Japanese Journal of Clinical Oncology 32:417-421 (2002)
© 2002 Foundation for Promotion of Cancer Research
Endoscopic Minilaparotomy Partial Nephrectomy for Solitary Renal Cell Carcinoma Smaller than 4 cm
Department of Urology and Reproductive Medicine, Graduate School Tokyo Medical and Dental University, Tokyo, Japan
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ABSTRACT |
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Background: For small, incidentally discovered renal cell carcinoma, partial nephrectomy is becoming more widely accepted as an alternative to radical nephrectomy and the need for minimally invasive approach is increasing.
Methods: We carried out endoscopic minilaparotomy partial nephrectomy in seven cases of solitary renal cell carcinoma smaller than 4 cm. Five of them were without renal pedicle clamping. All procedures were done through single skin incision (5–8 cm) using a 30° telescope. Hemostasis was achieved with a harmonic scalpel, a microwave tissue coagulator, an argon beam coagulator and autologous fibrin glue.
Results: There were no perioperative complications. All patients had negative surgical margins. The operating time was 157–275 min (average 209 min). The blood loss was 20–1200 ml (average 525 ml). Postoperatively, renal function as assessed by serum creatinine was within normal limits. Neither local recurrences nor metastases were observed during a follow-up of 6–15 months. The postoperative course was markedly improved over that expected from standard open surgery.
Conclusions: With minimal morbidity and complications, endoscopic minilaparotomy partial nephrectomy is feasible for small renal cell carcinoma.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Recently, the detection rate for small renal tumors has increased owing to the widespread use of ultrasound imaging techniques, which in turn has increased the need for nephron-sparing surgery. Although radical nephrectomy is the standard treatment for localized unilateral renal cell carcinoma with a normally functioning contralateral kidney, recent data suggest that partial nephrectomy provides effective and equivalent oncological treatment for renal cell carcinomas 4 cm or smaller (1,2).
With decreased morbidity, improved cosmesis and faster recovery, the laparoscopic approach has been evolving in urological surgery and has even been applied to partial nephrectomy for small renal cell carcinoma. Laparoscopic partial nephrectomy, however, has been hampered by difficulty in vascular control. On the other hand, minilaparotomy through a limited incision is a modification of the standard operation and matches laparoscopic surgery without impairing safety of surgery. We introduced improved visibility afforded by a laparoscope into minilaparotomy (endoscopic minilaparotomy) and have been applying this technique to retroperitoneal operations with favorable outcomes (3,4). We report our experience with endoscopic minilaparotomy partial nephrectomy in seven cases of renal cell carcinoma smaller than 4 cm.
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PATIENTS AND METHODS |
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TOPABSTRACTINTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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From June 2000 to January 2001, partial nephrectomy using the endoscopic minilaparotomy technique was performed in seven patients with solitary small renal cell carcinoma. All tumors were incidentally detected, unilateral and smaller than 4 cm. Patients’ ages ranged from 58 to 77 years (average 65 years). Six patients were men and the other was a woman. Distribution of laterality was right side in four and left side in three. Maximum diameter of the tumor was 1.9–3.5 cm. All tumors were located peripherally, protruded from the renal capsule and were well demarcated on computerized tomography (T1N0M0). Patients and families were informed of the potential risk of local recurrence.
The patient was placed in the flank position over the break in the table. A skin incision (5–8 cm) running obliquely forward following the line of the 12th rib was made. The distal end of the 12th rib was removed if necessary. The external oblique and internal oblique muscles were split to the anterior end of the wound. Then the transversalis fascia was digitally split. The branches of the 12th intercostal neurovascular bundle were spared by letting them move caudally. Gerota’s fascia covering the tumor was exposed. At this time, a 30° telescope was inserted through the incision and a video monitor was attached so that the field could be viewed both through the incision and on the screen. The ureter was identified on the peritoneal side of the wound. In cases 6 and 7, Gerota’s fascia was bluntly pushed medially off the psoas muscle and the renal pedicle was exposed for clamping. We used long instruments and a knot-maker for laparoscopic surgery modified by ourselves, which facilitated procedures deep in the wound. Microwave tissue coagulation was performed with a Microtaze OT-110 M microwave generator and needle-type monopolar applicator (Fig. 1A–C). The electrode was 1.0 cm long and 0.6 mm in diameter. The insertion line of the microwave electrode was 1 cm distant from the margin of the tumor. Along this line the renal parenchyma was punctured with the electrode (Fig. 1B). The puncture sites were 5 mm apart from each other and the number of punctures was 15–20. The coagulations were performed at 65 W for 50 s per session, followed by 10 s of dissociation. In case E2, the tumor of which was located uppermost of the right kidney, coagulation of the parenchyma was partially performed because of the difficulty in insertion of the needle electrode. The tumor was then excised with scissors or a harmonic scalpel (blunt blade at power level 3) by cutting the mid-portion of the coagulated zone without renal pedicle clumping (Fig. 1D), except for cases E6 and E7.
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After transected vessels had been ligated and lacerated collecting systems sutured, indigocarmin was injected intravenously to confirm no significant urine leakage. An argon beam coagulator was applied to achieve complete hemostasis on the cut surface (Fig. 1E and F). All renal defects were filled with autologous fibrin glue. The specimen was retrieved thorough the incision. After placing a drainage tube, the cut periosteum was approximated, paying attention to the intercostal bundle. Then the transversus, internal and external oblique muscles were approximated. The wound was closed with 3–4 interrupted sutures (Fig. 1G).
The results of the endoscopic minilaparotomy were compared with those of standard translumbar partial nephrectomy which was performed through frank incision from the end of the 12th rib to the lateral margin of the rectus abdominis muscle. Resection of the renal parenchyma was done with renal pedicle clumping and the cut surface was simply approximated with interrupted sutures with absorbable threads. Microwave tissue coagulation was not applied to any of the patients.
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RESULTS |
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Endoscopic minilaparotomy was successfully completed without complications in all of the cases. As shown in Table 1, the operating time was 157–275 min (average 209 min). Estimated blood loss was 20–1200 ml (average 528 ml), which was covered by autologous blood donation (400–800 ml). In case E2, the uppermost location of the tumor hindered application of a microwave tissue coagulator or an argon beam coagulator, which led to insufficient control of bleeding. No patient required an allogeneic blood transfusion. The postoperative course was uneventful. Wound pain was mild and analgesics were not necessary in five of the eight cases. Patients resumed oral intake within 2 days. Mobilization was started on the fifth postoperative day. Full convalesence was achieved within 2 months. In cases E5 and E7, there was mild urinary leakage from the drain, which was recovered within 4 weeks by placing a J stent (case E5) or without any treatment (case E7). There was no significant deterioration of renal function in any patient (Table 1, Fig. 2) and no case of delayed hematoma or abscess formation. There were no positive surgical margins. None of the cases demonstrated pathological multifocality. Neither local recurrences or metastases have been noted in any of the seven cases during a follow-up of 6–15 months (average 9.6 months).
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In the control group (standard translumbar partial nephrectomy), the operating time was 130–250 min (average 178 min) and the estimated blood loss was 40–900 ml (average 447 ml). Start of oral intake and mobilization were on the third and eighth postoperative day, respectively. Analgesics were required in eight of the nine patients.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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We have shown that partial nephrectomy can be performed safely through a limited incision using the endoscopic minilaparotomy technique for small renal cell carcinoma. In contrast to laparoscopic surgery, the techniques and tools used for open surgery can be simply transposed to endoscopic minilaparotomy. A magnified view of the operating field and manual palpation by the surgeon’s hand allow effective dissection, good vascular control and easy reconstruction of the collecting system. Hypothermia of the kidney is possible if necessary. Suzuki and co-workers (5–7) reported unique gasless laparoscopy-assisted renal surgery with excellent operative outcomes. In their approach, side effects caused by pnuemoperitoneum or pneumoretroperitoneum can be avoided and intact removal of the resected organs is possible. We refined this concept in endoscopic minilaparotomy that has much in common with standard open surgery. Whole procedures can be done through a single incision that is of the minimum size for retrieval of the resected specimens.
In partial nephrectomy there is a risk of excessive blood loss, which necessitates transfusion and also results in renal dysfunction if a vascular clamp is used for control of bleeding. The development of surgical tools that allow bloodless and non-traumatic section of the renal parenchyma make it possible to perform partial nephrectomy without clamping the renal pedicle. The microwave tissue coagulator, which has been used for controlling parenchymal bleeding in solid vascular organs such as the liver, has been successfully applied to partial resection of the kidney (8–11). The advantages of microwave coagulation are reduced blood loss, shorter operating time and minimal risk of vascular injury. In our experience, bleeding was well controlled by microwave coagulation of the renal parenchyma, incision of renal capsule and parenchyma with a harmonic scalpel (12), further hemostasis by an argon beam coagulator (13,14) and application of fibrin glue, which has been demonstrated to have the ability to stop venous oozing (15). In the initial two cases (cases E6 and E7), we employed vascular clamping which we considered to be better for patients’ safety. However, the excellent control of bleeding enabled us to perform whole procedures without clamping in the other five cases.
In laparoscopic partial nephrectomy, frequent ventilation of intraperitoneal gas is necessary to avoid heating of the intraperitoneal space and excessive intraperitoneal pressure while using the microwave tissue coagulator or the argon beam coagulator (9). There was no need for such ventilation in endoscopic minilaparotomy. This is another merit of endoscopic minilaparotomy and may facilitate operating procedures and lead to shorter operating times. In fact, the operating time was between 157 and 275 min in the endoscopic minilaparotomy group, which was not so longer than that in the standard open partial nephrectomy group (130–250 min). In addition, start of oral intake and mobilization were more rapid and less analgesics were required in the endoscopic minilaparotomy group. These results suggest that endoscopic minilaparotomy can contribute to excellent postoperative recovery as a new minimally invasive modality.
In conclusion, endoscopic minilaparotomy partial nephrectomy is safe and feasible for small renal cell carcinoma 4 cm or smaller.
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FOOTNOTES |
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+ For reprints and all correspondence: Yukio Kageyama, Department of Urology and Reproductive Medicine, Graduate School Tokyo Medical and Dental University, 1–5–45 Yushima, Bunkyo-ku, 113-8519 Tokyo, Japan. E-mail: kageyys.uro@tmd.ac.jp
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REFERENCES |
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Received April 15, 2002; accepted June 24, 2002
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