Impact of Obesity on Complications of Laparoscopic Simple or Radical Nephrectomy

Transcription

1 Original Paer DOI: / Received: November 20, 2014 Acceted: February 26, 2015 Published online: Setember 4, 2015 Imact of Obesity on Comlications of Laaroscoic Simle or Radical Nehrectomy Nicolas Arfi a Arnaud Baldini a Myriam Decaussin-Petrucci b Rene Ecochard c Alain Ruffion a Philie Paarel a a Deartement of Urology; b Deartement of Anatomoathology; and c Deartement of Biostatistic, Lyon Sud University Hosital, Pierre Benite, France Key Words Obesity Comlications Nehrectomy Abstract Objective: To determine the imact of obesity on comlications in laaroscoic simle or radical nehrectomy. Patients and Methods: The medical files of 215 atients who underwent laaroscoic simle or radical nehrectomy in our center between 2004 and 2014 were reviewed. A body mass index of 30 kg/m² was used to divide the atients into obese and non-obese grous. Pre-oerative data and intraand ost-oerative comlications were comared between the 2 grous. Results: There were resectively 163 and 52 atients in the non-obese and obese grous, which were comarable in terms of age, sex, and history of surgery. In the obese grou, oerative secimens were significantly heavier (772 vs. 534 g in the non-obese grou; = 0.005) and durations of surgery was significantly longer (244 vs. 216 minutes; = 0.003). However no significant differences were found between the 2 grous for duration of hositalization, surgical conversion, estimated blood loss, or intraor ost-oerative comlications. Conclusion: Laaroscoic simle or radical nehrectomy is technically feasible in obese atients but the surgery may take more time, notably due to dissection difficulties. Our results showed that the risk of intra- and ost-oerative comlications is not higher in obese atients comared to non-obese atients, excet for a ossible, but statistically undemonstrated, higher risk of abdominal wall comlications, and that the laaroscoic aroach should be the referred technique in atients with high body mass index. Coyright 2014 S. Karger AG, Basel Introduction Obesity is a growing, major ublic health roblem in industrialized countries. A 2012 eidemiological survey revealed that in France, 32.3% of adults were overweight [body mass index (BMI) 25 and < 30 kg/m 2 ] and 15% obese (BMI 30 kg/m 2 ) [1]. Obese atients run a greater risk of comorbidities [2, 3] such as diabetes, high blood ressure, atheroma, dysliidemia, and breathing disorders. This association of risk factors is directly correlated with an increase in intra- and ost-oerative comlications [4, 5]. Additionally, different studies have shown that obese atients have a greater risk of develoing certain cancers, among which is renal cell carcinoma [6, 7]. Therefore, the number of obese atients needing kidney cancer surgery will inevitably grow. The first case of laaroscoic nehrectomy was reorted by Clayman et al. [8] in 1991 and the technique raidly develoed thereafter throughout the 1990s. Comared to oen nehrectomy, the laaroscoic technique reduces ain and shortens ost-oerative recueration Fax karger@karger.ch S. Karger AG, Basel /14/ $38.00/0 Accessible online at: Nicolas Arfi Deartement of Urology, Lyon Sud University Hosital Pierre Benite (France) nicolas_arf@hotmail.com

2 Fig. 1. Changes in ort lacement in a atient with a BMI of 39 kg/m 2 for right nehrectomy. O: otical trocar, C1: oerator trocar for the right hand, A: trocar for the assistant, F: trocar for the liver. C1, C2 and O are the modified locations for an obese atient. with equivalent oncological results [9, 10]. In its early days, the laaroscoic aroach was contraindicated in obese atients where the technique was more difficult to erform and caused more comlications [11]. However, with its evolution, more recent studies have demonstrated that although laaroscoic nehrectomy remains more difficult in obese atients, it is nonetheless safe [12 15] and rovides clear benefits for them over oen surgery [16, 17]. Currently there is a focus on otimizing the surgical management of kidney cancer when simle or radical nehrectomy is indicated through the develoment of increasingly mini-invasive techniques, such as laaroscoic single-site surgery or vaginal extraction of the oerative secimen, in order to limit abdominal wall comlications [18 20]. The urose of the resent study was to assess the imact of obesity on intra- and ost-oerative comlications in atients treated by laaroscoic simle or radical nehrectomy. Patients and Methods A list of all atients who underwent kidney surgery at the Lyon Sud Hosital Center (Lyon, France) between January 2004 and January 2014 was obtained from the center s anatomic athology deartment. Of the 235 atients thus identified, 215 had undergone laaroscoic simle or radical nehrectomy and their atient files were retrosectively analyzed. All artial nehrectomies, oen nehrectomies, and nehroureterectomies were excluded as were all files that did not rovide the BMI, intra- and ost-oerative data, and anatomoathological data. All laaroscoic nehrectomies were erformed via an intraeritoneal aroach with 3 to 4 trocars as needed. All basic surgical rinciles were resected [21]. For overweight or obese atients, the trocars were ositioned slightly more exteriorly in comarison to non-obese atients (fig. 1). The otical trocar was laced closer to the costal edge than to the umbilicus. The incision for oerative secimen extraction was chosen as a function of the anatomy of the atient and the size of the kidney: choices included iliac, subcostal, suraubic (Pfannenstiel), or vaginal extraction routes. BMI was calculated in the standard fashion as the weight of the atient in kilograms divided by the square of his/her height in meters. In accordance with current World Health Organization indications, atients with a BMI 30 kg/m 2 were considered obese and thus laced in the obese grou whereas those under this threshold were laced in the non-obese grou. Asects comared between the 2 grous included sex, age, American Society of Anesthesiologists (ASA) score, comorbidities, indication for nehrectomy, side of nehrectomy, duration of surgery, extraction incision site, intra-oerative blood loss, estimated hemoglobin loss, weight and nature of the oerative secimen, mean length of hosital stay (MHS), intra- and ost-oerative comlications, and duration of ost-oerative follow-u. Early ost-oerative comlications were defined as those occurring within ost-oerative days 0 to 30 and were groued according to the Clavien-Dindo classification system. Late ostoerative comlications were defined as those occurring after ost-oerative day 30 and corresonded to hernia at the extraction incision. Assessed comorbidities included tye 2 or tye 1 diabetes, arterial hyertension, history of abdominal surgery, arterioathies (e.g., coronary heart disease, stroke), breathing disorders (i.e., chronic obstructive ulmonary disease, slee anea syndrome, current smoking, use of anticoagulants or antilatelet drugs, chronic renal failure or dialysis, and immunoderession (including HIV, use of immunosuressants for translants, or corticosteroids). Qualitative variables were analyzed using the chi-squared test and quantitative variables using the Student's t test. Associations between the occurrence of comlications and the different atient arameters were evaluated by multi-arameter logistic regression. Statistical significance was set at < Statistical analyses were erformed using SPSS Statistics 17 for Windows (SPSS Inc, Chicago, IL, USA). Results Patient Characteristics There were 163 atients in the non-obese grou (BMI < 30 kg/m 2 ) and 52 in the obese grou (BMI 30 kg/m 2 ). Patient characteristics are summarized in the first half of table 1. There were no statistically significant differences excet for the ASA score ( < 0.006). 150 Arfi/Baldini/Decaussin-Petrucci/ Ecochard/Ruffion/Paarel

3 Table 1. Comarison of the characteristics and reoerative data of non-obese and obese atients Non-obese atients BMI < 30 (kg/m 2 ²) Obese atients BMI 30 (kg/m 2 ) Number of atients BMI, kg/m² Age, years Ratio male/female, n Ratio left/right ASA score Serum creatinine mg/dl MDRD GFR ml/min/1.73m² Indication: Tumor, n (%) Non-functional kidney, n (%) PKD, n (%) Comorbidities, n (%) Tye 2/Tye 1 diabetes, n (%) HA, n (%) History of abdominal surgery, n (%) Arterioathy, n (%) COPD/SAS, n (%) Anticoagulant/Antilatelet use, n (%) Smoking, n (%) Chronic renal failure/dialysis, n (%) Immunoderession: translant, corticosteroids, HIV, n (%) ± ± /82 84/ ± ± ± (73%) 25 (15%) 20 (12%) 133 (83%) 9 (5.5%) 80 (49%) 99 (61%) 17 (10%) 15 (9%) 24 (15%) 28 (17%) 37 (23%) 11 (7%) ± ± /27 25/ ± ± ± (84%) 6 (12%) 2 (4%) 48 (92%) 13 (25%) 34 (65%) 31 (60%) 13 (25%) 13 (25%) 14 (27%) 8 (15%) 5 (10%) 4 (8%) < < Table 2. Comarison of oerative data of non-obese and obese atients Non-obese atients BMI < 30 (kg/m 2 ²) Obese atients BMI 30 (kg/m 2 ) Duration of surgery, min Conversion to oen surgery n, (%) Extraction incision site, n (%) Iliac fossa Subcostal Pfannenstiel Vaginal Blood loss, ml Hemoglobin loss, g/dl Intraoerative transfusion, n (%) Intraoerative comlication, n (%) Weight of the oerative secimen, g Anatomoathologically-confirmed cancer for renal tumor, n (%) 216 ± 62 8 (4.9%) 123 (75%) 24 (15%) 7 (4%) 9 (6%) 101 ± ± (6.7%) 3 (1.8%) 2 slenic lesions 1 ancreatic lesion 534 ± (86%) 244 ± 54 2 (3.8%) 41 (79%) 7 (13%) 1 (2%) 3 (6%) 105 ± ± ± (100%) Comorbidities and re-oerative data are summarized in the second half of table 1. In the non-obese and obese grous resectively, 133 (83%) and 48 (92%) of atients had at least one comorbidity. When considered in total, there was no statistically significant difference for comorbidities ( = 0.09). When considered individually however, the obese grou had statistically significant higher rates of diabetes ( < 0.001), arterial hyertension ( = 0.049), arterioathy ( = 0.009), chronic breathing disorders ( = 0.004), and anticoagulants or antilatelet drug use ( = 0.049), and the non-obese grou a significantly higher rate of chronic renal failure or dialysis ( = 0.035). Oerative and Post-Oerative Follow-U Data Oerative data are summarized in table 2. There were 8 (4.9%) cases of conversion to oen surgery in the non -obese grou and 2 (3.8%) in the obese grou. Reasons Imact of Obesity on Laaroscoic Renal Surgery 151

4 Table 3. Comarison of ostoerative comlications and follow-u data of non-obese and obese atients Non-obese atients BMI < 30 (kg/m 2 ²) Obese atients BMI 30 (kg/m 2 ) Mean length of hosital stay, days Serum creatinine mg/dl MDRD GFR ml/min/1.73m² GFR loss ml/min/1.73m² Number of intra or ostoerative comlications, n (%) Number of atients with early ostoerative comlications, n (%) Clavien-Dindo I and II Clavien-Dindo III to V Duration of ostoerative follow-u, months Number of atients with late ostoerative comlications, n (%) 5.6 ± ± ± ± (29%) 35 (21%) total: 30 transfusion: 7 arietal hematoma: 6 vaginal incision bleeding: 1 neumoathy: 5 ileus: 4 arietal abscess: 3 acute ancreatitis: 2 confusion: 1 cystitis: 1 total: 5 slenectomy: 1 evisceration + slenectomy: 1 hematoma of the erirenal sace: 1 ancreatic fistula: 1 setic shock/death: 1 23 ± 23 9 incisional hernias (5.8%) including 5 atients with no early comlications 6.0 ± ± ± ± (31%) 10 (19%) total: 8 arietal abscess: 3 arietal hematoma: 1 ileus: 1 neumoathy: 1 rostatitis: 1 fever: 1 total: 2 arietal cellulitis 1 symtomatic leural effusion: 1 20 ± 23 5 incisional hernias (10%) including 4 atients with no early comlications for conversion were, in the non-obese grou: difficulties with dissection due to adhesions associated with revious surgery, olycystic kidney, or recurrent yelonehritis in the oerated kidney (n = 5), toxic megacolon (n = 1), uncontrolled venous bleeding (n = 1) and an uncontrolled slenic lesion necessitating slenectomy (n = 1); and in the obese grou: arterial bleeding from a renal olar artery lesion (n = 2). There were 3 intraoerative comlications that did not require conversion, i.e., 2 slenic lesions and 1 ancreatic lesion, all in the non-obese grou. The duration of surgery and the weight of the oerative secimen were significantly higher in the obese grou, resectively = and = Data for ostoerative comlications are summarized in table 3. MHS was 5.6 ± 3.4 days (0 28 days) in the non-obese grou versus 6.0 ± 3.0 days (2 18 days) in the obese grou ( = 0.437). There were 47 (29%) intra or ost-oerative comlications in the non-obese grou versus 16 (31%) in the obese grou ( = 0.790). No statistically significant differences were found between the 2 grous concerning late ost-oerative comlications (incisional hernia). Risk Factor Analysis Table 4 summarizes risk factors for comlications. After univariate and multivariate analyses, significant risk factors for comlications included: age from 50 to 69 years or 70 years [ = 0.005, resective odds ratios (OR) of 3.0 (95% confidence interval (CI): ) and 3.7 (95% CI: )], ASA scores 2 and 3 4 [ 0.001, resective OR of 3.0 (95% CI: ) and 5.5 (95% CI: )], and weight of the oerative secimen 450 g [ = 0.004; OR of 2.4 (95% CI: )]. The comorbidities found to be significant risk factors for comlications were: arterial hyertension ( = 0.04, OR of 1. 9 (95% CI: ), history of abdominal surgery ( = 0.03, OR of 2.1 (95% CI: ), and chronic obstructive ulmonary disease / slee anea syndrome ( = 0.03, OR of 2.4 (95% CI: ). The analysis of the obesity risk factor adjusted for the other risk factors of ostoerative comlication found OR values statistically similar to the reference value, i.e., an OR of 1.1 (95% CI: ) ( = 0.79). Discussion The revalence of obesity is constantly increasing in industrialized countries. In France obesity increased from 8.5% in 1997 to 15% in 2012 in eole aged greater than 18 years [1]. In our series, 25% of simle/radical laaroscoic nehrectomies involved obese atients. 152 Arfi/Baldini/Decaussin-Petrucci/ Ecochard/Ruffion/Paarel

5 Table 4. Analysis of comlication risk factors and adjusted obesity Factor Sex Female Male Age < 50 years years 70 years Obesity BMI < 30 kg/m² BMI 30 kg/m² ASA score Kidney weight < 450 g 450 g Extraction Iliac fossa Subcostal Pfannenstiel Vaginal Duration of surgery < 200 min 200 min Tye 2/1 diabetes HA: History of ab. surgery Arterioathy COPD/SAS Anticoagulant/antilatelet Smoking Chronic renal failure/dialysis Immunoderession Factor analysis without adjustment Obesity adjusted for each factor Comlications n/n (%) OR (95% CI) OR (95% CI) 28/109 (26%) 35/106 (33%) 8/57 (14%) 32/97 (33%) 23/61 (38%) 47/163 16/52 6/48 (13%) 27/90 (30%) 23/52 (44%) 21/101 (21%) 42/108 (39%) 45/164 (27%) 6/22 (27%) 2/8 (25%) 1/12 (8%) 18/83 (22%) 42/125 (34%) 54/191 (28%) 8/22 (36%) 22/99 (22%) 40/114 (35%) 17/83 (20%) 45/130 (35%) 49/183 (27%) 13/30 (43%) 49/185 (26%) 13/28 (46%) 49/175 (28%) 13/38 (34%) 54/177 (31%) 8/36 (22%) 47/171 (27%) 15/42 (36%) 59/198 (30%) 3/15 (20%) 1.4 ( ) Ref 3.0 ( ) 3.7 ( ) 1.1 ( ) Ref 3.0 ( ) 5.5 ( ) 2.4 ( ) 1.4 (06 3.1) 1.1 ( ) 0.9 ( ) 0.24 (0 1.9) 1.8 ( ) 1.5 ( ) 1.9 ( ) 2.1 ( ) 2.1 ( ) 2.4 ( ) 1.3 ( ) 0.7 ( ) 1.5 ( ) 0.6 ( ) < ( ) 1.0 ( ) 0.99 ( ) 0.8 ( ) 1.1 ( ) 0.94 ( ) 1.0 ( ) 1.01 ( ) 1.1 ( ) 0.99 ( ) 0.96 ( ) 1.14 ( ) 1.12 ( ) 1.18 ( ) 1.12 ( ) Obesity is directly correlated with an increased risk of cardiovascular disease, high blood ressure, tye 2 diabetes, and restrictive lung disease [2, 3]. Numerous studies have confirmed a relationshi between obesity and altered immune resonse via the roduction of ro-inflammatory cytokines by the visceral fat cells, thus rovoking an infiltration of macrohages in the adiose tissue. The resulting chronic inflammation of the tissue lays a redominant role in the metabolic syndrome, associated with liid disorders, insulin resistance, and car- Imact of Obesity on Laaroscoic Renal Surgery 153

6 diovascular diseases [22, 23]. These observations oblige a cautious aroach to the surgical management of obese atients. Several teams have comared laaroscoic nehrectomy in obese and non-obese atients. Anast et al. [13] found that obese atients had not only longer durations of surgery but also greater blood loss and higher rates of transfusion than non-obese atients. Gong et al. [14] however, in their study on 239 atients who underwent radical or artial nehrectomy, did not find significant differences for blood loss between obese and non-obese atients, or significant differences for length of stay, surgical conversion, or ost-oerative comlications. Heimbach et al. [24] comared living donor laaroscoic nehrectomy in 172 obese and 381 non-obese atients. They found that obesity was associated with increased duration of surgery and abdominal wall comlication rates, but was not a risk factor for major comlications. Kurzer et al. [25] showed that BMI was a risk factor for intra-oerative comlications in renal laaroscoic surgery in their study involving 134 atients. Hagiwara et al. [26] suggested that the area of visceral fat measured by CT scan, which is increased in metabolic syndrome, should be taken into consideration, finding that its ability to redict technical difficulties during radical laaroscoic nehrectomy was better than that of BMI. In our study, obesity did not aear to be a significant risk factor for intra and ost-oerative comlications. Even when obesity was adjusted for the other risk factors considered in this study, our obese atients did not aear to be at greater risk of comlications. However, we did find that laaroscoy in obese atients resented technical difficulties rovoking longer durations for surgery and a need to reosition trocars according to the atient s anatomy. Also, oerative secimens were larger in the obese atients, necessitating a larger extraction incision and thus otentially increasing the risk of arietal comlications. Indeed, 10% of our obese atients resented with late incisional hernia, comared to 5.8% of our non-obese atients, although this difference was not statistically significant in our study. In Bird et al s [20] study on 175 atients, the risk of incisional hernia at aramedian extraction sites was increased in atients with high BMI. In a rosective study on general surgeries ranging from hernia reair to ancreaticoduodenectomy and involving 6,336 atients, of whom 1,616 were obese, Dindo et al. [27] found that obesity was not a risk factor for ost-oerative comlications, with the excetion of arietal infections in oen surgery, which romts a reference for a mini-invasive aroach in obese atients. Thus, to limit abdominal wall comlications, techniques such as single-ort laaroscoy and vaginal extraction of the oerative secimen have been develoed [19, 28]. In our series, 12 atients, including three who were obese, benefited from vaginal extraction. The results show romise, with a MHS of 2.2 days (0 4 days, including one ambulatory surgery atient). The only comlication among the vaginal extraction atients was 1 case of limited bleeding from the vaginal incision. In a study involving 1,076 atients, Kaouk et al. [18] demonstrated the feasibility of single-ort surgery, which ermitted a reduced skin incision length. The main limitation of our study is its retrosective nature. We do note, however, that all of our medical files are comuterized and include a rosective collection of information. This ermits a systematic aroach to the exloitation of data. Finally, another asect of our study that should be considered is that some of the cases of renal tumor in our series date to 10 years ago. Had these cases been analyzed today, some would have been assigned to artial nehrectomy. Conclusion Obese atients undergoing laaroscoic simle or radical nehrectomy do not encounter an increased number of intra- or ost-oerative comlications. However, our results may suggest that obese atients run a greater risk of arietal comlications, although we could not demonstrate this with statistical significance in our study. The develoment of single-ort laaroscoy and vaginal extraction of the oerative secimen show interest for and should be exlored in obese atients to reduce the imortance of skin incisions. Conflict of Interest Suorted by a grant from the Bibliothèque scientifique de l Internat de Lyon and les Hosices Civils de Lyon. 154 Arfi/Baldini/Decaussin-Petrucci/ Ecochard/Ruffion/Paarel

7 References Enquête OBEPI htt:// home/recherche/domaines_theraeutiques/ cardio_metabolisme/enquete_nationale_ obei_2012.html. Mokdad AH, Ford ES, Bowman BA, Dietz WH, Vinicor F, Bales VS, Marks JS: Prevalence of obesity, diabetes, and obesity-related health risk factors,2001. JAMA 2003;289: Aung K, Lorenzo C, Hinojosa MA, Haffner SM: Risk of develoing diabetes and cardiovascular disease in metabolically unhealthy normal-weight and metabolically healthy obese individuals. J Clin Endocrinol Metab. 2014;99: Hua X, Ying-Ying C, Zu-Jun F, Gang X, Zu-Quan X, Qiang D, Hao-Wen J: Obesity, hyertension and diabetes mellitus affect comlication rate of different nehrectomy techniques. Actas Urol Es 2014;38: Cantürk Z, Cantürk NZ, Cetinarslan B, Utkan NZ, Tarkun I: Nosocomial infections and obesity in surgical atients. Obes Res 2003; 11: Setiawan VW, Stram DO, Nomura AM, Kolonel LN, Henderson BE: Risk factors for renal cell cancer: the multiethnic cohort. Am J Eidemiol 2007;166: Renehan AG, Tyson M, Egger M, Heller RF, Zwahlen M: Body-mass index and incidence of cancer: a systematic review and meta-analysis of rosective observational studies. Lancet 2008;371: Clayman RV, Kavoussi LR, Soer NJ, Dierks SM, Meretyk S, Darcy MD, Roemer FD, Pingleton ED, Thomson PG, Long SR: Laaroscoic nehrectomy: initial case reort. J Urol 1991;146: Dunn MD, Portis AJ, Shalhav AL, Elbahnasy AM, Heidorn C, McDougall EM, Clayman RV: Laaroscoic versus oen radical nehrectomy: a 9-year exerience. J Urol 2000;164: Shuford MD, McDougall EM, Chang SS, LaFleur BJ, Smith JA Jr, Cookson MS: Comlications of contemorary radical nehrectomy: comarison of oen vs. laaroscoic aroach. Urol Oncol 2004;22: Mendoza D, Newman RC, Albala D, Cohen MS, Tewari A, Lingeman J, Wong M, Kavoussi L, Adams J, Moore R, Winfield H, Glascock JM, Das S, Munch L, Grasso M, Dickinson M, Clayman R, Nakada S, McDougall EM, Wolf IS, Hulbert J, Leveillee RJ, Houshair A, Carson C: Laaroscoic comlications in markedly obese urologic atients (a multi-institutional review).urology 1996;48: Fugita OE, Chan DY, Roberts WW, Kavoussi LR, Jarrett TW: Laaroscoic radical nehrectomy in obese atients: outcomes and technical considerations. Urology 2004;63: Anast JW, Stoller ML, Meng MV, Master VA, Mitchell JA, Bassett WW, Kane CJ: Differences in comlications and outcomes for obese atients undergoing laaroscoic radical, artial or simle nehrectomy. J Urol 2004;172: Gong EM, Orvieto MA, Lyon MB, Lucioni A, Gerber GS, Shalhav AL: Analysis of imact of body mass index on outcomes of laaroscoic renal surgery. Urology 2007;69: Feder MT, Patel MB, Melman A, Ghavamian R, Hoenig DM: Comarison of oen and laaroscoic nehrectomy in obese and non obese atients: outcomes stratified by body mass index. J Urol 2008;180: Klingler HC, Remzi M, Janetschek G, Marberger M: Benefits of laaroscoic renal surgery are more ronounced in atients with a high body mass index. Eur Urol 2003;43: Romero FR, Rais-Bahrami S, Muntener M, Brito FA, Jarrett TW, Kavoussi LR: Laaroscoic artial nehrectomy in obese and non-obese atients: comarison with oen surgery. Urology 2008;71: Kaouk JH, Autorino R, Kim FJ, Han DH, Lee SW, Yinghao S, Cadeddu JA, Derweesh IH, Richstone L, Cindolo L, Branco A, Greco F, Allaf M, Sotelo R, Liatsikos E, Stolzenburg JU, Rane A, White WM, Han WK, Haber GP, White MA, Molina WR, Jeong BC, Lee JY, Linhui W, Best S, Strou SP, Rais-Bahrami S, Schis L, Fornara P, Pierorazio P, Giedelman C, Lee JW, Stein RJ, Rha KH: Laaroendoscoic single-site surgery in urology: worldwide multi-institution alanalysis of 1076 cases. Eur Urol 2011;60: Adam E, Golfier F, Lunel Potencier A, Ruffion A, Paarel P: Laaroscoic nehrectomy with vaginal extraction in obese or overweight atients: the end of wound comlications? Prog Urol 2013;23: Bird VG, Au JK, Sandman Y, De Los Santos R, Ayyathurai R, Shields JM: Comarison of different extraction sites used during laaroscoic radical nehrectomy. J Urol 2009;181: Mucksavage P, McDougall EM, Clayman RV: Laaroscoic transeritoneal nehrectomy for renal cancer: the University of California, Irvine, technique. J Endourol 2011;25: Nieman DC, Henson DA, Nehlsen-Cannarella SL, Ekkens M, Utter AC, Butterworth DE, Fagoaga OR: Influence of obesity on immune function. J Am Diet Assoc 1999;99: Federico A, D Aiuto E, Borriello F, Barra G, Gravina AG, Romano M, De Palma R: Fat: a matter of disturbance for the immune system. World J Gastroenterol 2010;16: Heimbach JK, Taler SJ, Prieto M, Cosio FG, Textor SC, Kudva YC, Chow GK, Ishitani MB, Larson TS, Stegall MD: Obesity in living kidney donors: clinical characteristics and outcomes in the era of laaroscoic donor nehrectomy. Am J Translant 2005;5: Kurzer E, Leveillee R, Bird V: Obesity as a risk factor for comlications during laaroscoic surgery for renal cancer: multivariate analysis. J Endourol 2006;20:794. Hagiwara M, Miyajima A, Hasegawa M, Jinzaki M, Kikuchi E, Nakagawa K, Oya M: Visceral obesity is a strong redictor of erioerative outcome in atients undergoing laaroscoic radical nehrectomy. BJU Int 2012;110: Dindo D, Muller MK, Weber M, Clavien PA: Obesity in general elective surgery. Lancet 2003;361: Gill IS, Cherullo EE, Meraney AM, Borsuk F, Murhy DP, FalconeT: Vaginal extraction of the intact secimen following laaroscoic radical nehrectomy. J Urol 2002;167: Imact of Obesity on Laaroscoic Renal Surgery 155