Retroperitoneal Laparoscopic Surgery: Single Surgeon Experience

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1 european urology supplements 5 (2006) available at journal homepage: Retroperitoneal Laparoscopic Surgery: Single Surgeon Experience Alfredo Aguilera *, Sergio Alonso, Ramón Cansino, Jesús Cisneros, Luis Hidalgo, Javier de la Peña Servicio de Urología, Hospital Universitario La Paz, Madrid, Spain Article info Keywords: Laparoscopic retroperitoneal surgery Renal surgery Adrenal surgery Abstract Objectives: Laparoscopy has become an alternative procedure for various retroperitoneal conditions. It is not easy to learn, and special caution should be taken during its practice because of the presence of large vessels in the surgical field. We report here our 22-mo initial experience with retroperitoneal laparoscopic surgery. Material and methods: The analysed period covers June 2004 to April 2006 (i.e., 22 mo) during which time 128 laparoscopic retroperitoneal surgical procedures were performed. Seventy-eight laparoscopic nephrectomies (43 radical, 16 simple, 14 nephroureterectomies, and 5 in living donors) were performed during this time period. Other types of retroperitoneal laparoscopic surgery were carried out in 50 cases: 10 pyeloplasties, 10 adrenalectomies, 10 partial nephrectomies, 9 retroperitoneal biopsies, 6 stone removals, and 5 cyst marsupialisations. Results: Mean hospital stay was 3.5 d (range: 2 9) for the laparoscopic nephrectomies and 3.3 d (range: 1 7) for the other retroperitoneal laparoscopic surgeries. The conversion rate to open surgery was 1.5% (2 of 128). Conclusions: Learning about renal laparoscopic surgery should be gradual and guided by common sense. The approach to retroperitoneal pathology is technically complex and dangerous because of the presence of the great vessels. The learning curve is long and the potential complications are severe. # 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Corresponding author. P. Castellana 261, Madrid, Spain. Tel ; Fax: address: aaguilera11@yahoo.es (A. Aguilera). 1. Introduction Development and implantation of laparoscopy in urology has been slower as compared with other specialties (general surgery, gynaecology), probably because of the absence of a common condition easily resolved by laparoscopy such as cholecystectomy, ovarian cysts, or tubal ligation. However, there has been an obvious increasing use of this technique in our specialty over the past 10 yr, and while some indications may vary in the future, it may be stated that laparoscopy is here to stay [1] /$ see front matter # 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi: /j.eursup

2 984 european urology supplements 5 (2006) Retroperitoneal laparoscopic surgery is an alternative for a good number of procedures (simple and radical nephrectomy, adrenalectomy, pyeloplasty) and has even exceeded these limits with new indications (living donor extraction, heminephrectomy, retroperitoneal lymphadenectomy). If there is a field that benefits from the advantages of laparoscopy, it is the retroperitoneum. The 2000 review by Janetschek and Marberger [1] provides a list of laparoscopic urologic indications demonstrating this trend. However, the retroperitoneal field is characterised by the presence of large vessels and their branches. This anatomy means that, during plane dissection, if highly anatomic and partly performed by gas, it is essential to remain oriented at all times and to be extremely cautious to avoid a vascular accident that is usually difficult to resolve at laparoscopy. Multiple vascular and intestinal lesions have been reported in the literature [2 5]. After 2 yr in which radical laparoscopic prostatectomy was systematically performed, we started the retroperitoneal surgery program in June Material and methods The period analysed occurred from June 2004 to April 2006 (i.e., a total of 22 mo). A number of conditions were initially rejected because of their greater complexity, including renal tumour excision, radical nephrectomy for tumours greater than 7 cm in size, simple nephrectomy in xanthogranulomatous conditions, adrenalectomy of great masses, or pheochromocytoma. Because of the heterogeneity of indications, we divided the population into complex and less complex procedures (Table 1). We selected the transperitoneal route; it was considered a safer way to start the program because of its advantages of a wider working space and readily identifiable anatomic landmarks compared with the retroperitoneal approach [6,7]. Following our maximum safety principle, we decided to perform the first nephrectomies with manual help using the Gelport (Aesculap), which is a more expensive system than others available in the market (Omniport from Autosuture or LapDisc from Ethicon), but it allows for inserting instruments through the system with no gas loss [8]. After performing 10 nephrectomies, we decided to do without the assisted hand system. The first tumourectomy was performed after 22 retroperitoneal procedures had been completed (12 nephrectomies and 10 diverse surgical procedures). A tumour size greater than 4 cm and a location near the renal hilum were considered contraindications [9 11]. The first transperitoneal extraction from a living donor was carried out after 67 procedures (43 nephrectomies and 24 diverse procedures). In our department, organ extraction from living donors for paediatric receptors has been performed by open surgery since 1984, with a total experience of 63 cases. Table 1 Most common procedures Complex procedure Radical 43 Nephroureter 14 Live donor 5 Partial 10 Pyeloplastia 10 Less complex procedure Simple 16 Adrenalectomy 10 Biopsy 9 Stones 6 Cyst 5 With regards to nephroureterectomy, management of the ureteral time is the most complex part, and several techniques are reported in the literature [12]. In our case, endoscopic deinsertion with early ureteral clipping was performed when the tumour was in the renal pelvis or proximal ureter; below these limits, a bladder cuff was performed by laparoscopy. All surgical procedures were carried out by the same surgeon and assistant. 3. Results 3.1. Nephrectomies During the reported period, 78 laparoscopic nephrectomies (43 radical, 16 simple, 14 nephroureterectomies, and 5 in living donors) were performed in patients with a mean age of 61 yr (range: 22 79) and a mean body mass index (BMI) of 28.1 kg/ m 2 (range: 18 42). Clinical history revealed prior abdominal surgery in 27 (34.6%) cases. Anaesthetic risk score was American Society of Anesthesiologists (ASA) 1 in 26 patients, ASA 2 in 2, ASA 3 in 23, and ASA 4 in 3 (Table 2). Mean bleeding was 177 ml (range: ), and blood transfusions were required in five (6.4%) cases. However, transfusions were given before surgery in two cases because of hematuria causing anaemia and in a third patient after a radical cystectomy with laparoscopic nephroureterectomy. Mean hospital stay was 3.5 d (range: 2 9). Conversion to open surgery was required in two (2.5%) cases because of a lesion in the superior mesenteric artery requiring an endto-side aortomesenteric bypass and uncontrolled Table 2 Demographic data Laporoscopic nephrectomy Other retroperitoneal surgery Age (yr) (no. [range]) 61 (22 79) 50 (19 79) BMI (kg/m 2 ) (no. [range]) 28 (18 42) 25.2 (20 40) Abdominal surgery 27 (34%) 14 (28%)

3 european urology supplements 5 (2006) bleeding from a lumbar vein, respectively. Open surgical revision attributable to bleeding was needed in two (2.5%) cases: in case no. 5 for a perforating branch of the psoas muscles and in case no. 27 for adrenal gland bleeding. One patient died during surgery from uncontrollable arrhythmia 2 h after the start of the procedure. This patient was a 53-year-old male patient, a heavy smoker with a right kidney tumour, BMI of 34 kg/m 2, cardiologic history, high blood pressure, hypercholesterolemia, and ASA 3 anaesthetic risk. Two surgical wound abscesses also occurred, both in patients with BMI above 30 kg/m 2. Acute kidney failure developed after nephrectomy in four patients, all of them older than 70 yr. Other complications that occurred were controlled by medical management, including acute lung oedema (two cases), angina (one case), toxicoderma (one case), gastric ulcer (one case), and acute gastroenteritis (one case). The pathology study of excised specimens revealed 18 cases of classic renal carcinoma pt1, 1 case of pt2, and 22 cases of pt3. Urothelial carcinoma was pta in 2 cases, pt1 in 6, pt2 in 1, pt3 in 4, and pt4 in 1. An oncocytoma was found as single tumour in 2 patients, and kidneys were atrophic in 16 patients Other retroperitoneal laparoscopic surgeries During this time period, other types of retroperitoneal laparoscopic surgery were carried out in 50 cases: 10 pyeloplasties, 10 adrenalectomies, 10 partial nephrectomies, 9 retroperitoneal biopsies, 6 stone removals, and 5 cyst marsupialisations. Mean patient age was 50 yr (range: 19 79), and mean BMI 25.2 kg/m 2 (range: 20 40). Thirty-five patients were ASA 1, 9 were ASA 2, and 6 were ASA 3. Fourteen of the 50 (28%) patients had a history of abdominal surgery (Table 1). Mean intraoperative bleeding was 85 ml (range: ); heminephrectomies were also responsible for the greatest bleedings. Transfusion was required in two (4%) cases, both heminephrectomies. Mean hospital stay was 3.3 d (range: 1 7), and the longest stay corresponded to a tumour excision complicated by a urinary fistula. No case required conversion to open surgery Open retroperitoneal surgeries During these 20 mo we continued to perform retroperitoneal open surgery in cases not considered amenable to the laparoscopic technique. Thus, 56 nephrectomies were performed: 27 for tumours; 22 simple nephrectomies; 5 extractions from living donors, and 2 nephroureterectomies. Mean patient age was 63 yr (range: 33 83), and mean BMI was 27.3 kg/m 2 (range: 20 39). A history of abdominal surgery was found in 19 of the 56 (33.9%) patients. With regards to anaesthetic risk, there were 13 cases of ASA 1, 24 ASA 2, 17 ASA 3, and 2 ASA 4. Mean surgery time was 170 min (range: ), and tumours with caval thrombi were responsible for the longest procedures. Mean bleeding was 600 ml (range: ), and peroperative or postoperative transfusion was required in 19 (33.9%) patients. Mean hospital stay was 8.8 d (range: 4 15). It should be noted that this series cannot be compared with that of laparoscopic nephrectomies because it comprises cases in which this procedure was rejected because of their complexity (caval thrombus, xanthogranulomatous pyelonephritis, big tumour masses). The pathology study of the open nephrectomy specimens revealed 4 conventional kidney tumours pt1, 3 pt2 tumours, 15 pt3 tumours, 3 pt4 tumours, and 2 oncocytomas. One case each of nephroureterectomy was pt2 or pt4 tumour. Among simple nephrectomies, six cases corresponded to polycystic kidneys, seven to xanthogranulomatous pyelonephritis, and seven to renal atrophy, and two were emergency procedures performed for multiple trauma with renal hilum involvement. Complications included three surgical wound seromas, one duodenal fistula, one intra-abdominal abscess requiring surgical drainage, one pulmonary thromboembolism, one angina pectoris, one acute renal failure, one pneumonia, one acute gastroenteritis, and one postoperative death (case no. 22, an 83-year-old male with a big left kidney tumour that caused hematuria episodes inducing anaemia; the tumour turned out to be a pt4 conventional kidney tumour). With regards to other types of retroperitoneal surgery, a total of 21 open procedures were performed: 3 adrenalectomies, 3 for retroperitoneal fibroses, 4 partial nephrectomies, 5 for pyeloureteral junction stenoses, 5 for kidney stones (pyelonephrolithotomy), and 1 for a local relapse of a renal carcinoma. Mean patient age was 55.6 yr (range: 21 74), and mean BMI was 26.6 kg/m 2 (range: 23 30). Anaesthetic risk was ASA 1 in 8 cases, ASA 2 in 10 cases, and ASA 3 in 3 cases. A history of abdominal surgery was found in two patients. Mean surgery time was 163 min (range: ), and no patient required postoperative transfusions. Mean hospital stay was 7.8 d (range: 1 17). 4. Discussion Retroperitoneal laparoscopic surgery is a good alternative to the open approach.

4 986 european urology supplements 5 (2006) The two different techniques, transperitoneal and retroperitoneal, have clear characteristics: Whereas the transperitoneal approach provides a better space and orientation, retroperitoneoscopy offers a faster access to the renal hilum and allows for a decreased intestinal manipulation, but demands greater caution with intestinal lesions, generally thermal, that usually go unnoticed. Several studies have compared both approaches, and we agree with the conclusion they usually reached: The surgeon should use the approach with which he or she is more comfortable and experienced [6,13]. Our department chose the transperitoneal approach to start the program on the basis of these reasons. While we have subsequently performed some procedures using retroperitoneoscopy, we think it is a somewhat more complicated approach, particularly with regards to orientation. With regards to use of the manual port, our experience was positive in the early cases. Advantages of this system (a visual reference facilitating learning, touch, bowel loop separation, increased safety preventing vascular lesions, use of incision for specimen removal) are greater than its disadvantages (a somewhat larger incision generally, loss of gas, difficult placement in a small abdomen) [8,14]. However, as experience is gained, having a compromised hand and the increased difficulty for delicate dissection make it convenient to pass to pure laparoscopy. In our experience, the handassisted device has been relegated to laparoscopic organ removal from a living donor. Early contraindications have naturally varied over time so that cases in which laparoscopy is ruled out decrease as experience is gained. Tumour size is a good example of this. Laparoscopic nephrectomy initially was not considered to be indicated for tumours greater than 7 cm because of technical difficulties, while, in the most recent cases, we performed nephrectomies in patients with tumours up to 15 cm in size. In this regard, a review of literature reports in recent years would also show the changes in the criteria for considering tumour size as a contraindication. Thus, although no agreement exists about the maximum size, as early as 2001 various authors proposed the laparoscopic technique for tumours greater than 10 cm [15]. More recently, reference is found to handassisted laparoscopic nephrectomies in tumours greater than 9.5 cm in size, with authors concluding that the tumour limit is directly related to the surgeon s experience [16]. At our department, we currently think that the presence of a tumour thrombus in the vena cava is a contraindication for laparoscopy. This is a controversial subject in the literature. Desai et al. [17] reported a series of 16 cases of tumour thrombi with renal vein involvement (level I involvement) in which renal vein clamping was performed with laparoscopic mechanical suture encircling vein ostium. The thrombus was squeezed out towards the kidney in all cases, and a vena cava opening was not required. This study also discussed an animal model for performing this procedure with caval involvement by the tumour thrombus. In 2002, 2004, and 2005, there were at least three articles reporting hand-assisted right radical nephrectomy in the presence of a caval thrombus: Sundaram et al. [18] and Varkarakis et al. [19] reported cases of patients with tumour thrombi of 1 cm and 2 cm, respectively, in the vena cava in which a hand-assisted transperitoneal approach was used. Whereas in the first case the whole nephrectomy was hand-assisted, with prior embolisation of the renal artery, the four cases of Varkarakis renal vein and vena cava dissections were completely laparoscopic, with no prior embolisation. In their 2005 article, Disanto et al. [20] reported the case of an 87-year-old female patient with a right kidney tumour and a 7-cm-long tumour thrombus resolved by using a hand-assisted retroperitoneoscopic approach. Hand-assisted laparoscopy probably allows for performing this procedure, while undoubtedly demanding and requiring a great experience from the surgical team. In our view, the presence of a tumour thrombus beyond the renal vein is a contraindication to laparoscopy. A history of abdominal surgery was not considered an absolute contraindication. Because of our lower experience with retroperitoneoscopy, we initially decided to attempt the transperitoneal approach in these cases. Conversion to open surgery was not required in any of these procedures, which were all successfully completed. A careful approach is needed, inducing pneumoperitoneum through a minilaparotomy (approximately 2 cm) and placing at least one additional trocar to separate adhesions. In an interesting article, Viterbo et al. [21], in addition to a literature review on laparoscopic complications, reported their series of 48 patients with a history of abdominal radiation therapy and/or surgery undergoing retroperitoneoscopy for renal or adrenal conditions. These results were compared with a series of 30 patients with no such history, and no statistically significant differences were found between the groups (surgery time, bleeding, complications, hospital stay). We agree with their conclusion that retroperitoneoscopy is a good alternative in these patients. However, we think that a certain experience in

5 european urology supplements 5 (2006) the transperitoneal approach is required to learn retroperitoneoscopy. Today, after almost 2 yr of use of retroperitoneal laparoscopic surgery, we retain as absolute contraindications suspected local infiltration of tumour process with vascular or intestinal involvement, xanthogranulomatous pyelonephritis, and a caval tumour thrombus. Partial nephrectomy is probably the most demanding indication of the procedure and the one requiring more experience, and should not be performed if intracorporeal suture is not mastered. Highly experienced authors agree with this view in recent publications analysing their series, each consisting of approximately 200 cases and giving very interesting descriptions of the complications found that show the complexity of the procedure [9,22,23]. With regards to laparoscopic organ removal from a living donor, while not so technically demanding as partial nephrectomy, it should not be done until a substantial experience is gained in retroperitoneal laparoscopic surgery because of the complexities involved: It is a procedure affecting two patients, one of them healthy, and the kidney should be removed with no lesions and the maximal vessel length possible. Leventhal et al. [24,25] agreed with these views in several studies, one of which was a review of 500 cases of laparoscopic extraction. As for us, we perform this surgery only on left kidneys for the time being because we think that the length of the right renal vein is too short. In laparoscopic nephroureterectomy, the greatest complications, both technical and in terms of oncologic results, are found with ureter management. In an interesting article, Steinberg et al. [26] reviewed the different possible approaches to the ureter and their oncologic implications: What is the most appropriate approach, and are survival and disease recurrence compromised by any of the procedures? These authors concluded that no procedure currently appears to be superior to the others, and that the surgical oncologic criterion should of course prevail, with additional studies on oncologic results being required. A Gerber and Stockton [27] article based on questionnaires completed by 605 urologists from different countries (United States, Europe, Asia, and Canada) reported that European urologists most frequently perform open surgery, whereas the hand-assisted procedure is more popular among American urologists, and Asian urologists show the greatest preference for retroperitoneoscopy. Most urologists prefer open surgery to manage the ureter in nephroureterectomy. These results should not be regarded as categoric and extrapolative; however, this article demonstrates on the one hand the lack of consensus for ureter management, and on the other hand an ever increasing trend to use laparoscopy in urology (compared with the same study done in 2002), as well as the possible variations with regards to approach and indications depending on the country and surgical school. Whenever a new program is started, it may be expected that a number of complications will occur, but they will then decrease over time as more experience is gained. It is important to be prepared for such complications and to try and resolve them, by laparoscopic means if possible and always without endangering the life of the patient. The most serious complications in our series were a death in a nephrectomy patient because of uncontrolled arrhythmia, an acute stroke 24 h after an adrenalectomy in an 80-year-old female patient, and a lesion in the superior mesenteric artery in a radical nephrectomy requiring conversion to open surgery [28]. There are many references in the literature to complications of laparoscopic surgery, among which special mention should be made to a meta-analysis [29] focusing on renal surgery in which articles published between 1995 and 2004 were analysed. Among the 405 publications reviewed, only 56 met inclusion criteria, and a total of 4859 procedures were therefore analysed. Major and minor complications of the different pure and handassisted renal laparoscopic procedures (radical and simple partial nephrectomy, nephroureterectomy, living donor) were compared. Although difficulties in data collection because of the retrospective nature of the study and the lack of standardisation of complications in the literature were recognised, the authors arrived at some interesting conclusions: Major and minor complication rates were approximately 10% and 2%, respectively; the highest rate of major complications (21%) was associated with partial nephrectomy (need for transfusion and urinoma); and finally, the hand-assisted procedure is associated with a higher rate of incision complications (1.9% vs. 0.2%). 5. Conclusions As stated in the introduction, laparoscopic surgery in urology is obviously not a future project but a reality, and this observation is even clearer in its retroperitoneal application. The development of a retroperitoneal laparoscopic surgery program should be gradual, and it should not be intended

6 988 european urology supplements 5 (2006) to cover all conditions or patients from the beginning. On the other hand, for a program of retroperitoneal laparoscopic surgery to be implemented with the highest guarantee, a sufficiently high volume of patients (at least one procedure weekly) should be available to maintain and develop the skills of the surgical team. We prefer the transperitoneal approach because of its advantages (wider working space and readily identifiable anatomic landmarks). Hand assistance device may be useful in the beginning. As a final conclusion, we think that application of the laparoscopic technique in urology should not be disregarded no matter how difficult and strenuous it may be. Urologists must continue to strive to be in the forefront of surgery and pave the way for other surgical specialties. Our patients will undoubtedly benefit from this progress. References [1] Janetschek G, Marberger M. Laparoscopic surgery in urology. 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