Retroperitoneoscopic versus open surgical radical nephrectomy for large renal cell carcinoma in clinical stage cT2 or cT3a: quality of life, pain and reconvalescence

Is Continuous Wound Infiltration a Better Option for Postoperative Pain Management after Open Nephrectomy Compared to Thoracic Epidural Analgesia?

BACKGROUND

Despite increasingly advanced minimally invasive percutaneous ablation techniques, surgery remains the only evidence-based therapy in curative intent for larger (>3-4 cm) renal tumors. Although minimally invasive surgery using (robotic-assisted) laparoscopic or retroperitoneoscopic approaches has gained popularity, open nephrectomy (ON) is still performed in 25% of cases, especially in tumors with central localization (partial ON) or large tumors with/without cava thrombus (total ON). As postoperative pain is one of the drawbacks of ON, our study aims to assess recovery and post-operative pain management using continuous wound infiltration (CWI) compared to thoracic epidural analgesia (TEA).

METHODS

Since 2012, all patients undergoing ON at our tertiary cancer center at CHUV have been included in our prospective ERAS® (enhanced recovery after surgery) registry that is centrally stored in ERAS® Interactive Audit System (EIAS) secured server. This study represents an analysis of all patients operated on with partial or total ON at our center between 2012 and 2022. An additional analysis was performed for the estimations of the total cost of CWI and TEA, based on the diagnosis-related group method.

RESULTS

92 patients were included and analyzed in this analysis (n = 64 (70%) with CWI; n = 28 (30%) with TEA). Adequate oral pain control was earlier achieved in the CWI group compared to the TEA group (median 3 vs. 4 days; p = 0.001), whereas immediate postoperative pain relief was better in the TEA group (p = 0.002). Consequently, opioid use was higher in the CWI group (p = 0.004). Still, reported nausea was lower in the CWI group (p = 0.002). Median time to bowel recovery was similar in both groups (p = 0.03). A shorter LOS (0.5 days) was observed in patients managed with CWI, although this was not statistically significant (p = 0.06). The use of CWI has reduced total hospital costs by nearly 40%.

CONCLUSIONS

TEA has better results in terms of postoperative pain management compared to CWI following ON. However, CWI is better tolerated, and causes less nausea and earlier recovery, which leads to a shorter length of stay. Given its simplicity and cost-effectiveness, CWI should be encouraged for ON.

Oncologic and perioperative outcomes of laparoscopic versus open radical nephrectomy for the treatment of renal tumor (> 7 cm): a systematic review and pooled analysis of comparative outcomes

OBJECTIVE

Systematic evaluation of the effectiveness and safety of laparoscopic radical nephrectomy (LRN) for renal tumor (>7 cm).

METHODS

The databases PubMed, Scopus, SinoMed, ScienceDirect, and Google Scholar were systematically searched for trials up to November 2022. The pooled results were evaluated by weighted mean difference (WMD), odds ratio (OR), and hazard ratio (HR).

RESULTS

This meta-analysis (18 trials) demonstrated that compared to open radical nephrectomy (ORN), LRN had a longer operative time (OT) (WMD=15.99, 95% CI: 6.74 to 25.24, p = 0.0007), lower estimated blood loss (EBL) (WMD = -237.07, 95% CI: -300.02 to -174.12, p < 0.00001), lower transfusion rates (OR = 0.37, 95% CI: 0.24 to 0.55, p < 0.00001), and shorter length of stay (LOS) (WMD = -2.95, 95% CI: -3.86 to -2.03, p < 0.00001). No statistically relevant differences were found in overall survival (OS) (HR = 1.04, 95% CI: 0.81 to 1.35, p = 0.76), cancer-specific survival (CSS) (HR = 1.28, 95% CI: 0.97 to 1.68, p = 0.08), progression-free survival (PFS) (HR = 1.20, 95% CI 0.97 to 1.48, p = 0.1), recurrence-free survival (RFS) (OR = 1.27, 95% CI: 0.89 to 1.81, p = 0.56), local recurrence rate (OR = 0.85, 95% CI: 0.42 to 1.71, p = 0.65), and intraoperative and postoperative complications.

CONCLUSION

For patients with renal tumors (> 7 cm), LRN has specific perioperative advantages over ORN (LOS, EBL, and transfusion rates). However, the OT was prolonged in the LRN group. In addition, no differences in complication or oncological outcomes (OS, CSS, PFS, RFS, and local recurrence rate) were reported.

TRIAL REGISTRATION

PROSPERO CRD42022367114.

Influential Factors and Personalized Prediction Model of Acute Pain Trajectories after Surgery for Renal Cell Carcinoma

Background: Renal cell carcinoma (RCC) is the most common neoplasm in kidneys, and surgical resection remains the mainstay treatment. Few studies have investigated how the postoperative pain changes over time and what has affected its trajectory. This study aimed to characterize the variations in postoperative pain over time and investigate associated factors after RCC surgery. Methods: This retrospective study was conducted in a single medical center in Taiwan, where maximal pain scores in a numeric rating scale were recorded daily in the first five postoperative days (PODs) after RCC surgery. Latent curve models were developed, using two latent variables, intercept and slope, which represented the baseline pain and rate of pain resolution. These models explain the variations in postoperative pain scores over time. A predictive model for postoperative pain trajectories was also constructed. Results: There were 861 patients with 3850 pain observations included in the analysis. Latent curve analysis identified that female patients and those with advanced cancer (stage III and IV) tended to have increased baseline pain scores (p = 0.028 and 0.012, respectively). Furthermore, patients over 60 years, without PCA use (both p < 0.001), and with more surgical blood loss (p = 0.001) tended to have slower pain resolution. The final predictive model fit the collected data acceptably (RMSEA = 0.06, CFI = 0.95). Conclusion: Latent curve analysis identified influential factors of acute pain trajectories after RCC surgery. This study may also help elucidate the complex relationships between the variations in pain intensity over time and their determinants, and guide personalized pain management after surgery for RCC.

Retroperitoneoscopic nephrectomy: current status

The classic retroperitoneal open surgical access to the kidney has been duplicated while performing laparoscopy but is less common than transperitoneal laparoscopy. We reviewed minimally invasive retroperitoneoscopic nephrectomy as a part of the international consultation on urological diseases and European Association of Urology international consultation on minimally invasive surgery in urology. A Pubmed/Medline search was performed to identify studies assessing the feasibility, safety and efficacy of laparoscopic and robotic retroperitoneoscopic nephrectomy. The articles were reviewed to assess outcomes after simple, radical and donor nephrectomy and comparative trials between retroperitoneoscopic versus the open and transperitoneal route were evaluated. Retroperitoneoscopic nephrectomy is feasible for most cases of benign non-functioning kidneys. Retroperitoneoscopic radical nephrectomy is also feasible for most tumours and may be better suited for posteriorly located tumours. Both retroperitoneoscopic and transperitoneal nephrectomy have similar outcomes but the operative time may be shorter for the former. The data are insufficient for robotic retroperitoneoscopic nephrectomy probably because of limited space and lack of benefit of a robot in ablative surgeries.

Level of evidence: 3a

The role of open radical nephrectomy in contemporary management of renal cell carcinoma

Radical nephrectomy (RN) remains a cornerstone of the management of localised renal cell carcinoma (RCC). RN involves the en bloc removal of the kidney along with perinephric fat enclosed within Gerota's fascia. Key principles of open RN include appropriate incision for adequate exposure, dissection and visualisation of the renal hilum, and early ligation of the renal artery and subsequently renal vein. Regional lymph node dissection (LND) facilitates local staging but its therapeutic role remains controversial. LND is recommended in patients with high risk clinically localised disease, but its benefit in low risk node-negative and clinically node-positive patients is unclear. Concomitant adrenalectomy should be reserved for patients with large tumours with radiographic evidence of adrenal involvement. Despite a recent downtrend in utilisation of open RN due to nephron-sparing and minimally invasive alternatives, there remains a vital role for open RN in the management of RCC in three domains. Firstly, open RN is important to the management of large, complex tumours which would be at high risk of complications if treated with partial nephrectomy (PN). Secondly, open RN plays a crucial role in cytoreductive nephrectomy (CN) for metastatic RCC, in which the laparoscopic approach achieves similar results but is associated with a high reoperation rate. Finally, open RN is the current standard of care in the management of inferior vena caval (IVC) tumour thrombus. Management of tumour thrombus requires a multidisciplinary approach and varies with cranial extent of thrombus. Higher level thrombus may require hepatic mobilisation and circulatory support, whilst the presence of bland thrombus may warrant post-operative filter insertion or ligation of the IVC.

Effectiveness and Safety of Continuous Transverse Abdominal Plane Blocks vs Epidural Analgesia in Donor Nephroureterectomy

BACKGROUND

The transverse abdominal plane (TAP) block is sensitive and encompasses peripheral nerves of the anterior abdominal wall. It decreases 27% of the forced vital capacity, 58% of maximum inspiratory, and 51% of the maximum expiratory pressure on the first postoperative day. It is a postoperative analgesic alternative.

OBJECTIVE

The researchers sought to evaluate the effectiveness and safety of the TAP block compared with continuous epidural analgesia in donor nephroureterectomy.

MATERIAL AND METHODS

A controlled clinical trial of 30 randomized patients in 2 groups-TAP and continuous epidural analgesia-was used. In the TAP group, a catheter was installed in the transverse abdominal plane and ropivacaine, 0.375% 20 mL, and ropivacaine, 0.2%, were deposited in an elastomeric infuser. The other group was installed with an epidural catheter; at the end of the surgery, 10mL of ropivacaine 0.2% was administered and connected to an elastomeric infuser. Adverse effects and pain intensity were evaluated in the first 36 hours; Student t test and the χ² test were applied.

RESULTS

The study showed similar analgesia in both groups at 6 hours after the procedure (P = .256); better analgesia was seen in the TAP group in the next 30 hours (P = .000). Researchers also found time for bladder catheter removal, ambulation, and minor hospital discharge in the TAP vs the epidural group as follows: 18.2 ± 3.6 vs 21.7 ± 4.4 hours (P = .028), 20 ± 3.5 vs 23.5 ± 4.2 hours (P = .019), and 51.2 ± 8.4 vs 62.4 ± 17.6 hours (P = .035), respectively.

CONCLUSIONS

Continuous TAP blockade is an effective and safe technique. It favors early recovery, early removal of the bladder catheter, ambulation, and discharge.

Comparative Evaluation of Continuous Thoracic Paravertebral Block and Thoracic Epidural Analgesia Techniques for Post-operative Pain Relief in Patients Undergoing Open Nephrectomy: A Prospective, Randomized, Single-blind Study

BACKGROUND

Open surgical procedures are associated with substantial postoperative pain; an alternative method providing adequate pain relief with minimal side effects is very much required.

AIM

The aim of this study was a comparative evaluation of the efficacy of continuous thoracic paravertebral block (PVB) and thoracic epidural analgesia (EA) for postoperative pain relief in patients undergoing open nephrectomy.

SETTINGS AND DESIGN

Prospective, randomized, and single-blind study.

MATERIALS AND METHODS

Sixty adult patients undergoing open nephrectomy under general anesthesia were randomized to receive a continuous thoracic epidural infusion (Group E) or continuous thoracic paravertebral infusion (Group P) with bupivacaine 0.1% with 1 μg/ml fentanyl at 7 ml/h; both infusions were started after induction of anesthesia. The primary outcome measures were postoperative pain during rest (static pain), deep inspiration, coughing, and movement (getting up from supine to sitting position); the secondary outcome measures were postoperative nausea and vomiting, requirement of rescue antiemetic, hypotension, sedation, pruritus, motor block, and respiratory depression. These were assessed till the morning of the third postoperative day.

STATISTICAL ANALYSIS

Results were analyzed by the one-way ANOVA, Chi-square test, and Mann-Whitney U-test. P < 0.05 was considered significant.

RESULTS

Both the groups were similar with regard to demographic factors (P > 0.05). The visual analog scale scores at rest, deep breathing, coughing and movement, and postoperative fentanyl consumption were similar in the two groups (P > 0.05); the incidence of side effects was also similar in the two groups (P > 0.05).

CONCLUSIONS

Continuous thoracic PVB is as effective as continuous thoracic EA in providing pain relief in patients undergoing open nephrectomy in the postoperative period. The side effect profile of the two techniques was also similar.

Comparison of Postoperative Analgesic Requirements in Living Donors and Patients Undergoing Similar Surgical Procedures

BACKGROUND

More factors affect pain perception of donors than patients. We prospectively evaluated postoperative pain intensity and analgesic requirements in living kidney donors and patients with renal cell carcinoma undergoing laparoscopic nephrectomy with similar surgical procedures.

MATERIAL AND METHODS

The study included 30 living kidney donors and 30 patients with renal cell carcinoma undergoing laparoscopic nephrectomy from March 2013 to August 2014. All of the participants underwent similar surgical procedures under general anesthesia. Data including participants' demographics, surgical data, postoperative analgesic requirements, visual analog scale scores at rest and during coughing at postoperative 0.5, 2, 4, 8, 12, 24, and 48 hours, side effects, and overall satisfaction degree were compared between the 2 groups.

RESULTS

Time to the first tramadol request was significantly shorter in the donors. The donors received more intravenous doses of tramadol than the patients. Visual analog scale scores at 2 and 4 hours at rest and at 2, 4, and 8 hours during coughing after extubation were significantly higher in the donors. There were no significant differences between the groups according to the number of participants given pethidine, time to pethidine rescue, and adverse effects. The overall satisfaction degree was comparable between the 2 groups.

CONCLUSIONS

There were significant differences with respect to postoperative pain intensity and analgesic requirements in living kidney donors and patients undergoing retroperitoneal laparoscopic nephrectomy with similar surgical procedures.

Comparison of Acute and Chronic Pain after Open Nephrectomy versus Laparoscopic Nephrectomy: A Prospective Clinical Trial

We evaluated postoperative pain intensity and the incidence of chronic pain in patients with renal cell carcinoma undergoing laparoscopic or open radical nephrectomy. In this prospective study, 27 laparoscopic nephrectomy (Group LN) and 25 open nephrectomy (Group ON) patients were included. All patients received paracetamol infusion and intramuscular morphine 30 minutes before the end of the operation and intravenous patient controlled analgesia with morphine postoperatively. Data including patients' demographics, visual analog scale (VAS) pain scores at postoperative 0.5, 1, 2, 4, 6, 12, and 24 hours, postoperative morphine consumption, analgesic demand, analgesic delivery, number of patients requiring rescue analgesics, side effects because of analgesic medications, and overall patient satisfaction were recorded and compared between the two groups. Two and 6 months after the operation, patients were evaluated for chronic postsurgical pain (CPSP). Postoperative average VAS pain scores were not different between the two groups. However, only at 2 hours postoperatively, pain score was significantly higher in Group ON than in Group LN. In both groups, the highest pain scores were recorded at 30 minutes and 1 hour after surgery. Ninety-six percent of group ON patients and 88% of group LN patients required additional analgesia in the early postoperative period (P = 0.33). Postoperative morphine consumption and analgesic demand were found to be similar between the two groups. CPSP at 2 months after surgery was observed in 4 out of 25 patients (16%) in the ON group and 3 out of 27 patients (11.1%) in the LN group (P = 0.6). Chronic pain at 6 months after surgery was observed in 1 ON patient (4%) and 1 LN patient (3.7%, P = 0.9). This study demonstrated that postoperative acute pain scores were not different after laparoscopic or open nephrectomy and patients undergoing laparoscopic or open nephrectomy were at equal risk of developing CPSP. Pain control should be carefully planned in order to reduce early postoperative pain and also potentially prevent CPSP.

WITHDRAWN: Surgical management of localised renal cell carcinoma

This review is being updated and replaced following the publication of a protocol (Krabbe L‐M, Kunath F, Schmidt S, Miernik A, Cleves A, Walther M, Kroeger N. Partial nephrectomy versus radical nephrectomy for clinically localized renal masses [Protocol]. Cochrane Database of Systematic Reviews 2016, Issue 2. Art. No.: CD012045. DOI: 10.1002/14651858.CD012045) for a new review with a narrower scope. It will remain withdrawn when the new review is published.

The editorial group responsible for this previously published document have withdrawn it from publication.

Matched pair analysis of laparoscopic versus open radical nephrectomy for the treatment of T3 renal cell carcinoma

PURPOSE

The perioperative and oncological outcomes of laparoscopic radical nephrectomy (LRN) for T1-T2 renal cell carcinoma (RCC) are well established. We aim to determine whether LRN is a comparable alternative to open radical nephrectomy (ORN) in the treatment of T3 RCC using a matched pair analysis study design.

METHODS

A review of a prospectively collected database at the Western General Hospital, Edinburgh, between 2000 and 2011 was conducted. Patient pairs were matched based on age at operation, gender, histological subgroup, maximal tumour diameter, TNM stage and grade. Patient demographics, operative and post-operative outcomes were compared. Overall, cancer-specific and progression-free survival [overall survival, cancer-specific survival (CSS) and progression-free survival (PFS)] were estimated using the Kaplan-Meier method.

RESULTS

From 252 patients with T3 disease, 25 pairs were matched. Patients were of median age 66.2 years, 64 % male. Tumours were all clear cell RCC, were stage pT3a (32 %) or pT3b and had maximal tumour diameters of 8.7 cm for LRN and 10.0 cm for ORN. Estimated blood loss (100 ml LRN; 650 ml ORN, p < 0.001) and length of post-operative hospital stay (4 days LRN: 9 days ORN, p < 0.001) were lower in the LRN group. Operation time and post-operative complication rates were comparable. CSS and PFS were comparable with a mean CSS of 91.3 months for LRN and 88.7 months for ORN.

CONCLUSION

This study reports the longest median follow-up in a T3 LRN cohort. In matched patients, LRN has been shown to have a superior perioperative profile to ORN for the treatment of pT3a/b RCC, with no adverse effect on midterm oncological outcomes.

Thoracic paravertebral block for nephrectomy: a randomized, controlled, observer-blinded study

OBJECTIVE

This study evaluated whether adding a preoperative single thoracic paravertebral block (TPVB) to intravenous patient-controlled analgesia (IV PCA) would improve postoperative analgesia compared with using IV PCA alone in patients undergoing nephrectomy.

DESIGN

Prospective, randomized, controlled, observer-blinded trial.

SETTING

University hospital.

SUBJECTS

Thirty-four adult patients undergoing elective open nephrectomy.

METHODS

The patients were randomized to receive a TPVB plus IV PCA (group T) or IV PCA alone (group C). A single 18-mL injection of 0.75% ropivacaine was administered preoperatively under ultrasound guidance; fentanyl was used for IV PCA. Each patient's postoperative pain score based on a verbal numerical rating scale, postoperative fentanyl consumption, inspiratory volume by incentive spirometry, and complications were evaluated at 1, 3, 6, 12, and 24 hours after surgery. Changes in heart rate (HR), systolic arterial pressure (SAP), and mean arterial pressure (MAP) were evaluated following skin incision.

RESULTS

The postoperative pain score and fentanyl consumption were significantly lower in group T than in group C at all time points up to 24 hours after surgery. The postoperative inspiratory volumes were not significantly different. The changes in HR were similar, while the increases in SAP and MAP after skin incision were lower in group T than in group C.

CONCLUSIONS

A preoperative single TPVB improved postoperative analgesia by reducing the postoperative pain score and fentanyl consumption in patients undergoing nephrectomy.

Pain management in laparoscopic donor nephrectomy: a review

The management of postoperative pain is a key to patient early recovery, in particular, where the surgery was performed to benefit another human being. In recent years it has been recognized that multimodal analgesic methods are superior for postoperative pain relief. It is also imperative to remember that inadequately managed acute postoperative pain opens the doorway to possible suffering from chronic postoperative pain later. Although the laparoscopic donor nephrectomy has reduced the disincentives associated with open surgery, still significant percentage of donors suffers from postoperative pain. In the UK, patient-controlled analgesic system (PCAS) using morphine for postoperative pain relief is being used in majority of the transplant centres. Though opioids provide good analgesia, they are far from being an ideal analgesic due to their adverse effects. This paper pragmatically looks in depth on different modalities of pain management in patients undergoing laparoscopic live donor nephrectomy.

Comparison of single-surgeon series of transperitoneal laparoendoscopic single-site surgery and standard laparoscopic adrenalectomy

OBJECTIVE

To assess the feasibility, safety, and efficacy of transperitoneal laparoendoscopic single-site (LESS) adrenalectomy and determine whether it shows any objective advantage compared with standard laparoscopy.

METHODS

From August 2009 to May 2011, 13 transperitoneal LESS adrenalectomies were performed through a 2-3-cm skin incision using the TriPort access system. This cohort was compared with a contemporary 1:2 matched-pair group of 26 patients undergoing standard laparoscopic adrenalectomy by the same urologist. The perioperative outcomes, including cosmetic satisfaction scores, were statistically analyzed.

RESULTS

The 2 groups were comparable with respect to patient demographics, estimated blood loss, and postoperative hospitalization (P > .05). The LESS procedures had a longer mean operative time (148.5 vs 112.9 minutes, P = .032) but a significantly lower postoperative visual analog pain scale score (2.3 vs 3.7, P = .001), fewer patients requiring analgesics (30.8% vs 73.1%, P = .011), and an earlier resumption of oral intake (21.6 vs 26.0 hours, P = .002). The mean length of the scar in the LESS group was much smaller (2.3 vs 5.9 cm, P < .0001) with a statistically significant greater mean cosmetic satisfaction score (9.5 vs 9.1, P = .042).

CONCLUSION

The perioperative outcomes of transperitoneal LESS adrenalectomy for small adrenal tumors were comparable to those with the standard laparoscopic approach. It also provides better postoperative pain control, faster recovery of bowel function, and better cosmetic satisfaction than standard laparoscopy, albeit with a longer operative time.

Surgical management of localised renal cell carcinoma

BACKGROUND

Surgical excision remains the core to the management of localised renal cancer and several studies have evaluated the safety and clinical effectiveness of laparoscopic surgery and other recently introduced interventions for the localised disease.

OBJECTIVES

To identify and review the evidence from randomised trials comparing different surgical interventions in localised renal cell carcinoma.

SEARCH STRATEGY

Randomised or quasi randomised trials comparing various surgical interventions in the management of adults with surgically resectable localised renal cancer. RCTs were identified by searching The Cochrane Central Register of Controlled Trials (CENTRAL, Issue 3, 2009), MEDLINE (Silver Platter, from 1966 to August 2009), EMBASE via Ovid (from 1980 to August 2009), and a number of other data bases.

SELECTION CRITERIA

Studies were assessed for eligibility and quality, and data from published trials were extracted by two reviewers.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data.

MAIN RESULTS

No randomised trials were identified meeting the inclusion criteria reporting on the comparison between open radical nephrectomy with laparoscopic approach or new modalities of treatment such as radiofrequency or cryoablation. Three randomised controlled trials compared the different laparoscopic approaches to nephrectomy (transperitoneal versus retroperitoneal) and found no statistical difference in operative or perioperative outcomes between the two treatment groups. There were several non-randomised and retrospective case series reporting various advantages of laparoscopic renal cancer surgery such as less blood loss, early recovery and shorter hospital stay

AUTHORS' CONCLUSIONS

The main source of evidence for the current practice of laparoscopic excision of renal cancer is drawn from case series, small retrospective studies and very few small randomised controlled trials. The results and conclusions of these studies must therefore be interpreted with caution.

A review of the literature on the impact of renal cancer therapy on quality of life

AIM

To explore the impact of renal cancer treatment on patients' quality of life.

BACKGROUND

Renal cancer accounts for 95,000 deaths worldwide and its incidence rate is rising. At present there are several therapeutic approaches to the treatment of renal cancer, ranging through surgery, immunological therapies and vaccine treatment. Each of these therapies may have a substantial effect upon patients' quality of life. However, a systematic appraisal of the empirical evidence about treatment impact is lacking.

DESIGN

Literature review.

METHODS

A structured review of the empirical literature on the impact of renal cancer treatment upon quality of life was undertaken. Literature was appraised and themed according to the treatment modalities included in the study.

RESULTS

From 873 papers initially identified 52 were retrieved for detailed scrutiny resulting in a final 16 papers being included in the review.

CONCLUSIONS

This review discusses the complex effect of renal cancer upon a patient's quality of life as treatment modalities change. The need for nursing education and awareness of these issues is therefore highlighted to maximise patient care.

RELEVANCE TO CLINICAL PRACTICE

Understanding the impact of treatment for renal cancer enables nurses to empathise more significantly with patients and also act as mediators in regard to treatment choice and treatment cessation. It also enables nurses to inform and educate renal cancer patients prior to making treatment choices.

[Laparoscopic radical nephrectomy. Procedure, results, and complications]

Surgery is the treatment of choice for clear cell renal carcinoma not responding to chemotherapy, radiotherapy, or immunotherapy. The surgical procedure used has evolved over time in the past 40 years, mainly because of the development and widespread use of diagnostic procedures such as ultrasonography and CT. As a direct consequence, parenchymal-sparing surgery was no longer only used for patients with solitary kidneys and its indication started to be extended to patients with tumors up to 4 cm in diameter, in whom it has been shown to be a safe and effective alternative to radical nephrectomy. The other important milestone in development of renal cancer surgery undoubtedly was the revolution started in the 90s with advent of laparoscopic renal surgery, which has become established over the past 20 years approximately. Laparoscopic surgery initially raised concern about oncological safety, but clinical series with sufficiently long follow-up times and large sample sizes are now available to consider the laparoscopic approach as a reliable procedure. Technological development has caused the laparoscopic technique to be no longer seen as a procedure for the future, but rather as an absolutely current technique which should be implemented in most urology departments. Implementation of any new procedure usually involves a number of complications which we should be prepared to assume, while making every effort to try and prevent them. It is therefore essential to develop, and to implement using common sense, a training program on the procedure. Selection of patients and conditions to be treated is a crucial part of such a program.

Survival of patients with nonmetastatic pT3 renal tumours: a matched comparison of laparoscopic vs open radical nephrectomy

OBJECTIVES

To compare the oncological outcome of patients with pT3 renal tumours treated either by laparoscopic radical nephrectomy (LRN) or open RN (ORN).

PATIENTS AND METHODS

In a retrospective review of a multi-institutional database, we identified 1003 patients with a T3N0M0 renal tumour and with no vena caval invasion. Sixty-five patients treated by LRN were matched with up to four patients treated by ORN. Exact matches were made for age, gender, tumour size, perirenal fat invasion, renal vein invasion, and histological subtype. Following the matching process there were 44 patients treated by LRN and 135 by ORN. Qualitative and continuous variables were compared using chi-square and independent-sample t-tests, respectively. Differences in survival were compared using the Kaplan-Meier method. A Cox regression model was used to test the effect of variables on survival.

RESULTS

The two groups were comparable for age (P = 0.4), gender, tumour size (P = 0.4), tumour grade (P = 0.25) and histological subtype (P = 0.45). The mean follow-up was longer in the ORN group (55 vs 28 months, P < 0.001). There was no difference in survival between the ORN and LRN groups in the whole T3 population (P = 0.7), in those with perirenal fat invasion (P = 0.9), or in the subset with renal vein invasion (P = 0.31). In univariate analysis, the only predictor for death from cancer was tumour grade (P = 0.05). In multivariate analysis, no variable was significantly associated with cancer survival.

CONCLUSIONS

LRN has no adverse effect on cancer survival compared to ORN in patients with microscopic T3 renal cancer. Additional prospective evaluation is warranted.

Transperitoneal Laparoscopic Radical Nephrectomy for a 12 cm Renal Mass

Laparoscopic radical nephrectomy is now considered a standard of care for patients with T1 renal carcinoma not suitable for nephron-sparing surgery. In the hands of experienced laparoscopic urological surgeons also T2 renal cell carcinoma can be approached through the laparoscopic technique. We present the video of a radical laparoscopic nephrectomy in a patient with a 12cm renal mass of the right kidney. We chose the transperitoneal approach; the operative time was 240 minutes. There were neither intra- nor post-operative complications. The patient was discharged at day 4 postoperatively.

Quality of life and perioperative outcomes after retroperitoneoscopic radical nephrectomy (RN), open RN and nephron-sparing surgery in patients with renal cell carcinoma

OBJECTIVE

To prospectively evaluate health-related quality of life (HRQoL) and perioperative outcomes in patients with T1 and T2 renal cell carcinoma (RCC) after retroperitoneoscopic radical nephrectomy (RRN), open RN (ORN) or open nephron-sparing surgery (NSS).

PATIENTS AND METHODS

The data of 117 patients who had undergone RRN (36), ORN (37) or NSS (44) were evaluated. RRN data were obtained at Basel University Hospital, Switzerland, while the ORN and NSS data were collected at the University of Munich, Germany. Perioperative outcomes were analysed and compared. HRQoL was prospectively evaluated based on the Short Form 36 questionnaire with a mean follow-up of 22 months.

RESULTS

Operative duration was significantly longer in the RRN group compared with the ORN and NSS groups, at a mean (sem) of 146 (42) min vs 113 (48) min and 114 (42) min (P < 0.001). In the RRN group intraoperative blood loss was lower than in the ORN and NSS groups, at a mean (sem) of 231 (153) mL vs 424 (361) mL and 494 (360) mL (P < 0.001). Morbidity rates were 13.9% for RRN, 16.2% for ORN and 20.5% for NSS, the most relevant complications being bleeding requiring transfusions in RRN and NSS patients and haemorrhage (5% of patients in each group). Creatinine values at 6 months after surgery only recovered completely in the NSS group. Patients in the ORN group had a trend towards higher mental well-being scores than patients in the RRN and NSS groups, with a mean Mental Component Summary Score of 48.3 vs 48.0 and 44.5, respectively (not statistically significant), while all patients were in similar physical condition after surgery, with a mean Physical Component Summary Scores of 48.0 (ORN), 47.4 (RRN) and 47.2 (NSS). The physical condition scores of patients in all groups were higher than scores reached by an age and sex-matched population (45.8).

CONCLUSION

These real-world data show that each of the surgical techniques can be considered safe. Importantly, after surgery patients reported high QoL scores independent of the technique used.

Laparoscopic upper urinary tract surgery for benign and malignant conditions. Does aetiology have an effect on health-related quality of life?

INTRODUCTION

We present health-related quality of life (HRQoL) data on a cohort of patients undergoing upper urinary tract laparoscopy for a variety of benign and malignant conditions.

PATIENTS AND METHODS

The Short Form 8 (SF-8) Health Survey is a validated HRQoL questionnaire that calculates scores for physical (PCS8) and mental (MCS8) components of health. It was administered prospectively to 58 patients. Radical nephrectomy or nephroureterectomy was carried out for upper tract malignancy (n = 21). Laparoscopy for benign disease (n = 37) included simple nephrectomy for giant hydronephrosis and small non-functioning kidneys, de-roofing of renal cysts and pyeloplasty. Data were collected before and 6 weeks after surgery.

RESULTS

The mean pre- and postsurgery scores were 45.99; 47.43 and 43.93; 51.54 for PCS8 and MCS8 respectively. With regard to the PCS8 score, there was no significant difference before or after surgery (p = 0.585) or when analysing the benign (p = 0.343) or malignant (p = 0.509) groups individually. The MCS8 score, however, showed a significant increase after surgery (p < 0.0001). This remained significant when analysing just the benign (p < 0.0009) or the malignant (p < 0.0003) groups but neither group was more significant than the other (p = 0.750).

CONCLUSIONS

Laparoscopic upper urinary tract surgery significantly improves mental and does not appear to reduce physical HRQoL in patients regardless of aetiology, 4 weeks following surgery. Interestingly, those operated on for malignant conditions do not have a greater improvement in mental health when compared with benign disease.

Expanding the indications for laparoscopic radical nephrectomy

PURPOSE OF REVIEW

Laparoscopic radical nephrectomy is an established treatment for patients with clinical T1 renal cell carcinoma who are unsuitable for nephron-sparing surgery. In this review we summarize the expanding indications for laparoscopic nephrectomy, including large tumors, locally advanced disease, venous thrombi and cytoreductive surgery.

RECENT FINDINGS

Laparoscopic nephrectomy remains the foremost conventional laparoscopic procedure in urologic surgery. Multiple studies have demonstrated the feasibility of laparoscopic radical nephrectomy for stage T2 tumors, showing less morbidity and earlier return to activity compared to the open approach. Confirmation of durable oncologic control requires randomized prospective trials with longer follow-up. With growing experience, laparoscopic surgery has been extended to patients with renal cell carcinoma associated with limited local invasion and lymph node metastases. Experimental studies demonstrate the technical feasibility of laparoscopic radical nephrectomy in the presence of renal vein and inferior vena cava thrombi. In well-selected patients with metastatic renal cell carcinoma, laparoscopic cytoreductive nephrectomy can be performed safely, with less morbidity than open nephrectomy.

SUMMARY

Minimally invasive surgery results in significantly less postoperative morbidity than does open surgery. The intermediate oncologic outcomes of laparoscopic radical nephrectomy for advanced renal cell carcinoma are comparable to those historically achieved with open radical nephrectomy. Longer follow-up is needed to confirm survival equivalence.