A case re port of the first lap aro scopic rad i cal nephrectomy done at the Clinic of Urol ogy, Clin i cal Cen tre of Ser bia

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1 /PRIKAZ SLU^AJA UDK (497.11)(089) DOI: /ACI K A case re port of the first lap aro scopic rad i cal nephrectomy done at the Clinic of Urol ogy, Clin i cal Cen tre of Ser bia... B.M. Kajmakovi} 1, Z.M. D`ami} 1,2, S. Dragi}evi} 1, M. A}imovi} 1,2, B. Milojevi} 1, J. Had`i Djoki} 3 1 Clinic of Urol ogy, Clin i cal Cen tre of Ser bia, Bel grade 2 University of Bel grade, Fac ulty of Med i cine 3 Serbian Acad emy of Sci ences and Arts, Bel grade Lap aro scopic in ter ven tions are at the very be gin - ning of its evo lu tion in the Clinic of Urol ogy. The first steps have been made pri mar ily to cope with prob lem of varicocele. We con tin ued to gain lap - aro scopic ex pe ri ence by switch ing to solv ing some demanding intervention, primarily kidney cyst. The only log i cal next step lead to lap aro scopic re - nal sur gery. So, af ter a few suc cess ful pri mary sim ple nephrectomy, the next step was to perform a lap aro scopic rad i cal nephrectomy. To day, at the Clinic of Urol ogy, Clin i cal Cen ter of Ser bia we suc - cessfully perform much more demanding interven - tions, such as extraperitoneal lap aro scopic rad i cal pros ta tec tomy. In this pa per we pres ent our ex pe ri - ence with the first lap aro scopic rad i cal nephrectomy, which was done at the Clinic of Urol ogy, Clin i cal Cen - ter of Ser bia. Key words: lap a ros copy, lap aro scopic rad i cal nephrectomy, Veress nee dle, re nal cell car ci noma (RCC). rezime INTRODUCTION The first lap aro scopic rad i cal nephrectomy dates back to the late eight ies. The first "sin gle site" Lap aro - scopic nephrectomy was de scribed by Ro man and associates1 (2008 th ). At that same year, the same au thors de - scribes two more cases of the same in ter ven tion. In all three cases, there were no sig nif i cant com pli ca tions both, dur ing the in ter ven tion nor in the perioperative pe riod. The du ra tion of sur gery was 133 min utes, es ti mated intraoperative blood loss was about 30 ml and the length of the skin in ci sion for the ex trac tion of the sam ple was about 45 mm. Lap aro scopic nephrectomy was ac com pa - nied by a lesser de gree of post op er a tive pain and less need for post op er a tive an al ge sia. This pro ce dure re duces the num ber of hos pi tal iza tion days, re duced con va les cence time. A par tic u lar as pect may be thrown on the cos metic out come of the scar. Com pared to a con ven tional open sur gi cal pro ce dure, in the course of lap aro scopic sur gery is the ob served dif fer - ence in the perioperative com pli ca tions, as well as the intraoperative blood loss, even though it was found that, dur ing lap aro scopic sur gery is less blood loss due to better con trol hemostases 2,3. As well as any other sur gery, lap aro scopic rad i cal nephrectomy car ries out its own haz ards, which have to be rec og nized by urol o gist at any time dur ing the op er a - tions. Par tic u lar care should be taken on a coun ter in di ca - tions for this type of sur gery such as non-reg u lated coagulopathy, un treated in fec tions, es pe cially in fec tions of the an te rior ab dom i nal wall, as well as threat en ing hypovolemic shock 4. Ear lier sur gi cal in ter ven tion is not an ab so lute con tra in di ca tion for lap aro scopic rad i cal nephrectomy. In pa tients who were sub jected to prior sur gi cal pro ce dures in the ab do men, it is rea son able to ex pect a higher per cent age of ad he sions that ex tend the op er at ing time, as well as per cent age of bowel in jury dur - ing insufflation of gas through Veress nee dle, dis so ci a - tion, and bowel prep a ra tion. Much more dan ger ous is vi - o la tions of vas cu lar struc tures dur ing the prep a ra tion of re nal vas cu lar pedicel 5, which in some cases can end with death. All this im plies that when per form ing lap aro scopic in ter ven tions, in clud ing lap aro scopic rad i cal nephrectomy, it re quire an ex tra cau tion, es pe cially if the in ter ven - tion is tak ing in ex pe ri enced op er a tor. Ev ery be gin ning is dif fi cult, but if one take to ac count that the learn ing curve for lap aro scopic rad i cal nephrectomy, es pe cially for urol o gists who have al ready some ex pe ri ence in lap aro scopic re nal sur gery, is a rel a tively short 6,7,8, the fi nal out come can only be en cour age. CASE RE PORT We re port a case of a 55 year old pa tient RR, a se cu - rity guard from Bel grade. It is the pa tient who was two months prior to ad mis sion to the clinic be gan to feel pain in the right flank by type of re nal colic. The doc tors in pri mary med i cine has treated him with an al ge sic ther apy. Since the month of ini ti a tion of ther apy passed and his sit u a tion has not im proved, the pa tient was re ferred to the Clinic of Urol ogy for fur ther di ag no sis and treat ment.

2 108 B.M. Kajmakovi} et al. ACI Vol. LXI FIG URE 1. MSCT The pa tient had not had any as so ci ated chronic dis eases. He was not sub jected to pre vi ous sur gery. He was not a smoker nor con sumer of al co hol. The fam ily his tory did not state a pres ence of dis ease that would be of im por - tance to he red ity or cases of ma lig nant dis eases. At the first ex am i na tion the pa tient was pro vided with com plete blood count (CBC) anal y sis, bio chem i cal anal - y sis, as well as anal y sis of the urine sed i ment and urine cul ture (UC). The only de vi a tion from the ref er ence val - ues was ob served in the level of sed i men ta tion, which was ac cel er ated, with val ues of 32. Pa tient felt a dull pain in the right flank with the same in ten sity as prior re gard - less of an al ge sic ther apy. Oth er wise, the pa tient feel well with out any dis com fort in uri na tion. Ul tra sound exam ver i fied the nor mal find ings in the left kid ney, blad der was with or derly edges with out intraluminal pro lif er a tion and with small ho mo ge neous pros tate. On the right kid - ney was ob served the ex is tence of tu mor for ma tion, lo - cal ized interpolar with par tial ex pan sion on the hi lum of the right kid ney. For ma tion was non homogen demarcated and encapsulated, with overall dimensions of 70x55 mm. In ci den tally in up per calices group of right kid ney there was seen cal cu lus mea sur ing about 10 mm in di am e ter. There was no sign of any de gree of re nal de te ri o ra tion on both sides. Hilar glands did not ap pear en larged, nor glands in retroperitoneal space along the main blood ves - sels. It was de cided to per form MSCT for better un der - stand the sit u a tion and the de ci sion on de fin i tive treat - ment. Find ings on MSCT showed a pres ence of tu mor with size 73x54 mm, interpolary lo cal ized to the hi lum of the right kid ney. The tu mor was het er o ge neous soft tis sue char ac ter and with type of re nal cell car ci noma (RCC). Tu mor was not pen e trate kid ney cap sule and was not en - gage re nal blood ves sels, but was in close con tact with the same (Fig ure 1,2). In the up per pole of the kidney there was a stone measuring about 8 mm in diameter. Clin i cal stage was T2,N0,M0. Hav ing re gard to the po si tion of tu mor, the pa tient age and pre vi ous lap aro scopic ex pe ri ence, it was pro posed to pa tient a lap aro scopic rad i cal nephrectomy with pres er va - tion of ipsilateral adrenal gland. FIGURE 2. MSCT (CLEARLY VIS I BLE ONLY ONE RE NAL ARERY) FIGURE 3. THE PA TIENT PLACED IN THE LEFT DECUBITAL PO SI - TION Af ter a de tailed ex pla na tion of the na ture of the dis - ease, the planned sur gi cal treat ment with pos si ble com - pli ca tions and po ten tial risk for the con ver sion of the in - ter ven tion, the pa tient con sented to the pro posed in ter - ven tion, as ver i fied by per sonal sig na ture on the informed consent form.

3 Br. 1 A case re port of the first lap aro scopic rad i cal nephrectomy done at the 109 Clinic of Urol ogy, Clin i cal Cen tre of Ser bia FIGURE 4. POSITION OF PORTS FIGURE 5. HISTOPATHOLOGICAL SEMPLE FIGURE 6. POST OP ER A TIVE AP PEAR ANCE OF THE OP ER A TIVE FIELD SURGICAL TECHNIQUE The pa tient was ini tially placed in a su pine po si tion for premedication and for in tro duc tion to gen eral endotracheal an es the sia (GETA). Nasogastric suc tion was placed for de com pres sion of the stom ach and the uri - nary cath e ter to mon i tor fluid bal ance. The pa tient was placed in the left decubital po si tion and the clean ing of op er a tive field has been done (Fig ure 3). Af ter op er a tive field was pre pared, we pro ceed with sur gi cal in ter ven tion. In stru men ta tion that was used dur - ing the in ter ven tion fol lows be low: In stru men ta tion (gen eral): Scal pel; Two Alison grips; Surgical forceps; Scissors; Nee dle holder; Su ture for re con struc tion of sub cu ta ne ous tis sue (1/0); Su ture for the re con struc tion of the skin (3/0). Ports: One 10 mm work ing port (metal port); One 11 mm op ti cal port for the place ment of the cam era - plas tic port; Two 5-mm work ing port plas tic; Re duc tion of 10 mm port; Bi po lar ca ble A60003C, Monopolar ca ble A0357. Lap aro scopic in stru men ta tion: Monopolar scis sors A64320A (WA608800C sleeve, han dle WA60101C); Monopolar hook A64320A (sleeve WA608800C); Bi po lar Merryland dis sec tor WA6430C (sleeve WA60800C, dr{kawa60101c); Hem-o-Lock larger (M); Suc tion; Endobag 15 mm (M); Lap aro scopic Nee dle holder, Storz 26173KAF. All lap aro scopic in stru ments are Storz. Pneumothorax is es tab lished through place ment of the Veress nee dle along the right edge of the m. rectus 5 cm lat er ally and cra ni ally from um bi li cus. Dur ing place ment of Veress nee dle we re spected all the pos tu lates for safe place ment. Af ter the es tab lish ment of pneumothorax in the same place it was placed 11 mm op ti cal trocar. Ex - plo ra tion was per formed in or der to look for the pos si ble in jury dur ing place ment Veress nee dle. Af ter wards, we pro ceed with the place ment of the work ing ports. One 10 mm work ing port with gear is placed on the four fin ger breadths from the op ti cal port, and di ag o nal to the op ti cal port. Sec ond one, 5-mm port was placed on the mid dle line of the an te rior su pe rior iliac spine and the um bi li cus. An other 5-mm work ing port was placed near the ksifoid procesus, used for con tin ued trac tion and for prep a ra tion during operation and traction of the liver (Figure 4). The ini tial step was de lib er a tion of hepatic co lonic flex ure up to the level of the iliac ves sels. Af ter that we ap proached to in ci sion of the peri to neum along the avascular Told line, but not com pletely in or der to avoid the de scends of kid ney me dial. In that way one can avoid compromisation of re nal vas cu lar pedicle. Af ter that one per formed the de lib er a tion of du o de num for better ac cess to the lower v. cava. Af ter wards, the in ci sion of Gerot fas cia has per formed up high un der the liver that has been el e vated us ing clamps in tro duced through the fourth work ing port. Gerot fas cia is in cised over a length of 5 cm. Dis so ci a tion oc curred sub se quent to the front side of the in fe rior vena cava with the front wall of the ves sel fully de nuded. The lat eral side of the in fe rior vena cava was relesed. Af ter that one en coun tered the con flu ence of sper matic vein and the con flu ence of the re nal veins. By care ful dis so ci a tion one re leased the en tire lu men of the sper matic and re nal veins. Sper matic vein, that has been lib er ated in the length of 5 cm, was li gated with the two hem-of-lock clips and cat prox i mally and dis tally. Next step was into fur ther prep a ra tion of ad i pose tis sue parakaval lat er ally un til it was seen musculus psoas. Left ureter was iden ti fied, and lib er ated up to the level of the iliac ves sels. The ureter was li gated at the level of the iliac blood ves sels with one hem-o-lock clip and cut off. Fur ther ap proach to the re lease of the lower half of the

4 110 B.M. Kajmakovi} et al. ACI Vol.LXI right kid ney was en abled. Once the lower pole of the right kid ney has suf fi ciently been re leased, the op er at ing plan is re di rected to the re nal vas cu lar struc tures. Again the re nal vein was ex plored and gen er ally ad di tion ally re - leased. Af ter that it was easy to iden ti fied the re nal ar ter - ies. It po si tion was some what cra nial and pos te rior of re - nal vein. Re nal ar tery was li gated af ter a suf fi cient re - lease with hem-o-lock. We waited a few min utes to es - tab lish the re nal out flow in fully, as was con firmed by col laps ing the re nal veins. Next step was li ga tion of the re nal vein. This was done with two hem-on-lock clips prox i mally and dis tally; the lat ter are placed right next to the con flu ence of re nal vein in the in fe rior vena cava. Vein was cut, giv ing a clear plan to re nal ar tery, that was fur ther de lib er ated to a suitable length for safe ligation (3 cm in length). Afterwards, the placement of the two hem-o-lock clips were applied proximally and distally and renal artery was cut. With this a vas cu lar pedicle of the right kid ney has been en tirely re strained. Af ter that one can easy ap proach for safe de lib er a tion of up per pole of the right kid ney along a clear plan to the ad re nal gland. De lib er at ing the up per pole of the kid ney is eas ier with ap proach from the lat eral ab dom i nal wall and by the pos te rior side along the mus cle psoas. Thus, the right kid ney was en tirely freed and ready for extraction. Via 15 mm port, which was in tro duced in place of the first 5 mm port endobag has been in tro duced to place the right kid ney en tirely. In the in ter ven tion morselator was not used. Kid ney was drawn through the ex tended cut on the front of the ab dom i nal wall in the length of 5 cm, with it's lon gi tu di nal po si tion (Fig ure 5). When ex tend ing in ci sion mus cles of the an te rior ab dom i nal wall were only dissociated, not cut. Ad di tional con trol of hemostasis of re nal lodges was per formed, the po si tion of the hem-o-lock's were checked, fol lowed by the place ment of drain through the 10 mm port. Af ter that the evac u a tion of the re main ing gas from the ab dom i nal cav ity was made, ports were re - moved, and re con struc tion of sur gi cal wounds was per - formed of the port sites. The ban dage was placed on op - er a tional openings (Figure 6). DIS CUS SION Lap aro scopic rad i cal nephrectomy in volves re moval of the en tire kid ney with the cor re spond ing ureter to the level of the iliac ves sels, to gether with Gerot fas cia. Re - moval of the ad re nal gland is di rectly con di tioned by the po si tion of the tu mor, so that all tu mors lo cal ized in the up per third of the kid ney re quire re moval of the cor re - spond ing ad re nal gland. Lymphadenectomy is still con - tro ver sial. In this par tic u lar case there was no need for re - moval the ad re nal gland nor to per form lymphadenectomy. On the day of sur gery the pa tient re ceived a third-gen - er a tion cephalosporin (a one-time bolus), fol lowed by orally an ti bi otic ther apy with third gen er a tion of cephalosporin en tire time thor ough post op er a tive re cov ery. Time of sur gery was 150 min utes. Dur ing the op er a tion, FIG URE 7. HIS TOL OGY the to tal intraoperative blood loss was 50 ml. Quan tity of insufflated gas (CO2) was 352 li ters. Sim i lar pre lim i nary re sults were pub lished by other authors1. Al though some au thors re port burn ing sen sa tion on the side of pa tients, or some de gree of pain sen sa tion 9, d uring re cov ery, our pa tient did not feel any pain. Diuresis on uri nary cath e ter was ap prox i mately 2500 ml per day, and the drain was not evac u ated any con tent. The nasogastric tube was re moved im me di ately af ter trans port ing the pa tient from the op er at ing room. On the first post op er a tive day, the pa tient was trans fer to semi-in ten sive care ward. Drain was re moved at the sec - ond post op er a tive day. Dur ing first two post op er a tive days there was no evac u a tion of the con tents. The uri nary cath e ter was re moved at the sec ond post op er a tive day, the pa tient was then prop erly uri nated. He was dis - charged from the hos pi tal at the fifth post op er a tive day in good gen eral con di tion. Dur ing hos pi tal iza tion, the pa - tient wasn?t fe brile. Op er a tive in ci sions are healed pri - mar ily. On the tenth post op er a tive day, the stitches were re moved. Pa tient felt good and, said with his own words, "he fill like he was not op er ated on." Histopathologic find ings, spoke in fa vor of re nal cell car ci noma (RCC), clear cell type, with sec ond de gree of nu clear grade (by Fuhrman), and patho log i cal stage of dis ease was pt1b, Nx, Mx (PH num ber of bi op sies: /14 Fig ure 7). CON CLU SION Lap aro scopic rad i cal nephrectomy is an ad e quate sub - sti tute for an open sur gi cal pro ce dure. The ther a peu tic ef - fect is the same, radicallity of op er a tions is en sure, intraoperative blood loss is minimiz, the num ber of days of hos pi tal iza tion small and post op er a tive re cov ery and com fort of pa tients is in creas ing. This case has shown that even with a mod est lap aro scopic ex pe ri ence, a urol o - gist rel a tively ex pe ri enced in open sur gery, can quickly and safely, but at the same time with more cau tious, per - form rad i cal nephrectomy equally ef fec tive and safe.

5 Br. 1 A case re port of the first lap aro scopic rad i cal nephrectomy done at the 111 Clinic of Urol ogy, Clin i cal Cen tre of Ser bia SUMMARY Laparoskopske intervencije su na samom po~etku svoje evolucije na Klinici za urologiju. Prvi koraci su u~injeni prvenstveno u smislu re{avanja varikocele, nakon ~ega su laparoskopska iskustva nastavila da se sti~u prelaskom na re{avanjem ne{to zahtevnijih intervencija, prvenstveno cista bubrega. Kao jedini logi~an slede}i korak nametala se laparoskopska bubre`na hirurgija. Tako, nakon nekoliko primarnih uspe{nih jednostavnih nefrektomija, slede- }a stepenica je bila izvodjenje laparoskopske radikalne nefrektomije. Danas se na Klinici za urologiju, Klini~kog centra Srbije sa uspehom izvode i mnogo zahtevnije intervencije, kao {to je laparoskopska radikalna ekstraperitonealna prostatektomija. U ovom radu prikazujemo na{e iskustvo sa prvom laparoskopskom radikalnom nefrektomijom koja je bila u~injena na Klinici za urologiju, Klini~kog centra Srbije. Klju~ne re~i: laparoskopija, laparoskopska radikalna nefrektomij, Veress igla, re nal cell car ci noma (RCC). REF ER ENCE: 1. Raman JD, Bensalah K, Bagrodia A, et al. Lab o ra - tory and clin i cal de vel op ment of sin gle key hole um bil i cal nephrectomy. Urol ogy 2007 Dec;70(6): Fan X, Lin T, Xu K, et al. Laparoendoscopic sin - gle-site nephrectomy com pared with con ven tional lap aro - scopic nephrectomy: a sys tem atic re view and meta-anal y - sis of com par a tive stud ies. Eur Urol 2012 Oct;62(4): Hemal AK1, Kumar A, Kumar R, Wadhwa P, Seth A, Gupta NP. Lap aro scopic ver sus open rad i cal nephrectomy for large re nal tu mors: a long-term pro spec tive com par i son. J Urol Mar;177(3): Capelouto CC, Kavoussi LR (1993) Com pli ca tions of lap aro scopic sur gery. Urol ogy 42:2? Permpongkosol S, Link RE, Su LM, et al. Com pli ca - tions of 2,775 uro log i cal lap aro scopic pro ce dures: 1993 to J Urol 2007;177:580?5. 6. Keeley and Tolley.A re view of our first 100 cases of lap aro scopic nephrectomy: de fin ing risk fac tors for com - pli ca tions. Brit ish Jour nal of Urol ogy 1998;82;5: Rassweiler J, Tsivian A, Kumar AV, et al. Oncologic safety of lap aro scopic sur gery for uro log i cal ma lig nancy: ex pe ri ence with more than 1,000 op er a tions. J Urol 2003; 169: Fahlenkamp D, Rassweiler J, Fornara P, et al. Com - pli ca tions of lap aro scopic pro ce dures in urol ogy: ex pe ri - ence with 2,407 pro ce dures at 4 Ger man cen ters. J Urol 1999;162: M. G. Oefelein and Y. Bayazit, Chronic pain syn - drome af ter lap aro scopic rad i cal nephrectomy. Jour nal of Urol ogy, vol. 170, no. 5, pp , 2003.