Renal cell carcinoma is the most common malignancy involving the kidney and its incidence is increasing. Because these tumors are both radioresistant and chemoresistant surgery is the mainstay of therapy. As in other disciplines, advances in less invasive surgical techniques in urology are speeding patient recovery while maintaining good surgical oncological outcomes. For renal cell carcinoma, laparoscopic nephrectomy has supplanted open nephrectomy as the standard of care in as well as for benign diseases of the kidney where nephrectomy is indicated.
Renal cell carcinoma is the most common renal tumor accounting for 30,000 new cases per year and 12,000 deaths per year in the US. Owing in part to environmental factors and part to increased us of abdominal imaging the incidence of this cancer is increasing. Due to the increased us of ultrasound and CT scan the most common presentation today is as an incidental finding. Tumors discovered incidentally tend to be smaller and more likely confined to the kidney leading to a better prognosis, The classic triad of flank pain, flank mass and hematuria is rarely encountered. As a result of increased incidental finding there is a coincidental increase in nephron sparing surgery or partial nephrectomy. What has not changed, however, is the lack of sensitivity of these cancers to either chemotherapy or radiotherapy, making surgery the mainstay of treatment.
In urology, as in other surgical disciplines, there is an increased interest in less invasive techniques such as laparoscopic surgery which is most applicable to renal surgery. Two techniques are currently in use: hand assisted laparoscopy, which allows retrieval of the intact kidney, and standard laparoscopy, which necessitates morcellation of the kidney for removal. Both techniques offer the advantage of shorter hospital stay, lower narcotic requirement and shorter recovery time without sacrificing oncologic principles or results.
The surgical technique is similar whether the procedure is done with hand assist, or by the standard technique once the hand assist port is placed. For right-side procedures the hand port is placed in the right-lower quadrant to the level of the umbilicus. For left side procedure the port is placed in the midline in a periumbilical position. For the standard procedure laparoscopic ports are placed in these positions. Remaining working ports and camera ports are then placed as per Figures 1 & 2. Dissection begins by mobilizing the colon off the kidney (and duodenum on the right side) followed by mobilization of the liver or spleen out of the operative field. After dividing the ureter, the hilum is then exposed anteriorly and then inferiorly and posteriorly. The renal artery and vein are then stapled using an endoscopic vascular stapler. Mobilization of the kidney (and adrenal if necessary) is completed superiorly in a medial to lateral fashion. Lateral and posterior attachments are then divided and the kidney is placed in a bag and either delivered whole or morcellated and removed.
In a recent review, major complications consisting of cardiopulmonary complications, bleeding, bowel injury were 9% which compares favorably with open surgery in a historical series. (Landman, J., Lee, D. Clayman, R. AUA Update Series 2002; XXI: 194) Individual series have not demonstrated an increase in positive surgical margins, tumor spillage or recurrence rates with follow up at 3 years. Contemporary series however, have demonstrated a significant difference in narcotic use, hospital stay and return to work. Comparing laparoscopic surgery to open surgery, hospital stay averaged 2.5 days versus 4 days and return to work averaged 30 versus 50 days. When comparing standard laparoscopy versus hand assisted laparoscopy there is no significant difference in these parameters
The first laparoscopic nephrectomy was performed at Wausau Hospital in February of 2003 by Dr Babiarz. Subsequently, a total of 22 such nephrectomies, including two standard laparoscopic procedures, have been completed by our group. Results compare favorably to contemporary series with mean length of stay of 2.3 days and return to work averaging 28 days. One patient was converted to open when a pancreatic mass was discovered incidentally. One patient required a blood transfusion but there have been no other major complications.
Laparoscopic nephrectomy is indicated for any benign disease of the kidney where standard open nephrectomy would be considered including page kidney or nonfunctioning kidney as well as for most cases of malignant disease including both renal cell carcinoma and transitional cell carcinoma. Contraindications include inferior vena caval involvement, direct extension of the tumor into adjacent viscera and excessive size.
Laparoscopic nephrectomy offers the advantage of decreased post-operative pain, shorter hospital stay and faster recovery without sacrificing oncologic principles or results and without increasing the risk of complications. As such it has become the standard of care for most benign and malignant lesions of the kidney requiring nephrectomy. This technique is now available at Urology Specialist of Wisconsin where favorable outcomes have been achieved. Currently, techniques to allow laparoscopic partial nephrectomy are being perfected and will likely be available in the near future. Laparoscopic cryo-ablation is also now available for select individuals who are not candidates for nephrectomy or partial nephrectomy.