Port-site metastasis after laparoscopic surgery for urological malignancy: forgotten or missed

Recurrent Renal Cell Carcinoma Presenting as Port-Site Metastases, Detected on 18F-Fluorodeoxyglucose Positron Emission Tomography-Computed Tomography

The incidence of port-site metastases (PSMs) varies with the tumor type with adenocarcinoma having a high incidence. However, it is rarely seen in urological malignancies and more so in renal cell carcinoma (RCC). We hereby describe one such case of PSM after laparoscopic radical nephrectomy for RCC, which was detected on 18F-fluorodeoxyglucose positron emission tomography-computed tomography.

Minimally Invasive Surgery for Patients with Locally Advanced and/or Metastatic Renal Cell Carcinoma

Despite advances in systemic therapy and immunotherapy, surgery continues to have a role in management of advanced renal cell carcinoma (aRCC). Minimally invasive surgery (MIS) is considered standard of care for smaller, localized tumors due to faster recovery without compromising oncologic outcomes. There are concerns about MIS for aRCC due to a potential risk of inferior oncologic outcomes and unusual patterns of disease recurrence. Recent studies, however, suggest that in properly selected patients with aRCC, MIS can provide improved peri-operative outcomes without compromising oncologic control.

Incidence of Port Site Metastasis in Laparoscopic Radical Nephroureterectomy: Single-institution Experience

OBJECTIVE

To address the incidence and potential risk factors of port site metastasis (PSM) in patients who underwent laparoscopic radical nephroureterectomy (RNU) for upper tract urothelial carcinoma.

MATERIALS AND METHODS

Between January 2013 and December 2018 laparoscopic RNU were performed in 240 patients at our institution, including 145 with renal pelvic tumor and 135 with ureteral tumor (40 patients have both tumor). Laparoscopies were performed through the transperitoneal approach in 28 patients, and retroperitoneal in 212 patients. Clinical data are retrospectively collected.

RESULTS

Perioperative and pathologic data are available in all 240 cases. After a mean follow-up of 12.6 months (range 3-45 months), 4 patients (1.7%) developed PSM following retroperitoneal RNU at an average of 4.3 months. Tumor stage is T2N0M0 in one, T3N0M0 in two, and T3N1M0 in one, respectively. Tumor grade are high-grade urothelial carcinoma in all. The incidence of PSM is 2.8% (4/145) and 0.7% (1/135) in renal pelvic and ureteral tumor, respectively.

CONCLUSION

We report a 1.7% incidence of PSM in upper tract urothelial carcinoma after laparoscopic RNU. We suggest that air leakage during retroperitoneal approach, high tumor stage (pT3) and grade, and advanced renal pelvic tumor with micrometastases could increase the potential risks of PSM.

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.

Abdominal wall metastasis following open nephroureterectomy for upper tract urothelial carcinoma in a patient with Lynch syndrome

A 74-year-old man developed the rare complication of an abdominal wall metastasis following open nephroureterectomy for upper tract urothelial carcinoma (UTUC). This occurred in the setting of synchronous contralateral ureteric and metachronous colorectal carcinomas. Immunohistochemistry demonstrated loss of the mutS homolog 6 (MSH6) mismatch repair (MMR) protein in the metastatic abdominal wall and colonic lesions, which in conjunction with meeting the Amsterdam II criteria, is strongly suggestive of Lynch syndrome (LS). Surgical resection of the recurrence was performed with clear margins and neither recurrence nor spread during short-term follow-up.

Analysis of open and intracorporeal robotic assisted radical cystectomy shows no significant difference in recurrence patterns and oncological outcomes

OBJECTIVES

To report and compare early oncological outcomes and cancer recurrence sites among patients undergoing open radical cystectomy (ORC) and robotic-assisted radical cystectomy with intracorporeal urinary diversion (iRARC).

METHODS AND MATERIALS

A total of 184 patients underwent radical cystectomy for bladder cancer. ORC cases (n = 94) were performed between June 2005 and July 2014 while iRARC cases (n = 90) were performed between June 2011 and July 2014. Primary outcome was recurrence free survival (RFS). Secondary outcomes were sites of local and metastatic recurrence, cancer specific survival (CSS) and overall survival (OS).

RESULTS

Median follow-up for patients without recurrence was 33.8 months (interquartile range [IQR]: 20.5-45.4) for ORC; and 16.1 months (IQR: 11.2-27.0) for iRARC. No significant difference in age, sex, precystectomy T stage, precystectomy grade, or lymph node yield between ORC and iRARC was observed. The ORC cohort included more patients with≥pT2 (64.8% ORC vs. 38.9% iRARC) but fewer pT0 status (8.5% ORC vs.vs. 22.2% iRARC) due to lower preoperative chemotherapy use (22.3% ORC vs. 34.4% iRARC). Positive surgical margin rate was significantly higher in the ORC cohort (19.3% vs. 8.2%; P = 0.042). Kaplan-Meir analysis showed no significant difference in RFS (69.5% ORC vs. 78.8% iRARC), cancer specific survival (80.9% ORC vs. 84.4% iRARC), or OS (73.5% ORC vs.vs. iRARC 83.8%) at 24 months. Cox regression analysis showed RFS, cancer specific survival and OS were not influenced by cystectomy technique. No significant difference between local and metastatic RFS between ORC and iRARC was observed.

CONCLUSION

This study has found no difference in recurrence patterns or oncological outcomes between ORC and iRARC. Recurrent metastatic sites vary, but are not related to surgical technique.

Port site metastasis after surgery for renal cell carcinoma: harbinger of future metastasis

PURPOSE

Port site metastasis is a rare occurrence after minimally invasive treatment for renal cell carcinoma. However, its prognostic implications are unclear because reports in the literature are heterogeneous in detail and followup. We clarify the significance of port site metastasis in cancer specific survival and broaden our understanding of this phenomenon.

MATERIALS AND METHODS

A MEDLINE® search for published studies of renal cell carcinoma port site metastasis was performed. Contributing factors to port site metastasis, stage, Fuhrman grade, pathology, port site metastasis treatment method, followup protocol and long-term outcomes were collected. The corresponding authors of each publication were contacted to fill in details and provide long-term outcomes. We added 1 case from our recent experience.

RESULTS

A total of 16 cases from 12 authors (including ourselves) were found. Of the 12 authors 8 were available for correspondence and 9 cases were updated. Eventual outcomes were available for 11 of the 16 cases and survival curves showed poor prognosis with a 31.8% overall 1-year survival rate. Of the 16 cases 12 were radical nephrectomy and 4 were partial nephrectomy, and 13 involved multiple metastases in addition to the port site metastasis. Nine of the cases had no identifiable technical reason for port site metastasis formation such as specimen morcellation, absence of entrapment or tumor rupture. These tumors were uniformly aggressive, Fuhrman grade 3 or higher.

CONCLUSIONS

Port site metastasis after minimally invasive surgery for renal cell carcinoma is a rare occurrence with a poor prognosis. In most cases port site metastasis is not an isolated metastasis but instead is a harbinger of progressive disease. While technical factors can have a role in port site metastasis formation, it appears that biological factors like high tumor grade also contribute.

Long-term outcome of laparoscopic versus open liver resection for hepatocellular carcinoma: a case-controlled study with propensity score matching

BACKGROUND

Laparoscopic liver resection (LR) for hepatocellular carcinoma (HCC) is usually applied to superficial and left-side small lesions. Therefore, well designed comparative studies about the results of LR versus open liver resection (OR) for HCC are difficult and still uncommon. The aim of this study was to compare the perioperative and long-term oncologic outcomes of LR versus OR for HCC between well-matched patient groups.

METHODS

Between January 2000 and March 2012, 205 patients (43 with intent-to-treat with LR, 162 OR) underwent primary liver resection of less than three segments for HCC in our center. To select a comparison group, propensity score matching (PSM) was used at 1:1 ratio with covariates of baseline characteristics, including tumor characteristics. Outcomes were compared between the matched groups.

RESULTS

The two groups were well balanced by PSM and 29 patients were matched respectively. In LR, there was more non-anatomical resection (65.5 vs. 34.5 %; p = 0.012), less postoperative ascites (0.0 vs. 17.2 %; p = 0.025), and shorter hospital stay (7.69 ± 2.94 vs. 13.38 ± 7.37 days; p < 0.001). With the exception of these, there were no significant differences in perioperative and long-term outcomes. The 1-, 3- and 5-year survivals were 100, 100 and 92.2 % in LR, and 96.5, 92.2 and 87.7 % in OR (p = 0.267), respectively. The 1-, 3- and 5-year disease-free survivals were 81.7, 61.7 and 54.0 % in LR, and 78.6, 60.9 and 40.1 % in OR, respectively (p = 0.929).

CONCLUSIONS

The outcome of LR for HCC was technically feasible and safe in selected patients, and LR showed similar perioperative and long-term oncologic outcomes when compared with OR matched with PSM.

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.

Oncologic outcomes obtained after laparoscopic, robotic and/or single port nephroureterectomy for upper urinary tract tumours

INTRODUCTION

Open surgery (ONU) is still considered to be the gold standard approach for nephroureterectomy (NU); however, with the introduction of laparoscopic surgery, minimally invasive techniques have been applied to surgical therapy of upper urinary tract tumours (UUT-UC) and they are gaining adepts. However, several concerns still exist about the safety of laparoscopic nephroureterectomy (LNU) in the treatment of UUT-UC, and different authors suggest that, although it could be equivalent to open surgery, this equivalence is not accomplished in all UUT-UC, suggesting that more advanced disease should undergo open surgery. More controversial still is the application of robotic surgery (RALNU) or really novel minimally invasive techniques, such as laparoendoscopic single-site surgery (LESSNU), for the treatment of UUT-UC. Although all these techniques seem feasible, their influence on oncologic results is still a matter of concern.

METHODOLOGY

We present a review on the oncologic outcomes of minimally invasive laparoscopic techniques in the treatment of UUT-UC. We focus our analysis on oncologic outcomes and we also analyze the different techniques proposed for the treatment of the distal ureter during minimally invasive surgery for UUT-UC. In the absence of prospective randomized studies with large patient samples, we must base our conclusions on retrospective studies and longer follow-up.

CONCLUSION

Given the evidence accumulated so far, LNU has proven to be equivalent or non-inferior, in terms of recurrence-free survival (RFS) and cancer-specific survival (CSS) to ONU. Nevertheless, comparative studies are needed with longer follow-up before determining the equivalence of LNU in advanced tumours.