UROLOGICAL COMPLICATIONS OF LAPAROSCOPIC SURGERY: EXPERIENCE WITH 350 PROCEDURES AT A SINGLE CENTER

Initial Experiences of Laparoscopic Nephrectomy in a Tertiary Oncology Center: An Analysis of 142 Cases

INTRODUCTION

Kidney tumors have an important place among urological malignancies. The increased utilization of imaging methods has led to a rise in renal cell carcinoma (RCC) diagnoses, albeit with declining mortality rates, particularly in developed countries. Radical nephrectomy remains the gold standard treatment. The aim of this study was to share a tertiary oncology hospital's initial experiences with laparoscopic nephrectomy.

MATERIALS AND METHODS

This retrospective study analyzes data from patients who underwent laparoscopic nephrectomy, focusing on demographic characteristics, tumor features, and operative outcomes. Information regarding age, gender, tumor size, operative details, and pathology results was collected and analyzed.

RESULTS

One hundred forty-two patients were included in the study; 69 (48.60%) were female and 73 (51.40%) were male. The mean age of the patients was 57.11 ± 12.6 years, with tumors primarily located on the left kidney (52.80%). The mean tumor size was 53.01 ± 24.01 mm. Intraoperative complications included the need for conversion to open surgery in five cases and vascular, pneumothorax, or duodenal injuries in a subset of patients. However, postoperative complications, such as sepsis or mortality, were not observed.

DISCUSSION

Despite an initial learning curve associated with longer operation times, laparoscopic techniques offer benefits, including reduced blood loss, faster recovery, and improved cosmetic outcomes. Histologically, clear cell RCC was the most common tumor type encountered. This study underscores the safety and efficacy of laparoscopic radical nephrectomy, advocating for its widespread adoption while emphasizing the importance of surgeon experience and patient selection in optimizing outcomes.

İkinci basamak perifer devlet hastanesinde yeni uzman üroloğun erken dönem laparoskopik deneyimleri

Amaç: Devlet hizmet yükümlülüğü nedeniyle ikinci basamak perifer devlet hastanesinde görev yapan bir üroloji uzmanının ilk laparoskopik cerrahi deneyimlerinin retrospektif olarak değerlendirilmesi. Gereç ve Yöntem: Nisan 2016 – Ağustos 2018 tarihleri arasında Şanlıurfa Balıklıgöl Devlet Hastanesi Üroloji kliniğinde toplam 25 hastaya (16 erkek, 9 kadın) laparaskopik cerrahi girişim yapılmıştır. Hastalar demografik özellikler, cerrahinin uygulandığı taraf, cerrahi teknik, operasyon ve hastanede kalış süreleri, postoperatif analjezik ihtiyaç varlığı, peroperatif ve postoperatif komplikasyonlar kayıt edilmiştir. Bulgular: Çalışmaya dahil edilen hastaların yaş ortalaması 38,8 ± 11,6 yıl idi. Bunlar; basit nefrektomi (n = 10, %40), böbrek kist eksizyonu (n = 6, %24), üreterolitotomi (n = 6, %24), radikal nefrektomi (n = 1, %4), piyeloplasti (n = 1, %4) ve testis araştırılması (n = 1, %4) idi. Ortalama operasyon süresi ise 108,8 ± 31,6 dakika ve ortalama hastanede kalış süresi 3,8 ± 0,9 gün olarak tespit edildi. Tüm vakaların altısında (%24) retroperitoneal yaklaşım tercih edildi. Toplam altı (%24) hastada komplikasyon görüldü. Modifiye Clavien Komplikasyon derecelendirme sistemine göre Grade 1, 2 ve 3 komplikasyonlarının dağılımları sırasıyla dört (%66,6), bir (%16,6) ve bir (%16,6) idi. Olguların hiçbirinde grade 4 ve 5 komplikasyonları gözlenmedi. Sonuç: Laparoskopi konusunda tecrübeli merkezlerde asistanlık eğitimi alan yeni uzman ürologlar, kliniklerinde aldıkları bu eğitimi ve tecrübeyi, devlet hizmet yükümlülüğü nedeniyle gittikleri perifer devlet hastanelerinde uygulayabilir, gerek laparoskopik cerrahi ekipman temininde, gerekse yardımcı ameliyathane personeli eğitiminde öncülük yapabilirler.

Incidence rate and management of diaphragmatic injury during laparoscopic nephrectomies: single-center experience

Pneumothorax is a rare complication in laparoscopic renal surgery. However, due to the increasing renal pathologies managed by laparoscopic technique, this infrequent complication is a potential risk. We investigated the incidence rate of this complication in our experience of laparoscopic renal surgery, taking into account the laparoscopic approach, the type of intervention, the character of the pathology (neoplastic or other), the site of the intervention, as well as the localization of the lesion (in case of malignant pathology). About 384 laparoscopic nephrectomies were reviewed at our institution, with a total of four cases (1.04%) of diaphragmatic injury. Diaphragmatic repair was always carried out by intracorporeal suturing, with no complications. Repair of diaphragmatic injuries should always be attempted with intracorporeal suture since this is a safe and effective technique. Then, although in the retroperitoneal approach pneumothorax is more likely, our experience has shown that transperitoneal access is not free from this complication.

Does laparoscopic transperitoneal simple nephrectomy for inflammatory and non-inflammatory kidneys differ?

Background

Laparoscopic simple nephrectomy is the standard procedure for the removal of non-functioning benign kidney. It can be performed transperitoneally or retroperitoneally. There are several studies comparing the results of transperitoneally or retroperitoneally laparoscopic nephrectomy but there are limited numbers of study comparing results of laparoscopic transperitoneal simple nephrectomy in non-inflammatory and inflammatory non-functioning kidneys. The aim of this study was to compare the results of laparoscopic transperitoneal simple nephrectomy in non-inflammatory and inflammatory non-functioning kidneys.

Results

We retrospectively reviewed the records of patients who underwent laparoscopic nephrectomy for various inflammatory and non-inflammatory renal conditions at our institution from May 2012 to October 2015. We divided the patients in two groups. Group 2 involved the kidneys with stone disease and/or hydronephrosis, patients with previous renal surgery and patients with the history of recurrent infections. Group 1 involved the patients who had non-functioning kidney without these properties. All the surgeries were performed by transperitoneal approach and peroperative blood loss, operation time, hospitalization time, postoperative creatinine changes and haemoglobin drop were compared between groups. There were 22 patients with inflammatory and 27 patients with non-inflammatory non-functioning kidney. Operation time, peroperative blood loss, hospitalization time, postoperative haemoglobin drop and creatinine difference were not statistically different between groups. Surgical side and the presence of previous surgery did not affect the surgical results of inflammatory and non-inflammatory kidney nephrectomy. The only difference was postoperative fever which was more frequent after the nephrectomy of inflammatory kidney.

Conclusions

On the basis of our experience, surgical results of transperitoneal laparoscopic simple nephrectomy did not differ between inflammatory and non-inflammatory kidneys. Surgical times were higher in inflammatory group even if the difference was not significant.

Evaluation of 2,590 urological laparoscopic surgeries undertaken by urological surgeons accredited by an endoscopic surgical skill qualification system in urological laparoscopy in Japan

BACKGROUND

In 2003, the Japanese Urological Association (JUA) and Japanese Society of Endourology (JSE) established a urological laparoscopic skill qualification system, called the Endoscopic Surgical Skill Qualification System in Urological Laparoscopy of JUA and JSE (ESSQSJJ). The main goal of the system is to decrease the prevalence of complications associated with laparoscopic surgery. To validate the qualification system, perioperative outcome and the prevalence of complications in different types of urological laparoscopic surgery performed by accredited surgeons were evaluated.

METHODS

One hundred thirty-six surgeons who obtained the qualification in 2004 were prospectively asked to submit intraoperative and postoperative data of their latest 20 cases at the end of 2009, along with the number of laparoscopic urological surgeries performed in each year for a 5-year period (2004-2009). Intraoperative and postoperative complications were graded according to the Satava classification and modified Clavien classification, respectively.

RESULTS

Data of 2,590 urological laparoscopic surgeries of 130 surgeons, including 904 laparoscopic radical nephrectomies, 430 laparoscopic nephroureterectomies, 390 laparoscopic adrenalectomies, 320 laparoscopic radical prostatectomies, and 170 laparoscopic partial nephrectomies, were analyzed. Complications were noted in 97 (3.7%) patients. Major intraoperative complications (grade II or III) occurred in 32 (1.2%) patients, and major postoperative complications (grade III or higher) occurred in 24 (0.9%) patients. The prevalence of conversion to open surgery, allogeneic transfusion, and perioperative mortality was 2.5%, 1.6%, and 0%, respectively. The number of surgeries performed by each qualified surgeon or the role of the surgeon (main operator vs. mentor/instructor) in the surgery did not affect the prevalence of intraoperative complications or postoperative complications. The open conversion rate was significantly higher in surgeons with a low surgical volume.

CONCLUSIONS

ESSQSJJ can ensure urological laparoscopic surgeons who can perform various types of urological laparoscopic surgeries with a low prevalence of perioperative complications and reasonable outcomes.

Initial experience with transperitoneal laparoscopic nephrectomy in an Irish hospital setting

INTRODUCTION

Laparoscopic nephrectomy has gained widespread acceptance as a treatment for both benign and malignant conditions and is becoming increasingly popular in Irish hospitals. We report a single surgeon, single centre experience with 20 consecutive laparoscopic nephrectomies comparing them to 20 open cases performed prior to the establishment of a laparoscopic service.

METHODOLOGY

A retrospective comparative analysis was carried out over an 18 month period. Transperitoneal approach was used in the laparoscopic group with renal vessels divided using an Endo GIA stapling device. Parameters examined included age, weight, indication, operative time, blood loss, tumour size, length of stay and analgesic requirements. Comparison was made with 20 open nephrectomies.

RESULTS

Mean age (p=0.26) and weight (p=0.08) were similar in both groups. Average tumour size was similar (4.98 cm [range 2.8-9] in laparoscopic group versus 6.4 cm [range 3-10], p=0.61). Mean operative blood loss was reduced in the laparoscopic group (65 ml (range 50-200) versus 351 ml (50-1740) (p=or<0.05 L.N. versus O.N.). Laparoscopic patients were discharged earlier; 3.9 days (range 3-6) versus 6.5 (range 5-11) postoperatively (p=or<0.05 L.N. versus O.N.). Analgesia requirements were reduced in terms of both total hours using PCA (25.05 hours [range 1-45] versus 41.6 hours (range 7-226)) (p=or<0.05 L.N. versus O.N.) and total morphine requirements (35.5 mg [range 2-94] versus 72.4 mg [range 18-113] [p=or<0.05 L.N. versus O.N.]). There were no complications in the laparoscopic group, while one patient developed an incisional hernia in the open group.

CONCLUSION

Laparoscopic nephrectomy is less invasive and demonstrates improved results in terms of analgesia, blood loss and reduced overall stay.

Lymphatic sparing laparoscopic Palomo varicocelectomy for varicoceles in children: intermediate results

OBJECTIVES

Varicocele is a relatively rare disorder in children that can lead to testicular atrophy and infertility. The ideal surgical treatment for varicoceles is still a matter of controversy because of the frequency of postoperative complications. Here, we report our series of children who underwent lymphatic sparing laparoscopic Palomo varicocelectomy.

PATIENTS AND METHODS

A total of 46 boys, 9 to 14 years old, underwent laparoscopic repair for varicoceles between January 2002 and December 2007. All of them had a left-sided varicocele. The varicocele was diagnosed by physical examination and Doppler ultrasonography. The laparoscopic procedure included obligatory dissection and preservation of the lymphatic vessels, followed by double ligation of the spermatic vessels. Follow-up for these children included physical examination and Doppler ultrasonography.

RESULTS

Lymphatic sparing laparoscopic Palomo varicocelectomy was feasible in all 46 (100%) of the children. Mean operative time was 34.2 minutes (range, 25-42 minutes). There were no intraoperative complications. One patient recurred because of incomplete ligation of spermatic vein. Mean follow-up was 20 months (range, 7-32 months). Hydrocele formation, testicular atrophy, and testicular hypertrophy were not observed postoperatively. However, 2 preoperative hypotrophic testes were noted with 10.4% and 12.5% decreases in size.

CONCLUSIONS

Our study reveals that lymphatic sparing laparoscopic Palomo varicocelectomy in children is safe, effective, and the reliable treatment of pediatric varicocele. However, long-term follow-up is required to best characterize ultimate outcome.

Mechanisms of hemostatic failure during laparoscopic nephrectomy: review of Food and Drug Administration database

OBJECTIVES

To compare the complications with endovascular stapling devices, nonlocking titanium clips, and nonabsorbable polymer ligating (Hem-o-lok) clips during laparoscopic nephrectomy.

METHODS

The Food and Drug Administration Manufacturer and User Facility Device Experience Database was retrospectively reviewed for reports dated from January 1992 to March 2006 using the key words "nephrectomy" and "kidney." All episodes of pure and hand-assisted laparoscopic nephrectomy were evaluated.

RESULTS

Of 2172 total nephrectomy or kidney-related reports, 352 reported failure using laparoscopic hemostatic devices to secure the renal vasculature, and 223 complications (63%) resulted during the use of endovascular stapling devices, 111 (33%) from nonlocking titanium clips and 18 (5%) from locking clips. The leading causes of failure reported in stapling devices were staple line malformation (47%) and locking up (29%). In titanium clips, jamming/feeding difficulties (27%) and trouble closing or "scissoring" clips (26%) were the most common. In locking clips, dislodgement (44%) was most frequently reported. Three, one, and three deaths were reported after the use of the stapling device, titanium clip, and locking clip device, respectively.

CONCLUSIONS

All three methods used to secure the renal hilum in laparoscopic nephrectomy can result in malfunction. Because the overall denominator of use is not known, it would be inappropriate to conclude that one device is safer than another. When they occurred, these device malfunctions were potentially serious. Knowledge of the possible mechanisms of failure seen with each device could allow surgeons to anticipate potential complications and, therefore, perform laparoscopic surgery more safely.

Diaphragmatic repair and/or reconstruction during upper abdominal urological laparoscopy

PURPOSE

We present our experience with and the technique of laparoscopic mesh reconstruction or suture repair of intentional resection or intraoperative injury of the diaphragm.

MATERIALS AND METHODS

In a 10-year (1997 to 2006) review of 1,850 upper abdominal renal and/or adrenal laparoscopic procedures at our institution 13 patients (0.7%) sustained diaphragmatic entry, including iatrogenic injury in 7 (0.4%), deliberate laparoscopic excision of a portion of the diaphragm in 2 and diaphragmatic incision during transthoracic adrenalectomy in 4. Laparoscopic repair techniques involved primary suture repair in 11 cases and primary reconstruction with a synthetic graft in 2. A rubber catheter and water seal system were used to primarily evacuate the pneumothorax.

RESULTS

Inadvertent diaphragmatic injury in 7 cases occurred during transperitoneal (6) and retroperitoneal (1) laparoscopy, including partial nephrectomy in 4, radical nephrectomy in 2 and adrenalectomy in 1. A diaphragmatic breach occurred due to hook electrocautery in 5 cases, trocar insertion in 1 and liver retraction in 1. Deliberate diaphragmatic excision and mesh reconstruction in 2 cases were performed after en bloc excision of the diaphragm during radical nephrectomy in 1 and during excision of a metastatic diaphragmatic nodule in 1. Four transthoracic transdiaphragmatic adrenalectomies were completed successfully without any intraoperative complications. All cases were completed laparoscopically without open conversion. A chest tube was placed prophylactically in the initial 2 patients undergoing transthoracic transdiaphragmatic adrenalectomy.

CONCLUSIONS

Laparoscopic and transthoracic repair/reconstruction of the diaphragm is safe and effective.

Laparoscopic renal surgery for benign disease

Fifteen years after the first report, laparoscopic nephrectomy has demonstrated proven efficacy and safety comparable with an open approach, with a significant advantage of a faster recovery. Wide dissemination of these surgical techniques and continued improvement in instrumentation has made laparoscopy the preferred approach for treating benign pathologic conditions of the kidney. In this review, the expanding indications of laparoscopic simple nephrectomy and the outcomes of the larger clinical series are examined. We discuss the technical aspects of both transperitoneal and retroperitoneal approaches. Finally, laparoscopic cyst decortication and some of the novel applications of laparoscopic renal surgery are highlighted.

Meta-analysis of the complications of laparoscopic renal surgery: comparison of procedures and techniques

PURPOSE

We performed a meta-analysis of the literature to define the current expectations of complications during laparoscopic renal surgery.

MATERIALS AND METHODS

References were searched in the MEDLINE database from 1995 to 2004 using the terms complications and laparoscopic nephrectomy. Inclusion criteria were any series with greater than 20 cases, patient age older than 16 years and any complications listed for certain procedures, including laparoscopic radical nephrectomy, HA laparoscopic radical nephrectomy, LPN, HALPN, laparoscopic donor nephrectomy, HA laparoscopic donor nephrectomy, laparoscopic simple nephrectomy, laparoscopic nephroureterectomy and retroperitoneal laparoscopic nephrectomy. A data extraction form was created to categorize major or minor complications. A 5 member panel adhered to the strict criteria and extracted data from articles that met inclusion criteria. Data were entered into a spreadsheet and a meta-analysis was performed.

RESULTS

Initial review identified 73 of 405 references that were acceptable for retrieval and data extraction, of which 56 met inclusion criteria. The overall major and minor complication rates of laparoscopic renal surgery were 9.5% and 1.9%, respectively. There was a significant difference between the major complication rates of LPN and HALPN (21.0% vs 3.3%, p <0.05).

CONCLUSIONS

Our results show that patients who undergo laparoscopic renal surgery may have an overall major complication rate of 9.5%. The highest major complication rate is associated with technically challenging LPN (21%). There appears to be a significantly higher wound complication rate associated with HA surgery in comparison to that of standard laparoscopy (1.9% vs 0.2%, p <0.05).

Complicaciones de la nefrectomía laparoscópica

OBJECTIVE

To report the complications and their respective management in our series of laparoscopic nephrectomy.

MATERIAL AND METHODS

Between November 1992 and March 2004, 319 patients underwent laparoscopic ablative renal surgery: 152 were women and 167 were men, mean age was 45 years (range: 0,5-82 years). There were 70 radical nephrectomies, 16 radical nephroureterectomies, 63 partial nephrectomies, 124 simples nephrectomies, 15 simples nephroureterectomies, 8 heminephrectomies and 23 living donor nephrectomies.

RESULTS

The complication rate was 5.64%. The most frequent complications were bleeding (2.5%) and retroperitoneal haematoma (1.2%). There was not statically difference in complications rate by age, sex, or approach via: transperitoneal versus retroperitoneal. Complication rate was alike with laparoscopic or hand assisted technique. There was not mortality in the series.

CONCLUSIONS

We have a low complication rate in laparoscopic nephrectomy. We believe that laparoscopy is a safe technique for patients that require ablative renal surgery when the surgical team has experience in advanced laparoscopic surgery.

Testicular varicoceles

A testicular varicocele represents an abnormal degree of venous dilatation of the pampiniform plexus. It is a relatively common condition and may present at scrotal pain and swelling. An association with male subfertility is an area of debate. This article describes the present day radiological criteria and imaging techniques to aid accurate diagnosis of varicoceles. In addition, the role of the interventional radiologist in treating this condition is discussed.

PRIOR ABDOMINAL SURGERY AND RADIATION DO NOT COMPLICATE THE RETROPERITONEOSCOPIC APPROACH TO THE KIDNEY OR ADRENAL GLAND

PURPOSE

Laparoscopic renal and adrenal surgery is an accepted standard of care. This can be accomplished by a transperitoneal or retroperitoneal approach. In patients with extensive prior intra-abdominal surgery with or without radiation the retroperitoneal laparoscopic approach may avoid bowel adhesions and potential operative complications. We compared clinical outcomes of the laparoscopic retroperitoneal approach in patients with prior open abdominal surgery with or without radiation to outcomes in those with no surgical history.

MATERIALS AND METHODS

We evaluated clinical and functional parameters in 78 consecutive patients undergoing retroperitoneoscopic renal or adrenal surgery performed by a single surgeon in a 36-month period, including radical nephrectomy with or without ureterectomy in 50, nerve sparing surgery in 8, ablation in 16 and adrenalectomy in 4. All transperitoneal procedures during the same period were excluded from analysis. Patients were divided into 48 who underwent prior abdominal surgery with or without radiation (group 1) and 30 who did not (group 2). Prior abdominal surgeries in group 1 patients were open and they were major in 42 and/or minor in 39. An additional 6 patients in group 1 received prior abdominal radiation overlapping the planned surgical field.

RESULTS

No statistically significant differences were noted between the groups in any parameter assessed, including operative time, blood loss, time to first oral intake, hospital stay or the complication rate (p >0.05). There were no enterotomies in either group. There were no open conversions in group 1, while there were 2 in group 2 (renal vein injury and splenorrhaphy secondary to lymphoma, respectively). Pathological findings showed malignancy in 57 cases (renal cell carcinoma, transitional cell carcinoma, carcinoid disease and metastases) and benign disease in 21 (oncocytoma, adenoma, pyelonephritis and complex cysts). All margins were negative except in 1 group patient with carcinoma in situ at the bladder cuff margin.

CONCLUSIONS

The retroperitoneoscopic approach to the kidney and adrenal glands can be used in patients with extensive prior open abdominal surgery and/or radiation without significant increases in morbidity or convalescence.

Complications of laparoscopic urologic surgery

Laparoscopic techniques performed in the urologic setting have received great attention in the past decade. With the development of improved laparoscopic instrumentation, approaches to gonadal, renal, prostate, and bladder diseases have been successfully performed. A discussion of urologic laparoscopy (UL) with particular attention to potential complications and limitations is presented. Awareness of these evolving technologies remains critical to all surgeons with an interest in laparoscopy.

Laparoscopic radical prostatectomy: transperitoneal versus retroperitoneal approach: is there an advantage for the patient?

PURPOSE OF REVIEW

Radical prostatectomy is the standard treatment for localized prostate cancer; its translation to a laparoscopic approach is considered today not only as feasible and reproducible but also as a valid and teachable alternative to its open counterpart. Beyond the "classical" transperitoneal antegrade route codified by the Montsouris group, several extraperitoneal approaches were developed, claiming clinical equivalence and reduced risks of morbidity and operative times. This article summarizes various aspects of different approaches and their outcome.

RECENT FINDINGS

Complications reported about transperitoneal procedures definitely further the discovery or learning curves of the pioneering teams; the groups who developed extraperitoneal alternatives established their "new approaches" on a solid base of technical skills, acquired transperitoneally. Beyond the unsurpassed qualities of visual and working spaces belonging to the transperitoneal route, which should be taken into account with respect to teaching, transperitoneal antegrade approach to the prostate enables the surgeon with early hemostatic control and essential tactical choices to achieve negative surgical margins.

SUMMARY

So far, as oncological and functional results of both approaches seem equivalent, both approaches should be further developed and remain available for teaching purposes. The true benefit for patients lies more in global quality control of surgery than in an obsessional search for alternatives to established techniques that have already stood the proof of time.

Laparoscopic radical nephrectomy: techniques, results and oncological outcome in 125 consecutive cases

OBJECTIVES

Renal cell carcinoma is likely to become one of the most important indication for laparoscopic surgery. The laparoscopic technique combines the benefits of minimal invasive approach with established surgical principles. In our institution the laparoscopic transperitoneal approach with intact specimen removal has become the standard technique for radical nephrectomies. We report the indications, techniques and oncological outcome in a single center experience.

PATIENTS AND METHODS

Between July 1999 and March 2003 we performed laparoscopic radical nephrectomies for renal cell cancer in 125 patients. Their initial staging, complications, and postoperative course were evaluated. During this period a total of about 1800 laparoscopic cases were performed. To date 82 patients were available for follow up data and have been analyzed for oncological outcome. Patients with primary metastatic disease were excluded from this analysis.

RESULTS

123 procedures out of 125 were successful. In two cases (1.6%) conversion to open surgery was necessary due to bleeding (1 case) or bowel injury (1 case). In additional 3 cases (2.4%) intraoperative complications could be managed laparoscopically. In two cases (1.6%) postoperative bleeding lead to open revision for hemostasis. The mean tumor size was 5.1cm (range 2-14 cm); median blood loss was 210 ml (range 50-900 ml). The mean surgical time was 200 min (range 90-435), including the learning curves of five surgeons. Histological findings were pT1 in 78 (62.4%), pT2 in 12 (9.6%) and pT3 in 28 (22.4%) patients. In 7 cases (5.6%) histology did not confirm malignant disease. Positive lymph nodes were detected in 3 cases (2.4%); surgical margins were negative for tumor in all patients. Follow-up was between 3 and 50 months with an average of 23.5 months. Disease progression was observed in 3 cases after 6, 11 and 12 months. No cases of local recurrence or port metastasis occurred during observation.

CONCLUSIONS

Laparoscopic radical nephrectomy is a routine, effective treatment for patients with pT1-2N0M0 renal cell carcinoma. With more experience a tumor up to 10-12 m in size can be managed safely offering all the benefits of minimal surgery to the patients. Although no long-term follow-up is available our follow-up data up to 50 months confirm the effectiveness of laparoscopic radical nephrectomy in terms of surgical principles and oncological outcome.

Complications of laparoscopic nephrectomy: the Mayo clinic experience

PURPOSE

We present the incidence of complications and conversions during laparoscopic nephrectomy performed for various indications and discuss methods to help prevent future complications.

MATERIALS AND METHODS

From June 1999 to February 2003 at our institution 285 laparoscopic nephrectomy cases were performed, consisting of 113 radical nephrectomies, 101 donor nephrectomies, 27 simple nephrectomies, 23 partial nephrectomies and 21 nephroureterectomies. We reviewed the data base of patients who underwent laparoscopic nephrectomy to examine complications and analyze factors related to conversion to an open surgical procedure.

RESULTS

Major complications occurred in 16 patients (5.6%). Major complications were surgical in 12 patients and medical in 4. Of the major surgical complications 3, 6, 1, 1 and 1 occurred during laparoscopic radical nephrectomy, donor nephrectomy, nephroureterectomy, simple nephrectomy and partial nephrectomy, respectively. The predominant major surgical complication was bleeding requiring conversion to an open surgical procedure. The overall conversion rate was 4% (12 patients), consisting of 6 emergency and 6 elective conversions. The remaining 27 patients experienced minor surgical or postoperative medical problems, such as urinary retention or wound infection. The mortality rate in our series was 0%.

CONCLUSIONS

Laparoscopic renal surgery is becoming a routine procedure in the armamentarium of many urologists. Complications that are unique to laparoscopy exist but they should decrease with time with repetition and experience. We have learned many different precautions and procedures that should help decrease the risk of future complications associated with laparoscopic renal surgery.

Complications of abdominal urologic laparoscopy: longitudinal five-year analysis

OBJECTIVES

To analyze complications of abdominal laparoscopic surgery of the urinary tract at a single institution during a 5-year period.

METHODS

From 1996 to 2000, we identified 894 abdominal laparoscopic procedures performed at a single institution: 600 nephrectomies (live donor, simple, radical, nephroureterectomy, and partial), 112 pyeloplasties, 61 renal biopsies, 35 retroperitoneal lymph node dissections, 31 renal cyst ablations, 18 adrenalectomies, and 37 other abdominal procedures. The charts were retrospectively reviewed for complications, which were classified as operative, postoperative, or medical. Complications were correlated with patient age and American Society of Anesthesiologists score. Statistical analysis was performed with Fisher's exact test and chi-square tests.

RESULTS

A total of 118 complications (13.2%) occurred. Two patients (0.2%) died. As a result of operative complications, the procedure of 13 patients (1.5%) was converted to an open one. As a result of postoperative complications, 13 (1.5%) underwent operative and 6 (0.7%) nonoperative intervention. The most common intraoperative complications were vascular (n = 23), adjacent organ (n = 10), and bowel (n = 9) injuries. The most common postoperative complications were neuromuscular pain (n = 12), hematoma (n = 11), urine leak (n = 7), and wound infection (n = 7). The differences in the annual complication rates for all procedures did not attain statistical significance (P = 0.5). Among all procedures, excluding live donor nephrectomy, complications of any kind correlated with a greater patient American Society of Anesthesiologists score (P = 0.01).

CONCLUSIONS

Rather than decreasing, the overall incidence of laparoscopic complications did not change significantly during a 5-year period at our institution. The factors contributing to this observation likely included the progression of inexperienced individual surgeons through the learning curve, the introduction of new, more sophisticated laparoscopic procedures, and stable rates of patient comorbidity. This experience may represent the average complication rate for urologic laparoscopy at a large-volume, academic training center.

[Laparoscopic radical nephrectomy: indications, techniques, and oncological outcome]

Renal cell carcinoma is likely to become one of the most important indications for laparoscopic surgery worldwide. The laparoscopic technique combines the benefits of the minimally invasive approach with established surgical principles. In our institution the laparoscopic transperitoneal approach with intact specimen extraction has become the standard technique for radical nephrectomies. We report the indications, techniques, and oncological outcome in a single center experience in 100 cases. The mean tumor size was 5.9 cm (range: 2-11 cm), the blood loss was 220 ml, and the mean surgical time was 211 min, including the learning curves of five surgeons. Histological findings were pT1 in 66 (66%), pT2 in 11 (11%), and pT3 in 19 (19%) patients with an increasing tumor size according to the experience of the surgeons. In four cases (4%) histology did not prove malignant disease. Positive lymph nodes were detected in three cases (3%) and surgical margins were negative for tumor in all patients. To date 61 patients were available for follow-up; patients with primary metastatic disease were excluded from this analysis. Follow-up was between 1 and 30 months with an average of 12.9 months. Progressive disease occurred in two cases in patients with pT3G3 tumors. No cases of local recurrence or port metastasis occurred during observation. Laparoscopic radical nephrectomy is a routine, effective treatment for patients with renal cell carcinoma. Our follow-up data up to 30 months confirm the effectiveness of laparoscopic radical nephrectomy in terms of surgical principles and oncological outcome.

Hand-assisted laparoscopic radical nephrectomy-associated rhabdomyolysis with ARF

Intraoperative rhabdomyolysis with resultant acute renal failure is a rare complication seen, most commonly, with urologic surgical procedures. Since the early 1990s, the refinement of laparoscopic techniques has permitted their application more broadly. Among the procedures to benefit from these less invasive surgical methods has been radical nephrectomy. In general, this has resulted in less postoperative pain and shorter convalescence. Nonetheless, laparoscopic radical nephrectomy still represents major surgery and is not free from operative risks. To highlight one of these risks, we present a case of a young, obese man with renal cell carcinoma who underwent a hand-assisted laparoscopic radical nephrectomy that was complicated by rhabdomyolsis resulting in acute renal failure (ARF). We discuss the clinical insults that contributed to the development of azotemia with particular attention paid to our current understanding of the pathogenesis of myoglobinuric ARF. In addition, we review the literature concerning surgery-associated, rhabdomyolytic ARF with the aim of providing clinicians guidance for the avoidance and early recognition of this rare, but very serious, surgical complication.

Major complications in 213 laparoscopic nephrectomy cases: the Indianapolis experience

PURPOSE

We assessed the incidence of and analyzed factors that may help prevent major complications and open conversion during laparoscopic nephrectomy at our institutions.

MATERIALS AND METHODS

We retrospectively analyzed all laparoscopic nephrectomies performed between August 1, 1999 and July 31, 2001. Data were stratified for nephrectomy type, intraoperative and postoperative complications. Conversion to open surgery was stratified for emergency versus elective procedures.

RESULTS

Of the 292 laparoscopic procedures performed at our institutions in 2 years 213 (73%) involved laparoscopic nephrectomy, including 84 live donor nephrectomies, 61 radical nephrectomies, 55 simple nephrectomies and 13 nephroureterectomies. A total of 16 major complications (7.5%) occurred, including access related, intraoperative and postoperative complications in 3, 9 and 4 cases, respectively. The conversion rate was 6.1% (13 patients), the transfusion rate was 1.9% and the mortality rate was 0.5% (1 death). Only 1 complication was related to simple laparoscopic nephrectomy, although this group showed the highest rate of elective conversion (7 of 8 elective conversions). Laparoscopic live donor nephrectomy showed the highest rate for emergency conversion (3 of 5 emergency conversions).

CONCLUSIONS

Our results reinforce the importance of thorough preoperative imaging, careful patient selection, surgeon experience and skill maintenance in laparoscopy as well as a low threshold for conversion to open surgery. This series provides additional evidence to support the evolution of laparoscopic nephrectomy into a standard of care.

Major complications in 213 laparoscopic nephrectomy cases: the Indianapolis experience

PURPOSE

We assessed the incidence of and analyzed factors that may help prevent major complications and open conversion during laparoscopic nephrectomy at our institutions.

MATERIALS AND METHODS

We retrospectively analyzed all laparoscopic nephrectomies performed between August 1, 1999 and July 31, 2001. Data were stratified for nephrectomy type, intraoperative and postoperative complications. Conversion to open surgery was stratified for emergency versus elective procedures.

RESULTS

Of the 292 laparoscopic procedures performed at our institutions in 2 years 213 (73%) involved laparoscopic nephrectomy, including 84 live donor nephrectomies, 61 radical nephrectomies, 55 simple nephrectomies and 13 nephroureterectomies. A total of 16 major complications (7.5%) occurred, including access related, intraoperative and postoperative complications in 3, 9 and 4 cases, respectively. The conversion rate was 6.1% (13 patients), the transfusion rate was 1.9% and the mortality rate was 0.5% (1 death). Only 1 complication was related to simple laparoscopic nephrectomy, although this group showed the highest rate of elective conversion (7 of 8 elective conversions). Laparoscopic live donor nephrectomy showed the highest rate for emergency conversion (3 of 5 emergency conversions).

CONCLUSIONS

Our results reinforce the importance of thorough preoperative imaging, careful patient selection, surgeon experience and skill maintenance in laparoscopy as well as a low threshold for conversion to open surgery. This series provides additional evidence to support the evolution of laparoscopic nephrectomy into a standard of care.