A Prospective Randomized Study of Pfannenstiel Versus Expanded Port Site Incision for Intact Specimen Extraction in Laparoscopic Radical Nephrectomy

Health-related Quality of Life Assessment in Renal Cell Cancer: A Scoping Review

BACKGROUND AND OBJECTIVE

In oncology, patient-reported outcome measures (PROMs) capturing health-related quality of life (HRQOL) play an increasing role in clinical trials, drug approval, and policy making. This scoping review aimed to identify and elaborate on HRQOL-focussed PROMs used in renal cell cancer (RCC) clinical trials.

METHODS

MEDLINE, Web of Science, PsychINFO, Academic Search Elite, CINAHL, Embase, and the Cochrane Library were searched systematically for original peer-reviewed articles on clinical trials including RCC patients and using PROMs, published between 1950 and 2023. Prespecified trial characteristics and information on the PROMs used were extracted. Frequencies and proportions of categorical data, and ranges and medians of continuous variables were calculated.

KEY FINDINGS AND LIMITATIONS

Of the 48 unique studies included, the majority followed a randomised controlled design (34, 71%) and evaluated systemic treatments (38, 79%). The trials used 27 different PROMs (max = 6, median = 2), of which only 4 (15%) were developed specifically for kidney cancer patients. Of the trials, 46% did not use any RCC-specific PROM. European Quality of Life-5 Dimensions (EQ-5D), European Organisation for Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC QLQ-C30), Functional Assessment of Cancer Therapy Kidney Symptom Index (FKSI) -15/19-item version, FKSI-Disease Related Symptoms, and Functional Assessment of Cancer Therapy-General (FACT-G) were the most frequently used questionnaires, with pain, ability to work, fatigue, worry, and sleep quality being the most commonly assessed issues.

CONCLUSIONS AND CLINICAL IMPLICATIONS

A variety of PROMs are used in RCC patients, hindering interpretability across trials. The PROMs used differ in terms of both the domains assessed and how the issues are translated into questionnaire items. Though RCC-specific PROMs exist, these have flaws in terms of relevance to patients. To answer predefined relevant HRQOL research questions, revised RCC-specific PROMs and standardisation of their integration into clinical trials are warranted.

PATIENT SUMMARY

Researchers are more and more interested in the health-related quality of life of kidney cancer patients and use questionnaires to measure it. This review shows that there are many different health-related quality of life questionnaires that are used in different combinations in clinical trials for kidney cancer patients. This makes it very difficult to compare these study results and draw reliable conclusions for the actual clinical treatment. It was even found that some of the questionnaires used do not capture things that patients actually consider important (eg, emotional issues such as dealing with thoughts about cancer and depression). Therefore, more work needs to be done to develop questionnaires that ask what is really important to kidney cancer patients' health-related quality of life. If these questionnaires are used in a consistent way in clinical trials, the results can be better compared. This will help treat kidney cancer patients in the best possible way.

Minimally Invasive Laparoscopic Donor Nephrectomy With a Pfannenstiel Incision Using Size-Reduced Trocars

BACKGROUND

Laparoendoscopic single-site surgery is performed during laparoscopic donor nephrectomy (LDN) to reduce donor invasiveness. However, the procedure is difficult and does not improve cosmesis when the incision is made at the umbilicus. Therefore, we proposed a minimally invasive LDN with a Pfannenstiel incision using size-reduced trocars (mLDN) to achieve cosmesis and operability and aimed to assess its efficacy and safety.

METHODS

A total of 27 patients who underwent mLDN were recruited. Data on estimated blood loss, operative time, pneumoperitoneum time, warm ischemic time (WIT), complication rate, non-steroidal anti-inflammatory drugs (NSAIDs) used, and recipient serum creatinine levels were collected retrospectively. In mLDN, the Pfannenstiel position was incised to approximately 6 cm to retrieve the kidney, and three size-reduced trocars were placed in the left upper abdomen (2.5 mm and 5 mm) and umbilicus (5 mm).

RESULTS

The median operation time and pneumoperitoneum time were 245 and 194 minutes, respectively. The median WIT was 276 seconds, and the serum creatinine levels of the recipients at seven days and one, three, six, and 12 months were significantly improved compared with baseline. No intra- and postoperative complications (Clavien-Dindo grade ≥ 2) were observed, and no patients used additional NSAIDs after the operation. The scarring in the mLDN group was unnoticeable postoperatively.

CONCLUSIONS

mLDN can be performed safely, with high cosmesis, and with operability similar to that of conventional LDN. Although the WIT tended to be long, the function of the harvested kidney was maintained, and the use of analgesic NSAIDs was lower in this procedure. Our procedure should be considered as an option for LDN.

Single-Port Mini-Pfannenstiel Robotic Pyeloplasty: Establishing a Non-Narcotic Pathway Along with A Same-Day Discharge Protocol

OBJECTIVE

To analyze the feasibility of a same day discharge protocol following SP robotic pyeloplasty.

PATIENTS AND METHODS

From a single institution series, 23 patients (12 multi-port (MP), 11 single-port (SP)) who underwent primary robotic dismembered pyeloplasty between February 2018 and March 2021 were analyzed. The association between baseline and perioperative characteristics with functional outcome was analyzed using, chi-square, Fisher's exact, Mann Whitney U and t-tests.

RESULTS

All SP cases were completed using the mini Pfannenstiel incision without the need for conversion or additional ports. Baseline characteristics were comparable. No intraoperative complications were seen. Only one patient in the SP group had a Clavien II complication. All patients in the MP group had a drain placed, whereas drain was not placed in the SP group. Length of stay was shorter in the SP group (11.4 vs. 42.6 hours, p<0.001). Although visual analog pain score was comparable at discharge (p=0.633), the SP group had lower opioid usage (morphine milligram equivalent) in the hospital (p<0.001) and a lower rate of opioid prescription during discharge (18.2% vs. 91.7% p<0.001). At a median follow-up of 8 months, no patients had flank pain and all patients had good kidney drainage on follow-up images.

CONCLUSIONS

Single-port robotic dismembered pyeloplasty through a mini-Pfannenstiel access allows a same-day discharge protocol with minimal opiate use.

Robotic Single-Port Donor Nephrectomy with the da Vinci SP® Surgical System

OBJECTIVES

The da Vinci SP® Surgical System received U.S. Food and Drug Administration approval for urological procedures in 2018. Here, we describe the first experience performing single-port robot-assisted donor nephrectomy (RADN) using the da Vinci SP® surgical system, present 90-day clinical outcomes, and discuss tips for operative success.

METHODS

Seven consecutive patients underwent single-port RADN at a single institution between September 1, 2020 and March 31, 2021. Surgery was performed through a single, 60 mm Pfannenstiel incision with a 12 mm periumbilical assistant port for suction and vascular stapling. Donor characteristics, operative details, 90-day donor clinical outcomes, and recipient renal function were retrospectively evaluated.

RESULTS

Four female and three male patients successfully underwent single-port RADN without conversion to standard multiport or open approach. Six cases were left-sided. Estimated blood loss for each procedure was ≤ 50 mL. Mean operative time, warm ischemia time, and extraction time were 218.3 minutes (standard deviation [SD]: 16.3 minutes), 5 minutes 4 seconds (SD: 56 seconds), and 3 minutes 37 seconds (SD: 38 seconds). Mean pre-operative creatinine and estimated glomerular filtration rate were 0.79 mg/dL and 107.3 mL/min/1.73m2, respectively. At six week's follow up, they were 1.22 mg/dL and 66.1 mL/min/1.73m2. Average pain score at 48 hours postoperatively was 1.7/10. There were no Clavien-Dindo grade ≥ III complications within 90 days. All recipients experienced immediate and sustained return of renal function post-transplant.

CONCLUSION

Single-port RADN is a technically feasible and safe procedure with the da Vinci SP® system and can confer acceptable functional and cosmetic outcomes. Future studies are needed to define long-term outcomes and compare with previously established techniques for donor nephrectomy.

Laparoscopic Radical Nephrectomy

In addition to its established advantages, laparoscopic radical nephrectomy (RN) poses a unique set of challenges over traditional open surgery. In this study, we discuss preoperative considerations and detailed steps for laparoscopic RN. We review the transabdominal approach in detail, including patient positioning, equipment, and port placement in addition to the surgical steps. Intraoperative decisions such as adrenal management, renal preservation, and tumor identification are reviewed. Common complications of laparoscopic renal surgery are also summarized.

Single-Port Robot-Assisted Dismembered Pyeloplasty With Mini-Pfannenstiel or Peri-Umbilical Access: Initial Experience in a Single Center

OBJECTIVE

To assess the feasibility and describe the surgical technique for single-port robotic-assisted laparoscopic pyeloplasty using the new da Vinci SP surgical platform (Intuitive Surgical Inc., Sunnyvale, CA), and to describe the approach through a mini-pfannenstiel incision.

METHODS

Data from a prospectively maintained single-institution database on all patients undergoing single-port robotic-assisted pyeloplasty between November 2018 and November 2019 were reviewed. Pyeloplasty was performed with the da Vinci SP system through a pure single site approach (except for the first patient). The initial procedures were performed through a midline incision and the technique evolved to a mini-pfannenstiel incision. Patient demographics, intraoperative data, post-operative data and surgical outcomes were collected.

RESULTS

Overall, 10 patients were included and underwent the procedure without intraoperative complications or conversion to an alternate approach. The patients' ages ranged between 11 and 75 years. Mean operative time was 166 minutes (interquartile range [IQR] 146-181) and EBL was minimal. Pfannenstiel incision was performed for 6 patients and 4 patients had a vertical midline incision. The only complication recorded was a postoperative urinary tract infection treated with antibiotics. The median postoperative hospital stay was 21 hours (7-24). Postoperative pain management after discharge was managed exclusively with non-opioid medication. Overall success rate defined as the absence of pain and renal obstruction on post-operative imaging at 3 months after surgery was 100%.

CONCLUSION

Single-port robotic-assisted laparoscopic pyeloplasty is a safe and feasible procedure through a mini-pfannenstiel incision.

Iliac fossa vs Pfannenstiel retrieval incision in laparoscopic donor nephrectomy: A critical analysis

Objective: To compare two retrieval incisions, Pfannenstiel vs iliac fossa incision, in terms of operative technique-related variables and variables related to patient satisfaction postoperatively, in patients undergoing laparoscopic donor nephrectomy (LDN).

Patients and methods: This prospective randomised study was conducted between May 2016 and April 2017. All the voluntary kidney donors aged 18–60 years were randomised into two groups. Group 1, comprised patients undergoing graft retrieval via an iliac fossa incision, and Group 2 comprised those undergoing graft retrieval via a Pfannenstiel incision. Intraoperative assessment of the incision by the surgeon was done using a Likert scale-based questionnaire. Other variables studied were the operative time, retrieval time, warm ischaemia time, and length of incision. Postoperatively, visual analogue scale pain scores, analgesia consumption, and hospital stay were compared. During follow-up cosmetic outcome was compared.

Results: In all, 108 patients were enrolled in the study with 54 patients in each group. The mean operative time was shorter in Pfannenstiel-incision group, at 155.2 vs 171.67 min (P = 0.01). The retrieval incision length was significantly less in the Pfannenstiel arm, at 9.29 vs 9.85 cm (P < 0.001). In the surgeon Likert scale-based questionnaire, the Pfannenstiel incision scored better than the iliac fossa incision for ease of specimen retrieval (P = 0.015), ease of immediate check laparoscopy (P = 0.002), and ease of incision closure (P < 0.001). The Pfannenstiel-incision group required less postoperative analgesia, at a mean (SD) of 7.03 (8.82) vs 15.55 (11.1) mg nalbuphine (P < 0.001). During follow-up the Manchester Scar Scores were lesser in the Pfannenstiel-incision group (P < 0.001).

Conclusion: The Pfannenstiel incision was considered preferable during the critical steps of the LDN and had a smaller retrieval incision, lesser operative time and postoperative analgesia requirement, and better cosmesis than the iliac fossa incision.

Abbreviations: BMI: body mass index; LDN: laparoscopic donor nephrectomy; VAS: visual analogue scale; WIT, warm ischaemia time

Postoperative pain and cosmetic results of minilaparoscopic nephrectomy compared to the conventional technique

INTRODUCTION

In recent years urology has been focussing on less invasive forms of laparoscopy with less impact on the abdominal wall. The minilaparoscopy (ML) is promising in this regard. Our objective is to compare the results of a series of patients who underwent minilaparoscopic nephrectomy with another series who underwent conventional laparoscopy (CL).

MATERIAL AND METHODS

We chose 8 nephrectomies performed by mini-laparoscopy in a single hospital (NmL group) from a total of 110 patients included in multiple centres and compared them retrospectively with a contemporary series of 16 patients who underwent CL (NL group). From 1 to 3 3mm and 5mm trocars were used for the NmL and the NL, respectively, one 10mm trocar in the pararectal edge of a Pfannenstiel incision and another 11mm paraumbilical trocar for the optics. Age, BMI, ASA, complications, analgesic requirements in the postoperative period and cosmetic satisfaction were recorded using the Patient Scar Assessment Questionnaire (PSAQ), one month after the intervention.

RESULTS

Both groups were comparable and there were no differences in terms of surgery time, number of ports used, hospital stay or intra-and postoperative complications. In only one patient from the NmL group, a 3mm trocar had to be replaced by a 5mm trocar and one patient in the NL group was converted to hand-assisted surgery due to severe adherences. The patients in the NmL group had less postoperative pain on the VAS (±0 vs. 4±25, P=.05) and were more satisfied with their appearance on the PSAQ (8.5±1.4 vs. 16.6±3.1, P=.05) compared to the NL group.

CONCLUSIONS

The results obtained with the ML instrument were similar to those obtained by CL, but with the advantages of less postoperative pain and better cosmetic results.

Robotic Nephroureterectomy

Upper tract urothelial carcinoma is a rare malignancy that has an abundance of surgical treatment options, including open, laparoscopic, robotic, and endoscopic approaches. As advances in technology allow for shorter, less morbid operations, the variation in care of this uncommon disease has raised concerns about compromising oncologic principles. Many institutions have described their experience with promising results; however, there is a paucity of high-quality data that supports the use of robotic surgery as a new gold standard. This article describes how to perform the operation using a single-dock method and reviews contemporary literature on perioperative and oncologic outcomes.

Preperitoneal Surgical Approach to Treat Vesicoureteral Anastomotic Leakage, Distal Stenosis or Reflux After Kidney Transplantation

BACKGROUND

If endourological approaches are not applicable to treat vesicoureteral anastomotic complications after kidney transplantation, the surgical gold standard in many transplant centers is pyeloureterostomy or ureteroureterostomy using the native ureter. We report an original preperitoneal technique that can be used for vesicoureteral reanastomosis in kidney transplant recipients not eligible for endourological treatment.

METHODS

Between January 2011 and December 2015, 18 kidney transplant recipients underwent this new surgical procedure. Of this number, 15 subjects with at least 1 year of follow-up were included in the analysis. The indications were vesicoureteral reflux, anastomotic stenosis, and leakage in 8, 5, and 2 patients, respectively. Briefly, a double J stent was preoperatively inserted into the grafted ureter. Surgery was performed through a Pfannenstiel incision. The preperitoneal space surrounding the bladder was dissected and the distal part of the grafted ureter was identified and mobilized. The anastomotic area was resected and another vesicoureteral anastomosis was performed (Lich-Gregoir technique), keeping the JJ stent in place for three weeks.

RESULTS

This procedure was performed 213 days (range 17-2608) after kidney transplantation. Median surgical duration was 179 minutes (range 112-314) and median hospital stay 8 days (range 4-14). The success rate was 86.7% (13/15), with a median follow-up of 1148 days (range 517-1808). In two patients, symptomatic recurrence of vesicoureteral reflux required a pyeloureterostomy using the native ureter.

CONCLUSIONS

The authors describe a simple technique that avoids transperitoneal dissection, potentially yielding more esthetic results thanks to easy access, as well as excellent outcomes.

Pfannenstiel laparoendoscopic reduced-port radical nephrectomy

INTRODUCTION

We previously reported cases of laparoendoscopic single-site nephrectomy performed through an umbilical or pararectal incision. To improve cosmesis and operability, we performed three Pfannenstiel laparoendoscopic reduced-port nephrectomies.

MATERIALS AND SURGICAL TECHNIQUE

In the first case, a GelPOINT access was placed through a 2-cm umbilical incision, and two additional 3-mm trocars were inserted. The specimen was extracted through a 4-cm Pfannenstiel incision. In the second and third cases, a GelPOINT access was placed through a 5-cm Pfannenstiel incision, and two additional 3-mm trocars were inserted. The specimens were extracted without additional skin incisions. In all cases, the endoscope and vessel-sealing device were inserted through the GelPOINT access. We used 3-mm scissors, dissecting forceps, and bipolar forceps.

DISCUSSION

The operating time and estimated blood loss were 228, 280, and 155 min and 10, 410, and 5 mL, respectively. There were no intraoperative or postoperative complications. The 3-mm forceps showed similar efficacy as the conventional 5-mm forceps. Therefore, a Pfannenstiel reduced-port nephrectomy using 3-mm working trocars is a safe and feasible procedure with good cosmesis.