Metastatic renal cell cancer after laparoscopic radical nephrectomy: long-term follow-up

Recurrent Renal Cell Carcinoma Presenting as Port-Site Metastases, Detected on 18F-Fluorodeoxyglucose Positron Emission Tomography-Computed Tomography

The incidence of port-site metastases (PSMs) varies with the tumor type with adenocarcinoma having a high incidence. However, it is rarely seen in urological malignancies and more so in renal cell carcinoma (RCC). We hereby describe one such case of PSM after laparoscopic radical nephrectomy for RCC, which was detected on 18F-fluorodeoxyglucose positron emission tomography-computed tomography.

An unusual case of sarcomatoid renal cell carcinoma presenting in the skin by direct extension at a laparoscopic port site

Although renal cell carcinoma (RCC) is known for its propensity to metastasize widely throughout the body, cutaneous metastases are uncommon and seen in less than 3% of RCCs. A 56-year-old man presented with a painful red lesion with satellite nodules on his abdomen at a laparoscopic port site from a partial nephrectomy for a pT1a clear-cell RCC that was performed 28 months prior. The lesion was excised; however, after excision the lesion recurred with continued pain and drainage from the surgical site. This was treated with multiple courses of antibiotics. Because of the persistent nature of the lesion, it was re-biopsied, and an atypical, keratin-positive, spindle-cell proliferation was identified within the dermis. The patient's previous skin excision was reexamined, and the same atypical cells were identified within large areas of necrosis, granulation tissue, and fibrosis. Further workup was performed on the initial excision, and the atypical cells showed expression of CD10, CAIX, PAX8, EMA, and vimentin, consistent with cutaneous involvement by RCC. Because of the rarity of skin metastases in RCC and the location at a previous laparoscopic port site, this lesion is presumed to have resulted from direct extension of tumor at the time of surgery.

A Laparoscopic Morcellator Redesign to Constrain Tissue Using Integrated Gripping Teeth

Laparoscopic hysterectomy is a procedure that involves the removal of the uterus through an abdominal keyhole incision. Morcellators have been specifically designed for this task, but their use has been discouraged by the food and drug administration (FDA) since November 2014 because of risks of cancerous tissue spread. The use of laparoscopic bags to catch and contain tissue debris has been suggested, but this does not solve the root cause of tissue spread. The fundamental problem lies in the tendency of the tissue mass outside the morcellation tube to rotate along with the cutting blade, causing tissue to be spread through the abdomen. This paper presents a bio-inspired concept that constrains the tissue mass in the advent of its rotation in order to improve the overall morcellation efficacy and reduce tissue spread. A design of gripping teeth integrated into the inner diameter of the morcellation tube is proposed. Various tooth geometries were developed and evaluated through an iterative process in order to maximize the gripping forces of these teeth. The maximum gripping force was determined through the measurement of force–displacement curves during the gripping of gelatin and bovine tissue samples. The results indicate that a tooth ring with a diameter of 15 mm can provide a torque resistance of 1.9 Ncm. Finally, a full morcellation instrument concept design is provided.

Surgical Treatment of Uterine Fibroids Within a Containment System and Without Power Morcellation

Increased awareness regarding risks associated with intracorporeal electromechanical, or power, morcellation has urged surgeons to develop alternative methods for tissue extraction that may mitigate some of these risks during surgery. The use of containment systems during laparoscopic procedures has allowed surgeons to continue to offer and perform myomectomies that still benefit from being minimally invasive but which may minimize the risk of inadvertent tissue dispersion. Here, we will review techniques for performing contained tissue fragmentation without the use of a power morcellator.

Port-site metastasis as a primary complication following retroperitoneal laparoscopic radical resection of renal pelvis carcinoma or nephron-sparing surgery: A report of three cases and review of the literature

The present study reports the clinical data of two patients with renal pelvis carcinoma and one patient with renal carcinoma who developed port-site metastasis following retroperitoneal laparoscopic surgery. The current study aimed to identify the cause and prognosis of the occurrence of port-site metastasis subsequent to laparoscopic radical resection of renal pelvis carcinoma and nephron-sparing surgery. Post-operative pathology confirmed the presence of high-grade urothelial cell carcinoma in two patients and Fuhrman grade 3 renal clear cell carcinoma in one patient. Port-site metastasis was initially detected 1–7 months post-surgery. The two patients with renal pelvis carcinoma succumbed to the disease 2 and 4 months following the identification of the port-site metastasis, respectively, whereas the patient with renal carcinoma survived with no disease progression during the targeted therapy period. The occurrence of port-site metastasis may be attributed to systemic and local factors. Measures to reduce the development of this complication include strict compliance with the operating guidelines for tumor surgery, avoidance of air leakage at the port-site, complete removal of the specimen with an impermeable bag, irrigation of the laparoscopic instruments and incisional wound with povidone-iodine when necessary, and enhancement of the body's immunity. Close post-operative follow-up observation for signs of recurrence or metastasis is essential, and systemic chemotherapy may be required in patients with high-grade renal pelvis carcinoma and renal carcinoma in order to prolong life expectancy.

Intracorporeal electromechanical tissue morcellation: a critical review and recommendations for clinical practice

Electromechanical morcellators have come under scrutiny with concerns about complications involving iatrogenic dissemination of both benign and malignant tissues. Although the rapidly rotating blade has resulted in morcellator-related vascular and visceral injuries, equally concerning are the multiple reports in the literature demonstrating seeding of the abdominal cavity with tissue fragmented such as leiomyomas, endometriosis, adenomyosis, splenic and ovarian tissues, and occult cancers of the ovaries and uterus. Alternatives to intracorporeal electric morcellation for tissue extirpation through the vagina and through minilaparotomy are feasible, safe, and have been shown to have comparable, if not superior, outcomes without an increased need for laparotomy. Intracorporeal morcellation within a containment bag is another option to minimize the risk of iatrogenic tissue seeding. Patient safety is a priority with balanced goals of maximizing benefits and minimizing harm. When intracorporeal electromechanical morcellation is planned, physicians should discuss the risks and consequences with their patients. Although data are being collected to quantify and understand these risks more clearly, a minimally invasive alternative to unenclosed intracorporeal morcellation is favored when available. It is incumbent on surgeons to communicate the risks of practices and devices and to advocate for continued improvement in surgical instrumentation and techniques.

Port site metastasis after surgery for renal cell carcinoma: harbinger of future metastasis

PURPOSE

Port site metastasis is a rare occurrence after minimally invasive treatment for renal cell carcinoma. However, its prognostic implications are unclear because reports in the literature are heterogeneous in detail and followup. We clarify the significance of port site metastasis in cancer specific survival and broaden our understanding of this phenomenon.

MATERIALS AND METHODS

A MEDLINE® search for published studies of renal cell carcinoma port site metastasis was performed. Contributing factors to port site metastasis, stage, Fuhrman grade, pathology, port site metastasis treatment method, followup protocol and long-term outcomes were collected. The corresponding authors of each publication were contacted to fill in details and provide long-term outcomes. We added 1 case from our recent experience.

RESULTS

A total of 16 cases from 12 authors (including ourselves) were found. Of the 12 authors 8 were available for correspondence and 9 cases were updated. Eventual outcomes were available for 11 of the 16 cases and survival curves showed poor prognosis with a 31.8% overall 1-year survival rate. Of the 16 cases 12 were radical nephrectomy and 4 were partial nephrectomy, and 13 involved multiple metastases in addition to the port site metastasis. Nine of the cases had no identifiable technical reason for port site metastasis formation such as specimen morcellation, absence of entrapment or tumor rupture. These tumors were uniformly aggressive, Fuhrman grade 3 or higher.

CONCLUSIONS

Port site metastasis after minimally invasive surgery for renal cell carcinoma is a rare occurrence with a poor prognosis. In most cases port site metastasis is not an isolated metastasis but instead is a harbinger of progressive disease. While technical factors can have a role in port site metastasis formation, it appears that biological factors like high tumor grade also contribute.

Camera-port site metastasis of a renal-cell carcinoma after robot-assisted partial nephrectomy

BACKGROUND AND PURPOSE

Port-site metastasis (PSM) is a rare complication of laparoscopic intervention in urologic malignancies. Of the greater than 50 reported cases of PSM in the urologic oncology literature, only 9 have occurred after surgery for renal-cell carcinoma (RCC). We report a 10th instance of RCC metastasis-in this case to the camera-port site after robot-assisted partial nephrectomy (RAPN). To our knowledge, this case is the first reported PSM of RCC after RAPN.

PATIENT AND METHODS

A 68-year-old man underwent an uncomplicated right RAPN for a 4-cm right renal mass (stage T1aN0M0). Five months later, he was found to have metastatic disease with an isolated peritoneal recurrence at the camera-port site. Biopsy of the lesion confirmed RCC, and the lesion was surgically resected. A comprehensive MEDLINE search for all published studies of port-site recurrences after laparoscopic renal surgery for RCC was performed.

RESULTS

Nine cases of PSM after successful laparoscopic radical or partial nephrectomy for locally confined RCC have been reported. Proposed etiologic factors for port-site recurrence include biologic aggressiveness of the tumor, patient immunosuppression, local wound factors, and technique-related factors. We report an unusual case of PSM to a camera port that was not used for specimen manipulation or extraction.

CONCLUSION

PSM after laparoscopic renal surgery for RCC is a rare occurrence. Our case, in which PSM occurred without specimen bag rupture or extraction through the port in question, highlights the importance of local and systemic factors in contributing to PSM occurrence. We also demonstrate that when PSM is the only site of disease recurrence, it can be successfully managed with minimally invasive surgical resection.

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.

Complications of laparoscopic surgery for renal masses: prevention, management, and comparison with the open experience

CONTEXT

The initial excitement about the laparoscopic treatment of renal masses has been tempered by concerns related to increased operative time, technical complexity, and the suitability of laparoscopic approaches to oncologic surgery.

OBJECTIVE

To provide a comprehensive review of intraoperative and postoperative complications and their prevention and management during laparoscopic surgery of renal tumors.

EVIDENCE ACQUISITION

A literature review of the Medline and Google Scholar databases was performed, searching for renal cell carcinoma, renal mass, laparoscopy, laparoscopic radical nephrectomy, open radical nephrectomy, laparoscopic partial nephrectomy, open partial nephrectomy, laparoscopic cryoablation, laparoscopic radiofrequency ablation, complications, intra-operative, and post-operative. English-language articles published between 1990 and 2008 were reviewed.

EVIDENCE SYNTHESIS

Laparoscopic radical nephrectomy (LRN), whether transperitoneal or retroperitoneal, can be performed safely. The overall complication rate is low and does not significantly differ from that of the open experience. Laparoscopic partial nephrectomy (LPN), in contrast, is a technically challenging procedure. Although the intermediate oncologic outcomes are comparable to those of the open experience, there are concerns related to warm ischemia time, and there is a risk of major complications such as urinary leakage and hemorrhage requiring transfusion. Laparoscopic-assisted ablative therapies (cryotherapy and radiofrequency) are being performed more commonly for the treatment of small exophytic renal lesions with a low complication rate and intermediate oncologic outcomes similar to LRN and LPN.

CONCLUSIONS

Complications associated with the laparoscopic management of renal masses vary among the different procedures and with surgeon experience. The rate of complication appears to be similar to that of open surgery.

Port site metastases

PURPOSE OF REVIEW

The aim of this article is to provide an overview of the incidence, pathophysiology, risk factors and possible methods of reducing the risk of port site metastases following uro-oncological procedures.

RECENT FINDINGS

To our knowledge, 28 cases of port site metastasis have been reported in the urologic literature. There has been an increased interest in the use of intraperitoneal instillation of various tumoricidals in order to reduce the risk of port site seeding.

SUMMARY

The risk of port site metastases remains low, provided that surgeons rigorously adhere to the principles of oncological surgery.

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.

A Prospective Study of Laparoscopic Radical Nephrectomy for T1 Tumors—Is Transperitoneal, Retroperitoneal or Hand Assisted the Best Approach?

PURPOSE

We designed a prospective, randomized clinical trial to compare 3 common approaches to laparoscopic radical nephrectomy, namely transperitoneal, retroperitoneal and hand assisted.

MATERIALS AND METHODS

A total of 33 patients with a solid renal mass of 7 cm or less were prospectively enrolled in alternating fashion to a hand assisted procedure, a transperitoneal procedure with morcellation and a retroperitoneal procedure with intact specimen extraction. A single surgeon performed all operations. Preoperative, intraoperative and postoperative criteria were compared among the 3 techniques.

RESULTS

A total of 11 patients underwent each type of procedure. There was no significant difference in age, American Society of Anesthesiologists class, body mass index or tumor size among the groups. Mean operative time was significantly lower using the hand assisted approach, whereas estimated blood loss was similar in all 3 groups. Incision size, hospital stay and time to normal daily activity were less using the transperitoneal approach. While not significant, there was a trend toward less narcotic use in the transperitoneal group. Hernia formation was seen with increased frequency in the hand assisted group.

CONCLUSIONS

In our series the hand assisted approach had significantly shorter operative time than the transperitoneal or retroperitoneal approach but it had the greatest risk of hernia formation. The transperitoneal approach was associated with a significantly shorter hospital stay and the earliest resumption of normal activity.

Case Report: Port-Site Metastasis after Laparoscopic Radical Nephrectomy for Renal-Cell Carcinoma

A 65-year-old man with a 5.5 x 3.2-cm stage T(2)N(0)M(0) grade III renal-cell carcinoma suffered a port-site metastasis 8 months after laparoscopic radical nephrectomy with specimen removal in an organ-retrieval bag. This case underlines the need to be conversant with, and care to avoid, risk factors for this complication.

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.

Oncological outcome of 100 laparoscopic radical nephrectomies for clinically localized renal cell carcinoma

BACKGROUND

Laparoscopic renal surgery is now accepted within the urological community and its indication is extended to oncological operation. The oncological outcome and survival of patients undergoing laparoscopic radical nephrectomy for clinically localized renal cell carcinoma were evaluated.

METHODS

From October 1998 to July 2003, 100 patients underwent laparoscopic radical nephrectomy for clinically localized renal cell carcinoma. All operations were performed by transperitoneal approach with early vascular control. Perioperative events and pathological data were recorded prospectively. Patients were followed up by clinical examination, chest radiograph, ultrasonography and/or computed tomography where appropriate.

RESULTS

The median age of patients was 61 years. Median operating time was 120 min and blood loss was 100 mL. There were five open conversions. There was no perioperative mortality but 11 patients had complications. Resection margins were clear in all but one patient. The median tumour size was 4.6 cm. The median follow-up time was 30 months. All patients survived up to the date of review. No patient developed port-site recurrence but two patients had recurrence at the renal bed 1 year after the operation. Five patients developed distant metastases involving liver, lung and bone.

CONCLUSION

Laparoscopic radical nephrectomy is a safe and efficacious treatment option for clinically localized renal cell carcinoma. The intermediate-term oncological outcome appears favourable.

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.

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.

What are the Oncological Risks of Minimal Access Surgery for the Treatment of Urinary Tract Cancer?

OBJECTIVES

A review of the oncological safety of minimal access surgery for the treatment of urinary tract cancers. The particular areas reviewed were port-site metastases, local tumour recurrence and long-term survival.

METHODS

Review of the literature using Medline.

RESULTS

There is a low rate of port-site metastases following laparoscopic surgery for urological malignancies, these are usually related to the stage and grade of the tumour. So far follow-up data shows that laparoscopic surgery for urological malignancy does not result in higher levels of local recurrence or shorter survival than open surgery. Percutaneous (PCN) and ureteroscopic (URS) resection of TCC of the upper urinary tract are acceptable forms of treatment for grade 1 and 2 TCCs even in patients with normal contralateral kidneys. However, for grade 3 TCC nephroureterectomy should be utilised because of increased risk of local recurrence (URS) and track seeding (PCN).

CONCLUSIONS

Provided the principles of cancer surgery, combined with proper case selection are followed, minimal access surgery for urological cancer is safe and is rapidly emerging as the standard of care for many upper tract tumours.

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 Hand-Assisted Laparoscopic Urologic Surgery

Since the first urologic case was reported in 1997, hand-assisted laparoscopic surgery (HALS) has proven to be useful for both the experienced and the inexperienced laparoscopic surgeon. In a recent series of 196 cases at three major medical institutions, 18 patients (9.2%) suffered 32 major complications, and 28 patients (14.3%) had 31 minor complications. The most common major complications were small-bowel injury, requirement for open conversion to control bleeding, and need for reintubation. The most frequent minor complications were urinary retention, splenic capsular injury, and prolonged ileus. The author discusses ways of recognizing and managing the complications of HALS, including physiologic, access-related, intraoperative, and post-operative problems.

Evaluation of water jet morcellation as an alternative to hand morcellation of renal tissue ablation during laparoscopic nephrectomy: an in vitro study

OBJECTIVES

To evaluate the feasibility and safety of morcellation with a new prototype device that uses high-pressure water flow as a cutting/ablating tool and compare it with standard manual morcellation.

METHODS

Ten porcine kidneys were morcellated with the new water jet device and ten with conventional manual morcellation. Morcellation in all cases was performed in commercially available entrapment bags. The two groups were evaluated for morcellation time, fragment size, and perforation rates (macroscopic and microscopic).

RESULTS

The kidney size in both groups was similar. Morcellation was significantly (P <0.0001) faster in the water jet morcellator group than in the hand morcellation group (5.6 versus 11.9 minutes). The macroscopic evaluation after filling the entrapment bags with normal saline revealed 4 (40%) and 2 (20%) pinhole perforations in the water jet and hand morcellation groups, respectively. The microscopic evaluation revealed an 80% perforation rate in the water jet group and a 20% rate in the hand morcellator group. The size of the resulting fragments in the water jet group was not available, because the morcellated kidney was transformed in a semiliquid form. Therefore, cytology evaluation of the tissue was not possible.

CONCLUSIONS

Water jet technology can be used to morcellate renal porcine tissue effectively. It is faster, but the problems of safety and histologic evaluation must be solved before this promising technology can be used in a clinical setting.

Multiphasic Helical CT Criteria for Differentiation of Recurrent Neoplasm and Desmoplastic Reaction after Laparoscopic Resection of Renal Mass Lesions

BACKGROUND AND PURPOSE

Differentiation of recurrent neoplasm and desmoplastic reaction following laparoscopic resection of renal mass lesions poses a problem. The usefulness of multiphasic helical CT-generated criteria based on enhancement and morphologic characteristics was investigated.

PATIENTS AND METHODS

The findings in 5 female and 12 male patients aged 29 to 68 years having renal-cell carcinoma (11-38 mm; N = 15) or solitary angiomyolipomas (N = 2) treated by laparoscopic resection (N = 15) or open segmental surgery (N = 2) were analyzed. Multiphasic helical CT was performed in the preenhancement, arterial corticomedullary, parenchymal, and excretory phases generating 2.5- to 7-mm slices.

RESULTS

Both recurrent neoplasms showed median postcontrast enhancement of 119 HU in the arterial corticomedullary phase; the median enhancement of desmoplastic masses was 48 HU. In the parenchymal and excretory phase, recurrent neoplasms showed progressive loss of enhancement, whereas desmoplastic lesions sustained enhancement at about the same level. Recurrent neoplasms presented a defined mass with characteristic spiculation, whereas desmoplastic reaction was characterized by an ill-defined mass with spidery projections extending to abutting fat and residual fascial planes. On 2- to 3-month follow-up scans, recurrent neoplasms showed progressive increases in size and desmoplastic reaction a sharp decrease.

CONCLUSION

Enhancement of the mass at the operative site on arterial corticomedullary-phase CT to >90 HU strongly suggests recurrent renal-cell carcinoma, while progressive decrease in size on 1- to 3-month follow-up CT suggests a desmoplastic reaction.

Renal cell carcinoma: modern surgical approach

PURPOSE OF REVIEW

In the past decade, minimally invasive therapy options for renal cell carcinoma have been devised in an attempt to minimize operative morbidity while achieving comparable oncologic and functional outcomes. Herein, we evaluate the new developments related to the modern surgical and energy ablative techniques for renal cell carcinoma.

RECENT FINDINGS

When compared with the open counterpart, laparoscopic radical and partial nephrectomies have equivalent operative time, decreased blood loss, superior recovery, and improved cosmesis. Nowadays, laparoscopic radical nephrectomy can be performed for pT2 tumors (up to 15 cm), and level I renal vein thrombus is not a formal contraindication for the laparoscopic procedure. Ongoing advances in laparoscopic techniques and operator skills have allowed the development of a reliable technique of laparoscopic partial nephrectomy, which includes the ability to achieve effective intracorporeal renal hypothermia. Cryoablation and radiofrequency ablation therapies have been performed through a laparoscopic or percutaneous approach, using a combination of fine probes and high-resolution imaging studies to precisely target the lesions and accurately monitor the freezing or heating ablation process. Noninvasive tumor ablation can now be achieved by extracorporeally induced high-intensity focused ultrasound.

SUMMARY

These minimally invasive techniques represent the modern surgical approach for renal cell carcinoma, aiming to decrease patient morbidity. Laparoscopic radical and partial nephrectomy techniques duplicate the open approach. Results obtained with energy ablative techniques are encouraging. Based on the known slow growth rates of small renal cell carcinoma, one should be cautious when interpreting the short-term results of energy ablative therapies monitored by imaging only.

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.

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.

Oncological safety of laparoscopic surgery for urological malignancy: experience with more than 1,000 operations

PURPOSE

Although laparoscopy is being increasingly used to treat urological malignancies, there is still concern regarding the induction of local recurrence and port site metastasis. To our knowledge no major clinical study with long-term followup has been presented in the field of urological laparoscopy. We assessed the oncological safety of laparoscopy with emphasis on incidence of local recurrence and port site metastasis, analyzing the risk factors for such events based on a 10-year experience.

MATERIALS AND METHODS

From June 1992 to May 2002 we performed 1,098 laparoscopic procedures for urological malignancies, including 450 radical prostatectomies, 478 pelvic and 80 retroperitoneal lymph node dissections, 45 radical nephrectomies, 22 radical nephroureterectomies, 12 partial nephrectomies and 11 adrenalectomies. In 418 cases of laparoscopic radical prostatectomy pelvic lymphadenectomy was done simultaneously. Of the procedures 917 were performed transperitoneally, including 181 via retroperitoneal or extraperitoneal access. A total of 567 procedures were performed in case of histologically proven cancer, whereas 531 represented only staging operations.

RESULTS

Median followup was 58 months (range 4 to 127). Eight local recurrences were observed (0.73% overall, 1.41% of histologically proven cases). There were recurrences after nephroureterectomy for transitional cell carcinoma of the ureter in 1 patient, after radical nephrectomy for renal cell carcinoma in 1, growing teratoma after retroperitoneal lymph node dissection in 2, local recurrence of prostate cancer in 3 and after removal of an adrenal metastasis of melanoma in 1. Two port site metastases (0.18% overall, 0.35% of histologically proved cases) occurred, including metastasis of small cell lung carcinoma after adrenalectomy and a residual mass following 2 cycles of chemotherapy after retroperitoneal lymph node dissection.

CONCLUSIONS

According to our experience the incidence of local recurrence and the risk of port site metastases is low and seems to be mainly related to the aggressiveness of the tumor and immunosuppression status of the patient, respectively rather than to technical aspects of the laparoscopic approach.

Electrical prostate morcellator: an alternative to manual morcellation for laparoscopic nephrectomy specimens? An in vitro study

OBJECTIVES

To compare the safety and efficacy of morcellation with the electrical prostate morcellator (EPM) or manual morcellation of the kidney, using an internal view within the morcellation sac.

METHODS

Thirty porcine kidneys, mean renal mass 174.5 g, were divided into three groups of 10. All morcellations were performed inside the LapSac. Groups 1 and 2 underwent morcellation using the EPM, monitored inside the LapSac using the nephroscope and outside the LapSac with the laparoscope, respectively. Group 3 underwent manual morcellation with ring forceps. The groups were assessed for morcellation time, fragment size, and LapSac integrity.

RESULTS

In group 1, one pinhole perforation occurred; in group 2, nine perforations occurred (five large and four pinhole). No perforations occurred (P <0.001) in group 3 (manual morcellation). The mean morcellation time for groups 1 through 3 was, respectively, 86.9, 47.1, and 15.1 minutes (P <0.0001). The corresponding mean fragment size was 0.011, 0.015, and 1.36 g. The difference in mean fragment size was significantly different between the manual morcellation group and the EPM groups (P <0.001), but not between the two EPM groups (P = 0.12).

CONCLUSIONS

Manual morcellation was safe, fast, and superior to morcellation with the EPM monitored either inside or outside the LapSac. The high rate of LapSac perforation precludes the use of EPM after laparoscopic radical nephrectomy in the clinical forum.

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.