LAPAROSCOPIC NEPHRECTOMY USING A RETROPERITONEAL APPROACH : COMPARISON WITH A TRANSABDOMINAL APPROACH

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1 LAPAROSCOPIC NEPHRECTOMY USING A RETROPERITONEAL APPROACH : COMPARISON WITH A TRANSABDOMINAL APPROACH Yoshinari One,'" Shinichi Ohshirna, Satoshi Hirabayashi,3 Yukio Hatano,4 Toshibumi Sakakibara,S Hiroaki Kobayashi,6 and Yasuji Ichikawa7 'Department of Urology, Komaki Shimin Hospital, Komaki, Japan, Department of Urology, Shakai Hoken Chukyo Hospital, Nagoya, Japan, 3Department of Urology, Narita Memorial Hospital, Toyohashi, Japan, 4Department of Urology, Gamagori Shimin Hospital, Gamagori, Japan, Department of Urology, Nishio Shimin Hospital, Nishio, Japan, 6Department of Urology, Nagoya nd Red Cross Hospital, Nagoya, Japan, and 'Department of Urology, Hyogo Prefectural Nishinomiya Hospital, Nishinomiya, Japan To evaluate the efficacy of the retroperitoneal approach in laparoscopic nephrectomy, our procedures involving laparoscopic nephrectomy using a retroperitoneal approach are described and the clinical results of six patients treated in this way are compared with those of 3 transabdominally nephrectomized patients. Of the six retroperitoneally nephrectomized patients, six kidneys were successfully removed without severe complication, and 8 kidneys were successfully removed in the 3 intraabdominally approached group. Three of the 8 patients had complications requiring open laparotomy. The operating time was.7 hours in the 6 retroperitoneal patients and 4.4 hours in the 8 transabdominal patients. Estimated blood loss was 9 ml in the retroperitoneal group and 4 mi in the transabdominal group. The mean postoperative hospital stay was 8 days and 9 days, respectively. These results indicate that the retroperitoneal approach might be preferable in laparoscopic nephrectomy. Int J Urol 99;:-6 Key words: laparoscopic surgery, laparoscopic nephrectomy, kidney, nephrectomy INTRODUCTION In just a few years laparoscopic surgery has made great ad~ancesl-~ and the results have recently improved because of the "learning-curve'' effect. 'O-I However, there are still some difficulties with the transabdominal approach to retroperitoneal organs such as the kidneys and adrenal glands. The retroperitoneal approach developed by Gaur et al., might help to solve these difficulties associated with transabdominal laparoscopic nephrectomy and adrenalectomy. l To evaluate the efficacy of the retroperitoneal approach, we have used this procedure for laparoscopic nephrectomy since January 994. In this paper, we present our procedure for the retroperitoneal approach and compare our clinical results for retroperitoneally nephrectomized patients with those of transabdominally nephrectomized patients. PATIENTS AND METHODS Thirty-eight patients with benign renal disease entered our laparoscopic program between July 99 and May 994. Received Aug. 8, 994; accepted for publication in revised form Dec., 994. *Requests for reprints: Department of Urology, Komaki Shimin Hospital, - Johbushi, Komaki 48, Japan. The last 6 were treated using a retroperitoneal approach between January and May 994. In these 6 patients, the age ranged from 6 to 7 years, mean, 7 years; two patients were male and four female. Three patients had right-sided disease and three had leftsided. The original disease was urinary calculus in two patients, vesicoureteral reflux in one, ureteral stricture in one, ectopic ureter in one and arteriovenous malformation in one. All six kidneys were severely damaged and caused recurrent urinary tract infection, frank hematuria and flank pain. One of the 6 patients had previously undergone three gynecological operations. The other 3 patients were treated using a transabdominal approach. In these patients, the age ranged from 8 to 8 years, mean, 3 years; patients were male and 7 female. Twelve patients had right-sided disease and had left-sided. The underlying disease was urinary calculus in patients, vesicoureteral reflux in 9, renovascular disease in three, ureteric stricture in two, ureteropelvic junction obstruction in three, ectopic ureter in one and arteriovenous malformation in one. All the patients had severely damaged kidneys, with recurrent urinary tract infection, hypertension, frank hematuria and flank pain. One patient had a history of previous abdominal surgery involving laparoscopic cholecystectomy. The characteristics of each patient group are shown in Table I, /9/-/US$3. JUNCLJ 99

2 ~~ Laparoscopic nephrectomy using a retroperitoneal approach Table. Characteristics of the laparoscopic nephrectoniy patient groups. Transabdominal approach Retroperitoneal approach No of patients Sex (malelfemale) Age (years) Side (rightheft) Status of diseased kidney Hydronephrosis Atrophic kidney Normal Original disease Urinary calculus disease Vesicoureteral reflux Renovascular disease Ureteropelvic junction obstruction Ureteral stricture Ectopic ureter Arteriovenous malformation () () All 38 patients underwent bowel preparation as described previo~sly.~,~ Twenty-six of the 38 nephrectomy patients underwent renal arterial embolization on the day before surgery or the same day of surgery in order to minimize blood loss. The other nephrectomy patients did not receive embolization since their renal arteries were too small. After the induction of general anesthesia, 7 nephrectomy patients underwent ureteric catheterization cystoscopically, while the other nephrectomy patients did not. The first 3 transabdominally nephrectomized patients were placed in the semilateral (7") position while the next 9 transabdominal nephrectomized and the six retroperitoneal patients were operated on in the lateral position (9OOC). Retroperitoneal approach Six patients were treated by a retroperitoneal procedure (Table ). A -3 cm incision was made cm below the level of the umbilicus on the anterior axillary line. The external and internal oblique abdominal muscles and the transverse abdominalis were divided bluntly. Gerota's fascia was then exposed by finger dissection and was incised. Next, a balloon attached to a nephroscope (R. Wolf, Int., city Germany) was placed in the anterior aspect of the kidney. The balloon was inflated with -6 ml of normal saline to produce a working space in the anterior aspect of the kidney. Then the same procedure was repeated to create a working space in the posterior aspect of the kidney. Thereafter, the peritoneum was dissected medially from the abdominal wall. A mm trocar (B) was inserted 6 cm above the incision (Fig. ). On the posterior axillary line, a / mm trocar (C) was placed cm below the level of the umbilicus and a mm trocar (D) was placed cm above the level of the umbilicus. A / mm trocar (A) was placed at the site of the incision. Then, CO, insufflation at a pressure of mmhg was performed to maintain the working space in the retroperitoneal cavity. A laparoscope was inserted through port A for Table. Characteristics of patienrr undergoing Iaparoscopic nephrectomy using a retroperitoneal approach. Case Age Sex Side Original disease Status Size (cm) Operative Estimated blood Complication time (min) loss (ml) 73 F R Ureteral stricture Hydronephrosis x 8 x 8 7 No 7 M L VUR Atrophic kidney 6 x 4 x 3 Injury of the peritoneum 3 M L Urinary stone Hydronephrosis x 9x8 9 Injury of the peritoneum 4 7 F R AVM Normal 9x6~3 Injury of the peritoneum 6 F L Ectopic ureter Atrophic kidney 6 x 3 x 3 7 No 6 6 F R Urinary stone Hydronephrosis x~48 No 3

3 Int 3 Urol 99;:-6 I. 8 Anterior : Axillary Posterior Line Axillary Line Axillary Line Fig.. Site of ports in laparoscopic nephrectomy using a retroperitoneal approach. (left) right nephrectomy, (right) left nephrectomy. observation, and a mm retractor was introduced through port B to reflect the peritoneum medially. An additional / mm trocar was placed between port A and port C in some cases. Transabdominal approach Thirty-two nephrectomy patients were treated by the transabdominal approach. These patients received a CO, pneumoperitoneum and had five trocars inserted into the upper quadrant or the lateral abdominal wall as described previously. The line oftoldt was incised lateral to the ascending or descending colon and the colon was reflected medially by dissection under laparoscopic observation. The retroperitoneal structures were exposed by dissection of the peritoneum and Gerota s fascia. Procedure for nephrectomy The procedures for freeing a kidney were the same in both retroperitoneal and transabdominal approaches. The ureter was identified and exposed by dissection. It was then secured with ligature clips and cut with scissors. After retracting the renal end of the ureter upwards, the ureter and pelvis were dissected out. Then the renal vein and artery were exposed, dissected out, and secured with ligature clips. When the diameter of the vein was too great, larger ( mm) ligature clips were used. The secured vessels were transected with hock scissors. The lower pole and mid-portion of the kidney were dissected out from the perinephric structures. Thereafter, while retracting the kidney downwards, the upper pole was dissected out and the adrenal gland left in situ. Removal of the kidney The freed kidney was gripped with mm grasping forceps and removed through a 3-4 cm abdominal incision made at the site of the / mm trocar A in the first 3 transabdominal patients. In the next 9 transabdominal patients and the 6 retroperitoneal patients, a laparoscopy sack was introduced into the abdominal or retroperitoneal cavity and the freed kidney was maneuvered into the sack. The mouth of the sack was pulled out through the abdominal wall where trocar A had been positioned. The kidney was minced with scissors and forceps inside the sack, after which the sack was removed. The data was analyzed by Student s t test. RESULTS The six patients treated using a retroperitoneal approach, successfully underwent nephrectomy without any severe complications. The operating time was 7-9 min, mean, 6 min, and the estimated blood loss was - ml, mean, 9 ml. Three patients had injuries of the peritoneum which were caused by trocar insertion and these were not repaired. No difficulties were encountered during or after surgery. We also found no difficulty with a kidney in the patient having a history of gynecological surgery. No patients required blood transfusion. The postoperative hospital stay was 7- days, mean, 8 days. All patients achieved full convalescence, by an average of postoperative day 9. In the first 3 patients treated using a transabdominal approach, kidneys were successfully removed and one kidney could not be removed because of severe adhesions to the surrounding tissues (xanthogranulomatous pyelonephritis caused by pyonephrosis). Three of these patients required open laparotomy after nephrectomy for removal of a lost renal stone, splenectomy after injury to the spleen and ligation of an injured capsular artery as described previo~sly.~ The operative time ranged from 8 to 49 min, mean, 3 min. The estimated blood loss ranged from to 3, ml, with an average of 6 ml. Two of the patients received a blood transfusion ( and 8 units, respectively). The postoperative hospital stay was 8 to 4 days, mean: days, in nine patients without complications and to 7, mean: days, in three with complications. Full convalescence was achieved by an average of postoperative day 7 in these nine patients. Of the next 9 patients treated transabdominally, 6 including one patient with a previous laparoscopic cholecystectomy, underwent successful removal of their kidneys without severe complications. The procedure failed in three patients due to injury of the renal vein (n= ) or the vena cava (n = ) before nephrectomy was completed. We abandoned the laparoscopic procedure in order to minimize blood loss and prevent CO, embolism, and rapidly converted these three patients to open laparotomy in 4

4 Laparoscopic nephrectowiy using a retroperitoneal approach order to repair the injuries and remove the kidneys. The operating time was 4 to 33 min, mean, min, and the estimated blood loss was to 8 ml, mean, 7 ml, in the 6 patients. None of the 6 patients required blood transfusion. The postoperative hospital stay was seven to 4 days, mean, nine days. Full convale-scence was achieved by an average of postoperative day 8. Among the three patient groups, the operating time for the retroperitoneal approach group was shorter than those for the transabdominal approaches (p <. and p <.). Blood loss was also smaller with the retroperitoneal group than for either of the two transabdominal groups. However, there were no statistically significant difference in blood loss. There were also no differences in the postoperative hospital stay or the duration of convalescence among the three patient groups. DISCUSSION In recent years, laparoscopic nephrectomy and laparoscopic adrenalectomy have been performed for benign renal disease and benign adrenal tumors. These procedures were performed using a transabdominal approach and some problems were encountered such as injury to the intraabdominal organs and difficulty in retracting these organs. Additionally, in patients having undergone previous abdominal these procedures could not be performed. Such problems are inherent to the transabdominal approach. A retroperitoneal approach is attractive for urologists, who regularly treat renal and adrenal disease, since the kidney and adrenal gland are in the retroperitoneal space. We have employed a retroperitoneal approach for laparoscopic nephrectomy since January 994. In one patient who had undergone three gynecological operations previously, we successfully removed the kidney without any difficulties. We suggest that the retroperitoneal approach might be feasible even in patients with a history of multiple abdominal surgeries. There is less risk of injury to intraabdominal organs such as the liver, spleen, and gastrointestinal tract when the retroperitoneal approach is used. With the transabdominal approach, some authors have reported injuries to intraabdominal organs. We also experienced two splenic injuries in the transabdominal laparoscopic nephrectomy series and the laparoscopic radical nephrectomy series, and splenectomy was necessary in one of these case^.^,^,'^ In contrast, there was no injury to intraabdominal organs in the retroperitoneal series. With regard to retraction, only a mm or mm retractor was usually used for the intraabdominal organs in the retroperitoneal approach. In contrast, mm and mm retractors were usually required in the transabdominal approach. These results indicate that the retroperitoneal approach is superior to the transabdominal approach in terms of operative maneuvers. In addition, the mean operating time for the retroperitoneal approach was shorter than that for the transabdominal approach. It was even shorter than that for the last 9 transabdominal patients. Although the maneuver used to create a working space in the retroperitoneal cavity was time-consuming, it subsequently allowed easy dissection of the ureter and kidney. Maneuvers for exposing the kidney such as incision of the peritoneum and dissection of the anterior and posterior surface of the kidney in the transabdominal patients, are also unnecessary when the retroperitoneal approach is used. In conclusion, the retroperitoneal approach offers a time saving procedure in patients undergoing laparoscopic nephrectomy. These results suggest that the retroperitoneal approach is preferable for laparoscopic nephrectomy. However, it is necessary to gather more data on patients treated retroperitoneally in order to firmly establish its superiority to the transabdominal approach. ACKNOWLEDGMENT We thank Drs. Norio Katoh and Shin Yamada (Department of Urology, Komaki Shimin Hospital), Drs. Tsuneo Icinukawa and Ryohei Hattori (Department of Urology, Okazaki City Hospital) and Dr. Masafumi Sahashi (Department of Urology, Shizuoka Saiseikai General Hospital) for their excellent corporation. REFERENCES. Calyman RV, Kavoussi LR, Soper NJ, Dierks SM, Meretyk S, Darcy MD, Roemer FD, Pingleton ED, Thomson PG, Long SR. Laparoscopic nephrectomy: Initial case report. J Urol 99;46:78-8. Schuessler WW, Vancaillie TG, Reich H, Griffith DP. Transperitoneal endosurgerical lymphadenectomy in patients with localized prostatic cancer. J Urol 99; 4~ Matsuda T, Horii Y, Higashi S, Oishi K, Takeuchi H, Yoshida. Laparoscopic varicocelectomy: A simple technique for clip ligation of the spermatic vessels. J Urol 99;47: OnoY, Sahashi M,Yamada S, Ohshima S. Laparoscopic nephrectomy without morcellation for renal cell carcinoma: Report of initial cases. J Urol 993; : - 4. Terachi T, Matsuda T, Kawakita M, Mikami, HoriiY, Ogura K, Takeuchi H, Komatsu Y, Yoshida.

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