Retroperitoneal Laparoscopic Radical Nephrectomy for Large (>7 cm) Solid Renal Tumors: Comparison of Perioperative Outcomes with the Transperitoneal Approach

Transperitoneal vs retroperitoneal laparoscopic radical nephrectomy: a double-arm, parallel-group randomized clinical trial

OBJECTIVE

To compare the outcomes of patients undergoing Retroperitoneal laparoscopic Radical nephrectomy (RLRN) and Transperitoneal laparoscopic Radical nephrectomy (TLRN).

METHODS

A total of 120 patients with localized renal cell carcinoma were randomized into either RLRN or TLRN group. Mainly by comparing the patient perioperative related data, surgical specimen integrity, pathological results and tumor results.

RESULTS

Each group comprised 60 patients. The two group were equivalent in terms of perioperative and pathological outcomes. The mean integrity score was significantly lower in the RLRN group than TLRN group. With a median follow-up of 36.4 months after the operation, Kaplan-Meier survival analysis showed no significant difference between RLRN and TLRN in overall survival (89.8% vs. 88.5%; P = 0.898), recurrence-free survival (77.9% vs. 87.7%; P = 0.180), and cancer-specific survival (91.4% vs. 98.3%; P = 0.153). In clinical T2 subgroup, the recurrence rate and recurrence-free survival in the RLRN group was significantly worse than that in the TLRN group (43.2% vs. 76.7%, P = 0.046). Univariate and multivariate COX regression analysis showed that RLRN (HR: 3.35; 95%CI: 1.12-10.03; P = 0.030), male (HR: 4.01; 95%CI: 1.07-14.99; P = 0.039) and tumor size (HR: 1.23; 95%CI: 1.01-1.51; P = 0.042) were independent risk factor for recurrence-free survival.

CONCLUSIONS

Our study showed that although RLRN versus TLRN had roughly similar efficacy, TLRN outperformed RLRN in terms of surgical specimen integrity. TLRN was also significantly better than RLRN in controlling tumor recurrence for clinical T2 and above cases.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ( https://www.chictr.org.cn/showproj.html?proj=24400 ), identifier: ChiCTR1800014431, date: 13/01/2018.

Perioperative and oncologic outcomes of transperitoneal versus retroperitoneal laparoscopic radical nephrectomy for large-volume renal carcinoma (> 7 cm): a systematic review and pooled analysis of comparative outcomes

BACKGROUND

Recently, there has been a significant amount of debate concerning the question of whether laparoscopic surgery should be performed transperitoneally or retroperitoneally for treating large renal tumors.

AIM

The purpose of this research is to conduct a comprehensive review and meta-analysis of the previous research on the safety and efficacy of transperitoneal laparoscopic radical nephrectomy (TLRN) and retroperitoneal laparoscopic radical nephrectomy (RLRN) in the treatment of large-volume renal malignancies.

METHODS

An extensive search of the scientific literature was carried out utilizing PubMed, Scopus, Embase, SinoMed, and Google Scholar in order to locate randomized controlled trials (RCTs) and prospective and retrospective studies that compared the effectiveness of RLRN versus TLRN in the treatment of for large renal malignancies. For the purpose of comparing the oncologic and perioperative outcomes of the two techniques, data were taken from the research studies that were included and pooled together.

RESULTS

A total of 14 studies (five RCTs and nine retrospective studies) were incorporated into this meta-analysis. The overall RLRN had an association with significantly shorter operating time (OT) (MD [mean difference]: - 26.57; 95% CI [confidence interval]: - 33.39 to - 19.75; p < 0.00001); less estimated blood loss (EBL) (MD: - 20.55; CI: - 32.86 to - 8.23; p = 0.001); faster postoperative intestinal exhaust (MD: - 0.65; CI: - 0.95 to - 0.36; p < 0.00001). The terms of length of stay (LOS) (p = 0.26), blood transfusion (p = 0.26), conversion rate (p = 0.26), intraoperative complications (p = 0.5), postoperative complications (p = 0.18), local recurrence rate (p = 0.56), positive surgical margin (PSM) (p = 0.45), and distant recurrence rate (p = 0.7) did not show any differences.

CONCLUSIONS

RLRN provides surgical and oncologic results similar to TLRN, with potential advantages regarding shorter OT, EBL, and postoperative intestinal exhaust. Due to the high heterogeneity among the studies, long-term randomized clinical trials are required to obtain more definitive results.

Retroperitoneal laparoscopic radical nephrectomy (RLRN) is associated with poor integrity of Gerota's fascia and perirenal fat: A prospective comparative study

Purpose

To figure out the difference of integrity of Gerota's fascia and perirenal fat between Retroperitoneal Laparoscopic Radical Nephrectomy (RLRN) and Transperitoneal Laparoscopic Radical Nephrectomy (TLRN).

Methods

This is a prospective comparative study of patients with Renal Cell Carcinoma (RCC) from a designated tertiary center in Lanzhou, China. We have developed and propose a scoring tool to quantify the integrity of nephrectomy specimens from both approaches. The integrity score is based on 6 common conditions of nephrectomy specimens. Specimens are scored on a 1 to 6-point scale according to the integrity of Gerota's fascia and perirenal fat. We applied the integrity score to 142 consecutive patients. Integrity scores were compared between RLRN and TLRN groups. Factors associated with low integrity score were assessed by logistic regression.

Results

Among 142 patients, 79 (55.6%) patients and 63 (44.4%) patients, respectively, underwent RLRN and TLRN. There was a significant difference in the distribution of integrity score between the two groups (P < 0.001). RLRN (odds ratio 10.65, 95%CI 4.29-26.45, P < 0.001), tumor size (odds ratio 1.22, 95%CI 1.04-1.42, P = 0.015) and Body Mass Index (BMI) (odds ratio 0.83, 95%CI 0.72-0.96, P = 0.010) were significantly associated with low integrity score. The logistic regression equation showed good power to predict low integrity score.

Conclusion

RLRN has poor integrity of Gerota's fascia and the perirenal fat. The integrity score can be used to evaluate the extent of resection and specimen completeness in LRN. Postoperative evaluation of the integrity score is of great value for urologists to evaluate the risk of tumor residue.

Preoperative factors affecting the operative outcomes of laparoscopic nephrectomy

OBJECTIVES

Laparoscopic radical nephrectomy is the standard surgery for localized renal cell carcinoma. Both tumor and patient factors affect the difficulty of laparoscopic radical nephrectomy. Obesity is a major factor influencing technical difficulty in surgical procedures. This study examined preoperative tumor and patient factors affecting the operating time.

METHODS

The data of 123 patients who underwent laparoscopic radical nephrectomy at our institution between January 2014 and December 2018 were retrospectively analyzed. The operating time was determined based on the median pneumoperitoneum time. Surgical procedures with a pneumoperitoneum time of ≥130 min were defined as having prolonged pneumoperitoneum time. Multiple logistic regression analyses were performed to identify the preoperative factors affecting the prolonged pneumoperitoneum time, and risk stratification was performed based on these factors.

RESULTS

Multiple logistic regression analyses revealed that a total number of renal pedicle blood vessels ≥3 and a visceral fat volume ≥3000 cm³ were associated with prolonged pneumoperitoneum time of laparoscopic radical nephrectomy. Based on the multivariate analysis results, these factors were considered individually, and the cohort was stratified into three risk groups: low (0 point), intermediate (1 point), and high (2 points) risk groups. The pneumoperitoneum time was significantly prolonged as the number of risk factors increased.

CONCLUSIONS

We developed a risk stratification model using preoperative factors to predict the prolonged pneumoperitoneum time of laparoscopic radical nephrectomy, which can help select suitable cases that are appropriate for each surgeon's skill level.

A comparison of surgical practice and operative outcomes between retroperitoneal and transperitoneal laparoscopic nephrectomies – 6 years of data from the BAUS Nephrectomy database

Objectives:

While the choice of surgical approach for laparoscopic nephrectomy is broadly split between transperitoneal and retroperitoneal options, the evidence for the impact of this decision on perioperative outcomes is built on relatively small volume data, with often inconsistent findings and conclusions. We aimed to assess the impact of operative approach on perioperative outcomes for laparoscopic radical, partial and simple nephrectomy and nephroureterectomy through analysis of the British Association of Urological Surgeons (BAUS) Nephrectomy database.

Patients and methods:

All patients added to the BAUS Nephrectomy database with laparoscopic surgery between 2012 and 2017 inclusively were included and subdivided by operation and surgical approach. Preoperative patient and tumour characteristics, as well as intraoperative and post-operative short-term outcomes, were assessed.

Results:

Overall, 26,682 operations were documented over the review window (81.6% transperitoneal). Small increases in blood loss ( p = 0.001), transfusion rate ( p = 0.02) and operative length ( p = 0.01) were seen for transperitoneal radical nephrectomies and longer hospital stays seen for retroperitoneal procedures (radical nephrectomy p = 0.00l; partial nephrectomy p = 0.04). Retroperitoneal procedures were associated with increased rates of conversion for simple nephrectomy ( p = 0.02), nephroureterectomy ( p = 0.03) and most notably partial nephrectomy (10.5% versus 4.4%; p = 0.001). No further variation in intraoperative complications, post-operative complications, tumour margin positivity rates, unintended ITU admission, or likelihood of death was identified related to surgical approach.

Conclusion:

Observed variations in perioperative outcomes were generally modest in nature, and little ground is seen to support a change in operative technique for those committed to one approach. A caveat to this exists with open conversion for retroperitoneal partial nephrectomies and requires careful consideration of patient selection by the individual surgeon.

Level of evidence:

4

Laparoscopic nephrectomy: Moroccan experience of 68 cases

Background

The aim of this study was to analyze the feasibility and the safety of laparoscopic nephrectomy in the treatment of pathologies of the upper urinary tract through the experience of the Urology B department.

Methods

We have retrospectively and monocentrally selected patients who underwent laparoscopic nephrectomy from January 2017 to December 2019. The collection was carried out on archived files, based on demographic, clinical and perioperative data. The primary endpoint was the occurrence of complications and secondarily the length of the operation and the length of hospital stay. The statistical analysis was carried out using the SPSS software.

Results

A total of 68 patients were included in our series. The average age of our patients was 57.8 years. There was a slight female predominance: 39 female patients (57.4%) for 29 male patients (42.6%). Indications for nephrectomy were dominated by renal tumor (33.82%) followed by lithiasis (16.17%) and non-functioning kidney (16.17%) at the same rank. During the study period, 31 (45.6%) simple nephrectomy, 26 (38.2%) total nephrectomy, 1 (1.5%) partial nephrectomy and 10 (14.7%) nephroureterectomy were performed in our department. In our series, the average operating time was 180 min. Estimated blood loss averaged 321.8 ml with extremes of a few milliliter to 1100 ml. Intraoperative complications were reported in 10 (14.7%) patients; conversion was necessary in 6 cases (8.82%). The postoperative follow-up was straightforward in 53 (77.94%) patients with an average hospital stay of 3.6 days. The rate of postoperative complications according to Clavien–Dindo was 22.1%. Histological examination of the nephrectomies carried out in our department revealed mainly chronic non-specific pyelonephritis in 24 (35.3%) patients, followed by renal cell carcinoma in 23 (33.82%) patients and urothelial carcinoma in 9 (13.2%) patients.

Conclusion

Laparoscopic nephrectomy appears to be an efficient and reliable technique. This technique has led to a significant improvement in operative morbidity, mainly represented by the length of hospital stay, operating time and blood loss.

Minimally invasive radical nephrectomy: a contemporary review

Minimally invasive renal surgery has revolutionized the surgical management of renal cancer since the initial report of laparoscopic nephrectomy in 1991. Laparoscopic nephrectomy became the mainstay of management in surgically resectable renal masses since the 1990s. The growing body of literature supporting nephron-sparing surgery over the last two decades has meant that minimally invasive radical nephrectomy (MI-RN) is now the preferred treatment for renal tumors not amenable to partial nephrectomy. While there is a well-described experience with complex radical nephrectomy using standard laparoscopy, robot-assisted surgery has shortened the learning curve and facilitated greater uptake of minimally invasive surgery in difficult surgical scenarios traditionally performed open surgically. Increased experience and expertise with robot-assisted renal surgery has led to expansion of the indications for MI-RN to include larger masses, locally advanced renal masses invading adjacent tissues or regional hilar/retroperitoneal lymph nodes, cytoreductive nephrectomy (CN) in metastatic disease, and concurrent venous tumor thrombectomy for renal vein or inferior vena cava (IVC) involvement. In this article, we review the various surgical techniques and adjunctive procedures associated with MI-RN.

Retroperitoneal laparoscopic partial versus radical nephrectomy for large (≥ 4 cm) and anatomically complex renal tumors: A propensity score matching study

INTRODUCTION

To assess the safety and efficiency of retroperitoneal laparoscopic partial nephrectomy (RLPN) and retroperitoneal laparoscopic radical nephrectomy (RLRN) for large (≥4 cm) renal tumors with a RENAL nephrometry score ≥7.

MATERIALS AND METHODS

We retrospectively identified and analyzed the data of 254 patients who underwent RLPN or RLRN for large (≥4 cm) and anatomically complex renal tumors between 2008 and 2017. Propensity score matching (PSM) (1:1) method was conducted to adjust for preoperative clinical characteristics. Preoperative, renal functional, and oncological outcomes were compared.

RESULTS

Finally, no significant differences in the baseline characteristics existed between the two groups after PSM. Within the well-balanced matched cohort, longer operating time (OT) and higher estimated blood loss (EBL) were found in RLPN group (p = 0.015 and p = 0.019, respectively), and RLPN trended to protect renal function better at a higher risk of low-grade complications (-10.9 vs -16.8 ml/min, p = 0.001; 23.0% vs 10.8%, p = 0.048, respectively). The patients in the RLPN group had a better overall survival (OS) than those in RLRN group, but cancer-specific survival and progression-free survival didn't differ significantly between the two groups.

CONCLUSION

For patients with large (≥4 cm) and anatomically complex renal tumors, RLPN by highly experienced hands has an evident tendency to a better protection of renal function and a longer OS without waiving oncological control in comparison with RLRN, but at the expense of longer OT, a higher EBL and a higher risk of low-grade complications.