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The role of cytoreductive nephrectomy in the management of metastatic renal cancer remains controversial. Recent trials, like SWOG 8949 have suggested the usefulness of this approach at least in selected patients with good performance status and other favorable indicators. The timing of cytoreductive nephrectomy has also been controversial and remains so to this time.
SUMMARY: As the worldwide demand for donor kidneys soars, kidney donation via less invasive and minimally invasive laparoscopic techniques is emerging rapidly as a new and viable option to traditional, open-surgical harvesting techniques. Generally, this method of donation has been feasible by using the transperitoneal approach, but, more recently, it also has been accomplished through retroperitoneal access. The authors describe their modified, cost-reductive technique of live retroperitoneoscopic donor nephrectomy and its very good results. Laparoscopic donor nephrectomy appears to be promising; it reduces donor pain and suffering while maintaining excellent graft results.
Xanthogranulomatous pyelonephritis presenting with nephrocutaneous fistula is a rare condition, and its treatment of choice is nephrectomy. Laparoscopic management has been proved to be challenging in these inflammatory renal conditions. However, there was no previous report in the literature regarding laparoscopic treatment of nephrocutaneous fistula especially after previous operation. In this communication, we report the first case of hand-assisted laparoscopic nephrectomy for xanthogranulomatous pyelonephritis with nephrocutaneous fistula after previous failed flank exploration.
A 63-year-old man presented with marked swelling and inability to open the left eye immediately after laparoscopic nephrectomy for a left renal mass. A diagnosis of periorbital emphysema was made, and within 3 days, the emphysema spontaneously improved. This case demonstrates that periorbital emphysema, a rare condition, can be a benign complication of laparoscopic nephrectomy.
PURPOSE: We present an approach to laparoscopic radical nephrectomy and intact specimen extraction, which incorporates hand assisted and standard laparoscopic techniques. MATERIALS AND METHODS: A refined approach to laparoscopic radical nephrectomy is described and our experience is reviewed. A low, muscle splitting Gibson incision is made just lateral to the rectus muscle and the hand port is inserted. A trocar is placed through the hand port and pneumoperitoneum is established. With the laparoscope in the hand port trocar 2 additional trocars are placed under direct vision. The laparoscope is then repositioned through the middle trocar and standard laparoscopic instruments are used through the other 2 trocars including the one in the hand port. If at any time during the procedure the surgeon believes the hand would be useful or needed, the trocar is removed from the hand port and the hand is inserted. RESULTS: This approach has been applied to 7 patients. Mean estimated blood loss was 200 cc (range 50 to 300) and mean operative time was 276.7 minutes (range 247 to 360). Mean specimen weight was 767 gm. (range 538 to 1,170). Pathologically 6 specimens were renal cell carcinoma (grades 2 to 4) and 1 was oncocytoma. Mean length of hospital stay was 3.71 days (range 2 to 7). There were no major complications. CONCLUSIONS: We believe that this approach enables the surgeon to incorporate the advantages of the hand assisted and standard laparoscopic approaches.
PURPOSE: We evaluate results and long-term outcome after partial nephrectomy (PN) for unilateral Wilms tumor (ulWT) in relation to different histological features, performed as initial surgery or after induction chemotherapy (ChT). MATERIALS AND METHODS: Data from patients with ulWT who had undergone PN in the German Study SIOP 93-01/GPOH were analyzed for time of surgery in the treatment schedule, postoperative stage, histological features, surgical radicality and outcome. The results were correlated with overall survival and relapse-free survival, and compared with those of patients who had undergone total tumor nephrectomy (TN). RESULTS: A total of 770 patients underwent TN and 37 underwent PN, of which 766 (99.5%) and 36 (97.3%), respectively, were radical procedures. A total of 139 TNs and 15 PNs were performed at primary surgery, 630 TNs and 22 PNs after ChT, and 1 TN after irradiation. Two of 15 patients following primary PN and 1 of 22 following delayed PN had local recurrence. Two patients died of metastatic disease. Tumor stage, overall survival of 93% and relapse-free survival of 88% were equal after PN and TN in analysis of the whole group. This was also true for patients with surgery after ChT. One of 2 patients with histologically unfavorable disease had relapse after PN compared to only 3 of 35 patients with histologically low or intermediate risk disease. CONCLUSIONS: PN should be performed only for small, histologically low or intermediate risk tumors after good response to ChT to secure a complete resection.
PURPOSE: We evaluated the short-term morbidity and complications of laparoscopic radical nephrectomy (LRN) compared with laparoscopic partial nephrectomy (LPN). MATERIALS AND METHODS: From May 1998 to May 2002, 114 patients were identified with a single unilateral sporadic renal tumor and a normal contralateral kidney. These individuals had undergone LRN (35) or LPN (79). RESULTS: The LRN and LPN groups were analyzed for age, sex, American Society of Anesthesiologists score and body mass index. Mean tumor size in patients undergoing LRN and LPN was 2.8 +/- 1.2 (range 0.9 to 4.5) and 2.5 +/- 1.0 cm (range 1 to 4.5), respectively (p = 0.17). There were no differences between the 2 groups in terms of mean hospital stay, blood transfusion or surgical complications. There was no difference in mean preoperative and postoperative serum creatinine in patients in the LPN group. Mean postoperative serum creatinine was significantly higher than the mean preoperative level in patients in the LRN group (1.51 +/- 0.22 vs 1.18 +/- 0.37 mg/ml, range 0.6 to 2.4, p = 0.02). In each group 1 case was converted to open surgery due to bleeding. CONCLUSIONS: LPN is associated with similar postoperative convalescence and complications compared with LRN. The increase in serum creatinine noted in patients undergoing radical extirpation supports the use of LPN when clinically indicated.
PURPOSE: We compared pathological evaluation and postoperative recovery in patients undergoing transperitoneal laparoscopic nephrectomy at our institution with morcellated vs intact specimen extraction. MATERIALS AND METHODS: A prospective evaluation of 57 consecutive patients undergoing radical and simple transperitoneal laparoscopic nephrectomy was reviewed. One patient was excluded from study due to transitional cell carcinoma, which was detected intraoperatively. The 33 morcellated specimens were extracted at the umbilical port and the 23 intact specimens were extracted through a midline infraumbilical incision. Data were obtained on narcotic requirements, hospital stay, complications, estimated blood loss, mass size based on preoperative imaging, specimen weight and extraction incision length. RESULTS: Mean incision length in the morcellated and intact specimen removal groups was 1.2 and 7.1 cm, respectively (p <0.001). No significant differences in pain or recovery were noted between the 2 groups. Two cases of microscopic invasion of the perinephric adipose tissue in the intact specimen group were up staged from clinical T1 to pT3a disease. No change in patient treatment was made based on this information. CONCLUSIONS: We did not find a significant difference in surgical time, pain or hospital stay. Only incision length was statistically significant. Postoperative recovery appeared to be similar in these 2 groups. With modern imaging modalities information on pathological stage did not alter patient treatment.
PURPOSE: Concern has been raised about possible increased morbidity associated with laparoscopic donor nephrectomy (LDN) during the learning curve of the procedure and at centers with a low volume of living donors. We evaluated the safety and success of LDN at a low volume living donor transplant center with a skilled laparoscopic urologist and experienced renal transplant team. MATERIALS AND METHODS: We reviewed the records of all patients who underwent LDN at our institution. A single surgeon skilled in laparoscopy (JAC) performed all LDNs. Patient demographics, operative reports, complications and recipient outcomes were evaluated. RESULTS: A total of 17 LDNs were performed between January 2000 and September 2002. There was 1 elective conversion to an open procedure for kidney harvest due to complex hilar anatomy. Only 1 minor complication occurred (wound seroma) and 1 donor had creatinine persistently elevated to 1.9 mg/dl (normal 0.6 to 1.2). Mean operating room time, estimated blood loss and hospital stay were 250 minutes, 188 ml and 2.5 days, respectively. Recipient creatinine had a nadir mean of 1.2 mg/dl and a 90-day postoperative mean of 1.6 mg/dl. One recipient eventually lost the graft due to recurrent disease. CONCLUSIONS: LDN can be performed safely and efficiently at low volume transplant centers with a skilled laparoscopist and experienced renal transplant team. Laparoscopic skills developed during similar procedures, such as laparoscopic radical and partial nephrectomy, minimize the learning curve and morbidity of LDN to produce results consistent with those in the published literature.
PURPOSE: Standardized criteria for reporting the early complications of urological procedures are lacking. We reviewed the early complications of radical nephrectomy (RN) and partial nephrectomy (PN) in a large contemporary cohort using a standardized complication grading scale. MATERIALS AND METHODS: Between 1995 and 2002, 1,049 patients underwent RN (66%) or PN (34%) for renal cortical neoplasm. Records were reviewed for perioperative complications. Complications were graded using a 5-tiered scale based on the severity of impact or intensity of therapy required. RESULTS: A total of 235 complications occurred in 180 patients (17%). Overall 55% and 31% of complications were grade I and grade II, respectively. There were 3 perioperative deaths (0.2%). PN was not associated with more complications compared to RN when accounting for other variables. PN cases had more procedure related complications compared to RN (9% versus 3%, respectively, p = 0.0001) due to complications of urinary leak and the reintervention rate was subsequently higher (2.5% versus 0.6%, p = 0.02). All but 1 of the reinterventions for PN involved either endoscopy or radiology. By multivariate analysis operative time (p <0.0001) and solitary kidney (p = 0.06) were associated with procedure related complications of PN. CONCLUSIONS: RN and PN are associated with low rates of serious morbidity and mortality. Compared to RN, PN is associated with higher rates of procedure related complications, the majority of which are minor. Overall, however, PN is not associated with more complications than RN.
PURPOSE: From the experience of a large combined series of transperitoneal (TP) and retroperitoneal (RP) endoscopic complete and partial nephroureterectomies in children, we present a logical selective endoscopic approach to benign renal pathology. MATERIALS AND METHODS: During a 5-year period 122 complete nephrectomies and nephroureterectomies (bilateral 2, invisible ectopic 8) and 63 partial nephroureterectomies for duplex (52 upper, 8 lower) or singleton polar disease (xanthogranulomatous pyelonephritis 1, cyst 2) were performed. Of the partial nephrectomies, ureterectomy, bladder repair and lower moiety reimplantation were performed in 8. Patient age ranged from 2.7 months to 14 years (mean 2.9 years). Preoperative weight ranged from 2.7 to 98 kg (mean 12.3). The position of the renal remnant, the presence or absence of a refluxing ureter and the need for ureterectomy were the major determining factors affecting choice of endoscopic approach. RESULTS: A total of 179 (96.7%) procedures were successfully completed endoscopically. The 6 open conversions (3.2%) occurred early in our experience. The operating time reflected the complexity of the excision and lower urinary reconstruction (lateral and posterior RP 25 to 145 minutes [mean 92]) TP with ureterocelectomy and bladder neck repair 105 to 355 minutes [mean 153]. Hospital stay for RP and simple TP was 1.5 days (mean 1 to 4) and for complicated TP 2 to 8 days (mean 3.5). CONCLUSIONS: We suggest a posterior retroperitoneal approach with isolated renal excision without extended ureterectomy. The lateral retroperitoneal approach allows complete ureterectomy as well as better exposure to horseshoe and pelvic kidneys and, therefore, avoids exposure to intraperitoneal structures. Finally, the transperitoneal approach is recommended when complete moiety excision with lower urinary reconstruction is anticipated.
PURPOSE: We reviewed our first 30 hand assisted laparoscopic partial nephrectomies and compared the results of 8 centrally located vs 22 peripherally located tumors. MATERIALS AND METHODS: Tumors were classified by computerized tomography as central (less than 5 mm from the pelvicaliceal system or hilar vessels) or peripheral. The hand assisted technique consisted of mobilization and manual parenchymal compression without vascular occlusion or ureteral stent placement. Argon beam coagulation and a fibrin glue bandage were used for hemostasis. RESULTS: Mean tumor size was 2.6 cm (range 1.0 to 4.7). Mean operative time was 199 and 271 minutes, and estimated blood loss was 240 and 894 ml for peripheral and central lesions, respectively. No case required open conversion. The final diagnoses were renal cell carcinoma in 21 patients, angiomyolipoma in 4, benign or hemorrhagic cyst in 3 and oncocytoma in 2. Initial positive margins were found in 5 of 30 specimens (16.7%) (1 central and 4 peripheral) and all final resection margins were negative. Four central (50%) and 2 peripheral (9.1%) tumor cases required transfusion. Drain creatinine was elevated in 6 patients (20%) postoperatively, of whom 3 had a central and 3 had a peripheral lesion. All responded to conservative management except 1 patient (3.3%) who required stent placement. Postoperative bleeding in a central tumor case required transfusion of 4 units. There were no short-term local recurrences and 1 patient had an asynchronous tumor. CONCLUSIONS: Hand assisted laparoscopic partial nephrectomy is safe with excellent immediate cancer control. Careful dissection and frozen section analysis are mandatory to ensure a negative tumor margin. Blood loss and transfusion rates were higher in patients with centrally located tumors and renal hilar vascular control should be considered for central lesions.
PURPOSE: Laparoscopic partial nephrectomy (LPN) is a relatively recently introduced method of treating renal tumors and, as such, surgical technique is evolving. In open series urinary fistula formation represents a common postoperative complication. In the laparoscopic approach investigators have advocated the placement of a ureteral catheter with retrograde dye injection to visualize caliceal entry to aid in closure. In this study we assessed the necessity of ureteral catheter placement during LPN in decreasing urinary leakage. MATERIALS AND METHODS: From February 1998 until November 2002 laparoscopic partial nephrectomy was performed in 103 patients with renal tumors. The patients were assessed retrospectively and divided into 2 groups according to placement (group 1) or no placement (group 2) of an external ureteral catheter. Group 1 included 54 patients (mean age +/- SD 57.4 +/- 13.4 years) and group 2 included 49 patients (mean age +/- SD 57.5 +/- 10.9). Intraoperative and postoperative parameters including blood loss, operative time, ischemia time, mass size, complications and hospital stay were reviewed and compared between the 2 groups. RESULTS: There were no differences between the 2 groups in mean estimated blood loss (group 1, 394.7 cc vs group 2, 291.5 cc, p = 0.07), postoperative serum creatinine (group 1, 0.95 mg/dl vs group 2, 0.89 mg/dl, p = 0.12), requirement for pain medication (group 1, 8.9 mg vs group 2, 4.9 mg morphine equivalents, p = 0.12), hospital stay (group 1, 3.1 vs group 2, 2.9, p = 0.29) and warm ischemia time (group 1, 28 minutes vs group 2, 26.5 minutes, p = 0.18). Mean total operative time was significantly longer for group 1 compared to group 2 (191.1 vs 149.4 minutes, respectively, p = 0.001). Postoperative urinary leakage requiring prolonged drainage occurred in 1 patient in group 1 and 1 in group 2. In both cases caliceal entry was identified and sutured. CONCLUSIONS: With experience caliceal entry can be identified without the need for a ureteral catheter in patients undergoing LPN for a tumor less than 4.5 cm. Urinary fistula may occur despite caliceal entry and repair. A ureteral catheter may not decrease urinary fistula in patients undergoing LPN.
PURPOSE: Polyethylene glycol (PEG) based hydrogel is available as a tissue sealant and hemostatic aid. We determined the long-term safety and efficacy of its use as a tissue sealant for laparoscopic partial nephrectomy in a porcine model. MATERIALS AND METHODS: A total of 16 swine were cycled to 1 control group and 3 treatment groups, which underwent laparoscopic partial nephrectomy with hemostasis achieved only with application of a biodegradable PEG based hydrogel. The 3 treatment groups were sacrificed at 2, 6 and 12 weeks, respectively. Humoral immune response to the hydrogel used in the porcine abdomen was examined using enzyme-linked immunosorbent assay to detect antibodies in the serum at 0, 2, 6 and 12 weeks. Cell mediated immune response was examined using a lymphocyte proliferation assay to measure the response of leukocytes to various mitogens and antigens, including the polymerized hydrogel, at the same intervals. RESULTS: Hemostasis was satisfactory after hydrogel application. No adverse effects in the immediate and delayed periods were noted. At 2, 6 and 12 weeks there were no significant differences in hemoglobin or creatinine levels, or in the humoral immune response by enzyme-linked immunosorbent assay. There was no significant difference between test and control pig reactivity to hydrogel as an antigen in the lymphocyte proliferation assay at any time point. Histologically by 6 weeks the animals had almost absorbed the hydrogel with acute inflammation and foreign body reaction resolving by 6 to 12 weeks. No deleterious effect to renal tubules was seen. CONCLUSIONS: Biodegradable PEG based hydrogel is effective for long-term use as an agent for hemostasis. There was no detectable humoral immune response and no cell mediated immune response to sealant after 2 weeks. This represents promising sealant technology and it should be further investigated for human use.
Prenatal diagnosis of autosomal recessive polycystic kidney disease (ARPKD) implies a dire prognosis. Neonates affected by the more severe variants of ARPKD suffer respiratory failure caused by massive kidneys that restrict diaphragmatic expansion and result in pulmonary hypoplasia. Afflicted infants who survive the neonatal period and gain adequate respiratory function may subsequently suffer from an inability to tolerate enteral nutrition due to abdominal compression from the massive kidney and the systemic effects of renal compromise. Palliative unilateral or bilateral nephrectomy may be considered in rare instances to facilitate pulmonary expansion and gastrointestinal function. We report on an infant with severe ARPKD who was able to tolerate enteral nutrition only after left nephrectomy.
PURPOSE: We determined which clinical and molecular variables can predict cancer recurrence in patients following surgical management for localized renal cell carcinoma (RCC). MATERIALS AND METHODS: From a custom kidney cancer tissue microarray containing tumors specimens from 350 patients 193 undergoing nephrectomy for localized RCC at our institution between 1989 and 2000 were identified. The array was then analyzed by immunohistochemistry for certain molecular markers, namely CA9, CA12, Ki67, gelsolin, p53, EpCAM, pTEN and vimentin. The medical records of these patients were then reviewed for age, sex, TNM stage, tumor size, nuclear grade, Eastern Cooperative Oncology Group (ECOG) performance status, recurrence status and, when applicable, time to recurrence. Cox regression analyses were done to determine clinical and molecular predictors of time to tumor recurrence. RESULTS: Of the patients 15% demonstrated evidence of tumor recurrence following nephrectomy (29 of 193). Univariate Cox regression demonstrated that tumor size, T stage, grade, ECOG performance status, Ki67, EpCAM and p53 were significantly associated with recurrence (p <0.05). A multivariate Cox regression model showed that T stage (p = 0.018), ECOG (p = 0.004) and p53 (p = 0.003) were the 3 most significant predictors. p53 expression correlated significantly with nuclear grade (Pearson correlation 0.22, p = 0.023) but not with any other clinical factors. Patients with localized tumors demonstrating mean p53 staining values above and below 20% of cells had recurrence rates of 37.7% and 14.4%, respectively (RR = 3.28, p = 0.018). CONCLUSIONS: p53 is a significant molecular predictor of tumor recurrence, as identified in patients undergoing treatment for localized RCC.
PURPOSE: Hemostasis represents a primary challenge during laparoscopic partial nephrectomy (LPN). We typically clamp the renal artery/vein en bloc and perform LPN expeditiously under warm ischemia conditions. We evaluated Helix Hydro-jet assisted LPN without renal hilar vascular control in the survival calf model. MATERIALS AND METHODS: Staged bilateral LPN using the Hydro-jet was performed without renal hilar vessel control in 10 survival calves (20 kidneys). Parenchymal hydrodissection was performed with a high velocity, ultracoherent saline stream at 450 psi through a small nozzle with integrated suction at the tip. The denuded intrarenal parenchymal blood vessels were precisely coagulated with a BIClamp bipolar instrument and transected. Followup involved biochemical, radiological and histopathological evaluation at designated sacrifice intervals of 1 and 2 weeks, and 1, 2 and 3 months, respectively. RESULTS: All LPNs were completed successfully without open conversion. Of 20 LPNs 18 (90%) were performed without hilar clamping. Pelvicaliceal suture repair was necessary in 5 of 10 chronic kidneys (50%). Mean Hydro-jet(R) partial nephrectomy time was 63 minutes (range 13 to 150), mean estimated blood loss was 174 cc (range 20 to 750) and mean volume of normal saline used for hydro-dissection was 260 cc (mean 50 to 1,250). No animal had a urinary leak. Histological sections from the acute specimen revealed a thin (1 mm) layer of adherent coagulum at the amputation site with minimal thermal artifact. At 2 weeks a layer of adherent fibro-inflammatory pseudomembrane with giant cell reaction was seen. CONCLUSIONS: In this more stringent and robust survival calf model Hydro-jet assisted LPN can be performed without hilar vessel control, thus, completely avoiding warm ischemia. This approach has the potential to decrease the level of technical difficulty inherent in LPN.
PURPOSE: Local recurrence of renal cell carcinoma in the renal fossa without distant metastatic disease is an infrequent occurrence. Management of this lesion can be challenging, with relatively few series in the literature. We describe our use of surgical extirpation with adjuvant intraoperative radiation. MATERIALS AND METHODS: The University of California, San Francisco Urologic Oncology database and the University of California, San Francisco Radiation Oncology database were queried for all patients with locally recurrent renal fossa recurrence. Only patients with recurrence of renal cell carcinoma in the renal fossa were included. Survival, complications and the use of adjuvant therapy in the form of intraoperative radiation therapy were noted. RESULTS: A total of 14 patients were treated for this lesion between 1990 and 2003. Mean time to recurrence was 40 months (range 5 to 180). Only 1 patient was symptomatic preoperatively, while in 13 disease had been detected on routine computerized tomography followup. Mean size of the recurrent tumor was 6.35 cm (range 2 to 17). 9 patients died of progressive, metastatic disease after a mean of 17 months (range 1 to 56) and 5 are alive with a mean survival of 66 months (range 14 to 86). The time to recurrence after nephrectomy approached statistical significance (p =0.06) when comparing the patients who were alive vs those who died of disease. Additionally, there was no statistical difference in size of mass recurrence between these 2 groups. There was no difference in survival due to adjuvant intraoperative radiation therapy. Local fossa re-recurrence developed in 2 patients. Survival was 40% at 2 years and 30% at 5 years from surgery. Complications, including minor complications, occurred in 42% of patients and there was no perioperative mortality. CONCLUSIONS: Selected patients with isolated local recurrence in the renal fossa may have favorable and durable outcomes following surgical resection and possibly adjuvant intraoperative radiation therapy for isolated renal fossa recurrence following radical nephrectomy. Development of novel and effective systemic therapy is needed in high risk patients with renal cancer.