Is laparoscopic radical nephrectomy with specimen morcellation acceptable cancer surgery?

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.

The effect of kidney morcellation on operative time, incision complications, and postoperative analgesia after laparoscopic nephrectomy

INTRODUCTION

Compare the outcomes between kidney morcellation and two types of open specimen extraction incisions, several covariates need to be taken into consideration that have not yet been studied.

MATERIALS AND METHODS

We retrospectively reviewed 153 consecutive patients who underwent laparoscopic nephrectomy at our institution, 107 who underwent specimen morcellation and 46 with intact specimen removal, either those with connected port sites with a muscle-cutting incision and those with a remote, muscle-splitting incision. Operative time, postoperative analgesia requirements, and incisional complications were evaluated using univariate and multivariate analysis, comparing variables such as patient age, gender, body mass index (BMI), laterality, benign versus cancerous renal conditions, estimated blood loss, specimen weight, overall complications, and length of stay.

RESULTS

There was no significant difference for operative time between the 2 treatment groups (p = 0.65). Incision related complications occurred in 2 patients (4.4%) from the intact specimen group but none in the morcellation group (p = 0.03). Overall narcotic requirement was lower in patients with morcellated (41 mg) compared to intact specimen retrieval (66 mg) on univariate (p = 0.03) and multivariate analysis (p = 0.049). Upon further stratification, however, there was no significant difference in mean narcotic requirement between the morcellation and muscle-splitting incision subgroup (p = 0.14).

CONCLUSION

Morcellation does not extend operative time, and is associated with significantly less postoperative pain compared to intact specimen retrieval overall, although this is not statistically significant if a remote, muscle-splitting incision is made. Morcellation markedly reduces the risk of incisional-related complications.

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.

Laparoscopic partial nephrectomy: evaluation of long-term oncological outcome

PURPOSE

Laparoscopic partial nephrectomy (LPN) has emerged as a viable alternative to open surgery for renal tumors less than 4 cm. We present oncological followup of patients treated with laparoscopic nephron sparing surgery at our institution.

MATERIALS AND METHODS

Between September 1996 and December 2001, 48 patients who underwent LPN for clinically localized tumors were found to have pathologically proven renal cell carcinoma. Medical and operative records were reviewed for clinical characteristics, pathological findings and followup information.

RESULTS

Mean patient age was 59.7 years (range 32 to 81) and mean followup was 37.7 months (range 22 to 84). Mean tumor size was 2.4 cm (range 1.0 to 4.0). Final pathological stage was pT1 in 42 patients (87.5%) and pT3a in 6 (12.5%). Histology revealed clear cell in 32 patients (66.7%), papillary in 10 (20.8%), chromophobe in 3 (6.3%), collecting duct in 1 (2.1%) and unclassified in 2 (4.2%). Intraoperative frozen section biopsies revealed negative margins in all cases. Final surgical margins were positive in 1 patient (2.1%). Followup evaluation consisting of physical examination and yearly cross-sectional imaging, which revealed no recurrences in 46 of 48 patients (95.8%). One patient with von Hippel-Lindau disease was found to have local recurrence 18 months after LPN and observation was elected. The second patient had recurrence in the same kidney away from the original tumor site approximately 4 years later.

CONCLUSIONS

LPN is an effective treatment modality for clinically localized renal cell carcinoma. Oncological outcomes at a mean followup of 3 years are promising, although the durability of oncological outcomes must be determined.

Laparoscopic nephrectomy: assessment of morcellation versus intact specimen extraction on postoperative status

PURPOSE

We compared pathological evaluation and postoperative recovery in patients undergoing transperitoneal laparoscopic nephrectomy at our institution with morcellated vs intact specimen extraction.

MATERIALS AND METHODS

A prospective evaluation of 57 consecutive patients undergoing radical and simple transperitoneal laparoscopic nephrectomy was reviewed. One patient was excluded from study due to transitional cell carcinoma, which was detected intraoperatively. The 33 morcellated specimens were extracted at the umbilical port and the 23 intact specimens were extracted through a midline infraumbilical incision. Data were obtained on narcotic requirements, hospital stay, complications, estimated blood loss, mass size based on preoperative imaging, specimen weight and extraction incision length.

RESULTS

Mean incision length in the morcellated and intact specimen removal groups was 1.2 and 7.1 cm, respectively (p <0.001). No significant differences in pain or recovery were noted between the 2 groups. Two cases of microscopic invasion of the perinephric adipose tissue in the intact specimen group were up staged from clinical T1 to pT3a disease. No change in patient treatment was made based on this information.

CONCLUSIONS

We did not find a significant difference in surgical time, pain or hospital stay. Only incision length was statistically significant. Postoperative recovery appeared to be similar in these 2 groups. With modern imaging modalities information on pathological stage did not alter patient treatment.

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.

Specimen morcellation after laparoscopic radical nephrectomy: confirmation of histologic diagnosis using needle biopsy

BACKGROUND AND PURPOSE

Laparoscopic radical nephrectomy (LRN) is being increasingly offered for the management of renal-cell carcinoma (RCC). Specimen removal may be performed through a small or hand-port incision or by specimen morcellation. Limited studies exist addressing the accuracy of histopathologic diagnosis in morcellated renal tumors. Because of concerns about the lack of a diagnosis secondary to the morcellation process, we performed premorcellation needle biopsies to obtain nondisrupted tissue for pathologic analysis. Herein, we compare the histopathologic diagnosis achieved via needle biopsy prior to morcellation with that of the final specimen.

PATIENTS AND METHODS

Following successful laparoscopic resection, specimens were entrapped in a Lapsac. Needle biopsies were performed manually through the mouth of the Lapsac, and morcellation was then done in some patients using manual and mechanical methods. The histopathologic diagnoses in the needle biopsy specimens and the morcellated material were compared.

RESULTS

Laparoscopic radical nephrectomy with specimen morcellation was performed in 15 patients. Nine patients had premorcellation needle biopsies. Eight of these biopsies had sufficient tissue for diagnosis of RCC. This finding correlated with final diagnosis from the morcellated material. Perinephric fat invasion was identified in three morcellated specimens.

CONCLUSIONS

Needle biopsy prior to specimen morcellation confirmed the histologic diagnosis of the morcellated specimen. This finding suggests that such histopathology material is adequate for diagnosis and may make premorcellation needle biopsy redundant.

Novel method of assessing surgical margin status in laparoscopic specimens

OBJECTIVES

To develop a novel method of inking laparoscopic specimens before piecemeal extraction to evaluate the surgical margins.

METHODS

Methylene blue, indigo carmine, and India ink were tested in vitro on cadaveric bovine kidneys before manual morcellation in laparoscopic retrieval bags, and subsequently in pigs in vivo undergoing laparoscopic nephrectomy. Tissue fragments were examined both grossly and microscopically after routine histologic processing. On the basis of the findings in these experiments, we used India ink clinically in 4 cases of laparoscopic nephrectomy and adrenalectomy for suspected tumor and assessed the ability to indicate specimen margins grossly and microscopically.

RESULTS

Methylene blue and India ink were the substances that best covered the surface of the surgical specimen completely, were best retained on the tissue, and were most easily washed from the retrieval bag. Gross inspection of the morcellated specimens easily distinguished the inked pieces, signifying tissue present at the surgical margin, from the uninked pieces. During morcellation, neither contamination of central tissue with ink nor leakage of ink from the bag occurred. India ink consistently endured fixation, embedding, and sectioning, with the black, inked margins of the specimen visible microscopically.

CONCLUSIONS

Application of India ink before laparoscopic organ morcellation specifically marks the margins of the specimen. This technique allows pathologic determination of the surgical margin status, as well as fractionation of the tissue fragments, and addresses a criticism of organ morcellation. These improvements in the pathologic analysis of laparoscopically excised specimens may obviate the need for intact organ removal.

Kidney morcellation in laparoscopic nephrectomy for tumor: recommendations for specimen sampling and pathologic tumor staging

Laparoscopic nephrectomy is a novel approach for small renal tumors in selected patients; however, removal of the kidney through the small laparoscopic abdominal wall incision site requires the kidney to be morcellated into small fragments while still in situ. Morcellation presents two problems for the pathologist. First, guidelines for optimal sampling of morcellated fragments have not been described. Second, morcellation precludes complete pTNM tumor staging, in particular, tumor size, margins, and renal vein involvement. Based on our initial experience with 23 laparoscopic nephrectomies/nephroureterectomies (13 clinically suspected neoplasms, confirmed pathologically as renal cell carcinoma [RCC, n = 7], urothelial carcinoma of the renal pelvis [n = 3], angiomyolipoma [n = 1], and cystic nephroma [n = 1], and 10 clinically benign entities) and a conservative statistical model, we present a decision analysis model of various specimen sampling protocols that optimize cost, labor, or time to diagnosis (single vs sequential sampling). Using the tumor-to-kidney volume ratio (TKR), calculated from preoperative radiologic imaging and specimen gross weight, several specimen sampling algorithms were compared. For the average situation in which TKR is > or =0.15, the algorithm that most significantly optimizes cost and labor is one that initially samples 5% of the morcellated specimen. However, additional sampling may be required in one fourth of the cases. The optimal amount of sampled tissue may indeed be less than 5% because this assumes no suspicious tissue is grossly visible and in all our cases of RCC grossly visible tumor was identified. Additional nomograms for a spectrum of TKR, sampling success, and cost are presented to allow pathologists their own discretion in determining optimal sampling of the morcellated kidney. Tumor staging is severely limited by morcellation. Tumor size, renal capsule involvement, and renal vein involvement cannot be fully pathologically evaluated for RCC, whereas invasion cannot be definitively assessed for urothelial carcinoma of the renal pelvis. Knowledge of the radiologic features (lesion size, capsule, and vein involvement) is important in sampling and staging morcellated kidneys removed laparoscopically.

Laparoscopic partial nephrectomy. The European experience

Laparoscopic partial nephrectomy is technically difficult but oncologically effective. The operation should be performed in centers with expertise. Hemostasis can be achieved using bipolar coagulation and fibrin glue-coated cellulose. Further studies will determine whether less invasive alternatives (focused ultrasound, cryotherapy) will meet the high standard of open (or laparoscopic) nephron-sparing surgery for small renal cell carcinoma.