Laparoscopic Radical Nephrectomy- the current gold standard

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1 Laparoscopic Radical Nephrectomy- the current gold standard Anoop M. Meraney, M.D Director, Urologic Oncology, Helen and Harry Gray Cancer Center, Hartford Hospital and Connecticut Surgical Group.

2 Is it the gold standard? Oncologic Outcomes Transperitoneal vs. Retroperitoneal Laparoscopic nephrectomy Transperitoneal and retroperitoneal laparoscopic radical nephrectomy tips and tricks Expanding indications of laparoscopic radical nephrectomy

3 Oncologic Outcomes Portis et al. (2002) JH (2004) Hemal et al (2006) T2 Columbo et al (2008) Berger et al (2009) Number F/U (median) 54 mos 73 mos 51.4 mos (mean) 65 mos 134 mos Tumor size (mean) 4.3 cm 5.1 cm 9.9 cm 5.4 cm 5 cm OS 5 yr, 81% 5 yr, 88 % 5 yr, 81% 10 yr, 65% CSS RFS 5 yr, 98% 5 yr, 98% T1 5 yr, 95% T2 5 yr, 92% 5 yr, 98% T1 5 yr, 84% T2 5 yr, 95% 5 yr 98% 10 yr, 92% 5 yr 93% 5 yr, 92% 10 yr, 86%

4 Trans vs. Retro Transperitoneal (n=20) vs. Retroperitoneal (n=20) Radical nephrectomy for pt1-pt3b tumors, performed by 2 surgeons with different degrees of experience. No statistically significant difference in preoperative and intraoperative parameters. Oral consumption on POD #1 in 100% TP vs. 75% RP Bias. No indication that physicians operating and involved in postoperative care were blinded ie. Intervention bias. Nambirajan T, et al. Urology 2004; 64:

5 102 patients (pt1-pt3b) randomized to undergo transperitoneal (n=, 50) or retroperitoneal (n= 52) laparoscopic radical nephrectomy. Exclusion criteria a. body mass index (BMI) greater than 35 or b. prior abdominal surgery in the quadrant of interest.

6 Desai et al.

7 Desai et al.

8 Both approaches were similar in terms of blood loss, intraoperative and postoperative complications, length of stay, analgesia requirements, resumption of ambulation, oral intake, duration of hospitalization, and convalescence. RP associated with quicker hilar control. Intervention bias.

9 Laparoscopic Transperitoneal Radical Nephrectomy Patient position Port Placement Procedure Incision of line of Toldt and Reflection of Colon Identification of landmarks (Psoas, lateral border of Aorta/IVC), and Identification and dissection of ureter and gonadal vein. Dissection, control of renal hilum and Mobilization of specimen Specimen entrapment and Extraction

10 Patient Preparation (in OR before positioning) antiembolic stockings foley catheter OG tube shave wide area Mark midline When supine Mark extraction incision

11 Patient Positioning semi-lateral decubitus umbilical line over kidney rest neuro arm board axillary roll kidney rest down table flexed Lower leg flexed Immobilize with 3 inch cloth tape

12 2 mm Port Placement Right Nephrectomy 5 mm mm camera 30 or 45 degree laparoscope is needed when using umbilical port as camera port Alternative camera/retr action port

13 2 mm Port Placement Left Nephrectomy 5 mm 10 mm camera Alternative camera/retr action port

14 Laparoscopic Transperitoneal Radical Nephrectomy Patient position and Port Placement

15 Laparoscopic Transperitoneal Radical Nephrectomy Retract GV and ureter anteriorly and develop a plane of dissection anterior to psoas Trace GV superiorly to identify RV

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17 Laparoscopic Retroperitoneal Radical Nephrectomy Patient position and Retroperitoneal access Identification of landmarks (psoas, lateral border of IVC/Aorta), and identification, dissection and control of hilum Mobilization of specimen, Entrapment and extraction

18 Laparoscopic Retroperitoneal Radical Nephrectomy Patient position and retroperitoneal access Secondary Ports Primary Port 800 cc Origin (R) - Blunt Tip Port Balloon Cuff

19 LANDMARKS FOR ORIENTATION KIDNEY IVC PSOAS

20 Laparoscopic Transperitoneal Radical Nephrectomy Endo GIA for controlling vein

21 Specimen mobilization TIP: use a broad fan retractor to mobilize specimen

22 Specimen entrapment TIP: for large specimens entrap within peritoneal cavity

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24 Retroperitoneal laparoscopy is associated with a limited working space. Familiarity with orientation in the retroperitoneal space. Versatility ie. Role for both.

25 Expanding indications Extended lymphadenectomy Larger tumors (Cytoreductive) Vein involvement

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27 N=50 Initial 36 cases, left side tumors- paraaortic and rightparacaval. Next 14 cases, interaortocaval nodes included, retrocaval on the right. Node positive cases = 5 All with tumors >7 cm, grade 3 or 4, and T3 or T4.

28 N= 38 Mean tumor size = 8 cm Systemic therapy in an average of 41 days

29 Systemic therapy in 36 days for lap vs. 61 days for open.

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33 Conclusions Laparoscopic Radical Nephrectomy is Oncologically safe and the gold standard for T1 and T2 lesions. It is useful to have expertise in both retroperitoneal and transperitoneal laparoscopic surgery With increased experience, indications for Laparoscopic radical nephrectomy are expanding to include larger tumors and tumors with venous involvement.

34 Thank you

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36 Anoop M. Meraney, M.D Director of Urologic Oncology Helen and Harry Gray Cancer Center Hartford Hospital/Connecticut Surgical Group

37 Laparoscopic Transperitoneal Radical Nephrectomy Patient position and Port Placement

38 Laparoscopic Retroperitoneal Radical Nephrectomy Mobilization of specimen, Entrapment and extraction

39 Piece of surgical glove tied to a red rubber catheter.

40 Initial Retroperitoneal Laparoscopic Nephrectomy: Simple nephrectomy: retroperitoneal approach.gaur DD. J Endourol Dec;14(10): Initial Retroperitoneal Laparoscopic Radical Nephrectomy Laparoscopic radical nephrectomy: the Nagoya experience. Ono Y, Katoh N, Kinukawa T, Matsuura O, Ohshima S. J Urol

41 Historical Initial laparoscopic transperitoneal radical nephrectomy was done for a 3 cm renal mass in Clayman RV, Kavoussi LR, Soper NJ, et al: Laparoscopic nephrectomy: Initial case report. J Urol 1991; 146:

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44 Role of Lymphadenectomy for RCC Extent of dissection? Diagnostic/Prognostic vs. Therapeutic?

45 Laparoscopic Transperitoneal Radical Nephrectomy Incision of line of Toldt and Reflection of Colon