Ralph V. Clayman

Laparoscopic Nephrectomy: Initial Case Report

A tumor-bearing right kidney was completely excised from an 85-year-old woman using a laparoscopic approach. A newly devised method for intra-abdominal organ entrapment and a recently developed laparoscopic tissue morcellator made it possible to deliver the 190 gm. kidney through an 11 mm. incision.

LAPAROSCOPIC VERSUS OPEN RADICAL NEPHRECTOMY: A 9-YEAR EXPERIENCE

PURPOSE The laparoscopic approach for renal cell carcinoma is slowly evolving. We report our experience with laparoscopic radical nephrectomy and compare it to a contemporary cohort of patients with renal cell carcinoma who underwent open radical nephrectomy. MATERIALS AND METHODS From 1990 to 1999, 32 males and 28 females underwent 61 laparoscopic radical nephrectomies for suspicious renal cell carcinoma. Clinical data from a computerized database were reviewed and compared to a contemporary group of 33 patients who underwent open radical nephrectomy for renal cell carcinoma. RESULTS Patients in the laparoscopic radical nephrectomy group had significantly reduced, estimated blood loss (172 versus 451 ml., p <0.001), hospital stay (3.4 versus 5.2 days, p <0.001), pain medication requirement (28.0 versus 78.3 mg., p <0.001) and quicker return to normal activity than patients in the open radical nephrectomy group (3.6 versus 8.1 weeks, p <0.001). The majority of laparoscopic specimens (65%) were morcellated. Operating time and cost were higher in the laparoscopic than the open nephrectomy group. Average followup was 25 months (range 3 to 73) for the laparoscopic and 27.5 months (range 7 to 90) for the open group. Renal cell carcinoma in 3 patients (8%) recurred in the laparoscopic group versus renal cell carcinoma in 3 (9%) in the open group. When stratified patients with tumors larger than 4 to 10 cm. experienced similar benefits and results as patients with tumors less than or equal to 4 cm. To date there have been no instances of trocar or intraperitoneal seeding in the laparoscopic radical nephrectomy group. CONCLUSIONS Laparoscopic radical nephrectomy, although technically demanding, is a viable alternative for managing localized renal tumors up to 10 cm. It affords patients with renal tumors an improved postoperative course with less pain and a quicker recovery while providing similar efficacy at 2-year followup for patients with T1 and T2 tumors.

Complications of laparoscopic nephrectomy in 185 patients : a multi-institutional review

PURPOSE We document the incidence of complications associated with laparoscopic nephrectomy in a multi-institutional study. MATERIALS AND METHODS The study included the initial 185 patients undergoing laparoscopic nephrectomy at 5 centers in the United States between June 1990 and July 1993. RESULTS A total of 30 patients (16%) had 34 complications. There was no mortality. Access-related complications included 2 cases of hernia formation at the trocar site, 1 abdominal wall hematoma and 1 trocar injury to a hydronephrotic kidney. Intraoperative complications included 5 cases of vascular injury, 1 splenic laceration and 1 pneumothorax. Postoperative complications involved the gastrointestinal tract in 6 cases, cardiovascular system in 6, genitourinary tract in 4, respiratory system in 4 and musculoskeletal system in 2. Miscellaneous complications occurred in 3 patients. Open surgical intervention was required electively in 8 patients and on an emergency basis in 2. The incidence of complications decreased with experience: 71% occurred during the initial 20 cases at each institution. CONCLUSIONS In our early experience the complication rate for laparoscopic nephrectomy was 12% in patients with benign renal disease and 34% in those with renal cancer. Based on this collective experience, recommendations for prevention, recognition and treatment of complications are made.

Laparoscopic nephroureterectomy for upper tract transitional cell cancer: the Washington University experience.

PURPOSE The recognized form of therapy for patients with ureteral or renal pelvis transitional cell carcinoma is total nephroureterectomy with excision of the ipsilateral periureteral cuff of bladder mucosa. We report our experience with 10 patients who underwent laparoscopic nephroureterectomy for upper tract transitional cell carcinoma through July 1994 and compare them to a contemporary group of patients undergoing open nephroureterectomy for the same disease. MATERIALS AND METHODS A total of 10 patients undergoing laparoscopic nephroureterectomy for upper tract transitional cell carcinoma was evaluated with respect to operative time, surgical specimen weight, pathological stage, postoperative analgesia requirement, interval to resume normal oral intake, postoperative recovery and results of postoperative surveillance. Of the patients 8 who underwent open surgical nephroureterectomy during a contemporary period for the same diagnosis were evaluated for the same parameters and compared to the laparoscopic group. RESULTS Laparoscopic nephroureterectomy averaged twice as long as open nephroureterectomy. However, the laparoscopic patients resumed oral intake sooner, required less postoperative analgesia and had a shorter hospital stay compared to the open surgical group. The laparoscopic nephroureterectomy patients returned to normal activities within less than half the time (2.8 versus 6 weeks) and completely recovered 5 times more rapidly (6 weeks versus 7.4 months). CONCLUSIONS Laparoscopic nephroureterectomy is a feasible treatment option for patients with upper tract transitional cell carcinoma. However, 2 major drawbacks to the approach persist, that is the lengthy operative time and the need for significant laparoscopic experience on the part of the surgeon.

LONG-TERM FOLLOWUP AFTER LAPAROSCOPIC RADICAL NEPHRECTOMY

PURPOSE Laparoscopic radical nephrectomy has been shown to be less morbid than traditional open radical nephrectomy. The long-term oncological effectiveness of laparoscopic radical nephrectomy remains to be established. MATERIALS AND METHODS At 3 centers patients undergoing laparoscopic radical nephrectomy before November 1, 1996 with pathologically confirmed renal cell carcinoma were identified. A representative group of patients undergoing open radical nephrectomy for clinical T1, T2 lesions was also identified. Staging, operative details and postoperative course were reviewed. Followup consisted of review of clinical, laboratory and radiological records. Kaplan-Meier analysis was performed. RESULTS The study included 64 patients treated with laparoscopic and 69 treated with open radical nephrectomy with respective average ages of 60.6 and 61.3 years at surgery. On preoperative imaging open lesions were larger (6.2 cm., range 2.5 to 15) than laparoscopic radical nephrectomy lesions (4.3 cm., range 2 to 10, p <0.001). Pathology reports revealed no difference in specimen weight (425 and 495 gm., p = 0.146) or average Fuhrman grade (1.88 and 1.78, p = 0.476) between laparoscopic and open radical nephrectomy, respectively. Median followup was 54 months (range 0 to 94) for laparoscopic and 69 months (range 8 to 114) for open radical nephrectomy. Kaplan-Meier analysis with log rank comparison revealed 5-year recurrence-free survival of 92% and 91% for laparoscopic and open radical nephrectomy, respectively (p = 0.583). At 5 years cancer specific survival was 98% and 92% (p = 0.124), and nonspecific survival was 81% and 89% (p = 0.260) for laparoscopic and open radical nephrectomy, respectively. CONCLUSIONS Laparoscopic radical nephrectomy confers long-term oncological effectiveness equivalent to traditional open radical nephrectomy.

Laparoscopic nephrectomy for renal cell cancer: evaluation of efficacy and safety: a multicenter experience

OBJECTIVES Although laparoscopic radical nephrectomy is a safe and minimally invasive alternative to open surgery, the long-term disease-free outcome of this procedure has not been reported. We evaluated our experience with the laparoscopic management of renal cell carcinoma to assess the clinical efficacy of this surgical modality. METHODS Between February 1991 and June 1997, 157 patients at five institutions were retrospectively identified who had clinically localized, pathologically confirmed, renal cell carcinoma and had undergone laparoscopic radical nephrectomy. Operative and clinical records were reviewed to determine morbidity, disease-free status, and cancer-specific survival. Of the patients followed up for at least 12 months (n = 101), 75% had an abdominal computed tomography scan at their last visit. RESULTS The mean age at surgery was 61 years (range 27 to 92) and all patients were clinical Stage T1-2,NO,MO. Fifteen patients (9.6%) had perioperative complications. During a mean follow-up of 19.2 months (range 1 to 72; 51 patients with 2 years or more of follow-up), no patient developed a laparoscopic port site or renal fossa tumor recurrence. Four patients developed metastatic disease, and 1 patient developed a local recurrence. The 5-year actuarial disease-free rate was 91%+/-4.8 (SE). At last follow-up, there were no cancer-specific mortalities. CONCLUSIONS The laparoscopic surgical management of localized renal cell carcinoma is feasible. Short-term results indicate that laparoscopic radical nephrectomy is not associated with an increased risk of port site or retroperitoneal recurrence. Longer follow-up is necessary to compare long-term survival and disease-free rates with those of open surgery.

Laparoscopic radical nephrectomy for renal tumor: the Washington University experience.

PURPOSE We report our experience with laparoscopic radical nephrectomy in 17 consecutive patients with renal tumors. MATERIALS AND METHODS The clinical data on 17 consecutive patients undergoing laparoscopic radical nephrectomy were reviewed. Of the patients 12 with stage pT1 or pT2 renal cell carcinoma 7 cm. in diameter or smaller undergoing laparoscopic radical nephrectomy were compared to 12 undergoing open radical nephrectomy for stage pT1 or pT2 renal cell carcinoma 6 cm. in diameter or smaller. RESULTS Among the 17 patients undergoing laparoscopic radical nephrectomy average operative time was 6.9 hours (range 4.5 to 9) and average estimated blood loss was 105 cc (range 50 to 600). Average weight of the surgical specimen was 402 gm. (range 190 to 1,100). In 12 of 16 patients in whom laparoscopic radical nephrectomy was completed the specimen was removed intact. The patients required an average of 24 mg. morphine sulfate equivalent (range 2 to 220) for postoperative pain. Average hospital stay was 4.5 days (range 3 to 11) and average interval to resume normal activities was 3.5 weeks (range 2 to 4). The 12 patients in the open and laparoscopic radical nephrectomy groups were similar with respect to age, American Society of Anesthesiologists score and interval surgery. Laparoscopic radical nephrectomy required significantly more operative time than open radical nephrectomy (6.9 versus 2.2 hours, respectively). However, the laparoscopic radical nephrectomy group compared to the open radical nephrectomy group had significantly less postoperative pain (24 versus 40 mg. morphine sulfate equivalent required for postoperative analgesia), shorter interval to resuming oral intake (1 versus 3 days), more rapid discharge from the hospital (4.5 versus 8.4 days) and more rapid return to normal activities (3.5 versus 5.1 weeks). The laparoscopic nephrectomy group also fully recovered more rapidly than the open surgical group (5.8 versus 39 weeks). To date, during a 4-year period there was no retroperitoneal recurrence or seeding of port site. CONCLUSIONS Laparoscopic radical nephrectomy is a lengthy and demanding procedure. However, it affords patients with renal cell carcinoma a markedly improved postoperative course while accomplishing the necessary surgical goals.

Evaluation of a Vessel Sealing System, Bipolar Electrosurgery, Harmonic Scalpel, Titanium Clips, Endoscopic Gastrointestinal Anastomosis Vascular Staples and Sutures for Arterial and Venous Ligation in a Porcine Model

PURPOSE We assessed the usefulness of the LigaSure (Valleylab, Boulder, Colorado) vessel sealing system for vascular control during laparoscopic surgery and compared it with other available hemostatic modalities. MATERIALS AND METHODS A total of 31 domestic pigs were divided into 5 groups. In groups 1 and 2 the vessel sealing system was compared with titanium clips and Endo-GIA (United States Surgical, Stamford, Connecticut) staples. In group 3 the vessel sealing system was compared with standard Klepinger (Karl Storz, Culver City, California) bipolar forceps. In group 4 the harmonic scalpel and Trimax (United States Surgical) bipolar forceps were compared. In group 5 in vivo laparoscopic application of the vessel sealing system was evaluated. RESULTS The 5 mm. laparoscopic vessel sealing system sealed arteries up to 6 mm. and veins up to 12 mm. in diameter at supraphysiological bursting pressure. We evaluated 13 arteries with a diameter of 6 mm. or less at a mean bursting pressure of 662 mm. Hg (range 363 to 1,985) and 11 veins with a diameter of 12 mm. or less with a mean bursting pressure of 233 mm. Hg (range 63 to 440). Collateral tissue damage extended 1 to 3 mm. from the application site. Standard bipolar energy with Klepinger and Trimax forceps was less reliable and in some cases vessel sealing could not be accurately assessed before vessel division. Collateral tissue injury was 1 to 6 mm. The harmonic scalpel did not reliably seal vessels larger than 3 mm. but resulted in the least acute collateral tissue injury of 0 to 1 mm. CONCLUSIONS In the porcine model the LigaSure system is a viable option for laparoscopic management of arteries up to 6 mm. and veins up to 12 mm. in diameter.

LOWER CALICEAL STONE CLEARANCE AFTER SHOCK WAVE LITHOTRIPSY OR URETEROSCOPY: THE IMPACT OF LOWER POLE RADIOGRAPHIC ANATOMY

PURPOSE We determine whether there is a significant relationship between the spatial anatomy of the lower pole, as seen on preoperative excretory urography (IVP), and the outcome after shock wave lithotripsy or ureteroscopy for a solitary lower pole caliceal stone 15 mm. or less. MATERIALS AND METHODS Between January 1992 and June 1996, 34 patients with 15 mm. or less solitary lower pole stone underwent ureteroscopy with intracorporeal lithotripsy (13) or extracorporeal shock wave lithotripsy (ESWL) with a Dornier HM3 lithotriptor (21). On pretreatment IVP lower pole infundibular length and width, infundibulopelvic angle of the stone bearing calix were measured. Stone size and area were determined from an abdominal plain x-ray. A plain x-ray of the kidneys, ureters and bladder was obtained in all patients at a median followup of 12.3 and 8 months in the ureteroscopy and ESWL groups, respectively. RESULTS After initial therapy the overall stone-free rate was 62 and 52% in the ureteroscopy and ESWL groups, respectively. Stone-free status after ESWL was significantly related to each anatomical measurement. Infundibulopelvic angle 90 degrees or greater, and infundibular length less than 3 cm. and width greater than 5 mm. were each noted to correlate with an improved stone-free rate after ESWL. In contrast, the stone-free rate after ureteroscopy was not statistically significantly impacted by these anatomical features, although a clinical stone-free trend was identified relating to a favorable infundibular length and infundibulopelvic angle. The infundibulopelvic angle was 90 degrees or greater in 4 stone-free patients (12% overall), including 2 who underwent ureteroscopy and 2 who underwent ESWL. On the other hand, in 2 and 4 stone-free patients (18% overall) who underwent ureteroscopy and ESWL, respectively, favorable radiographic features consisted of a short, wide but acutely angulated infundibulum with the infundibulopelvic angle less than 90 degrees, and infundibular length less than 3 cm. and width 5 mm. or greater. In contrast, in 4 and 6 patients (29% overall) who underwent ureteroscopy and ESWL, respectively, all 3 radiographic features were unfavorable with the infundibulopelvic angle less than 90 degrees, and infundibular length greater than 3 cm. and width less than 5 mm. In these cases the stone-free rate was 50 and 17% after ureteroscopy and ESWL, respectively. CONCLUSIONS The 3 major radiographic features of the lower pole calix (infundibulopelvic angle, and infundibular length and width) can be easily measured on standard IVP using a ruler and protractor. Each factor individually has a statistically significant influence on stone clearance after ESWL. A wide infundibulopelvic angle or short infundibular length and broad infundibular width regardless of infundibulopelvic angle are significant favorable factors for stone clearance following ESWL. Conversely, these factors have a cumulatively negative effect on the stone clearance rate after ESWL when they are all unfavorable. In ureteroscopy spatial anatomy has less of a role in regard to stone clearance but it may have a negative impact when there is uniformly unfavorable anatomy.

Complications of Laparoscopic Pelvic Lymph Node Dissection

Intraoperative and postoperative complications were assessed in the first 372 patients undergoing laparoscopic pelvic lymph node dissection at 8 medical centers. In 16 patients laparoscopic node dissection could not be completed due to patient body habitus or technical difficulties. Of these aborted procedures 14 occurred during the initial 8 dissections at each institution. A total of 55 complications (15%) occurred: 14 were noted in the intraoperative and 41 in the postoperative period. Of these patients 13 required open surgical intervention for the treatment of a complication. Complications included vascular injury (11 patients), viscus injury (8), genitourinary problems (10), functional/mechanical bowel obstruction (7), lower extremity deep venous thrombosis (5), infection/wound problem (5), lymphedema (5), anesthetic complications (2) and obturator nerve palsy (2). Based on our experience, there is a significant learning curve associated with performing laparoscopic pelvic node dissection. However, with experience and adherence to laparoscopic surgical principles, the risk of complications may be minimized.