eMedicine Specialties > Urology > Surgery

Transperitoneal Laparoscopic Radical Nephrectomy: Follow-up

Author: William J Harmon, MD, Director of Minimally Invasive Urologic Surgery, Urology San Antonio, PA, Associate Clinical Professor, Division of Urology, UTHSC, San Antonio, TX
Coauthor(s): Robert P Caruso, MD, Director of Robotic and Laparoscopic Urologic Surgery, Essex-Hudson Urology PC, Bloomfield, New Jersey; Jay T Bishoff, MD, Associate Clinical Professor, Department of Surgery, University of Utah College of Medicine; Director, Intermountain Urological Institute, Intermountain Health Care
Contributor Information and Disclosures

Updated: Mar 3, 2009

Outcome and Prognosis

The operative results for laparoscopic radical nephrectomy (LRN) are presented as a series of commonly asked questions.

Are the survival and recurrence rates of laparoscopic radical nephrectomy similar to those of open radical nephrectomy?

The actuarial disease-free rate among 157 patients undergoing LRN in a large multi-institutional review was 91%. This series reported one local recurrence at the ureteral stump, which was subsequently resected. Unfortunately, the patient developed another recurrence at the bladder neck. The remaining recurrences were distant metastases.14

Four large single-institution reviews also report favorable recurrence and survival rates. Some of these patients are included in the above multi-institutional review. Dunn et al reported on 35 patients who underwent LRN for localized renal cell carcinoma (RCC), for which a minimum of 6 months and a mean of 25 months of follow-up were available.15 Three recurrences occurred in this group; 2 were metastatic and one was local (the above-mentioned ureteral stump recurrence). Gill et al reported 2 metastatic recurrences among 42 patients16 (mean follow-up of 13 mo), Ono et al reported metastases in 2 of 60 patients17 (mean follow-up of 24 mo), and Barrett et al reported no recurrences among 57 patients18 (mean follow-up of 21 mo). In the Barrett et al series, only physical examination, serum tests, and chest radiography were used for follow-up.

Portis et al reviewed experience with laparoscopic nephrectomy and open nephrectomy at 3 centers; the median follow-up period was 54 months. Sixty-four laparoscopic cases (mean tumor size was 4.5 cm) were compared with 69 open cases (mean tumor size was 6.2 cm). The Furman nuclear grade between the two groups did not significantly differ. The 5-year recurrence-free survival rate was 98% versus 92% (not statistically significant).19

Does the cancer recur at the port site used for intact tumor removal or morcellation?

To date, 9 port-site recurrences have been reported, 4 in conjunction with morcellation. In two of these cases, the entrapment bag was permeable and therefore inappropriate. In another, the tumor was stage T3N0, grade 4, with sarcomatoid features. In another case, a stage T1N0 grade 2 tumor was associated with ascites, which was thought to be a contributing factor.

The incidence of this may be underreported.11 Successful principles used to avoid this complication include the use of a bag for intact specimen removal, use of an impermeable sack for morcellation, and separate draping prior to morcellation with changing of gloves before surgery is resumed. (Clayman and Kavoussi both have >10 y of experience with morcellation, with no reported recurrences.)

What is the learning curve for laparoscopic radical nephrectomy?

Good evidence indicates that approximately 20 cases are required before a laparoscopic surgeon becomes facile with LRN. In the multi-institutional review of laparoscopic nephrectomies, Gill et al showed that 9 of the 14 technical complications occurred in the first 20 patients.16 Furthermore, of the 10 patients in whom open conversion was necessary, 8 were among the initial 20 patients. Overall, 71% of complications occurred in the first 20 patients from each institution, while 33% occurred in the remainder.

Can an adequate margin be obtained with laparoscopic radical nephrectomy?

If the laparoscopic surgeon follows the successful guidelines of established open radical nephrectomy, the margins are equivalent.

How do the costs of laparoscopic radical nephrectomy compare with those of open radical nephrectomy?

In the recent past, LRN had cost 29% more than open radical nephrectomy at the Cleveland Clinic; similarly, LRN had cost roughly $2000 more at Washington University in St. Louis. The higher cost was due mainly to longer operative times and more intraoperative disposables.

Operative times have decreased significantly since these studies were performed. Contemporary studies now suggest that LRN costs less than open radical nephrectomy.20,21 With the decreased operative times, the length of stay seems to have become the main determinant in cost.22 Typically, the length of stay following LRN is half or less than half than following open radical nephrectomy.

The cost to the patient’s quality of life is what should be considered when making these comparisons. In virtually every review of laparoscopic renal surgery, patients who undergo LRN experience less pain and return to normal activities (including work) in half the time compared with those who undergo open surgery; these are much more important costs to consider.

Future and Controversies

Laparoscopic radical nephrectomy (LRN) has become the standard of care for kidney cancer surgery. An open approach is necessary for only about 5% of patients. Shorter hospital stays with less postoperative pain are possible for patients who undergo LRN, and they return to activities in half the time required for patients who undergo open surgery. Survival and recurrence rates associated with LRN are excellent and compare favorably with those associated with open surgery series.

 


More on Transperitoneal Laparoscopic Radical Nephrectomy

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Follow-up: Transperitoneal Laparoscopic Radical Nephrectomy
Multimedia: Transperitoneal Laparoscopic Radical Nephrectomy
References
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References

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Further Reading

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Keywords

transperitoneal laparoscopic radical nephrectomy, laparoscopic radical nephrectomy, LRN, TLRN, renal cell cancer, laparoscopy, renal cell carcinoma, kidney cancer, RCC, open radical nephrectomy, transperitoneal LRN, laparoscopic surgery, adrenalectomy, urologic laparoscopy, renal malignancy, renal cancer, nephrectomy, renal hilar dissection, kidney removal, kidney tumor, renal tumor

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Contributor Information and Disclosures

Author

William J Harmon, MD, Director of Minimally Invasive Urologic Surgery, Urology San Antonio, PA, Associate Clinical Professor, Division of Urology, UTHSC, San Antonio, TX
William J Harmon, MD is a member of the following medical societies: American Urological Association and Phi Beta Kappa
Disclosure: Nothing to disclose.

Coauthor(s)

Robert P Caruso, MD, Director of Robotic and Laparoscopic Urologic Surgery, Essex-Hudson Urology PC, Bloomfield, New Jersey
Robert P Caruso, MD is a member of the following medical societies: Alpha Omega Alpha, American Urological Association, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Jay T Bishoff, MD, Associate Clinical Professor, Department of Surgery, University of Utah College of Medicine; Director, Intermountain Urological Institute, Intermountain Health Care
Jay T Bishoff, MD is a member of the following medical societies: American College of Surgeons and American Urological Association
Disclosure: Pfizer Honoraria Speaking and teaching; PerSys None Consulting

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Dan Theodorescu, MD, PhD, Paul Mellon Professor of Urologic Oncology, Department of Urology, University of Virginia Health Sciences Center
Dan Theodorescu, MD, PhD is a member of the following medical societies: American Cancer Society, American College of Surgeons, American Urological Association, Medical Society of Virginia, Society for Basic Urologic Research, and Society of Urologic Oncology
Disclosure: Nothing to disclose.

CME Editor

J Stuart Wolf Jr, MD, FACS, David A Bloom Professor of Urology, Director of Division of Minimally Invasive Urology, Department of Urology, University of Michigan
J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology
Disclosure: Terumo Corporation Consulting fee Consulting; Omeros Corporation Consulting fee Consulting

Chief Editor

Bradley Fields Schwartz, DO, FACS, Associate Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine
Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoendoscopic Surgeons, and Society of University Urologists
Disclosure: Nothing to disclose.

 
 
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