Original Paper
Urologia
Received: April 18, 2013 Accepted after revision: July 15, 2013 Published online: November 27, 2013
Urol Int 2014;92:400–406 DOI: 10.1159/000354391
Internationalis
Retroperitoneal Laparoscopic Partial Nephrectomy for Moderately Complex Renal Hilar Tumors Ben Xu Qian Zhang Jie Jin Department of Urology, Peking University First Hospital and Institute of Urology, Peking University, National Urological Cancer Center, Beijing, China
Abstract Objectives: To report our initial experience in retroperitoneal laparoscopic partial nephrectomy (LPN) for moderately complex renal hilar tumors and summarize the feasibility of the retroperitoneal laparoscopic approach. Materials and Methods: 14 patients with renal hilar tumors underwent retroperitoneal LPN between June 2010 and January 2012 at our institution. All of the masses were confirmed in the hilar location by computed tomography preoperatively and then evaluated with the R.E.N.A.L. nephrometry scoring system; all were defined as moderately complex lesions. A three-port retroperitoneal approach with a dorsal incision was used in all cases. Patient baseline demographics, perioperative outcomes and pathological characteristics were recorded based on a retrospective data collection and telephone interview. Results: All operations were performed successfully without conversion to radical nephrectomy or open surgery. Only two complications of perirenal fluid collection occurred, but the patients recovered with active surveillance. Mean operative time was 134.3 min, mean estimated blood loss 133.2 ml, mean warm ischemia time 30.6 min and mean retroperitoneal drainage 2.2 days. Mean postoperative hospital stay was 4.7 days. No recurrence or metastasis occurred in these
© 2013 S. Karger AG, Basel 0042–1138/13/0924–0400$38.00/0 E-Mail [email protected] www.karger.com/uin
patients at a mean follow-up of 18.6 months. Conclusions: Our initial experience suggests that retroperitoneal LPN is a feasible, safe and effective procedure for moderately complex renal hilar tumors. Although it remains technically challenging, this approach can be recommended in some complex cases when in experienced hands. © 2013 S. Karger AG, Basel
Introduction
In contrast to peripheral simple renal tumors, central tumors, particularly hilar tumors, are quite rare in the general population. A hilar tumor can be similarly defined as a lesion located at the renal hilum, in contact with or within 5 mm of the hilar arteries, veins or the renal pelvis [1] on preoperative computed tomography (CT) or magnetic resonance imaging (MRI). Since laparoscopic partial nephrectomy (LPN) was first reported with hilar tumors by Gill et al. [2], a number of reports have demonstrated that LPN is a safe and less invasive alternative to conventional open surgery for hilar tumors. With the advent of the R.E.N.A.L. nephrometry scoring (RNS) system (lesions with a RNS of 4–6 points are designated as low complexity, 7–9 points as moderate complexity and 10–12 points as the highest complexity) developed by Kutikov and Uzzo [3] in 2009, the reproducible standardized classification system quantitates the anatomy of renal Qian Zhang Department of Urology, Peking University First Hospital and Institute of Urology Peking University, National Urological Cancer Center 8 Xishiku Street, Xicheng District, Beijing 100034 (China) E-Mail zhangqian @ bjmu.edu.cn
Downloaded by: UCSF Library & CKM 128.218.166.245 - 5/14/2015 11:18:43 PM
Key Words Hilar tumors · Laparoscopic · Retroperitoneal · Partial nephrectomy · Nephrometry
From June 2010 to January 2012, retroperitoneal LPN for renal hilar tumors was performed at our institution on 14 patients by a single surgeon (Dr. Q. Zhang). No solitary kidney was present, and no patient had undergone renal surgery previously. Relevant data were obtained from our prospectively maintained database after obtaining approval from our institutional review board. The preoperative evaluations, including hemoglobin (Hb) and serum creatinine (SCr) levels, B-scan ultrasonography and CT, were routinely applied to all patients. All of the masses were confirmed in the hilar location by CT preoperatively and then evaluated with the RNS system; all were defined as moderately complex lesions by the surgeon. A typical moderately complex renal hilar tumor is depicted in figure 1. Three-port retroperitoneal LPN was performed in all patients and was considered elective in the presence of a normal contralateral kidney. Our surgical technique for hilar tumors followed the same standard steps. The patient was positioned in the full lateral decubitus position with overextension. A 1-cm skin incision was
initially made at the cross point of the line 2 cm above the iliac crest and the longitudinal line close to the anterior auxiliary line. A handmade balloon dilating device was then placed to create a retroperitoneal space, and the first 13-mm port was inserted into the retroperitoneal space at a 30° angle to the perpendicular line. After the pneumoperitoneum had been maintained at 13–15 mm Hg, the laparoscope was inserted through the first port and moved right and left with its tip and trunk to enlarge the retroperitoneal cavity. The two other ports were subsequently placed at cross points of the subcostal line and anterior and posterior auxiliary lines under direct visualization. The three trocars formed an equilateral triangle (fig. 2a) to provide a nearly empty cavity without any abdominal organs disturbing the manipulation. After the construction of a retroperitoneal cavity, the paranephric fat was dissected off Gerota’s fascia, which was subsequently opened and incised away from the tumor to facilitate excision and suturing. By dissecting cautiously, the renal vessels were dissected free, and the renal artery was clamped with laparoscopic bulldog clamps. Afterwards, intraoperative ultrasonography was used to delineate the tumor margin as well as the location, depth and proximity to the collecting system and vessels. Based on ultrasound guidance, a more dorsal incision was made in all of the involved kidneys, regardless of whether the tumors were located anteriorly or posteriorly. When the hilar parenchymal tumor margin was exposed by the dorsal incision, cold scissors were used to gradually perform separation from the normal renal parenchyma to the lesion, leaving larger and deeper kidney defects in the resection bed simultaneously (fig. 2b, c). Hemostasis was achieved by two layers of suturing: a deep layer at the excision bed to suture the collecting systems with the application of 2-0 Vicryl continuous sutures and another more superficial layer at the renal capsule to reapproximate the renal parenchyma with the application of 1-0 Vicryl con-
Retroperitoneal LPN for Moderately Complex Renal Hilar Tumors
Urol Int 2014;92:400–406 DOI: 10.1159/000354391
masses and provides theoretical support for LPN for some complex hilar tumors. We summarize and analyze our retroperitoneal laparoscopic experience in the treatment of moderately complex renal hilar tumors to determine whether expanding the indications of retroperitoneal LPN to such cases is safe, feasible and effective. To the best of our knowledge, our series of 14 patients is the largest concerning retroperitoneal LPN for hilar tumors to date. Materials and Methods
401
Downloaded by: UCSF Library & CKM 128.218.166.245 - 5/14/2015 11:18:43 PM
Fig. 1. Preoperative coronal and axial CT of the abdomen revealed typical moderately complex renal hilar tumors (white arrows).
Color version available online
a
b
c
d
Fig. 2. Intraoperative photographs of the
retroperitoneal laparoscopic technique. a Three laparoscopic ports were placed to form an equilateral triangle. b Laparoscop-
ic photograph of a renal hilar tumor separated from the normal renal parenchyma with cold scissors. c The appearance of a larger and deeper cavity after tumor removal. d The successfully continuously sutured renal reconstruction.
tinuous sutures (fig. 2d). All sutures were end-loaded with Hemo-lok clips to avoid knot tying. Following renorrhaphy, the vascular clamp was removed and hemostasis was evaluated. An endobag was used to retrieve the specimen. A suction drain was placed in the retroperitoneal cavity, and all port site skin edges were closed with skin adhesive. Postoperatively, the specimen was sent for pathological analysis including tumor histology, TNM stage, Fuhrman grade, vascular invasion and margin status. Approximately 4–6 weeks later, the levels of Hb and SCr were remeasured and CT was performed. Importantly, patient baseline demographics, perioperative outcomes and pathological characteristics were recorded based on a retrospective data collection and telephone interview. All of the clinical data were statistically analyzed using SPSS 10.0 (Statistical Package for Social Science, USA). Descriptive data are presented as numbers and percentages. Continuous data are shown as means ± standard deviation. The pre- and postoperative level of Hb and SCr were separately compared by Student’s t test, and a p value
Urologia
Received: April 18, 2013 Accepted after revision: July 15, 2013 Published online: November 27, 2013
Urol Int 2014;92:400–406 DOI: 10.1159/000354391
Internationalis
Retroperitoneal Laparoscopic Partial Nephrectomy for Moderately Complex Renal Hilar Tumors Ben Xu Qian Zhang Jie Jin Department of Urology, Peking University First Hospital and Institute of Urology, Peking University, National Urological Cancer Center, Beijing, China
Abstract Objectives: To report our initial experience in retroperitoneal laparoscopic partial nephrectomy (LPN) for moderately complex renal hilar tumors and summarize the feasibility of the retroperitoneal laparoscopic approach. Materials and Methods: 14 patients with renal hilar tumors underwent retroperitoneal LPN between June 2010 and January 2012 at our institution. All of the masses were confirmed in the hilar location by computed tomography preoperatively and then evaluated with the R.E.N.A.L. nephrometry scoring system; all were defined as moderately complex lesions. A three-port retroperitoneal approach with a dorsal incision was used in all cases. Patient baseline demographics, perioperative outcomes and pathological characteristics were recorded based on a retrospective data collection and telephone interview. Results: All operations were performed successfully without conversion to radical nephrectomy or open surgery. Only two complications of perirenal fluid collection occurred, but the patients recovered with active surveillance. Mean operative time was 134.3 min, mean estimated blood loss 133.2 ml, mean warm ischemia time 30.6 min and mean retroperitoneal drainage 2.2 days. Mean postoperative hospital stay was 4.7 days. No recurrence or metastasis occurred in these
© 2013 S. Karger AG, Basel 0042–1138/13/0924–0400$38.00/0 E-Mail [email protected] www.karger.com/uin
patients at a mean follow-up of 18.6 months. Conclusions: Our initial experience suggests that retroperitoneal LPN is a feasible, safe and effective procedure for moderately complex renal hilar tumors. Although it remains technically challenging, this approach can be recommended in some complex cases when in experienced hands. © 2013 S. Karger AG, Basel
Introduction
In contrast to peripheral simple renal tumors, central tumors, particularly hilar tumors, are quite rare in the general population. A hilar tumor can be similarly defined as a lesion located at the renal hilum, in contact with or within 5 mm of the hilar arteries, veins or the renal pelvis [1] on preoperative computed tomography (CT) or magnetic resonance imaging (MRI). Since laparoscopic partial nephrectomy (LPN) was first reported with hilar tumors by Gill et al. [2], a number of reports have demonstrated that LPN is a safe and less invasive alternative to conventional open surgery for hilar tumors. With the advent of the R.E.N.A.L. nephrometry scoring (RNS) system (lesions with a RNS of 4–6 points are designated as low complexity, 7–9 points as moderate complexity and 10–12 points as the highest complexity) developed by Kutikov and Uzzo [3] in 2009, the reproducible standardized classification system quantitates the anatomy of renal Qian Zhang Department of Urology, Peking University First Hospital and Institute of Urology Peking University, National Urological Cancer Center 8 Xishiku Street, Xicheng District, Beijing 100034 (China) E-Mail zhangqian @ bjmu.edu.cn
Downloaded by: UCSF Library & CKM 128.218.166.245 - 5/14/2015 11:18:43 PM
Key Words Hilar tumors · Laparoscopic · Retroperitoneal · Partial nephrectomy · Nephrometry
From June 2010 to January 2012, retroperitoneal LPN for renal hilar tumors was performed at our institution on 14 patients by a single surgeon (Dr. Q. Zhang). No solitary kidney was present, and no patient had undergone renal surgery previously. Relevant data were obtained from our prospectively maintained database after obtaining approval from our institutional review board. The preoperative evaluations, including hemoglobin (Hb) and serum creatinine (SCr) levels, B-scan ultrasonography and CT, were routinely applied to all patients. All of the masses were confirmed in the hilar location by CT preoperatively and then evaluated with the RNS system; all were defined as moderately complex lesions by the surgeon. A typical moderately complex renal hilar tumor is depicted in figure 1. Three-port retroperitoneal LPN was performed in all patients and was considered elective in the presence of a normal contralateral kidney. Our surgical technique for hilar tumors followed the same standard steps. The patient was positioned in the full lateral decubitus position with overextension. A 1-cm skin incision was
initially made at the cross point of the line 2 cm above the iliac crest and the longitudinal line close to the anterior auxiliary line. A handmade balloon dilating device was then placed to create a retroperitoneal space, and the first 13-mm port was inserted into the retroperitoneal space at a 30° angle to the perpendicular line. After the pneumoperitoneum had been maintained at 13–15 mm Hg, the laparoscope was inserted through the first port and moved right and left with its tip and trunk to enlarge the retroperitoneal cavity. The two other ports were subsequently placed at cross points of the subcostal line and anterior and posterior auxiliary lines under direct visualization. The three trocars formed an equilateral triangle (fig. 2a) to provide a nearly empty cavity without any abdominal organs disturbing the manipulation. After the construction of a retroperitoneal cavity, the paranephric fat was dissected off Gerota’s fascia, which was subsequently opened and incised away from the tumor to facilitate excision and suturing. By dissecting cautiously, the renal vessels were dissected free, and the renal artery was clamped with laparoscopic bulldog clamps. Afterwards, intraoperative ultrasonography was used to delineate the tumor margin as well as the location, depth and proximity to the collecting system and vessels. Based on ultrasound guidance, a more dorsal incision was made in all of the involved kidneys, regardless of whether the tumors were located anteriorly or posteriorly. When the hilar parenchymal tumor margin was exposed by the dorsal incision, cold scissors were used to gradually perform separation from the normal renal parenchyma to the lesion, leaving larger and deeper kidney defects in the resection bed simultaneously (fig. 2b, c). Hemostasis was achieved by two layers of suturing: a deep layer at the excision bed to suture the collecting systems with the application of 2-0 Vicryl continuous sutures and another more superficial layer at the renal capsule to reapproximate the renal parenchyma with the application of 1-0 Vicryl con-
Retroperitoneal LPN for Moderately Complex Renal Hilar Tumors
Urol Int 2014;92:400–406 DOI: 10.1159/000354391
masses and provides theoretical support for LPN for some complex hilar tumors. We summarize and analyze our retroperitoneal laparoscopic experience in the treatment of moderately complex renal hilar tumors to determine whether expanding the indications of retroperitoneal LPN to such cases is safe, feasible and effective. To the best of our knowledge, our series of 14 patients is the largest concerning retroperitoneal LPN for hilar tumors to date. Materials and Methods
401
Downloaded by: UCSF Library & CKM 128.218.166.245 - 5/14/2015 11:18:43 PM
Fig. 1. Preoperative coronal and axial CT of the abdomen revealed typical moderately complex renal hilar tumors (white arrows).
Color version available online
a
b
c
d
Fig. 2. Intraoperative photographs of the
retroperitoneal laparoscopic technique. a Three laparoscopic ports were placed to form an equilateral triangle. b Laparoscop-
ic photograph of a renal hilar tumor separated from the normal renal parenchyma with cold scissors. c The appearance of a larger and deeper cavity after tumor removal. d The successfully continuously sutured renal reconstruction.
tinuous sutures (fig. 2d). All sutures were end-loaded with Hemo-lok clips to avoid knot tying. Following renorrhaphy, the vascular clamp was removed and hemostasis was evaluated. An endobag was used to retrieve the specimen. A suction drain was placed in the retroperitoneal cavity, and all port site skin edges were closed with skin adhesive. Postoperatively, the specimen was sent for pathological analysis including tumor histology, TNM stage, Fuhrman grade, vascular invasion and margin status. Approximately 4–6 weeks later, the levels of Hb and SCr were remeasured and CT was performed. Importantly, patient baseline demographics, perioperative outcomes and pathological characteristics were recorded based on a retrospective data collection and telephone interview. All of the clinical data were statistically analyzed using SPSS 10.0 (Statistical Package for Social Science, USA). Descriptive data are presented as numbers and percentages. Continuous data are shown as means ± standard deviation. The pre- and postoperative level of Hb and SCr were separately compared by Student’s t test, and a p value
