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Keywords:

  • laparoscopic radical nephrectomy;
  • renal cell cancer;
  • laparoscopy;
  • kidney cancer
Abbreviations
(L)(O)(R)N

(laparoscopic) (open) (radical) nephrectomy.

INTRODUCTION

  1. Top of page
  2. INTRODUCTION
  3. INDICATIONS
  4. TRANSPERITONEAL LRN
  5. RETROPERITONEOSCOPIC RN
  6. HAND-ASSISTED LRN
  7. TECHNIQUE OF SPECIMEN EXTRACTION
  8. CLINICAL SERIES OF LN AND THEIR OUTCOMES
  9. COMPLICATIONS OF LRN
  10. CONCLUSIONS
  11. CONFLICT OF INTEREST
  12. REFERENCES

The first laparoscopic total nephrectomy was in 1990, by Clayman et al.[1] at Washington University Medical School, St. Louis, MO, USA. Adaptation and persistent efforts by clinical investigators worldwide have truly refined the technical aspects of the procedure and have ushered a revolution in minimally invasive renal surgery, and indeed laparoscopic urological surgery. Herein, we review the progress of laparoscopic nephrectomy (LN) for RCC from these beginnings to its present status.

INDICATIONS

  1. Top of page
  2. INTRODUCTION
  3. INDICATIONS
  4. TRANSPERITONEAL LRN
  5. RETROPERITONEOSCOPIC RN
  6. HAND-ASSISTED LRN
  7. TECHNIQUE OF SPECIMEN EXTRACTION
  8. CLINICAL SERIES OF LN AND THEIR OUTCOMES
  9. COMPLICATIONS OF LRN
  10. CONCLUSIONS
  11. CONFLICT OF INTEREST
  12. REFERENCES

Early in the development of laparoscopic radical nephrectomy (LRN), tumours with clinical stage T1N0M0 were the ideal cases for this technique [2,3]. However, with greater surgeon experience, these criteria have been expanded to encompass T2, T3a, N0M0, with tumour sizes of up to 16 cm reported [4,5].

TECHNICAL CONSIDERATIONS

Three approaches have been used for renal extirpation, i.e. pure laparoscopic transperitoneal, retroperitoneoscopic, and hand-assisted laparoscopic transperitoneal. The technique adopted depends on patient factors (obesity, comorbid disease), characteristics of the tumour (size, clinical stage) and most importantly, the surgeon’s comfort with the specific approach used. The following will briefly describe the nuances of each approach.

TRANSPERITONEAL LRN

  1. Top of page
  2. INTRODUCTION
  3. INDICATIONS
  4. TRANSPERITONEAL LRN
  5. RETROPERITONEOSCOPIC RN
  6. HAND-ASSISTED LRN
  7. TECHNIQUE OF SPECIMEN EXTRACTION
  8. CLINICAL SERIES OF LN AND THEIR OUTCOMES
  9. COMPLICATIONS OF LRN
  10. CONCLUSIONS
  11. CONFLICT OF INTEREST
  12. REFERENCES

Positioning of the patient for LRN is perhaps one of the most important parts of the procedure, as it enables gravity-induced passive retraction of the dissected organs (colon, spleen and pancreas) allowing them to fall away from the kidney. Liberal use of the rotational features of the operative table can further enhance the gravitational retraction.

We routinely use a Veress needle to obtain the pneumoperitoneum by placing it 4 cm above and 4 cm medial to the anterior superior iliac spine. Then, a point 4 cm below the costal margin in the mid-clavicular line is selected for placing the first trocar. We typically use a 12-mm visual trocar and then, after removing the obturator, inspect the peritoneal cavity to ensure safety of the previously passed Veress needle and for intra-abdominal pathology. A second 12-mm port is placed at the site of Veress insertion and the primary camera either in the midline above the umbilicus (in thin patients) or lateral to the rectus sheath (in obese patients).

The peritoneal incisions for a right nephrectomy include the line of Toldt, dissection of the duodenum off Gerota’s fascia (i.e. Kocher manoeuvre), and incision of the hepatic triangular ligament, as well as the hepatic posterior coronary ligament medially to expose the supra-adrenal vena cava. The anterior surface of the vena cava is traced caudal to identify the insertion of the right gonadal vein. Following the anterior surface of the vena cava will lead to the origin of the right renal vein, posterior to which the renal artery will be found.

For the left side, the lateral border is defined by incisions along the splenophrenic attachments cephalad, and the line of Toldt, caudal. The descending mesocolon is then sharply and bluntly separated from Gerota’s fascia. The splenocolic ligament is then incised followed, when possible, by the splenorenal ligament. The gonadal vein is then identified and provides the path to the renal vein and artery. After the hilar dissection, we routinely staple the renal artery followed by the renal vein. We also prefer to use the Ligasure device (Valleylab, Boulder, CO, USA) instead of clips, to secure the adrenal, lumbar and gonadal veins, to enhance the safe firing of the stapler. If there is significant hilar bleeding before the vessels are completely dissected, Rapp et al.[6] showed that en bloc stapling of the renal hilum is safe. They had no documented arteriovenous fistulae in the 26 cases (6% of 433 patients) in which this had to be done, with a mean follow-up of 26 months. We also routinely place the specimen into an 20 × 25 cm Lap Sac (Cook Urological Inc., Spencer, IN, USA) and manually morcellate after delivering the mouth of the sac through the lowermost 12-mm incision, which is extended to 2 cm and triply draped before initiating morcellaton [7]. With the untimely passage of the high-speed electrical tissue morcellator, this process is now done manually using a Sopher ring forceps (jaw dimensions ≈ 6 cm long by ≈ 2 cm wide). Immediately after morcellation the triple drape is removed, the morcellation site is irrigated with Betadine, and the entire morcellation team re-gowns and re-gloves. Alternatively, the specimen can be entrapped and removed via a 7–10 cm midline, Gibson or Pfannenstiel incision.

RETROPERITONEOSCOPIC RN

  1. Top of page
  2. INTRODUCTION
  3. INDICATIONS
  4. TRANSPERITONEAL LRN
  5. RETROPERITONEOSCOPIC RN
  6. HAND-ASSISTED LRN
  7. TECHNIQUE OF SPECIMEN EXTRACTION
  8. CLINICAL SERIES OF LN AND THEIR OUTCOMES
  9. COMPLICATIONS OF LRN
  10. CONCLUSIONS
  11. CONFLICT OF INTEREST
  12. REFERENCES

The technique for RN was extensively described and refined by Gill and Rassweiler [8]; other significant contributors to the technique are Gaur [9] and Abbou et al.[10].

The most common site for placing the first incision to develop the retroperitoneal space is just below the tip of the 12th rib via a 2–2.5 cm incision. This permits visual entry into the retroperitoneum by piercing the lumbodorsal fascia digitally, with a haemostat, or sharply with a knife or electrosurgical cutting current. Of extreme importance is for the plane of blunt dissection to be anterior to the psoas and posterior to Gerota’s fascia. A commercially available retroperitoneal distension balloon (United States Surgical, Norwalk, CT, USA) filled with 40 pumps (instils ≈ 1 L) of the accompanying inflation bulb, or a 14 F red rubber catheter secured to the middle finger of a size 8 latex glove filled with either air or 700–1000 mL of saline, respectively, is used to develop the retroperitoneal space. Then a 10- or 12-mm blunt-tip balloon port (United States Surgical) is used as the camera port; inflation of the sealing balloon to 30 mL and cinching of the outer foam ring against the skin prevents leakage of the pneumo-retroperitoneum. The former accepts 5 and 7 or 8 mm instruments, whereas the latter accepts 5 and 10 mm instruments. After dissecting and identifying the medial edge of the psoas muscle, a longitudinal incision in Gerota’s fascia parallel to the psoas muscle will lead to the renal hilum, which can be secured in the usual fashion. However, in this approach, the artery is appreciated first. It is important to be cognisant throughout the dissection that the peritoneal organs are close and therefore remain susceptible to injury [8]. The specimen is removed usually via a 7–10 cm flank incision.

HAND-ASSISTED LRN

  1. Top of page
  2. INTRODUCTION
  3. INDICATIONS
  4. TRANSPERITONEAL LRN
  5. RETROPERITONEOSCOPIC RN
  6. HAND-ASSISTED LRN
  7. TECHNIQUE OF SPECIMEN EXTRACTION
  8. CLINICAL SERIES OF LN AND THEIR OUTCOMES
  9. COMPLICATIONS OF LRN
  10. CONCLUSIONS
  11. CONFLICT OF INTEREST
  12. REFERENCES

The hand-assisted approach is essentially the same as the transperitoneal LRN, albeit with the surgeon’s subordinate hand placed into the abdomen via a hand-port device, i.e. the Gelport (Applied Medical, Rancho Santa Margarita, CA, USA) or Lap Disc (Ethicon Endo-Surgery, Cincinnati, OH, USA). For right-handed surgeons, the hand-port can be placed in the right lower quadrant with the left hand inserted, or a peri-umbilical incision can be made when performing a right nephrectomy. For a left nephrectomy, the hand incision can be made in a peri-umbilical or upper midline location. For a left-handed surgeon the port placement is a mirror image. The intra-abdominal hand facilitates the dissection and retraction necessary to free the kidney. The specimen can then be entrapped and removed intact through the hand-port site [7].

TECHNIQUE OF SPECIMEN EXTRACTION

  1. Top of page
  2. INTRODUCTION
  3. INDICATIONS
  4. TRANSPERITONEAL LRN
  5. RETROPERITONEOSCOPIC RN
  6. HAND-ASSISTED LRN
  7. TECHNIQUE OF SPECIMEN EXTRACTION
  8. CLINICAL SERIES OF LN AND THEIR OUTCOMES
  9. COMPLICATIONS OF LRN
  10. CONCLUSIONS
  11. CONFLICT OF INTEREST
  12. REFERENCES

The excised kidney can be removed intact by extending one of the port-site incisions or it can be morcellated in an appropriate entrapment sac. One concern about morcellation is whether the pathology can be assessed accurately. To this end, Pautler et al.[11] took needle biopsies before morcellation and after the specimen had been placed inside an entrapment sac. They found that these correlated with the histopathology of the morcellated tissue, and thus were deemed redundant. Also, by morcellating with a ring forceps via a 2-cm incision, sufficiently large pieces of tissue are retrieved and suitable for diagnosing tumour type, vascular invasion, and even fat invasion. Second, there is the question of whether morcellation results in less postoperative discomfort; reports attempting to answer this question have been conflicting. In this regard, Hernandez et al.[12] prospectively evaluated 57 consecutive patients undergoing LRN, of which 33 kidneys were morcellated and 23 were removed via an infra-umbilical incision. They found no significant difference in analgesic requirement or length of hospital stay. Importantly, two patients with intact removal were upstaged at final pathology, but this did not alter further management. Gettman et al.[13] also prospectively compared seven patients undergoing morcellation with five who had intact removal, and found no difference, when using analogue scales, in analgesia or time to return to normal activity. By contrast, and in a larger study, Camargo et al.[14] showed a statistically significant difference in analgesic use when comparing morcellation with intact removal through a muscle-cutting but not muscle-splitting incision. There was also a higher rate of wound complications in the intact removal group. Similarly, in a retrospective study from Washington University [15], the morcellation patients tended to have a shorter hospital stay and used less analgesics.

The third and most serious reservation about morcellation is the possibility of port-site seeding. To date, three cases related to morcellation have been reported worldwide, with two of these coming from the same institution early in their experience with the technique [16–18].

By contrast, there have been no case reports of wound seeding in the author’s experience spanning 16 years. In addition, in an international study involving 19 institutions, no cases of tumour seeding were noted in >800 reported cases [19]. Meticulous attention to placing protective drapes over the extraction port before initiating the morcellation process is recommended. Until there is an effective adjuvant therapy for patients with RCC, the administration of which is based on accurate histopathological staging, the authors see the benefits and no detriment associated with morcellation.

CLINICAL SERIES OF LN AND THEIR OUTCOMES

  1. Top of page
  2. INTRODUCTION
  3. INDICATIONS
  4. TRANSPERITONEAL LRN
  5. RETROPERITONEOSCOPIC RN
  6. HAND-ASSISTED LRN
  7. TECHNIQUE OF SPECIMEN EXTRACTION
  8. CLINICAL SERIES OF LN AND THEIR OUTCOMES
  9. COMPLICATIONS OF LRN
  10. CONCLUSIONS
  11. CONFLICT OF INTEREST
  12. REFERENCES

TRANSPERITONEAL TECHNIQUE

Since the initial description of LN many series have been published highlighting the indications and outcomes of this procedure. In the early series from Washington University Medical School, Kavoussi et al.[20] reported on the first eight patients treated using a transperitoneal technique and compared them to 58 undergoing an open nephrectomy (ON) procedure at the same institutions over the study period. All tumours treated were <6 cm. Despite this being the initial series, there was a lower major complication rate, less blood loss, shorter hospital stay and faster return to usual activity than for the ON group. Based on these outcomes, LRN/total nephrectomy was on its way to acceptance at other centres throughout the world.

The Washington University experience was updated and extended to 9 years of follow-up. Overall, between 1990 and 1999, there were 61 LRNs for suspicion of RCC. With a mean (range) follow-up of 25 (3–73) months there was an 8% recurrence rate (three patients, two with metastatic disease and one with a local recurrence in the ureteric stump). This review again showed a significantly shorter hospital stay, less blood loss, lower analgesic requirement and quicker return to normal activities than in a group of 33 patients undergoing an open RN (ORN) procedure at the same institution [15].

Ono et al.[2] presented their experience in Nagoya, Japan; between 1992 and 1997 they treated 25 patients with small RCC, 11 via a standard transperitoneal and 14 via a retroperitoneal approach. All masses were <5 cm. This group was compared to a matched group of 17 patients undergoing ORN. Again, the hospital stay, time to full convalescence and analgesic requirement were lower in the LRN group. However, the major complication rate was higher in the LRN group, as one patient undergoing a retroperitoneal procedure had a duodenal injury. With a mean follow-up of 22 months, no patient had evidence of metastases, local or port-site recurrence. This series was updated to include 60 LRNs and 40 ORNs. The 5-year disease-free survival was 95.5% for the LRN-treated patients and 97.5% in the ORN group.

The Saskatoon data provided by Barrett et al.[3] comprised 66 LRNs between 1993 and 1997, with a mean tumour size of 4.5  (1.0–9.0) cm; they found no port-site recurrences or evidence of disease progression at a mean of 21.4 months. However, as previously noted, one patient with a large sarcomatous RCC developed a port-site recurrence.

Initially viewed as the ideal for low clinical-stage tumours, many studies have supported the efficacy of LN in this regard. Saika et al.[21] reviewed 195 LRNs and 68 ORNs between 1992 and 2002. With a median follow-up of 40 (2–121) months, the disease-free survival was 91% and the patient survival was 94% in the LRN vs 87% and 94%, respectively, for the ORN group. All patients had pathological T1 disease. Makhoul et al.[22] reported a similar outcome in their series from France, citing a disease-free survival of 100% at a mean follow-up of 20 months; they used a retroperitoneal approach.

Most recently, Permpongkosol et al.[23] at Johns Hopkins provided data with 10-year projections (i.e. median follow-up of 73 months). Notably, in their study there was a trend toward improved T1 actuarial survival among the 67 LRN vs the 54 ORN patients (P = 0.07). The recurrence-free and cancer-specific survival for T1 and T2 disease, in each instance, tended to be 7–9% higher for the LRN.

As with all surgical procedures, initial difficulty in learning the method followed by achieving proficiency encourages expansion of the spectrum of disease treated. To this end, some groups have reported their series of LN for more locally advanced disease and in the face of metastatic disease as a prelude to the administration of systemic immunotherapy [24,25]. Steinberg et al.[5] used cytoreductive LRN in 65 patients with tumours of >7 cm and compared them with 39 similar patients undergoing ORN, and 166 patients with tumours of <7 cm also undergoing LRN. The larger tumours were associated with greater blood loss (100 vs 200 mL) and although this was statistically significant, probably did not result in a difference in transfusion requirements between the groups. There was less blood loss, similar complication rates and shorter operative durations in both LRN groups than in the ORN group. The shorter operation for LRN in this series clearly reflects the high volume of this centre and the advanced level of laparoscopic skills, as at most other centres, the ORN is faster. Tumours with renal vein and vena caval thrombus have also been successfully approached laparoscopically, as have tumours much larger than 16 cm (Fig. 1), but this is clearly not the standard of care in 2007, and should only be considered by the most experienced laparoscopist in highly selected cases and in specialized centres [4,26].

image

Figure 1. (A) A large 25-cm left-sided abdominal mass clearly visible on abdominal X-ray. (B) CT showing the mass to be renal in origin. This was subsequently removed by a hand-assisted approach at the University of California Irvine.

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RETROPERITONEAL TECHNIQUE

For the retroperitoneal approach, Gill et al.[27] published their experience with this technique in 47 patients undergoing 53 retroperitoneoscopic RNs at the Cleveland Clinic. The mean tumour size was 4.6  (2–12) cm, with a mean procedure time of 2.9 (1.2–4.5) h and blood loss of 128 mL. Almost 70% of the patients were discharged from the hospital within 23 h. After this, a prospective randomized trial of transperitoneal vs retroperitoneal LRN was initiated at the same institution [28], with 50 patients undergoing the former and 52 having the latter approach. Notably, with the retroperitoneal approach there was a faster time to control the renal vasculature and shorter total operative duration. However, blood loss, complication rate, hospital stay and analgesic requirement were similar in both groups. All cases had intact specimen extraction.

Another prospective randomized trial comparing the two techniques was published in 2004, by Nambirajan et al.[29]. They compared 20 patients having a transperitoneal with another 20 having a retroperitoneal LRN. They found no significant difference in hospital stay, analgesic requirement, blood loss or operative duration. The time to first oral intake was, counter-intuitively, longer in the retroperitoneal group. They also noted that the difficulty scores were higher for both the surgeon and the assistant in the retroperitoneal approach, although this was not statistically significant. This group, understandably, prefers the transperitoneal approach for larger (clinical stage T2) tumours.

Cicco et al.[30] reported on 50 consecutive patients who had a retroperitoneal approach to their LRN. The operative duration was 139 (60–330) min and the estimated blood loss was 149 (0–1500) mL. Three conversions occurred in this series. However, the mean hospital stay was somewhat long, at 6 days. At the time, this group recommended that the retroperitoneal approach be limited to small tumours (<5 cm).

HAND-ASSISTED TECHNIQUE

Considering hand-assisted LRN, this approach is widely used in many centres worldwide. Initially considered not only as a safety step for the surgeon in the progression towards proficiency for the pure laparoscopic procedure, but also as a technique to expedite renal extirpation and intact specimen removal, this approach remains a first-line option for many skilled and experienced urologists.

Nakada et al.[31] introduced the Pneumo-Sleeve for use during hand-assisted LN; before this, Tsachada et al.[32] reported manual assistance during LN to facilitate dissection, and since the former report, many new hand-assist devices have been introduced for this application. Wolf et al.[33] subsequently compared the hand-assisted approach to standard laparoscopy (for benign nephrectomy, RN and nephroureterectomy) and found significantly lower procedure times and fewer complications in favour of hand-assistance. They later reviewed standard and hand-assisted LRN in 16 and 22 patients, respectively. Notably, there was no difference in the complication rate, hospital cost or stay, return to activity or overall pain score, but there was a trend to more pain and wound-related complications in the hand-assisted group.

Nakada et al[34]. compared the hand-assisted LRN approach with ORN in 18 patients in each arm. Although this was a retrospective review, the mean hospital stay, time to return to normal activity and time to return to work were all significantly less for the hand-assisted LRN patients.

In a retrospective review by Patel and Leveillee [35] the outcomes for T1 vs T2 RCC treated by hand-assisted LRN were compared. Of 60 patients, 50 were classified as T1 and 10 were T2, with a mean tumour size of 4.68 cm and 9.22 cm, respectively. There was no difference in the operative duration. Interestingly there was less blood loss in the T2 group. With a follow-up of 15.5 and 9.5 months, respectively, there were no recurrences. On a similar theme, Harano et al.[36] performed 96 consecutive hand-assisted LRNs of which 93 were completed in this manner. There were three conversions, two due to haemorrhage and one due to the intraoperative discovery of renal vein thrombus. With a mean follow-up of 25 months the cancer-specific survival was 100%. The 4-year disease-free survival was 88% and this compared favourably with 78 patients treated by an ORN at the same centre.

Comparing the approaches to LRN just described, Nadler et al[37] prospectively randomized patients to one of the three techniques. To this end, 33 patients with a renal mass of <7 cm were enrolled in the study; 11 had each procedure. Key findings were a significantly faster operation for the hand-assisted LRN, although there was a higher frequency of hernias. The blood loss was similar in all approaches. Incision size, duration of hospital stay and time to normal daily activity was less for the transperitoneal group. There was also a trend toward less narcotic use in this group. The specimen was morcellated in the transperitoneal group, vs intact removal through the hand-port for the hand-assisted cases, and intact removal through an incision in the flank connecting two ports for the retroperitoneal group. This might have accounted for the increased pain noted in the retroperitoneal group, as their extraction incision was in the flank.

COMPLICATIONS OF LRN

  1. Top of page
  2. INTRODUCTION
  3. INDICATIONS
  4. TRANSPERITONEAL LRN
  5. RETROPERITONEOSCOPIC RN
  6. HAND-ASSISTED LRN
  7. TECHNIQUE OF SPECIMEN EXTRACTION
  8. CLINICAL SERIES OF LN AND THEIR OUTCOMES
  9. COMPLICATIONS OF LRN
  10. CONCLUSIONS
  11. CONFLICT OF INTEREST
  12. REFERENCES

Complications after LRN are undoubtedly related to the surgeon’s experience. These occurrences span many organ systems and familiarity with their clinical presentation is of prime importance for the laparoscopic surgeon, as a delayed or missed diagnosis can have devastating and even fatal consequences. Although laparoscopy is minimally invasive, its complexity is not minimal.

Complications can occur at any point during the laparoscopic procedure. Although not specifically related to urological laparoscopy, the Swiss Association for Laparoscopic and Thoracoscopic Surgery analysed data on 14 243 patients undergoing laparoscopic surgery, for trocar or Veress needle injuries [38]; they found a 0.18% incidence. Small bowel injuries were the most common organ injuries, followed by large bowel and liver. Vascular injuries were minor (greater omental or mesenteric vessels) except for one right iliac artery injury. Injuries occurred more often with midline trocar or needle insertion. After this report, Thomas et al.[39] analysed their experience with the optical access trocar (Visiport, United States Surgical) as the first port placed in 1283 patients, 14.3% of whom had a LRN. Access was gained in the upper quadrants in >90% of cases. There was a 0.31% incidence of complications, including two epigastric vessel injuries, one bowel injury and one mesenteric vascular injury.

Bishoff et al.[40], in a landmark article, characterized the presentation of laparoscopic bowel injury, i.e. abrasion or perforation. They noted that abrasions occurred in 0.6% and perforations in 0.2% of cases. Perforations have an atypical presentation, characterized by severe single-trocar-site pain, abdominal distension, diarrhoea and, paradoxically, leucopenia, albeit with a left shift. These signs can be followed by sepsis within 96 h after surgery. Of note the usual peritoneal symptoms and signs of diffuse abdominal pain, nausea and vomiting, ileus and associated fever >38 °C were uncommon clinical findings. The lone patient with an abrasion that was thought to be insignificant and not repaired presented 2 weeks later with an abscess and an enterocutaneous fistula. At present, the accepted and recommended approach to intraoperative recognition of a bowel injury is suture repair in a two-layer standard fashion.

The other organ at risk, particularly during left LRN, is the pancreas. Varkarakis et al.[41] reported a 2.1% incidence of pancreatic injuries in their series, which included 95 left LRNs. Notably, larger lesions and difficult dissection due to the treated pathology are associated with a higher chance of injury. Of these two patients, one was observed and the second was treated conservatively with a nasogastric tube and somatostation. The hospital stay for these patients was 4 and 6 days, respectively. The operating urologist must therefore pay particular attention to the location of the pancreas at all times; the importance of complete mobilization of the spleen and descending colon cannot be overemphasised, allowing both to fall medially and thereby carry the tail of the pancreas away from the field of dissection around the adrenal gland and upper pole of the kidney (Fig. 2).

image

Figure 2. CT showing the intimate relationship of the upper pole of the left kidney, the left adrenal gland, the pancreas and the spleen.

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More recently, Pareek et al.[42] reported a meta-analysis of published studies on the complications of laparoscopic renal surgery. For transperitoneal LRN there was a major complication rate of 10.7% and a minor complication rate of 3.3%. Hand-assisted LRN incurred a 9.3% (major) and 3.4% (minor) complication rate, while retroperitoneal LRN had an 11.3% (major) and 0.5% (minor) morbidity. Apart from a higher wound complication rate with the hand-assisted approach, the incidence of major complications appears to be equivalent (≈ 10%) for each technique.

Another serious concern is the potential for port-site recurrence. Chen et al.[43] reported a case of hand-port-site recurrence after retrieval of a 10-cm tumour through an 8-cm hand-port incision. This specimen was not placed in an entrapment sac and although it appeared completely intact, the likelihood of this occurrence might have been lessened (although not avoided) by placing it within a sac. Dhobada et al.[44] also reported port-site recurrences under three incisions, despite the use of a specimen-entrapment bag with no morcellation or documented leakage from the bag. As cited previously, in separate reports, Barrett and Fentie [16], followed by Castilho et al.[17,18], also reported on port-site metastases in patients with T3 and T1 disease, respectively. Ascites was present at the time of the procedure in the second report and, as noted in gynaecology reports, might have been a risk factor for seeding associated with ascites in general. Iwamura et al.[45] reported another case of port-site seeding in a haemodialysis patient, in whom the specimen was removed intact through a posterior skin incision without the use of an entrapment sac. However, as mentioned previously, in a multi-institutional analysis of >2000 patients, of whom 826 had morcellation, there were no port-site recurrences [19]. A summary of the various published reports of LRN is shown in Table 1.

Table 1.  A summary of clinical series of transperitoneal, retroperitoneal and hand-assisted LRN
RefNo. of patientsMean (range) tumour size, cmOperative duration, minEBL, mLMeanRecurrence rate, %Complication rate, %
analgesic need, mg morphinehospital stay, daysTRA, weeksfollow-up, months
  1. NR, not reported; NA, not addressed; Tr, transfusion; TRA, time to resuming normal activity; EBL, estimated blood loss.

Transperitoneal
[3] 664.5 (1.0–9.0)175Two TrNR 4.4NR21.4 5Minor 6.9
[15] 615.333017228 3.4 3.625 8Major 3.3; minor 34.4
[46] 675.1 (1–13)256289NR 3.8NR35.6 3Overall 15
[47]1033.1 (1.1–4.8)282254NRNR2329 (median) 3.9Major 10.7; minor 1.9
[23] 675.1 cmNANANANANA73 6NA
Retroperitoneal
[27] 474.6 (2.0–12.0)17412831 1.6 413 4.2Major 4; minor 17
[30] 503.86 (2.0–9.0)139149NR 6.0 24.76 2.0Overall 8
[21]1953.7276248NRNR2240 5.6Major 10
[22] 39<5134133NR 5.5NR12.4 0Major 2.5; minor 2.5
Hand-assisted
[31] 184.5 (2–11)220.5170.836.9 (32.4 i.v.;  4.5 oral) 3.926.812.2 0Major 5.5; minor 11
[35] 606.95187.5147.5NR 2.8NR12.5 0Major 6.5; minor 4.3
[36] 964.3246251NR 11.4NR2512Major 2.1; minor 8.3

CONCLUSIONS

  1. Top of page
  2. INTRODUCTION
  3. INDICATIONS
  4. TRANSPERITONEAL LRN
  5. RETROPERITONEOSCOPIC RN
  6. HAND-ASSISTED LRN
  7. TECHNIQUE OF SPECIMEN EXTRACTION
  8. CLINICAL SERIES OF LN AND THEIR OUTCOMES
  9. COMPLICATIONS OF LRN
  10. CONCLUSIONS
  11. CONFLICT OF INTEREST
  12. REFERENCES

LRN has been shown to have equivalent oncological outcomes to standard ORN. This comes with lower postoperative morbidity and improved cosmesis. At present there is no strong evidence to support one of the three techniques over the others; as such, surgeon experience and judgement with the selected approach should form the basis for making the choice.

CONFLICT OF INTEREST

  1. Top of page
  2. INTRODUCTION
  3. INDICATIONS
  4. TRANSPERITONEAL LRN
  5. RETROPERITONEOSCOPIC RN
  6. HAND-ASSISTED LRN
  7. TECHNIQUE OF SPECIMEN EXTRACTION
  8. CLINICAL SERIES OF LN AND THEIR OUTCOMES
  9. COMPLICATIONS OF LRN
  10. CONCLUSIONS
  11. CONFLICT OF INTEREST
  12. REFERENCES

Dr. Clayman is a paid consultant to Karl Storz Inc., Cook Urological, and Endocare Inc. He receives research support and royalties from Cook Urological and Boston Scientific Inc. In addition, he receives research support from Omeros and Endocare. He receives royalties from Greenwald Inc. and Orthopedic Systems Inc.

REFERENCES

  1. Top of page
  2. INTRODUCTION
  3. INDICATIONS
  4. TRANSPERITONEAL LRN
  5. RETROPERITONEOSCOPIC RN
  6. HAND-ASSISTED LRN
  7. TECHNIQUE OF SPECIMEN EXTRACTION
  8. CLINICAL SERIES OF LN AND THEIR OUTCOMES
  9. COMPLICATIONS OF LRN
  10. CONCLUSIONS
  11. CONFLICT OF INTEREST
  12. REFERENCES