Laparoscopic radical nephrectomy: oncologic efficacy

Laparoscopic radical nephrectomy versus open radical nephrectomy in T1-T3 renal tumors: An outcome analysis

Aims:

To compare laparoscopic radical nephrectomy (LRN) with open radical nephrectomy (ORN) in T1-T3 renal lesions.

Materials and Methods:

The records of 65 patients who underwent LRN between January 2002 and December 2006 were entered prospectively in a database. The patients were compared with 56 patients who had undergone ORN between January 2000 and December 2005. The two groups were comparable in terms of age, body mass index (BMI) and tumor size. LRN was compared with ORN in terms of operative room time, blood loss, complications, analgesic requirement, hospital stay and start of oral intake. The oncologic efficacy was evaluated in stages T1 and T2 in terms of cancer-free and overall survival.

Results:

The laparoscopy group had a significantly shorter hospital stay (5.72, range 3-23 days vs. 9.18, range 4-23 days, p value: < 0.0001), analgesia requirement (175.65, range 50-550 mg vs. 236, range 0-1100 mg of tramadol, p value: < 0.03), hemoglobin decline (1.55, range 0.1 to 4.4 mg/dl vs. 2.25, range 0.2 - 7 mg/dL, p value: < 0.001) and hematocrit drop (4.83, range 0.3 - 12.9 vs. 7.06 range 2 -18, p value: < 0.0001). The majority of specimens showed renal cell carcinoma. In the laparoscopy group, 29 tumors were T1 stage, 18 were T2, while eight were T3. In the open surgery group, 25 tumors were T1, 19 were T2 and 12 were T3. The cancer-free survival rate at 24 months for ORN and LRN in T1 lesions was 91.7% and 93.15% respectively and the patient survival rate was 100% in both groups. The cancer-free survival rate at 24 months for ORN and LRN in T2 lesions was 88.9% and 94.1%, respectively and the patient survival was 100% and 94%, respectively. After LRN, there was one instance of port site metastasis, local recurrence and distant metastasis. All recurrences were distant after ORN.

Conclusion:

Laparoscopic radical nephrectomy has advantages in terms of shorter hospitalization and a lower analgesia requirement. It is feasible and produces effective cancer control in T1 lesions, comparable to that of its open counterpart in T2 and selected cases of T3 lesions.

Renal cell carcinoma with an emphasis on drug therapy of advanced disease, part 1

PURPOSE

The diagnosis, staging, and management of renal cell carcinoma (RCC) are reviewed. The mechanism, pharmacokinetics, toxicity, clinical activity, and application of molecularly targeted agents in RCC are emphasized.

SUMMARY

RCC is the eighth most commonly diagnosed malignancy in the United States. The most common signs and symptoms are gross hematuria, flank pain, and the presence of a flank mass. Localized disease is found in about 55% of patients, 19% of patients have locally advanced disease, and 20% of patients have metastatic disease. Surgical resection is the mainstay of therapy for stage I-III RCC. The pharmacotherapy of RCC is undergoing significant change. Standard therapy used to include the cytokines interferon alfa and aldesleukin. High-dose aldesleukin is used to treat select patients. Its major value is the durability of responses in the few patients who achieve a complete remission. However, cytokines have been largely displaced by sorafenib tosylate, sunitinib malate, and temsirolimus due to their lower rates of toxicity and positive effects on progression-free survival. Bevacizumab has also shown activity in patients with advanced disease. Estimated five-year survival rates for patients with RCC are 89.6% for localized disease, 60.8% for regional disease, and 9.5% for patients with distant metastases. Studies are currently under way to assess the activity of combinations of available agents and new targeted agents as adjuvant therapy and for the management of advanced RCC.

CONCLUSION

The options available for the management of advanced RCC have expanded considerably in the past five years with the advent of molecularly targeted therapies.

Effect of Advanced Age on Laparoscopic Urologic Procedures

PURPOSE

To evaluate the effect of increasing age of urology patients on the outcome of laparoscopic procedures.

PATIENTS AND METHODS

We performed a retrospective review of patients undergoing laparoscopic urologic procedures from 1998 to 2005, comparing patients 75 or older with all other patients undergoing the same procedures. Data were available on 175 patients. Length of hospitalization, complications, estimated blood loss (EBL), operative time, ASA class, and the Charlson comorbidity index (CCI) were taken from hospital and outpatient records. Subgroup analysis was performed on older patients, one group aged 65 to 74 years and the other > or =75 years. Statistical analysis was done using a two-tailed t-test and chi-square test.

RESULTS

Patients aged 75 or older had no statistically significant differences in operative time (318 minutes v 319 minutes; P = 0.967), EBL (271 mL v 331 mL; P = 0.487), or complication rate (14.6% v 12.9%; P = 0.434). However, there was a significant increase in the length of stay (6.06 days v 3.74 days; P = 0.0015). In the subgroup analysis of patients 65 to 74 years v > or =75 years, a significant increase in the length of hospitalization was still present despite controlling for complications.

CONCLUSIONS

Laparoscopic procedures in patients 75 years and older entail a significantly longer hospital stay than in younger patients despite similar medical comorbidities. Overall, there was no significant increase in perioperative complications related to age.

Laparoscopic management of advanced renal cell carcinoma with level I renal vein thrombus

OBJECTIVES

To present our series of laparoscopic radical nephrectomy in patients with level I tumor thrombus. The existence of renal vein tumor thrombus presents a technical challenge in securing hilar control during the resection of a renal mass. To our knowledge, this experience represents one of the largest series of laparoscopic nephrectomy for renal cell carcinoma associated with a macroscopic renal vein thrombus.

METHODS

From April 2002 to June 2004, 12 patients (8 men and 4 women) were diagnosed with renal masses. In addition to computed tomography, cavography and magnetic resonance imaging were used to determine the levels of tumor thrombi preoperatively in those who had suspicious involvement of the renal vein on computed tomography.

RESULTS

Laparoscopic nephrectomy was performed in a standard fashion. Hand-assisted laparoscopic nephrectomy was used in 6 cases involving large tumors with bulky hilar adenopathy. All renal veins were stapled using an endoscopic vascular stapler. Intraoperative laparoscopic ultrasonography was used to delineate the extent of the vein thrombus in 4 cases to enable proper stapler positioning. No intraoperative complications occurred, and 2 cases were electively converted to open nephrectomy. The postoperative narcotic requirements and hospitalization times were low. Pathologic examination of the tumor specimens demonstrated negative resection margins in all patients.

CONCLUSIONS

In carefully selected patients, laparoscopic resection of renal masses with level I renal vein thrombi is feasible. Because of technical considerations that may be identified intraoperatively, early conversion to open nephrectomy should be anticipated. Long-term results regarding oncologic control continue to be assessed.

Cost Containment in Laparoscopic Radical Nephrectomy: Feasibility and Advantages over Open Radical Nephrectomy

PURPOSE

To highlight the impact of the laparoscopic experience of the surgical team on achievement of satisfactory results with cost containment in performing laparoscopic radical nephrectomy (LRN).

PATIENTS AND METHODS

We compared the cost components of 15 consecutive uncomplicated LRNs performed in 2001 (LRN01) with 15 consecutive uncomplicated laparoscopic radical nephrectomies performed in 2003 (LRN03) and with 15 consecutive uncomplicated procedures performed at our institution by the same surgical team in the year 1999 matched for patient age, tumor size, and disease stage. The groups were comparable in demographics.

RESULTS

The operative times were 250, 225, and 195 minutes in the LRN01, LRN03, and open-surgery groups, respectively, while the lengths of postoperative stay were 3.8, 3.1, and 6.5 days. Operating room costs, excluding the disposable instruments, were 11.00 /min for the open surgery and 10.00 /min for laparoscopic nephrectomy, and the cost of the postoperative stay was 300 to 310 per day. The cost of disposable instruments was 952.18 for LRN01 and 146.37 for LRN03. The overall costs were 4155.00 for the open-surgery group, 4672.00 for LRN01, and 3336.37 for LRN03.

CONCLUSIONS

Cost containment in laparoscopic nephrectomy is possible. A proper team learning curve and the employment of reliable reusable instruments is the key to reducing costs, making this procedure as economically advantageous as the equivalent open procedure.

[When is aftercare useful in renal cell cancer?]

Diagnosis of tumor recurrence and of therapy-related side effects as well as psychological support are the main goals of a surveillance program of cancer patients. While the latter may represent a time-consuming effort, most diagnostic procedures are expensive. Whether we can efficiently detect tumor recurrence in renal cell carcinoma depends on various parameters of the recurrent disease (e.g., frequency, localization, or therapeutic options). Available data lend support to "lean" follow-up strategies in patients with renal cell carcinoma.

Laparoscopic Radical Nephrectomy: Long-Term Outcomes

BACKGROUND

Although more than a decade of experience with laparoscopic radical nephrectomy indicates it is an alternative to open surgery for localized renal-cell carcinoma (RCC), the long-term oncologic effectiveness of this procedure remains to be established.

MATERIALS AND METHODS

A thorough MEDLINE and PubMed literature research on long-term outcomes of laparoscopic radical nephrectomy was performed, and all pertinent articles were reviewed in detail. This review was formulated on the current cancer indication, the oncologic basis, the oncologic efficacy, and the longterm oncologic effectiveness of the procedure, including laparoscopic cytoreductive nephrectomy, with regard to metastasis, port-site tumor recurrence, and the relation to laparoscopic partial nephrectomy. Furthermore, the authors' previous report on the intermediate-term efficacy of laparoscopic radical nephrectomy was updated.

RESULTS

With increasing experience, the indications for laparoscopic radical nephrectomy continue to expand. There were many reports of intermediate-term, two reports of long-term, and our up-to-date outcomes analyzing the management of localized RCC that showed effective cancer control with no statistically significant difference between laparoscopic and open radical nephrectomy in the true 5- and 10-year survival analysis.

CONCLUSION

Long-term data, critical in the evaluation of any treatment for cancer, are currently available with respect to laparoscopic radical nephrectomy for localized RCC.

Rezidivtumor beim Nierenkarzinom

Locally recurrent renal cell carcinoma (RCC) is 0-10% after nephron-sparing surgery, 2.5-4% after thermoablative interventions and 2-3% after (radical) nephrectomy. Risk-factors are: sporadic or hereditary origin, tumor size, multifocality, histologic phenotype and incomplete resection. To date, there are no significant differences in the incidence of locally recurrent tumors independently of whether open or laparoscopic techniques were preferred. Caution still has to be taken with the use of alternative tools for minimally invasive tumor ablation.Finally, no statistically proven standard therapy exists that would clearly provide a superior outcome for patients with an isolated local recurrence. However, meta-analyses strongly support the performance of a resection of the recurrence as the primary working principal.

Trends toward laparoscopic nephrectomy at a community hospital

PURPOSE

For proper indications at university hospitals laparoscopic nephrectomy is often considered the standard of care. At community hospitals past surveys have not demonstrated this change. We describe the changing practice patterns of performing laparoscopic nephrectomies in indicated patients at our community hospital. We reviewed our data on monitoring our training program.

MATERIALS AND METHODS

A retrospective chart review was performed of 381 consecutive complete nephrectomies performed at our institution from February 2000 to December 2003, including 62 live donor nephrectomies. Patient age, pathological size, operative time, estimated blood loss, duration to solid food intake and duration of hospitalization were compared between open nephrectomy and laparoscopic nephrectomy groups using the Wilcoxon 2-sample test. Surgical practice and surgeon characteristics were also described.

RESULTS

Patients who underwent laparoscopic nephrectomy demonstrated superior postoperative recovery with earlier return to solid diet and shorter hospitalization. The 2 groups were similar in regard to major complication rates. The number of laparoscopic nephrectomies increased annually, while the number of open nephrectomies decreased. The number of laparoscopic urologists increased annually. More importantly laparoscopic urologists performed an increasing number of nephrectomies, while nonlaparoscopic urologists faced a decrease in the number of nephrectomies performed. There appeared to be little evidence of hand assisted laparoscopic nephrectomy as a bridge to learning standard laparoscopic nephrectomy.

CONCLUSIONS

Our training paradigm has safely and effectively trained community urologists to perform laparoscopic nephrectomies. Laparoscopic nephrectomy is now considered a standard treatment option along with conventional open surgery and it should be offered to the patient in the medical setting. Although fellowship trained urologists can certainly add expertise to any program, community based hospitals do not have to depend on them.

New Approaches to the Minimally Invasive Treatment of Kidney Tumors

The incidence of renal cortical neoplasms has dramatically increased with the widespread use of abdominal imaging over the past 20 years. Coincidentally, the proportion of tumors that are smaller and incidentally detected has risen as well, indicative of a stage migration. The widespread application of minimally invasive and laparoscopic techniques to other organ systems has spurred the development of minimally invasive approaches to the management of renal tumors. The available data regarding laparoscopic nephrectomy, laparoscopic partial nephrectomy, and tissue ablative techniques, such as renal cryoablation, radiofrequency ablation, and high-intensity focused ultrasound are reviewed.