Early experience of laparoscopic radical nephrectomy for T3b renal cell carcinoma

Laparoscopic radical nephrectomy for patients with pathologic T3b renal-cell carcinoma: the Johns Hopkins experience

BACKGROUND AND PURPOSE

Surgical therapy for renal-cell carcinoma (RCC) with vascular involvement has traditionally been performed via an open approach. As laparoscopic techniques have improved, more surgeons are attempting laparoscopic nephrectomy for higher stage RCC. The goal of our study was to evaluate the safety and short-tem oncologic efficacy of laparoscopic radical nephrectomy in patients with renal vein involvement.

PATIENTS AND METHODS

We reviewed the clinical and pathologic data for 37 patients who underwent a pure laparoscopic radical nephrectomy for RCC with renal vein thrombus from 2005 to 2008 by dedicated laparoscopic surgeons. Perioperative and oncologic outcomes were assessed. Median age of our study population was 65 years, and mean follow-up was 14 months.

RESULTS

Median pathologic tumor size was 7.5 cm. One (2.7%) patient needed conversion to an open procedure. Median estimated blood loss (EBL) was 200 mL (interquartile range [IQR]) 100-850), and median length of stay (LOS) was 3 days (range 3-5 d). The overall perioperative complication rate was 14%, and there were no perioperative mortalities. Of the 32 patients without metastatic disease at the time of surgery, 29 (91%) are alive without evidence of disease.

CONCLUSION

Laparoscopic radical nephrectomy in the setting of renal vein thrombus is a complex surgical procedure that necessitates significant laparoscopic skills. Our data demonstrate that laparoscopic radical nephrectomy is safe and effective in patients with RCC who have renal vein involvement, albeit with short-term oncologic follow-up. Long-term follow-up in larger series of patients is necessary to further define the role of laparoscopic nephrectomy in this subset of patients.

Laparoscopic Management of Renal Tumors

Laparoscopy has become commonplace in the management of genitourinary malignancies and, in some institutions, has largely replaced open surgery as the primary treatment method for renal tumors. Outside of laparoscopic radical nephrectomy, other modalities, such as nephron-sparing partial nephrectomy and energy-based ablative procedures, have been extended to laparoscopy. In this article, we present our experience and review the literature regarding the utility of laparoscopy in the management of renal tumors.

Laparoscopic Radical Nephrectomy for Renal Carcinoma with Known Level I Renal Vein Tumor Thrombus

OBJECTIVES

Laparoscopic nephrectomy in patients with known venous involvement is an emerging technique. The goal of this study was to describe our experience and outcomes with laparoscopic nephrectomy for patients with preoperatively diagnosed level I (renal vein) tumor thrombus.

METHODS

The data from all patients undergoing laparoscopic nephrectomy by one surgeon from July 1, 2004 to February 28, 2006 were reviewed. The patients with a preoperatively diagnosed tumor thrombus were included in the study. A pure laparoscopic transperitoneal technique was used with intraoperative ultrasonography to ensure complete removal of the thrombus. The medical records were reviewed for clinical, operative, and follow-up information.

RESULTS

Five patients were identified. The mean age, American Society of Anesthesiologists score, and tumor size were 59.8 years (range 34 to 81), 2.6 (range 2 to 3), and 5.5 cm (range 4 to 6), respectively. The mean operative time and estimated blood loss were 119.6 minutes (range 92 to 180) and 150 mL (range 50 to 300), respectively. The mean hospital stay was 3.6 days (range 2 to 4), and no complications occurred. The final stage was T3b with negative margins in all cases. The mean Fuhrman grade was 2.4 (range 2 to 3). Two patients had known metastases and underwent cytoreductive nephrectomy. These 2 patients were alive at a mean follow-up of 11.5 months. Of the other 3 patients, at a mean follow-up of 8.7 months, 2 had no evidence of disease, and 1 had developed recurrence in the liver and was treated with sorafenib, resulting in tumor regression.

CONCLUSIONS

Pure laparoscopic transperitoneal nephrectomy for patients with preoperatively diagnosed level I tumor thrombus is safe and effective in experienced hands. Additional series are needed to examine the long-term oncologic outcomes.

Pure Laparoscopic Radical Nephrectomy for Stage T3b Renal-Cell Carcinoma: More than 2-Year Follow-Up

BACKGROUND AND PURPOSE

Renal-vein tumor thrombus associated with renal malignancy has traditionally been approached with open surgery, and preoperative diagnosis of stage T(3b) renal tumors often mandates open surgery. However, early arterial division and "milking" of the thrombus away from the inferior vena cava may facilitate laparoscopic surgery. We describe our single-surgeon experience with laparoscopic nephrectomy in patients with tumor extension into the renal vein.

PATIENTS AND METHODS

Among 240 laparoscopic nephrectomies performed by a single surgeon from 2002 to 2005, six patients (2.6%) were found to have renal-vein tumor thrombus. These patients included three men and three women with a mean age of 55.8 years (range 43-78 years). Data collected prospectively were evaluated to characterize this cohort.

RESULTS

All six tumors were right-sided, stage T(3b), and all were managed laparoscopically without major complications. Three tumors were suspected to have renal-vein thrombus on preoperative imaging; the other three tumor thrombi were discovered on pathologic examination. The mean tumor size was 9.5 cm (range 7.5-11.5 cm). Two tumors were grade 2, three were grade 3, and one patient had a grade 4 rhabdoid cell-type tumor. At a mean follow-up of 27 months, all patients were without evidence of disease with the exception of the patient with grade 4 disease, who developed recurrence in the chest.

CONCLUSION

Laparoscopic nephrectomy for tumor with renal-vein thrombus can be accomplished safely with adherence to proper oncologic techniques.