Novel method of assessing surgical margin status in laparoscopic specimens

Margins in skin excision biopsies: principles and guidelines

Skin biopsies are usually undertaken to confirm a clinical diagnosis, to remove a lesion, and to determine the adequacy of excised tissue margin. A surgical margin is technically defined as the "edge" of the tissue removed. The term is especially pertinent when the tissue excised is suspected of being involved by a malignant process. One of the most important predictive and prognostic factors of a malignant lesion is whether the margins of the resected specimen are involved by the tumor or not. The purpose of this review is to provide an insight into grossing of a skin biopsy specimen with emphasis on techniques and reporting of excision biopsy margins.

Safety of laparoscopic adrenalectomy in patients with large pheochromocytomas: a single institution review

BACKGROUND

Laparoscopic adrenalectomy is the procedure of choice for small adrenal tumors, but some concerns have been voiced when this approach is adopted for larger tumors and pheochromocytomas. The aim of this study was to examine the results of the laparoscopic resection of large pheochromocytomas.

METHODS

A retrospective review of adrenalectomies performed for adrenal pheochromocytomas>6 cm in diameter. We compiled and analyzed the early operative complications, histologic findings, and cure rates with a minimum of 1 year of follow-up after surgery.

RESULTS

From 1996 to 2005, a total of 445 laparoscopic adrenalectomies were performed in our institution using the anterolateral transperitoneal approach. From this series we identified 18 procedures for pheochromocytomas with an average diameter on imaging of 78.2 mm (range 60-130 mm). All patients were rendered safe with a standard departmental protocol involving calcium-channel blockade initiated at least 2 weeks prior to surgery. The average peak intraoperative blood pressure was 187 mmHg. Capsular disruption occurred in two cases. One patient required an intraoperative blood transfusion due to intraoperative blood loss. No immediate conversions to an open procedure were required, but one patient underwent a delayed laparotomy for hematoma formation. Histologically, four of the adrenal tumors displayed evidence of vascular invasion. Biochemical cure was achieved in all patients after a median follow-up of 58 months (16-122 months).

CONCLUSIONS

Laparoscopic adrenalectomy appears to be a safe and effective approach for large pheochromocytomas when no preoperative or intraoperative evidence of local invasion is present.

Laparoscopic Nephroureterectomy with Bladder-Cuff Resection: Techniques and Outcomes

Advancements in minimally invasive instrumentation and technique have provided the impetus to performing urologic procedures with reduced perioperative morbidity, shorter hospital stays, and, most importantly, efficacious oncologic results. At multiple centers of excellence, laparoscopic nephroureterectomy (LNU) has evolved into a new standard for the management of upper-tract transitional-cell carcinoma (TCC) that is not amenable to endoscopic resection. An LNU may be performed via a transperitoneal or retroperitoneal approach together with excision of the distal ureter and a bladder cuff. Analysis of present-day studies comparing LNU with open techniques demonstrates equivalent oncologic outcomes. In addition, those patients undergoing LNU fare better than their counterparts having open surgery with respect to hospital stay, analgesic requirements, and convalescence. With multiple options for excision of a cuff of bladder, a consensus has not been established. However, LNU has emerged as the new standard of care for the treatment of upper- tract TCC. Review of the techniques and outcomes of LNU from the minimally invasive urology community are described.

Evaluation of the intact specimen after laparoscopic radical nephrectomy for clinically localized renal cell carcinoma identifies a subset of patients at increased risk for recurrence

PURPOSE

Laparoscopic radical nephrectomy (LRN) is emerging as a standard approach for low stage renal cell carcinoma (RCC). Some suggest that specimen morcellation for extraction results in less morbidity and a faster recovery. However, morcellation may preclude accurate pathological staging and may hinder precise pathological grading. With pathological evaluation of an intact specimen we identified patients harboring high risk disease that was not anticipated preoperatively, defined as pT2 high grade (G3-4) or lesions greater than pT2.

MATERIALS AND METHODS

We retrospectively reviewed the records of 192 patients who underwent LRN for renal lesions at The University of Texas M. D. Anderson Cancer Center between April 2002 and April 2004.

RESULTS

A total of 192 patients underwent LRN for presumed RCC. In all cases specimens were removed intact. Of these cases 137 were cT1/T2 N0 M0 and had a final pathological diagnosis of RCC. All surgical margins were negative. Of the 137 patients 40 (29.2%) were at increased risk for recurrence based on high risk features. Specifically up staging from cT1-2 to pT3 disease occurred in 30 patients (21.9%) while 12 patients (8.8%) were found to have pT2 G3-4 disease. All 40 patients with high risk disease underwent more intensive surveillance and 17 (43%) participated in adjuvant systemic therapy trials.

CONCLUSIONS

In our study 21.9% of patients with clinical T1-2 disease were pathologically up staged and 29.2% were identified as being at high risk for recurrence after intact specimen extraction for localized RCC. These patients are candidates for more intensive followup treatment and may benefit from enrollment in adjuvant therapy protocols.

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.

Changing Concepts in the Surgical Management of Renal Cell Carcinoma

The foundations of the generally accepted principles underlying the surgical management of renal cell carcinoma (RCC) were best annunciated in 1969 by Robson in his classic description of the radical nephrectomy [J Urol 1969;101;297]. Since then, much has changed in our understanding of the basic biology and genetics of kidney cancer, advances in renal imaging and clinical staging have led to the increased detection of incidental, lower stage, organ-confined tumors more amendable to expanded surgical options, surgical techniques themselves have evolved, and surgical equipment technology has advanced to make possible new methods of managing renal tumors in situ. Thus, the management of both localized and metastatic RCC has changed dramatically in the last 20 years, predicated on these major advancements in renal imaging, surgical techniques, and the development of effective immunotherapies for advanced disease. In this review, the evolution in thinking regarding the tenets of the radical nephrectomy will be examined, including the necessity for removal of the entire kidney, the possibility of sparing the adrenal gland, when and how extensive a lymphadenectomy should be performed, the development of laparoscopic and percutaneous nephron-sparing surgery using ablative technologies, and the role of nephrectomy and metastasectomy in patients with metastatic RCC. Here, we review current concepts and outcomes on the surgical management of RCC to help elucidate some of these changes, from the evolution of open to laparoscopic to percutaneous, from radical to partial to ablative approaches.

Laparoscopic radical nephrectomy: oncologic efficacy

Laparoscopic radical nephrectomy has evolved tremendously over the past decade to the point where it should be considered the standard of care for localized renal tumors not amenable to nephron-sparing surgery. The benefits of decreased postoperative pain, shortened hospital stay, quicker convalescence, and improved cosmesis have been proved in numerous studies. Long-term oncologic results of LRN have demonstrated equivalent outcomes to ORN.

Pathologic sampling of laparoscopically morcellated kidneys: a mathematical model

BACKGROUND AND PURPOSE

Kidney morcellation permits tissue removal through a port site; however, standard methods of histopathologic examination of the numerous specimen fragments thus produced have not been established. We developed a model to guide pathologic evaluation of the morcellated kidney.

MATERIALS AND METHODS

A mathematical model was created to determine the quantity of morcellated tissue needed to establish a diagnosis. Inputs into the equation included estimated lesion size, total specimen volume, and the desired certainty of identifying at least a portion of the lesion on pathologic analysis. Nomograms were calculated to illustrate the model and provide clinically relevant guidelines.

RESULTS

The hypergeometric distribution was used to develop the formula: P = 1 - (1 - k/N)(n), where k/N represents the fraction of total specimen with tumor, n is the amount of specimen that must be sampled to yield a diagnosis, and P is the probability of encountering the tumor in the sampled tissue. The model provided nomograms that were feasible and would guide a practical approach to the pathologic analysis of laparoscopically morcellated specimens.

CONCLUSIONS

The increasing application of laparoscopy to the removal of solid organs with suspected tumors has raised several important issues. Morcellation of these specimens precludes traditional pathologic examination and necessitates an alternative method of specimen sampling and diagnosis. We describe a novel, systematic model to assist in the histopathologic examination of morcellated specimens. Issues of pathologic staging remain unresolved, but this sampling system provides a nonarbitrary framework to help arrive at a histologic diagnosis.