Laparoscopic Radical Nephrectomy: Long-Term Outcomes

Robotic transperitoneal versus retroperitoneal approach for anterior renal mass nephron-sparing surgery

Robotic nephron-sparing surgery is traditionally performed via a transperitoneal (TP) approach. However, the retroperitoneal (RP) approach has gained popularity, particularly for posterolateral renal masses. The RP approach is associated with shorter operative time, less blood loss, and shorter length of stay, while preserving oncologic outcomes in selected masses. Here, we aim to assess the feasibility of the RP approach in excising anterior renal masses. Patients ≥ 18 years of age who underwent robotic nephron-sparing surgery for anterior renal masses were retrospectively identified (2008-2022). Baseline demographics, tumor characteristics, and perioperative data were collected and characterized based on TP vs RP approaches. Wilcoxon rank sum test and Pearson's Chi-squared test were used to compare continuous and categorical variables, respectively. Two hundred and sixteen patients were included-178 (82.4%) underwent TP approach and 38 (17.6%) underwent RP approach. Baseline demographics, preoperative tumor size, and renal nephrometry scores were similar. The RP approach was associated with shorter operative (150 vs 203 min, p < 0.001) and warm ischemia time (12 vs 21 min, p < 0.001), and less blood loss (20 vs 100 cc, p = 0.002) (Table 1). The RP approach was associated with shorter length of stay (1 vs 2 days, p < 0.001) and less total complications (5.3% vs 19.1%, p = 0.038). Major complication (Clavien-Dindo Grade > 3) rates were similar. There was no difference in positive surgical margin rates or pathologic characteristics. Robotic RP approach for nephron-sparing surgery is feasible for eligible anterior tumors and is associated with favorable perioperative outcomes with preserved negative surgical margin rates. Table 1 Patient baseline demographics Overall Transperitoneal Retroperitoneal p value Median/N IQR/% Median/N IQR/% Median/N IQR/% N 216 178 82.4% 38 17.6% Age (years) 60.5 (52.1-67.7) 60.4 (52.8-67.7) 61.6 (49.1-69.2) 0.393 Sex Male 126 58.3% 100 56.2% 26 68.4% Female 90 41.7% 78 43.8% 12 31.6% 0.165 Race White 162 75.0% 137 77.0% 25 65.8% Asian 4 1.9% 2 1.1% 2 5.3% Black 21 9.7% 18 10.1% 3 7.9% Hispanic 26 12.0% 18 10.1% 8 21.1% Other 2 0.9% 2 1.1% 0 0.0% 0.197 Body mass index (kg/m2)  < 25 32 14.8% 25 14.0% 7 18.4% 25-30 68 31.5% 55 30.9% 13 34.2% 30-35 60 27.8% 50 28.1% 10 26.3% 35 +  56 25.9% 48 27.0% 8 21.1% 0.808 Prior abdominal surgery Yes 118 54.6% 104 58.4% 14 36.8% No 98 45.4% 74 41.6% 24 63.2% 0.015 Prior kidney surgery Yes 10 4.6% 9 5.1% 1 2.6% No 206 95.4% 169 94.9% 37 97.4% 0.518 Chronic kidney disease stage ≥ 3 Yes 45 20.8% 38 21.3% 7 18.4% No 171 79.2% 140 78.7% 31 81.6% 0.687 Charlson comorbidity index 0 138 63.9% 116 65.2% 22 57.9% 1 46 21.3% 38 21.4% 8 21.1% 2 19 8.8% 13 7.3% 6 15.8%  ≥ 3 13 6.0% 11 6.2% 2 5.3% 0.412 Tumor size (cm) 2.7 (2-3.6) 2.8 (2-3.5) 2.55 (2-3.7) 0.796 Tumor laterality Left 100 46.3% 78 43.8% 22 57.9% Right 116 53.7% 100 56.2% 16 42.1% 0.114 Clinical T stage cT1a 186 86.1% 152 85.4% 34 89.5% cT1b 30 13.9% 26 14.6% 4 10.5% 0.509 RENAL Nephrometry score Low (4 to 6) 94 43.5% 76 42.7% 18 47.4% Intermediate (7 to 9) 112 51.9% 94 52.8% 18 47.4% High (≥ 10) 19 4.6% 8 4.5% 2 5.3% 0.829 TE tumor enucleation, SPN standard margin partial nephrectomy, IQR interquartile range.

Local tumor progression after ultrasound-guided percutaneous microwave ablation of stage T1a renal cell carcinoma: risk factors analysis of 171 tumors

PURPOSE

To retrospectively review long-term oncologic outcomes after ultrasound (US)-guided percutaneous microwave ablation (MWA) of T1a renal cell carcinoma (RCC) and to identify the incidence and risk factors that predict local tumor progression (LTP) after MWA of RCC.

MATERIALS AND METHODS

The present study was approved by the institutional review board. A total of 162 patients with 171 RCC nodules (mean size, 2.6 ± 0.8 cm; range, 0.6-4.0 cm) were treated by MWA between April 2006 and January 2017. The influence of eight factors (age; sex; longest tumor diameter; tumor number, location and pathology type; ablation power and time) affecting the risk of LTP was assessed. Univariate Kaplan-Meier and Cox proportional hazard models were used for statistical analysis.

RESULTS

LTP occurred in five patients (5 tumors) after US-guided percutaneous MWA of stage T1a RCC. The overall occurrence of LTP was 2.9% per tumor and 3.0% per patient with a median follow-up of 45.5 months. Among the 162 patients, there were no instances of LTP-related deaths; however, 20 patients died of other diseases. All patients with LTP survived through follow-up. The survival rate of LTP-free patients at 1, 3 and 5 years were 98.7%, 89.5% and 82.1%, respectively (p = .38). Univariate and multivariate analysis identified tumor location to be the only independent predictor of LTP.

CONCLUSIONS

US-guided percutaneous MWA for T1a RCC achieved a relatively low LTP incidence rate. Tumors adjacent to the renal pelvis or bowel increased the potential of LTP occurrence.

Laparoscopic Management of Kidney Cancer: Updated Review

BACKGROUND

Laparoscopy has emerged as the preferred option for the surgical management of kidney cancer. Although many reports have been published regarding the operative outcome of renal cell carcinoma (RCC) and upper-tract transitional cell carcinoma (TCCA) treated laparoscopically, few review the oncologic outcome of these pathologies treated with laparoscopic techniques.

METHODS

We review the literature regarding the laparoscopic approaches, the complications related to laparoscopic surgery, and the long-term oncologic results of laparoscopic radical nephrectomy, partial nephrectomy, and nephroureterectomy.

RESULTS

Laparoscopic radical nephrectomy has become the new standard of care for most patients with suspected RCCs that are not amenable to nephron-sparing procedures. Laparoscopic techniques for managing RCC and TCCA are safe, follow well-established guidelines for surgical dissection, and meet or exceed perioperative convalescence and oncologic outcomes compared to traditional open procedures. The surgical techniques and the long-term outcome data for laparoscopic partial nephrectomy continue to mature.

CONCLUSIONS

Laparoscopy is a minimally invasive option available to most patients with kidney cancer. The immediate benefits of laparoscopy are well established and include less estimated blood loss, decreased pain, shorter perioperative convalescence, and improved cosmesis. Long-term oncologic outcomes of patients treated laparoscopically for kidney tumors resemble those of the open surgical approach.

Combination therapy of three-dimensional (3D) visualisation operative treatment planning system and US-guided percutaneous microwave ablation in larger renal cell carcinomas (D ≥ 4 cm): preliminary results

PURPOSE

To analyse the clinical outcomes of combination therapy of three-dimensional (3D) visualisation operative treatment planning system and US-guided percutaneous microwave ablation (PMWA) in larger renal cell carcinomas (RCCs) (D ≥ 4 cm).

MATERIALS AND METHODS

The results from 20 patients with 20 larger RCCs treated with a 3D visualisation operative treatment planning system and US-guided PMWA were reviewed retrospectively. The patients were followed up by contrast-enhanced images at 1, 3, and 6 months and every 6 months thereafter. The outcomes of overall survival and local tumour progression rate were statistically analysed.

RESULTS

The median follow-up period was 26 months. The mean time of ablation for one tumour was 1.1 ± 0.3 sessions. The average number of ablation points of one tumour was 4.5 ± 0.9. The mean output power of ablation was 50.50 ± 2.2 W. The mean time of ablation for one tumour was 1374.4 ± 391.1 s. Artificial ascites was used in 12 (60%) tumours adjacent to the intestinal tract, and thermal monitoring system was used in all tumours (100%). Technical effectiveness and metastasis-free status were achieved in all tumours. The 1- and 2-year local tumour progression rates were both 5%. The cancer-specific survival rate and 2-year overall survival rates were both 100%. No severe major complications occurred. There was no significant difference in creatinine or urea nitrogen before or 3 days after ablation.

CONCLUSIONS

Combination therapy of 3D visualisation operative treatment planning system and US-guided PMWA appeared to be a safe and effective technique for the management of larger RCCs, which could improve clinical efficacy.

Fast access and early ligation of the renal pedicle significantly facilitates retroperitoneal laparoscopic radical nephrectomy procedures: modified laparoscopic radical nephrectomy

Background

The objective of this study was to develop a modified retroperitoneal laparoscopic nephrectomy and compare its results with the previous technique.

Methods

One hundred retroperitoneal laparoscopic nephrectomies were performed from February 2007 to October 2011. The previous technique was performed in 60 cases (Group 1). The modified technique (n = 40) included fast access to the renal pedicle according to several anatomic landmarks and early ligation of renal vessels (Group 2). The mean operation time, mean blood loss, duration of hospital stay conversion rate and complication rate were compared between the groups.

Results

No significant differences were detected regarding mean patient age, mean body mass index, and tumor size between the two groups (P >0.05). The mean operation time was 59.5 ± 20.0 and 39.5 ± 17.5 minutes, respectively, in Groups 1 and 2 (P <0.001). The mean intraoperative blood loss was 147 ± 35 and 100 ± 25 ml, respectively, in Groups 1 and 2 (P <0.001). No significant differences were detected regarding the conversion rate and the complication rate between the two groups (P >0.05).

Conclusions

Early ligature using fast access to the renal vessels during retroperitoneal laparoscopic radical nephrectomy contributed to less operation time and intraoperative blood loss compared with the previous technique. In addition, the modified technique permits the procedure to be performed following the principles of open radical nephrectomy.

Laparoscopic radical and partial nephrectomy: technical issues and outcome

The laparoscopic approach has been established as a treatment modality for the performance of radical nephrectomy during the recent years, while laparoscopic partial nephrectomy represents an alternative under investigation in several centers of laparoscopic excellence around the world. Significant advantages of laparoscopic surgery when compared to the classical open approach have extensively documented for over 2 decades. Nevertheless, laparoscopy is an evolving surgical field, which is characterized by the rapid adaptation of technical innovations. Laparoscopic renal surgery includes approaches for radical and partial nephrectomy with oncological outcome similar to open surgery and decreased postoperative morbidity and therefore can be considered for the same indications as open surgery. Several issues regarding the technical feasibility and refinement as well as the oncological efficacy of these procedures are presented.

Robotic oncological surgery: our initial experience of 164 cases

Minimal access surgery is an accepted modality for benign surgery. Despite the advantages of laparoscopy, its acceptance in oncology is slow. Robotic surgery is an emerging field with rapid acceptance because of the 3-dimensional image, dexterity of instruments and autonomy of camera control. We report here our experience of using the Da Vinci robot for various oncological procedures. We performed 164 oncological surgeries from November 2009 to June 2011. The surgeries performed included thoracic, colorectal, hepatobiliary, gynaecological and urological system. We could complete 163 cases robotically. We share our initial experience of robotic surgery in oncology with comparison with other series.

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.

Current perceptions of resident training in laparoscopic nephrectomy

OBJECTIVES

To determine the perceived degree of training of residents in laparoscopic nephrectomy. Laparoscopic nephrectomy is well established in the field of urology and has seen increasing penetrance in urologic practice. The degree to which this recent technical shift has been integrated into urologic training at the residency level has not been characterized.

METHODS

An electronic survey was sent to 518 urology residents and recent graduates and to 85 laparoscopic specialists at academic medical centers. Both residents and practicing urologists were queried regarding the level of resident participation for each step of laparoscopic nephrectomy and opinions on the necessity of fellowship training. The data were analyzed using the Wilcoxon rank-sum and chi(2) tests.

RESULTS

Attending surgeons perceived a significantly greater level of resident involvement in performing all aspects of laparoscopic nephrectomy, with the exception of hilar dissection and port closure. To perform laparoscopic nephrectomy, 12.5% of attending physicians and 5% of residents reported that a fellowship is necessary.

CONCLUSIONS

Significant disagreement exists between attending surgeons and residents on the perceived degree of resident involvement in most aspects of laparoscopic nephrectomy. This could have significant implications on resident education for a procedure that is arguably the standard of care for treatment of uncomplicated renal masses. Most attending physicians and residents were in agreement that fellowship is not necessary to perform this procedure. These results raise questions regarding the future of laparoscopic training and bring to light the need for better regulation of laparoscopic training.

Salvage of local recurrence after primary thermal ablation for small renal masses

The management of renal tumors has evolved rapidly over the last two decades, with the ascendance of nephron-sparing surgery (NSS), largely spurred by the increased incidental detection of small renal masses (SRMs) and evidence that preservation of renal parenchyma reduces the risk of chronic kidney disease. The field of NSS itself has advanced beyond the standard of open partial nephrectomy, with the application of minimally invasive techniques, such as laparoscopy and thermal ablation. Energy-based ablative therapies, which include cryoablation and radiofrequency ablation, are associated with reduced morbidity and represent a nascent but promising alternative to surgical extirpation in the treatment of SRMs. However, thermal ablation is associated with a higher rate of local tumor recurrence when compared with surgical excision, indicating that salvage therapy will be a necessity for some patients. With recent studies indicating that surgical excision of previously ablated kidneys can be complicated by significant fibrosis, clinicians who advocate thermal ablation must be cognizant of the sequelae of this treatment modality and versed on the potential difficulties associated with salvage surgery. We provide, herein, an assessment of the efficacy and limitations of primary thermal ablation and strategies for salvage treatment of local recurrence in this growing patient population.

Choice of operation for clinically localized renal tumor

The cornerstone of treatment for localized renal tumors is surgical excision, which until recently was accomplished primarily through radical nephrectomy. The last 2 decades have seen a rapid evolution in the surgical management of renal cell carcinoma, marked by the increased use of nephron-sparing surgery and the application of minimally invasive techniques. A plethora of surgical options now are available. This article discusses the optimal surgical approach to renal tumors in various clinical scenarios. In all these discussions we assume that a proactive approach to treatment is indicated and desired, recognizing that active surveillance is always an additional option to consider in certain subpopulations such as the elderly or infirm.

Robotic Oncological Surgery: Technology That's Here to Stay?

A robot functioning in an environment may exhibit various forms of behavior emerge from the interaction with its environment through sense, control and plan activities. Hence, this paper introduces a behaviour selection based navigation and obstacle avoidance algorithm with effective method for adapting robotic behavior according to the environment conditions and the navigated terrain. The developed algorithm enable the robot to select the suitable behavior in real-time to avoid obstacles based on sensory information through visual and ultrasonic sensors utilizing the robot's ability to step over obstacles, and move between surfaces of different heights. In addition, it allows the robot to react in appropriate manner to the changing conditions either by fine-tuning of behaviors or by selecting different set of behaviors to increase the efficiency of the robot over time. The presented approach has been demonstrated on quadruped robot in several different experimental environments and the paper provides an analysis of its performance.

[Urological therapy of renal cell cancer]

Renal cell carcinomas, which originate within the renal cortex, constitute 80-85% of primary renal neoplasms. Patients can present with a range of symptoms due to the tumor itself (e.g., mass, pain), invasion of the urinary tract (e.g., hematuria), paraneoplastic syndromes, or the presence of metastases. Renal cell cancer is more frequently being diagnosed incidentally as a consequence of increased use of imaging procedures for other reasons. Surgery is curative in the majority of patients without metastatic disease and is therefore the preferred treatment for patients with stages I, II, and III disease. The five-year survival following the treatment correlates well with the anatomic extent of disease. Systemic therapy with molecularly targeted therapy or immunotherapy is the primary approach for patients with unresectable or recurrent disease.

Current status of debulking nephrectomy in the era of tyrosine kinase inhibitors

Cytoreductive nephrectomy (CN) has an established role against metastatic renal cell carcinoma (mRCC) in properly selected patients and offers a survival advantage when performed prior to cytokine therapy. With the emergence of new, effective targeted molecular therapies for mRCC, well-designed prospective trials are needed to clarify the biologic effects of CN to determine when and for whom CN should be performed in the context of targeted systemic therapy. Consequently, a thorough characterization of the systemic effects afforded by CN is imperative for developing individualized treatment strategies that effectively address the underlying biology of mRCC while maximizing patient quality of life during therapy. Until then, debulking surgery, which provides a survival benefit for select patients with mRCC, should continue to be used in patients before or after targeted systemic therapy.

Tumor Location Does Not Affect Long-Term Renal Function After Partial Nephrectomy

OBJECTIVES

To study the effect of central tumor location on the glomerular filtration rate (GFR) after partial nephrectomy for renal cortical tumor.

METHODS

We reviewed our institutional database to identify patients who had undergone partial nephrectomy from January 1995 to July 2005. Central tumors were defined as those encroaching on the collecting system or renal sinus or that did not distort the renal contour; all others were categorized as peripheral on preoperative abdominal imaging. We calculated the GFR preoperatively, during the hospital stay, and at 1 and 12 months after surgery. Linear regression models were fit to determine the association of tumor location with the changes in GFR at each period, after controlling for age, sex, operative and ischemic times, comorbidities, and blood loss.

RESULTS

A total of 248 central and 333 peripheral tumors were available for analysis. Patients with central tumors were younger than those with peripheral tumors (62 versus 59 years, P = 0.014) and experienced longer intraoperative renal ischemia times (40 versus 29 minutes, P <0.001) and longer operations (195 versus 179 minutes, P = 0.004). On multivariate analysis, tumor location was not significantly associated with the change in GFR at any of the intervals, after adjusting for the covariates.

CONCLUSIONS

The results of our study have indicated that tumor location does not appear to affect long-term renal function. Thus, partial nephrectomy should not be withheld from this subset of patients.

Comparison of Laparoscopic Radical and Partial Nephrectomy: Effects on Long-Term Serum Creatinine

OBJECTIVES

Laparoscopic partial nephrectomy (LPN) and radical nephrectomy (LRN) have been shown to be safe and effective treatment options for renal tumors. However, limited data are available regarding the long-term effect on postoperative renal function in patients undergoing LPN and LRN who have a normal preoperative serum creatinine (sCr) less than 1.5 mg/dL and a two-kidney system. We compared the long-term sCr in patients who were treated with LPN and LRN.

METHODS

From October 2002 to April 2006, a total of 93 and 171 patients with a single, unilateral, sporadic renal tumor, a normal contralateral kidney and sCr less than 1.5 mg/dL underwent LPN and LRN, respectively. Perioperative, pathologic data and sCr at least 6 months after surgery were compared between the two groups.

RESULTS

A total of 42 and 55 patients with at least 6 months of follow-up after LPN and LRN were evaluated. Tumors treated with LPN were significantly smaller (2.4 versus 5.4 cm, P <0.001) than those in the LRN group. The mean age, body mass index, sex, tumor location, and sCr (0.91 and 0.91 mg/dL, P = 0.93) were similar between the two groups. The mean operative time was longer for LPN (222 versus 182 minutes, P = 0.002) with a mean warm ischemia time of 37 minutes (range 13 to 55). The mean 6-month sCr was significantly greater for patients undergoing LRN (1.4 versus 1.0 mg/dL, P <0.001). Similarly, a greater number of LRN patients developed renal insufficiency (sCr 1.5 mg/dL or greater) compared with LPN (36.4% versus 0%, P <0.001).

CONCLUSIONS

Despite the warm ischemia and longer operative times, LPN preserves the kidney function better than LRN. In properly selected patients, LPN should be preferentially performed to prevent chronic renal insufficiency.

Laparoscopy Simulators

To reduce the complication rate associated with laparoscopic surgery and to improve training, several simulators have been incorporated into training curricula and skills courses. We discuss the advantages and disadvantages and compare the different types of simulators available. We also reviewed the literature to assess the acquisition of skills using these simulators and their transfer to real operations. It is important to realize that currently, any form of simulation is merely an adjunct to, and not a replacement for, traditional methods of training and that supervision and feedback are essential. More collaboration is needed between urologists and simulator companies to produce operation-specific simulated modules for urologic procedures.

Renal cell carcinoma

PURPOSE OF REVIEW

In this review we will highlight the recent novel contributions to the treatment of renal cell carcinoma in the fields of anti-angiogenesis, immunotherapeutics, and surgical management. In addition, this review will update recent advances in diagnostic and imaging modalities for renal cell carcinoma and dietary and environmental relationships to the epidemiology of this growing disease.

RECENT FINDINGS

Advancements in the use of innovative treatment strategies for the management of localized renal cell carcinoma and the introduction of new targeted therapeutics with benefit in the metastatic setting has produced a major impact on the treatment of this disease.

SUMMARY

The management of metastatic renal cell carcinoma has undergone a revolution in the past year with groundbreaking treatment strategies encompassing a broad range of therapeutic modalities. At the other end of the spectrum, emerging data is beginning to change our perspective about the management of small, localized renal tumors that are being discovered with increasing frequency. This review will update recent findings supporting diet and tobacco exposure as etiologic factors in the development of renal cell carcinoma, the molecular concepts that underlie the disease and the targeted therapeutics designed to inhibit specific kinase activities, and emerging use of minimally invasive therapies for localized disease.

Left laparoscopic radical nephrectomy with direct access to the renal artery: technical advantages

OBJECTIVES

To evaluate the technical advantages of early ligature of the renal artery at the level of the Treitz ligament during left laparoscopic radical nephrectomy (LRN).

MATERIAL AND METHODS

Twenty-six patients underwent LRN for organ-confined lesions. We grouped measured parameters (see Results) on the basis of the first 13 and last 13 patients, and compared both subgroups. All parameters were correlated to stage of disease (pT1 vs pT2-3). The Student t test was used for statistical analysis.

RESULTS

The mean (range) for measured parameters are as follows: age: 56.5 +/- 11.6 (41-77) years; American Society of Anesthesiologists score: 2.4 +/- 1 (1-3); body mass index: 23.4 +/- 3.4 (21.1-33); lesion size at computed tomography: (6.2 +/- 2.4 (4-12) cm; operative skin to skin time: 130 +/- 20 (125-170) minutes; blood loss: 255 +/- 120 (100-800) ml; hospital stay: 6.5 +/- 2.0 (4-15) days; analgesic consumption (Tramadol 100 mg): 2.5 +/- 1 (2-4) vials; follow-up time: 30.5 +/- 5.6 (3-48) months. No intra-operative complications occurred. Pathologic analysis showed 12 pT1N0, five pT2N0, eight pT3aN0 and one pT3b N2 with mean lesion size of 6.2 +/- 1.6 (4-13) cm. Mean number of removed lymph nodes was 9.8 +/- 1.6 (7-17). No statistical difference was observed between the two subgroups (p > 0.05), and between pT1 and pT2-3 stage (p > 0.05) groups.

CONCLUSIONS

Early ligature using direct access to the renal artery at the Treitz ligament permits the surgeon to follow the classic steps and principles of radical nephrectomy.

Retroperitoneoscopic versus open surgical radical nephrectomy for large renal cell carcinoma in clinical stage cT2 or cT3a: quality of life, pain and reconvalescence

OBJECTIVES

To determine whether retroperitoneoscopic radical nephrectomy for large renal cell carcinoma in stage cT2 or cT3a is a feasible, safe and effective therapy option and if it shows any advantage regarding quality of life in comparison to open procedure.

METHODS

23 patients who underwent RPNx for tumor size greater than 7 cm (group 1) were matched and compared with 25 patients, who underwent ONx (group 2) for tumor with similar size characteristics. Patient and surgical data, QoL variables and complications were statistically analyzed.

RESULTS

The median followup was 12 (range: 6-18) months for both groups. Group 1 had significantly (p < 0.001) less blood loss, shorter hospital stay, and shorter postoperative analgesic requirements. No conversion to open surgery was necessary, and no major complications requiring an invasive intervention occurred. Retroperitoneoscopic patients had significantly better QoL and pain scores postoperatively to 6 months (p < 0.001) and they return to baseline QoL status faster (p < 0.001).

CONCLUSIONS

RPNx for large RCC in stage cT2 or cT3a is a safe and efficacious procedure with good short-term outcome results and significantly shorter recovery of QoL variables.