Cytology of morcellated renal specimens: significance in diagnosis and dissemination

Port-site metastasis after laparoscopic surgery for urological malignancy: forgotten or missed

Purpose. Port-site metastasis has been a concern with the common use of laparoscopy in urologic oncology. We conducted this study to provide a review of port-site metastases reported after the laparoscopy in managing urologic malignancies, possible contributing factors and preventative measures. Materials and Methods. An electronic search of MEDLINE using the combined MESH key words “port-site metastasis” and “Urology”. Results. 51 articles addressing port-site metastasis after laparoscopic surgery for urolo¬gical malignancy were identified. Conclusion. Port-site metastasis after laparoscopic surgery for urolo¬gical malignancy is rare. The incidence is comparable to the rate for surgical wound metastases.

Examination of laparoscopic retrieval bag washings for malignant cells after hand-assisted laparoscopic radical nephrectomy and intact specimen removal

OBJECTIVES

Port site metastases after hand-assisted laparoscopic radical nephrectomy have been described in the literature. There is no uniform agreement among urologists regarding the use of a retrieval bag before intact specimen removal. The aim of this study was to determine whether LapSac renal extraction bag washings contain malignant cells.

METHODS

We prospectively obtained washings from the LapSac retrieval bag after hand-assisted laparoscopic radical nephrectomy and intact specimen removal for renal cell carcinoma. In 30 consecutive cases, after removal of the kidney specimen from the LapSac, the LapSac was irrigated with 50 mL sterile Hank's balanced salt solution. These washings were sent for cytologic examination. Cytologic evaluation was performed with a Thin Prep and the Papanicolaou method.

RESULTS

We performed 30 hand-assisted laparoscopic radical nephrectomies for suspected renal cell carcinoma with the above protocol. One specimen was benign and one showed transitional cell carcinoma; these were excluded from the study. Six specimens were stage T1a, 17 were T1b, 1 was T2, 2 were T3a, and 2 were T3b. Histopathology revealed 27 specimens with clear cell renal cell carcinomas with Fuhrman grades from 1 to 4; 1 specimen showed chromophobe renal cell carcinoma. Margins were negative in all cases, and there were no gross or microscopic tumor violations. The cytologic results from 27 cases were negative and in 1 case with T3b renal cell carcinoma the LapSac washings were positive for malignant cells.

CONCLUSIONS

The preliminary findings from our study show that low-stage, low-grade tumors removed laparoscopically with minimal manipulation do not exfoliate cells into their LapSac retrieval bags.

Laparoscopic versus Open Cytoreductive Nephrectomy in Advanced Renal-Cell Carcinoma

BACKGROUND AND PURPOSE

There is growing evidence of the benefit of cytoreductive nephrectomy prior to immunotherapy in patients with advanced renal-cell carcinoma (RCC). We compared the outcomes of patients with metastatic RCC undergoing laparoscopic and open cytoreductive nephrectomy prior to systemic therapy.

PATIENTS AND METHODS

We retrospectively analyzed 27 patients undergoing cytoreductive nephrectomy for metastatic RCC between 2000 and 2004, 16 laparoscopically and 11 by an open approach. Patients with inferior vena-caval tumor thrombus were excluded from analysis. The two groups were comparable with regard to tumor size, clinical stage, and performance status. Surgical, pathologic, and perioperative characteristics and outcomes were compared.

RESULTS

The laparoscopic technique was associated with reduced blood loss (149 v 1135 mL; P = 0.03), transfusion rate and quantity (13% v 55%; P = 0.03; 0.13 v 2.0 units of packed red blood cells; P = 0.007), shorter time to oral intake (1.2 v 2.7 days; P < 0.001), and shorter hospitalization (3.6 v 6.8 days; P < 0.001) compared with open nephrectomy. No significant differences were observed with respect to pathologic stage, operative time, complications, fraction receiving subsequent systemic therapy, time to systemic therapy, or survival.

CONCLUSIONS

Laparoscopic cytoreductive nephrectomy is associated with reduced morbidity and hospital stay compared with open surgery. There was no increase in complications, and the ability to proceed with subsequent systemic therapy was maintained in the majority of patients. The laparoscopic approach can be considered in patients with metastatic RCC as part of a cytoreductive and systemic-therapy regimen.

Laparoscopic specimen extraction: morcellation

OBJECTIVES

To review our experience with intact extraction and morecellation of nephrectomy specimen, and the advantages and disadvantages of morcellation indicated by current reports.

PATIENTS AND METHODS

In a previous study, 56 consecutive patients undergoing radical and simple transperitoneal laparoscopic nephrectomy were prospectively evaluated. Morcellation specimens (33) were extracted at the umbilical or lateral port sites and intact specimens (23) through an infraumbilical incision. Data were obtained on pathology, narcotic requirements, hospital stay, complications, estimated blood loss, size of renal mass based on preoperative imaging, specimen weight and extraction incision length.

RESULTS

The mean incision length was 1.2 cm in the morcellation group and 7.1 cm in the intact group (P< 0.001). There were no significant differences in pain or recovery between the groups. In two cases of tumor nephrectomy, microscopic invasion of the perinephric adipose tissue in the intact specimen group were up-staged from clinical T1 to pT3a disease; there was no change in patient treatment based on this information.

CONCLUSIONS

With proper technique, morcellation is safe for extracting renal tumours. The specimen can be evaluated for histology but not for pathological staging, limiting its use with transitional cell carcinoma. Port-site seeding is rare, and does not appear to be more frequent than with open nephrectomy. Although morcellation is cosmetically more desirable, there was no significant advantage in operating time, pain or duration of hospital stay. The choice od extraction method depends on the surgeon's preference and patient choice.

Novel direct-vision renal morcellation with orthopedic rotary shaver-blade instrumentation

BACKGROUND AND PURPOSE

When small ports are the only entry (and exit) points during laparoscopic nephrectomy, one is forced either to make an accommodating incision for final renal delivery or to perform renal morcellation. To date, morcellation has been performed in a blind manner with a specimen entrapped in a nonpenetrable, nonpermeable sac within the peritoneal cavity. Through the use of current laparoscopic equipment and a novel rotary shaver-blade system, we studied the safety, feasibility, and efficiency of directly observed renal morcellation.

MATERIALS AND METHODS

Ten porcine renal units with a mean mass of 143 g (range 92-192 g) were morcellated via a custom 5.5-mmx28-cm Dyonics (Smith & Nephew, Andover, MA) rotary shaver blade placed through a standard operative laparoscope (ACMI LAP 11-56W). Each kidney was entrapped in a standard 8x10-inch LapSac (Cook Urological, Spencer, Indiana), which was placed in a preconfigured abdomen model. Morcellation was performed under direct visual guidance with continuous-flow irrigation and suction. We then studied the feasibility, safety, technical ease, and efficiency of morcellation; the size of the fragments; and entrapment-bag integrity with each renal morcellation.

RESULTS

The mean time required to complete morcellation was 8:02 minutes (range 4:45-14:00 minutes). The morcellation efficiency mean was 20.7 g/min (range 12.00-31.41 g/min), with the Dyonics EP-1 generator system morcellating most effectively at 2000 rpm in its oscillate mode. Of ten random fragments, the mean size was 8.7x4.7 mm. The integrity of one LapSac was lost when the bag was not filled to complete distention, creating susceptible in folding.

CONCLUSION

This novel technique of laparoscopic renal delivery provides a feasible, safe, technically simple, and efficient means of morcellation. Directly viewed renal morcellation must occur with a kidney freely floating within a completely distended entrapment sac in order to preserve the integrity of the sac itself. Tissue fragments are large enough for pathologic review, which may permit superior oncologic surgical margins.