Port-Site Metastasis after Laparoscopic Partial Nephrectomy: Case Report and Literature Review

Peritoneal carcinomatosis after partial nephrectomy for renal cell carcinoma: Our experience and literature review

OBJECTIVE

Peritoneal carcinomatosis associated with renal cell carcinoma is an infrequent entity, usually associated with large renal masses, and with a very rare presentation after surgery of localized renal tumors. Our objective is to review the literature and analyze the factors involved in the development of peritoneal carcinomatosis after laparoscopic partial nephrectomy in localized tumors.

MATERIAL AND METHODS

We present our experience with two cases of peritoneal carcinomatosis after laparoscopic partial nephrectomy. We reviewed the literature and analyzed the factors associated with the development of peritoneal carcinomatosis after laparoscopic partial surgery in renal cell carcinoma.

RESULTS

Between 2005-2018, 225 patients underwent laparoscopic partial nephrectomy for localized renal neoplasia in our service. Two patients developed peritoneal carcinomatosis during follow-up, at 1.5 and 7 years after surgery. Few cases of postoperative peritoneal carcinomatosis for renal neoplasia have been described in the literature, being more frequently associated with large renal masses, with multiple metastases at diagnosis, with a poor prognosis. The dissemination of tumor cells during surgery, direct tumor extension or metastasis by hematogenous route, are among the factors involved in the development of this condition.

CONCLUSIONS

Peritoneal carcinomatosis after laparoscopic partial nephrectomy constitutes a very rare event. However, it should be taken into consideration, and, since it is the only factor we can influence, we must maximize precautions during the surgical act, following oncological principles.

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.

Spontaneous perirenal hemorrhage (Wunderlich syndrome): An analysis of 28 cases

INTRODUCTION

This study aimed to analyze the characteristics, etiology, and treatment of a series of patients with spontaneous perirenal hemorrhage (Wunderlich syndrome [WS]).

METHODS

We retrospectively reviewed the records of 26 patients hospitalized for WS in a tertiary urological center between 2011 and 2018. All patients were evaluated for perirenal hemorrhage observed on computed tomography (CT) in the emergency department. Clinical variables (age, underlying diseases, symptoms, shock, and hospitalization period), laboratory test results, and radiological and pathological results were reviewed.

RESULTS

The series included 28 events from 26 patients with a mean follow-up period of 20.2 ± 18.0 months. Flank pain was most common symptoms (92%). Twelve patients (46%) had visible renal lesions and associated hematoma and 14 only showed perirenal hematoma. In six patients with shock (systolic blood pressure < 90 mm Hg), 2 underwent emergency angioembolization. Twelve patients (46%) underwent exploration and total nephrectomy. In the final diagnosis, 4 cases of renal cell carcinoma, 3 of angiomyolipoma, 4 of simple renal cyst, 2 of acquired cystic kidney disease, 4 of sarcoma or other malignancy, 4 of chronic pyelonephritis, and 5 of idiopathic WS were observed. Patient age was associated with prediction of renal cell carcinoma in the patients with WS.

CONCLUSION

Renal masses are the main cause of WS, and CT is the diagnostic procedure of choice. Old age is a possible risk factor for renal cell carcinoma in etiology of WS. Surgical treatment is preferred in patients diagnosed with renal malignancy and in cases of hemodynamic instability.

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.

Specimen retrieval approaches in patients undergoing laparoscopic colorectal resections: a literature-based review of published studies

OBJECTIVE

To review the published studies reporting various specimen retrieval incisions being used by colorectal surgeons in patients undergoing laparoscopic colorectal resections (LCR).

METHODS

Standard medical electronic databases were searched to find relevant articles and a summary conclusion was generated.

RESULTS

There were 43 studies reporting various approaches used for the purpose of specimen retrieval in 2388 patients undergoing LCR. The most common approaches were periumbilical midline incision (1260 reported case in the literature), transverse incision (583 reported cases in the literature) in the right- or left iliac fossa, depending on the side of colonic resection, and Pfannensteil incision (293 reported cases in the literature). Periumbilical midline incision was associated with the higher risk of developing incisional hernia (odds ratio 53.72; 95% confidence interval 7.48-386.04; Z = 3.96; P = 0.0001). In terms of surgical site infection (SSI), there was no difference between the three common approaches to specimen retrieval. Transanal and transvaginal approaches were associated with higher risk of SSI.

CONCLUSIONS

Midline, transverse and Pfannensteil incisions were the most commonly used approaches for specimen retrieval following LCR. Midline incision was associated with higher risk of incisional hernia. Risk of SSI was similar in all three common approaches. The transanal and transvaginal approaches pose a higher risk of SSI. These conclusions are based on the combined outcome of published case series, case reports and comparative studies. Randomized, controlled trials with longer follow-up are required before recommending the routine use of any approach for specimen retrieval in patients undergoing LCR.

Laparoscopic partial nephrectomy: An experience in 227 cases

OBJECTIVE

To evaluate our long-term experience with laparoscopic partial nephrectomy (LPN) and to review the literature.

MATERIAL AND METHODS

We performed a retrospective chart review, evaluating 227 consecutives laparoscopic partial nephrectomies performed between June 1995 and June 2010. Perioperative were recorded along with clinical a oncological outcomes.

RESULTS

Mean age was 56.4 years (18-87) and clinical stages were T1a, T1b and T2 in 90.74% (206/227), 7.48% (17/227) and 1.76% (4/227), respectively. Median blood loss was 250 mL (10-1800). The mean operative time was 108.42 minutes (30-240) and median warm ischemia time was 25 minutes (10-60). The intraoperative complication rate was 2.64% (6/227), 5 (2.2%) secondary to bleeding. The postoperative complication rate was 5.72% (13/227) and bleeding is also the most frequent in 3% (7/227) of the cases. According to the Clavien classification, 1.32% (3/227), 0.88% (2/227) and 3.52% (8/227) were grade I, II and IIIb, respectively. The mean hospital stay was 3.66 days (1-12). Clear cell carcinoma was the most common histological finding in 74.6% (150 patients). TNM clasification was T1a, T1b y T2 in 90.74% (206/227), 7.48% (17/227) and 1,76% (4/227), respectively. No conversion or mortality was reported. Positive surgical margins were found in 4 patients (2.7%), with no local recurrence after long-term follow-up. At a mean follow up of 27 months, one patient had port site and peritoneal recurrence.

CONCLUSION

Laparoscopic partial nephrectomy is a safe and viable alternative to open partial nephrectomy, providing equivalent oncologic outcomes and comparable morbidity to the traditional approach in experienced centers.

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.

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.

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.