Organ-Preserving Endoscopic Kidney Cancer Resection

Transcription

1 european urology 50 (2006) available at journal homepage: Surgery in Motion Organ-Preserving Endoscopic Kidney Cancer Resection Elmar Heinrich, Tobias Egner, Michael Noe, Frank Schiefelbein, Georg Schoen * Department of Urology, Missionsärztliche Klinik Würzburg, Germany Article info Article history: Accepted July 25, 2006 Published online ahead of print on August 10, 2006 Keywords: Endoscopic nephrectomy Kidney cancer Laparoscopy Organ preserving Abstract Objective: Recently, minimally invasive therapies for renal cell carcinoma have been devised to minimise operative morbidity yet achieve comparable oncologic and functional outcomes. This video summary of laparoscopic transperitoneal organ-preserving kidney cancer resection shows the procedure from the surgeon s view. Methods: The video and photos show the main steps of the procedure. The results of 40 transperitoneal and retroperitoneal procedures performed during are discussed. Preoperative preparation includes abdominal computed tomography and ureteral catheterisation. Tumour margins were determined by laparoscopic renal ultrasonography. Vessel control was done by en bloc clamping or solitary clamping of the artery. For optimal macroscopic evaluation of the resection margins, tumour excision was solely done with cold Endoshears followed by pelvicaliceal suture repair and parenchymal closure over surgical bolsters with a biologic haemostatic agent. Results: In 40 cases, we converted to the open procedure only once. The average patients age was 53 yr and mean tumour size was 26 mm. No patient showed positive surgical margins. The mean warm ischemia time was 21 min. Final histopathology revealed renal clear cell carcinoma as the major cell type followed by papillary renal carcinoma. Two patients required blood transfusion. Estimated mean blood loss was 270 ml. Median time of hospitalisation was 6 d. Conclusion: Endoscopic partial nephrectomy can be performed by experienced surgeons in selected patients. Tumour location and size and the surgeons experience and preference are the main parameters to make the decision of the type of access. # 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Corresponding author. Department of Urology, Missionsärztliche Klinik Würzburg, Salvatorstraße 7, Würzburg, Germany. Tel ; Fax: address: georg.schoen@missioklinik.de (G. Schoen) /$ see back matter # 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi: /j.eururo

2 european urology 50 (2006) Introduction Since the introduction of minimal invasive surgery techniques, they have become increasingly important in the field of uro-oncologic surgery. In the past decade, minimally invasive therapy options for renal cell carcinoma have been devised in an attempt to minimise operative morbidity while achieving comparable oncologic and functional outcomes. The result of the improvement is that today the endoscopic techniques are comparable with open methods in almost all parameters of oncologic surgery [1]. Complete tumour excision with maximal preservation of unaffected nephrons remains the goal. The indication for laparoscopic or retroperitoneoscopic partial nephrectomy is the same as for the open technique. The most important limiting parameters are the size and the localisation of the tumour. Therefore, a maximum size of 4 cm of treated renal mass has been the limit in almost all published studies [2]. Endoscopic access to the kidney is possible transperitoneally or retroperitoneally. The decision on the approach should be based on the tumour location on the kidney surface. For polar or posterolateral masses the retroperitoneal approach is preferred. The transperitoneal approach is best suited to anterior and medial lesions [3]. The decision to apply a particular technique appears to be depend on surgeon experience and preference [4]. This article is based on the video summary Organ-preserving endoscopic kidney cancer resection. We present the technique of transperitoneal access to treat a renal mass located at the lower pole of the right kidney. Additionally we show our retrospective data of 40 partial nephrectomies. 2. Methods Fig. 1 Setting of endoscopic ports. required, the port can be replaced easily. After CO 2 insufflation, two working ports are placed under direct vision, that is, one distal of the costal arch and one superior of the spina iliaca anterior superior (Fig. 1). After placement of all ports and retraction of the liver, the right colon flexure and the duodenum have to be dissected, to view the anterior side of the inferior vena cava. To face the main renal vessels the musculus psoas has to be dissected followed by blunt retraction of the connective tissue. To lift and stabilise the kidney for exact demonstration of the main renal vessels, an additional locking plier over a 3-mm port can be placed. The renal artery and vein are exposed in preparation for vascular control with laparoscopic bulldog or Satinsky clamps (Fig. 2). In the case of Satinsky clamps an additional 12-mm port is necessary; for separate artery and vein control bulldog clamps can be brought in through a 10-mm port. After retraction of the renal fat capsule around the tumour mass, the resection margins are determined with flexible ultrasound (Fig. 3). The fascia Gerota and the perirenal fat have to be retracted as far as necessary to get perfect vision of the tumour mass and to allow good handling for tumour excision and 2.1. Procedure In the following steps we describe the procedure of a transperitoneal organ-preserving kidney cancer resection. As an example, a renal mass of 4 3 cm at the lower pole of the right kidney has been diagnosed by ultrasound and was confirmed by a computed tomography (CT) examination. To localise lesions of the collecting system during the procedure via retrograde injection of indigo carmine (mixed with saline), a mono J ureter stent has to be implanted preoperatively with the patient in the lithotripsy position. Afterwards the patient has to be placed in a strict flank position. The main port for the laparoscope should be placed at the upper abdomen strictly pararectally. Therefore, we use a Hasson trocar, which is placed under direct vision through a 3-cm incision; afterwards the incision can be used for the removal of the retrieval bag or, if immediate sectioning is Fig. 2 Demonstration of renal vessels and vascular control by laparoscopic bulldog clamps.

3 734 european urology 50 (2006) Fig. 3 Intraoperative detection of resection margins with a flexible ultrasound. suturing. If the tumour mass is located at the lower pole, less mobilisation of Gerota and perirenal fat is necessary compared to tumours at the upper pole. To avoid the very complicated laparoscopic re-resection of the tumour area, the tumour has to be resected with a secure 5 10-mm margin circumferentially around the entire mass. For a better evaluation of the resection margin by the pathologist, electrocauterisation is used only for the renal capsule. Just before the tumour resection with cold Endoshears, the bulldog or Satinsky clamps are placed on the renal vessels. To minimise the warm ischemia time all required materials such as sutures, Tabotamp 1 (Johnson & Johnson, New Brunswick, NJ), and the retrieval bag are placed intra-abdominally. To localise apertures of the collecting system, indigo carmine mixed with saline is then injected through the preoperatively placed ureteral catheter. Leaks are closed with intracorporeal knotted polyglactin-910 monofilament sutures (Fig. 4A and B). To avoid contamination with tumour cells, the specimen is immediately wrapped in a retrieval bag and removed through the incision by the Hasson trocar by the end of the operation. In macroscopic suspect tumour margins immediate sectioning follows; to avoid prolonged ischemia time the procedure has to be finished. In the case of positive resection margins, laparoscopic or open re-resection has to be done, or as a final possibility, a laparoscopic nephrectomy can be performed. We are not carrying out explorative excisions from the resection area because they are a possible source of false-negative results. Haemostasis of the resection wound is done by farreaching sutures with CT-X needles, fixed with pledget locking clips on both ends. In our technique, we place sutures through the ground of the resection area and fix them first with the pledget locking clips on both sides (video and Fig. 5A and B); afterwards the two free ends of the suture are tied together above the surgical bolster (Tabotamp 1 ) to enforce the pressure on the resection area (Fig. 5C and D) and to avoid tearing out the sutures. Additionally Flowseal 1 (Baxter, Deerfield, IL) is applied on the resection area to ensure haemostasis. After removal of the vessel clamps, haemostasis has to be controlled Fig. 4 (A) Schematic demonstration of collecting system closure. (compare with the section at 1 min in the video). (B) Intraoperative view of collecting system closure with intracorporeal knotted sutures (compare with minute 8 of the video). at physiologic blood pressure. Finally, the retrieving bag with specimen has to be removed Selection criteria All cases in this study were elective. We treated tumours up to 45 mm with unilateral application. Contraindications for a laparoscopic procedure are the presence of hilar tumours, obvious involvement of the collecting system, tumour size >45 mm, or American Society of Anesthesiologists status > III. Alternatively, we performed laparoscopic nephrectomy, mainly for bigger tumours, or open partial nephrectomy, for example, in the case of a solitary kidney. 3. Results After 30 transperitoneal and 10 retroperitoneal organ-preserving endoscopic partial kidney cancer resections performed from 2001 to 2005, we had a

4 european urology 50 (2006) Fig. 5 (A) Sutures through the resection ground, armed with pledged locking clips. (B) Insertion of the surgical bolster after Flowseal W application at the resection area. (C+D) Schematic (C) and intraoperative (D) result of the parenchyma suturing. mean operative time of 150 min (range: min without placement of ureteral catheter and change of patient positioning). The mean tumour size was 26 mm (range: 8 45 mm), and the average patient age was 53 yr. The estimated blood loss was 270 ml; twice a blood transfusion was necessary because of parenchymal bleeding. The mean warm ischemia time was 21 min (range: min). Because of accurate patient selection we converted only once to the open procedure, and this case was Table 1 Histopathologic characteristics Histopathology No. Renal cell carcinoma Clear cell 16 Papillary 6 Chromophobe 4 Benign masses Oncocytoma 4 Angiomyolipoma 4 Cyst 4 Scar 2 considered a nephrectomy. The most frequent intraoperative complication was bleeding due to iatrogenic vessel injury (except main renal vessels) with two (5%) postoperatively, five sub-ileus (12.5%), two urine leakage (5%), and one temporary renal insufficiency (2.5%). After pathologic examination, none of the specimens showed tumour-positive resection margins. Clear cell carcinoma and papillary tumours made up a majority of the histologic cell types (Table 1). After a comparative follow-up time of 12 mo we did not detect any port-side metastasis or local recurrence. The follow-up examination included physical examination, abdominal ultrasonography, and abdominal computed tomography. The mean time of hospitalisation was 6 d. 4. Discussion Laparoscopic nephron-sparing surgery was first performed clinically in 1993 by Winfield et al. for benign disease [5]. Since then, other groups have reported successful outcomes with laparoscopic

5 736 european urology 50 (2006) partial nephrectomy for benign and malignant disease and reported results that compare favourably with those of open partial nephrectomy [6 11]. The transperitoneal and the retroperitoneal [12] approaches have been used for endoscopic partial nephrectomy. The transperitoneal approach offers a greater working space and familiar landmarks but requires bowel mobilisation to expose the kidney. In case of posterior renal masses it may be difficult to use the transperitoneal approach and full kidney mobilisation may be required to visualise the mass. The advantages of the retroperitoneal approach are an easier access to the renal artery, less bowel manipulation, and prevention of blood or urine contact with the bowel, which speeds up the postoperative bowel function and avoids long hospital stays [3]. The risk of peritoneal opening and consecutive loss of the working space remains the main disadvantage of the retroperitoneal access. For selecting the approach the primary decisionmaking parameters of importance are the surgeon s experience, tumour location, infiltration depth, and tumour size. For some surgeons the transperitoneal approach is more favourable due to its larger working space and the wider separation of ports, which allows more conducive angles for laparoscopic suturing [4]. Others prefer the retroperitoneal procedure because of its direct access to the kidney and especially to the hilum [3]. The oncologic outcome of patients who had endoscopic instead of open partial nephrectomy is the main topic of discussion since this technique has been available. Positive resection margins in laparoscopic procedures are mainly prevented by a greater margin around the tumour mass. In the case of macroscopic suspect resection margins, immediate sectioning must follow. Due to the possible source of false-negative results, exploratory excisions of the resection area are not favourable. In 2004, the first intermediate/long-term oncologic follow-up on 48 patients was presented by Allef et al. [13]. One patient in this series had a positive margin. At a mean follow-up of 37.7 mo, two patients had recurrence in the operated kidney, including one with von Hippel-Lindau disease. The largest and latest follow-up data have been presented recently by the group of Gill [14] with data on 100 laparoscopic partial nephrectomies. In this series just one patient with renal cell carcinoma was found to have a focal positive margin on final histopathologic analysis. Cancer-specific survival at a median follow-up of almost 3.5 yr was 100% in this very impressive study. Contemporary open partial nephrectomy series are showing cancer-specific survival rates of 80 90% at 5 yr and 73% at 10 yr of follow-up [15,16]. Compared with the results of the presented studies of the leading groups in this field, our data are absolutely in accordance [17,18]. The results indicate that this technique can also be performed successfully by smaller groups with experienced surgeons. As presented by Ramani et al. [19], the major perioperative complication is acute or delayed haemorrhage, which occurred in 9.5% of 200 patients in their study. Urinary leakage occurred in 4.5% of patients, but none required operative reintervention. These current data are in complete accord with the complication rate reported in modern open partial nephrectomy series. However, the indolent nature of a majority of small renal tumours requires a longer follow-up of 5 or 10 yr to document definitive oncologic outcome data. 5. Conclusion Endoscopic partial nephrectomy minimises perioperative morbidity while achieving comparable oncologic and functional outcomes. The decision between the transperitoneal or retroperitoneal access musto be based on the tumour location and size and surgeon preference. Although the field of endoscopic kidney surgery is growing, this technique is still applicable for well-selected patients. Acknowledgement I (E. Heinrich) want to thank the head of our department Dr. Georg Schoen for introducing me to the field of endoscopic kidney surgery. Many thanks to Julia, our physician assistant, for organising all the patients records. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi: / j.eururo and via com. Subscribers to the printed journal will find the supplementary data attached (DVD). References [1] Matin SF, Abreu S, Ramani A, et al. Evaluation of age and comorbidity as risk factors after laparoscopic urological surgery. J Urol 2003;170:1115.

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