnson, New Brunswick, New Jersey) is placed into the resected area as a bolster and secured with suture. For exophytic masses (0.5 cm deep or less) the renal hilum is not clamped and the mass is excised using bipolar cutting forceps. Application of an argon beam coagulator and/or FloSeal to the bed of the resected mass is done as needed to aid in hemostasis. Data collection and analysis. Data were collected from the medical records, radiology archive and the Michigan Urology Center laparoscopy database. Recovery data were obtained with a validated self-administered questionnaire.13 RESULTS

On preoperative CT average renal tumor size for radical nephrectomy was 4.6 cm (range 2.9 to 7). For partial nephrectomy the greatest tumor diameters were 2.3, 2 and 1.3 cm. In the partial nephrectomy group 1 tumor abutted the collecting system and the renal hilum was clamped with a warm ischemia time of 32 minutes. Operative time was 140 to 315 minutes (median 172) and estimated blood loss was 100 to 5,000 ml (median 225). Average day of discharge home was postoperative day 1.5 (range 1 to 6) (see table). During 2 radical nephrectomies, which were each on the left side, there was extensive bleeding from portosystemic collateral veins. One case resulted in a 5,000 ml blood loss after a large inferior phrenic vein was entered, requiring a 6 U intraoperative packed red blood cell (PRBC) transfusion and conversion to open nephrectomy. The patient received an additional 10 U PRBCs postoperatively but recovered without further intervention and was discharged home on postoperative day 6. In another patient a dilated anterior retro-

Patient demographics Pt No.—Age—Sex

Blood Loss (cc)

Hospital Stay (days)

Surgery

Side

1—57—F 2—57—F*

Radical nephrectomy, no adrenalectomy Radical nephrectomy, no adrenalectomy

Rt Lt

100 500

1 4

3—56—F 4—57—M 5—59—F 6—63—M 7—61—F

Radical Radical Radical Radical Radical

Lt Rt Lt Lt Lt

150 1,400 2,300 50 5,000

1 3 2 1 6

Rt Rt Rt

350 100 100

1 2 1

nephrectomy, no adrenalectomy nephrectomy, no adrenalectomy nephrectomy ⫹ adrenalectomy nephrectomy, no adrenalectomy nephrectomy, no adrenalectomy

8—46—F Partial nephrectomy 9—57—M* Partial nephrectomy 10—61—M Partial nephrectomy * After liver transplantation.

Complication None Postop day 1 hemorrhage requiring transfusion ⫹ transient ascites worsening None None Intraop hemorrhage requiring transfusion None Intraop hemorrhage requiring transfusion ⫹ conversion to open procedure None None None

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peritoneal collateral vein was entered, requiring endoscopic stapling and 4 U intraoperative PRBCs for a 2,300 ml blood loss (fig. 1). This woman was subsequently rehospitalized 1 week after discharge home due to a transient increase in ascites and ileus. After left radical nephrectomy another patient required 4 U PRBCs on postoperative day 1 for decreased hematocrit, which stabilized by postoperative day 2. These 3 patients with hemorrhage experienced the only complications in our series for a 30% overall complication rate. Pathological examination revealed that all masses were renal cell carcinoma with 9 pT1N0 tumors and 1 pT3N0 tumor. The latter was removed with radical nephrectomy. All surgical margins were tumor-free. No patients had recurrence at a median of 8.5 months of followup. DISCUSSION

Radical nephrectomy or in select cases partial nephrectomy is considered the standard treatment for localized renal cell carcinoma. Laparoscopic radical nephrectomy has become an acceptable alternative to open radical nephrectomy due to its decreased morbidity, postoperative pain, patient convalescence and favorable cosmetic outcome. Although laparoscopic partial nephrectomy is not as well established, it is also being applied more frequently. In the patient with cirrhosis the morbidity of any surgical approach has been well documented.3 We hoped that a retroperitoneoscopic approach would be a useful surgical option in this group of patients and we present our experience. While a clear understanding of the established collateral pathways of the portosystemic communications in patients with cirrhosis and portal hypertension is necessary prior to surgery, we noted considerable variation in the location and degree of dilatation in retroperitoneal collateral circulation. Moll et al completed a retrospective review of collateral pathways in portal hypertension.14 They divided their findings into classic anastomoses and nonclassic collateral pathways. In descending incidence, classic anastomoses were to the left gastric, short gastric, recanalized umbilical, paraumbilical or superior rectal veins. Interestingly they also found some nonclassic collateral pathways. In particular, they found splenorenal or gastrorenal veins, reverse perfusion of the inferior mesenteric vein, direct anastomosis between the inferior or superior mesenteric vein and the inferior vena cava via reverse perfusion of pancreatic branches, and veins running caudal from the splenic hilum. In a review of collateral flow from the left gastric vein (LGV) in 193 patients Widrich et al found that the most common portosystemic communication (28.5% patients) occurred between the LGV and left renal vein.15 The most significant collateral pathway trav-

FIG. 1. Preoperative CT shows dilated retroperitoneal collaterals (x) in patient with cirrhosis.

eled from the LGV to the inferior phrenic vein and then to the adrenal vein, ultimately reaching the systemic circulation at the left renal vein or inferior vena cava. In addition, there were communications between gastroesophageal varices and the right inferior phrenic vein. An understanding of the possible collateral pathways is of interest to the surgeon operating in the retroperitoneum (fig. 2). In our series 2 cases required intraoperative blood transfusion. The 2 patients had well developed collateral pathways on the left side. In 1 case a large inferior phrenic vein was entered while dissecting superior to the adrenal gland. Ultimately we needed to convert to open surgery to gain control. In the other case we carefully dissected the kidney away from an array of grossly dilated veins abutting the superior pole of the kidney, projecting toward the renal vein (fig. 1). While completing radical nephrectomy, a vein dilated to the caliber of the renal vein and coursing along the posterior aspect of the peritoneum, was entered. Ultimately after gaining control of the point of hemorrhage this vein was dissected proximal and distal, and ligated with a stapler. This vein appeared to be a branch of the splenic vein. Our experience is consistent with the findings of Moll14 and Widrich15 et al, in that nonclassic portosystemic communications to the left renal vein were significant in some patients. All 3 complications in our series (2 intraoperative hemorrhages and 1 postoperative hemorrhage) occurred with left nephrectomy. Three of the 5 left renal operations were complicated by hemorrhage but hemorrhage did not occur in association with any of the 5 right procedures. Our small sample size precludes definitive conclusions but the left side appears to be at greater risk for hemorrhage, likely due to the

FIG. 2. Possible left retroperitoneal collateral veins in patient with cirrhosis. Right gastroepiploic anastomoses to left gastroepiploic off of splenic vein are not shown. Of systemic origin are left renal vein (1), gonadal vein (2), lumbar vein (3) and inferior phrenic vein (4). Of portal vein origin are splenic vein (5), inferior mesenteric vein (6), superior mesenteric vein (7), left gastric vein (8) and esophageal vein (9). Paranephric branches are caudal branches off of splenic vein (10) and lateral branches off of inferior mesenteric vein (11). Primary portosystemic anastomosis are inferior mesenteric vein to lumbar vein (12) and esophageal vein to inferior phrenic vein (13). Hatching indicates left renal vein. Light blue areas represent portal system. Purple areas represent systemic system. Dark blue areas represent primary portosystemic anastomosis.

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proximity of the left kidney to collateral venous flow originating from the splenic, inferior mesenteric and esophageal veins (fig. 2). An appreciation of the complex collateral venous circulation in the retroperitoneum, especially on the left side, may decrease the risk of hemorrhage. The choice of a retroperitoneoscopic approach to nephrectomy in the patient with cirrhosis offers some clear advantages and disadvantages. In this patient population with ascites and dilated varices avoiding the abdominal cavity is of great benefit. Although the overall complication rate in our series was 30%, all were hemorrhagic and only 1 required more than blood transfusion or intraoperative intervention (hospital admission for treatment of worsening ascites). When hemorrhage occurs, the limited working space in the retroperitoneum makes surgical control difficult but operating under a pressure of 15 mm Hg dampens some venous bleeding. One of our patients required a 4 U PRBC transfusion on postoperative day 1 for retroperitoneal hemorrhage, which stabilized by the following day. The patient recovered and was discharged home on postoperative day 4. Using meticulous laparoscopic techniques and having a clear understanding of normal and abnormal anatomy in the patient cirrhosis can help minimize complications. For instance, while developing the retroperitoneal space with balloon dilation, great care must be taken because engorged anterior veins are more liable to rupture than in a patient without cirrhosis. Although blunt dissection is used with great success in most retroperitoneoscopic procedures, in the patient with cirrhosis blunt dissection should be minimized. If a vessel is opened, typical coagulation and clipping techniques may be less effective because of the fragile venous walls and the endoscopic stapler may be more useful. Surgeons with the ability to perform intracorporeal suturing may place sutures as necessary to gain hemostasis. Overall surgeons should be comfortable with retroperitoneal laparoscopy and the surrounding anatomy in patients without cirrhosis prior to operating in patients with cirrhosis. As for all laparoscopic surgery, the decision to convert to an open procedure should not be delayed if progress is not made in achieving hemostasis. CONCLUSIONS

Patients with cirrhosis are challenging surgical candidates. This group may benefit from a retroperitoneal laparoscopic approach intraoperatively and during postoperative recovery. Appreciation of the complex collateral venous circulation in the retroperitoneum, especially on the left side, facilitates success with this approach.

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