Laparoscopic Management of Kidney Cancer

Abstract and Introduction

Abstract

Background: Laparoscopy has emerged as the preferred option for the surgical management of kidney cancer. Although many reports have been published regarding the operative outcome of renal cell carcinoma (RCC) and upper-tract transitional cell carcinoma (TCCA) treated laparoscopically, few review the oncologic outcome of these pathologies treated with laparoscopic techniques.
Methods: We review the literature regarding the laparoscopic approaches, the complications related to laparoscopic surgery, and the long-term oncologic results of laparoscopic radical nephrectomy, partial nephrectomy, and nephroureterectomy.
Results: Laparoscopic radical nephrectomy has become the new standard of care for most patients with suspected RCCs that are not amenable to nephron-sparing procedures. Laparoscopic techniques for managing RCC and TCCA are safe, follow well-established guidelines for surgical dissection, and meet or exceed perioperative convalescence and oncologic outcomes compared to traditional open procedures. The surgical techniques and the long-term outcome data for laparoscopic partial nephrectomy continue to mature.
Conclusions: Laparoscopy is a minimally invasive option available to most patients with kidney cancer. The immediate benefits of laparoscopy are well established and include less estimated blood loss, decreased pain, shorter perioperative convalescence, and improved cosmesis. Long-term oncologic outcomes of patients treated laparoscopically for kidney tumors resemble those of the open surgical approach.

Introduction

Minimally invasive options for managing patients with kidney cancers are evolving rapidly. Since the first report of a laparoscopic radical nephrectomy (LRN) by Clayman et al^[1] in 1991, laparoscopy has gained rapid acceptance as the new standard of care for removing kidneys suspected of harboring a renal cell carcinoma (RCC) or transitional cell carcinoma (TCCA). Pioneers in laparoscopy have elegantly demonstrated equivalent oncologic outcomes, comparable complication rates, and improved perioperative morbidity for patients undergoing laparoscopic procedures compared to standard open surgical techniques for managing kidney cancers.^[2-9]

With innovative equipment design and increasing surgeon experience, laparoscopic techniques can now be considered in the management of most patients who are candidates for radical nephrectomy, nephroureterectomy, and nephron-sparing procedures. This paper presents the indications, operative procedures, and outcomes of renal tumors treated with laparoscopic techniques.

Diagnosis and Staging of Kidney Cancer

The preoperative assessment of patients with a kidney tumor has three principal aims: to make the diagnosis of RCC or TCCA, to assess the stage of disease, and to delineate the anatomic detail necessary for operative planning. Patients with RCC can present with many different signs and symptoms attributable to the primary tumor, although the classic triad of flank pain, a palpable mass, and hematuria is increasingly uncommon. Today, with the frequent use of cross-sectional imaging, the majority of RCCs are diagnosed incidentally during the investigation of unrelated complaints.^[10] Upper-tract TCCA is usually detected during the workup of gross or microscopic hematuria.

RCCs comprise 85% to 90% of renal parenchymal tumors that are radiologically demonstrated to be solid. Differentiation of renal cysts exhibiting complex features such as thickness, nodularity, calcification of the cyst wall, internal septations, or heterogeneity is mandatory, and a systematic assessment using these objective criteria facilitates the estimation of the risk of malignancy.^[11] Needle biopsy of renal masses is prone to inaccuracy.^[12,13] Other than for suspected metastases or lymphoma, biopsy is not routinely recommended for making management decisions.^[14,15] Upper-tract TCCAs typically appear as collecting system filling defects on contrast-enhanced studies. The diagnosis of TCCA and differentiation from other filling defects (eg,stones,blood clots, papillary necrosis, fungus) are established with a combination of radiographic studies, urinary cytology, uri-nary biomarkers, and possibly ureterorenoscopy with or without tissue biopsy.

Clinical staging of kidney cancers requires radio-logic assessment of the extent of local or distant disease. Imaging of the chest, abdomen, and pelvis should be performed with computed tomography (CT) or a combination of CT with magnetic resonance imaging or standard chest radiograph. Laboratory biochemical evaluation includes a routine complete blood count and a complete metabolic panel specifically evaluating the serum creatinine, blood urea nitrogen, liver function tests, serum calcium, and alkaline phosphatase. If the patient complains of atypical musculoskeletal discomfort or if the biochemical studies indicate possible bone metastases, a bone scan should be considered. Presently, positron-emission tomography is not considered part of the staging workup for the newly diag-nosed kidney cancer when other diagnostic studies reveal no evidence for systemic disease.^[16] The advances in imaging technology have dramatically enhanced the visualization of anatomic detail, especially vascular anatomy. Such detail is crucial for nephron-sparing cases.

Selection of Patients for Laparoscopic Surgery

Although most patients with kidney cancer could be managed with laparoscopic techniques, careful patient selection is paramount to achieving successful outcomes. Patients with moderate to severe cardiopulmonary comorbidities require careful preoperative assessment due to the physiologic disturbances brought about by the mechanical effects of abdominal insufflation and hypercarbia associated with a carbon dioxide pneumoperitoneum. A detailed history is crucial to identify patients with an uncorrected coagulopathy,extensive prior abdominal and pelvic surgeries, mesh hernia repairs, and previous intra-abdominal infections or abscesses due to a perforated viscus. Open surgical procedures or other management options should be strongly considered in these scenarios. Patients with organomegaly, iliac or aortic aneurysms, umbilical hernias, and prior abdominal surgery might require alternative sites for trocar placement or initial open access utilizing the Hasson technique.^[17] Other relative contraindications to laparoscopic renal surgery include abdominal ascites and pregnancy. Obese patients undergoing laparoscopic renal surgery have improved perioperative outcomes including decreased blood loss, narcotic requirements, time to oral intake, length of hospital stay, and convalescences.^[18,19] However, complication rates are possibly higher due to technical factors such as the inadequate length of operating instruments, the need for increased insufflation pressures to elevate the abdominal wall, and the higher amounts of intra-abdominal mesenteric and retroperitoneal fat, all of which make orientation more challenging.^[19]

Complications of Laparoscopic Renal Surgery

Complication rates associated with laparoscopic surgery decrease as the experience of the operating surgeon expands.^[94,95] Simon et al^[96] presented complications of 285 laparoscopic renal cases, including 113 cases of LRN. Major complications occurred in 16 patients (5.6%),including 12 (4%) who required open conversion (6 emergency indications: 4 with hemorrhage that could not be controlled laparoscopically and 2 with splenectomy). Six patients had elective conversion because of failure to progress laparoscopically. Many urologists argue that elective conversion to an open case for failure to progress should not be considered a complication of the laparoscopic approach. Major complications in the remaining 4 patients included splenic laceration treated conservatively, tumor fragmentation during specimen retrieval, immediate postoperative hypotension requiring open exploration, and pneomothorax.^[96] Pareek et al^[97] recently reviewed the reported complications of laparoscopic renal surgery. Overall, 10.7% of patients undergoing a pure LRN experienced a major complication compared with 9.3 % of patients who underwent a hand-assisted LRN (no statistical significance). The most frequent major complications in the LRN group included venous and arterial bleeding (1.8% and 1.0%). In the hand-assisted LRN group, the most common major complications included wound infection (1.5%) and arterial hemorrhage (1.0%). Wound infection rates were significantly higher in patients managed with hand-assisted LRN compared with patients treated with pure laparoscopic techniques.

Steinberg et al^[4] compared complication rates in patients undergoing open surgery and LRN. Intraoperative complications occurred in 7.2% of patients who were treated with LRN for pT1 tumors, 7.7% of patients who underwent LRN for pT2 tumors, and 17.6% of patients who underwent surgery with standard open techniques for pT2 tumors. Although there was an apparent higher complication rate for the open group, the difference was not statistically significant. The most common intraoperative complication in each of the groups was vascular injury and hemorrhage. The rates of postoperative complications were similar (19.9%, 21.5%, and 26.5%, respectively). Interestingly, wound-related complications and postoperative ileus were higher in the laparoscopic groups compared with the open group, which the authors attributed to differences in recovery expectations and reporting by the operating surgeons.^[4]

Complication rates associated with LPN are higher than rates reported for other laparoscopic renal surgeries.^[98] To no surprise, complication rates are less with exophytic lesions (10%) compared with 47% for intra-parenchymal lesions and 50% for renal hilar lesions.^[99] Pareek et al^[97] reported a major complication rate of 21% in their literature review of 591 patients undergoing LPN. The most common of these major complications included bleeding that required blood transfusion (4.4%), urinoma (3.9%), and vascular injury (2.5%). Other less frequent (less than 2% incidence) but major complications included cardiac dysrhythmia, renal failure, venous thrombosis, wound infection, retroperitoneal hematoma, and ureteral injury. Although LPN typically requires more advanced laparoscopic skills, the open conversion rate was only 1.9%. A small number of patients (1.4%) underwent reoperation.

Ramani et al^[53] reported a detailed experience of complications associated with LPN. The overall complication rate in 200 patients was 33%: 5.5% intraoper-ative,12% postoperative,and 15.5% delayed. Most com-plications (18%) were related directly to urologic issues. Nearly 1 in 10 patients (9.5%) experienced sig-nificant bleeding (intraoperative, postoperative, and delayed in 3.5%, 2%, and 4%, respectively). A urine leak occurred in 9 patients (4.5%). Leaks were managed in 8 patients with ureteral stents or treated conservatively in 1 patient. Only 2 patients required percutaneous drainage of an urinoma.