Minimally Invasive Radical Nephrectomy and Nephroureterectomy
Michael J. Schwartz, Nikhil Waingankar, Louis R. Kavoussi
Laparoscopic renal surgery is well established for the treatment of benign and malignant conditions of the kidney. Now, because of more than 20 years experience, perioperative advantages of laparoscopy with respect to open surgery are widely known. These include shorter hospital stay and convalescence, decreased blood loss, less analgesic requirement, and improved cosmesis.1-10 Benefits in terms of overall cost and quality of life have also been established.11,12 Moreover, oncologic equivalence has been demonstrated between open and laparoscopic partial and radical nephrectomy and nephroureterectomy for the treatment of renal parenchymal and collecting system malignancies, respectively.2,3,7,10 For these reasons, the laparoscopic approach is regarded by many to be the standard of care for most renal surgery.
With surgeons’ increased experience and comfort with the laparoscopic environment, the breadth of cases considered for a laparoscopic approach has also increased. Large renal tumors, complex partial nephrectomy, and inflammatory pathology of the kidney (xanthogranulomatous pyelonephritis), once all considered to be relative contraindications to a laparoscopic approach, are now undertaken with regularity.13-20
Minimally invasive techniques, regardless of the approach, require a skill set separate from that required in open surgery. Just as with any type of surgery, complications are unavoidable, even in the most experienced of hands. Multiple factors may contribute to the occurrence of complications, including surgeon experience, patient-specific factors, the operating room environment, and equipment failures. Perhaps the most significant portion of the learning curve involves understanding the potential pitfalls and management of the complications that can arise at each step of the surgery.21,22 The following chapter is a discussion of surgical technique and potential complications associated with standard laparoscopic, robotic, and single-incision laparoscopic radical nephrectomy and nephroureterectomy.
The indications for laparoscopic radical nephrectomy (LRN) are similar to that of open surgery. They encompass all solid renal lesions where partial nephrectomy is not feasible and, depending on surgeon comfort level, this may include patients with renal vein or low-level vena caval tumor thrombus.23-27 Patients with metastatic disease may also be considered for cytoreductive or palliative nephrectomy.28-31 Laparoscopic nephroureterectomy (LNU) is indicated for individuals with transitional cell carcinoma of the renal pelvis and ureter.
Benign indications for laparoscopic nephrectomy include inflammatory conditions primarily related to stone disease, recurrent infection, or both conditions. These include xanthogranulomatous pyelonephritis, recurrent infection originating from a nonfunctional kidney, symptomatic polycystic kidneys in the end-stage renal disease and transplant populations, and other conditions related to chronic obstruction. Laparoscopic donor nephrectomy, because of the rapid convalescence it offers an otherwise healthy patient, has become the gold standard for living-donor renal transplant surgery.
Data gathered in preoperative consultation include routine medical and surgical histories. While a history of prior abdominal surgeries may alter trocar placement or approach (transperitoneal vs retroperitoneal), it is not a contraindication to laparoscopic surgery.
The only true absolute contraindications for laparoscopic surgery include uncorrected coagulopathy, untreated infection, and hypovolemic shock.32 Preoperative laboratory specimens should include urinalysis and blood for type and screen, coagulation profile, complete blood count, and basic metabolic panel. EKG and a chest X-ray should also be obtained preoperatively, depending on patient age and comorbidities. Abdominal cross- sectional imaging should be performed to delineate important anatomical landmarks, tumor size, location, clinical stage, neovascularity, number and location of renal vessels, presence of lymphadenopathy, and the course of the ureter. Three-dimensional reconstructions should be performed before laparoscopic donor nephrectomy. When obtaining informed consent, the surgeon should advise the patient of all potential risks of surgery, which will be expanded on in the remainder of the chapter: bleeding, infection, damage to adjacent structures (including bowel, neurovascular structures, spleen, liver, pancreas, and gallbladder), conversion to open surgery, and port-site hernia. Patients should be advised to stop taking antiplatelet and anticoagulant drugs up to one week before surgery. Cardiac stents are increasingly prevalent and may preclude coming off all antiplatelet therapy. A discussion should be held with the patient’s cardiologist to plan perioperative cardiac management. Finally, all patients should start mechanical bowel prep the night before and remain NPO after midnight the day of surgery.
For a transperitoneal approach, the patient is positioned in a modified flank position with the operative side elevated 30 degrees to 45 degrees, the ipsilateral arm folded across the chest, the contralateral arm secured to an arm board, and the legs, hips, and torso secured to the bed. Care should be taken to pad all pressure points; paresthesias or rhabdomyolysis may occur without proper padding, particularly in obese patients. Images should be present in the operating room to verify the side of the surgery. After prepping and draping the patient, the abdomen is insufflated with a Veress needle. An incision is made along the ipsilateral edge of the umbilicus for insertion of a 10-mm trocar that will be used for the camera. A 12-mm trocar is positioned at the level of the umbilicus lateral to the rectus muscle for instrumentation during the procedure. A third incision is made 2cm below the xiphoid process for insertion of a 5-mm or 10-mm port. A fourth trocar may be placed in the lower midline, subcostal region, or in the axillary line if necessary for additional retraction or instrumentation. In obese patients, all trocars are typically shifted laterally to the ipsilateral side, and longer trocars or instruments may be required. Access-related injuries to intraabdominal structures are uncommon and have been demonstrated to be equally likely with both open and closed access techniques.33
Left-sided surgery begins with medial mobilization of the descending colon by incising the white line of Toldt and developing the plane between the bowel mesentery and Gerota’s fascia. The superior extent of the dissection involves division of the lienocolic and lienorenal ligaments to allow the spleen to be mobilized medially with the colon and pancreas. Full splenic mobilization will facilitate exposure of the upper pole and hilum. Injuries to the spleen can usually be controlled with either argon beam coagulation or topical hemostatic agents and pressure.34,35 Extensive injury may require splenectomy if bleeding cannot otherwise be controlled.
The tail of the pancreas will be encountered during these maneuvers, because it lies near the inferior border of the spleen and should be identified during visceral mobilization.
Superficial injury to the pancreas can be managed conservatively with drain placement and observation. If the tail of the pancreas is inadvertently transected during dissection, it should first be copiously irrigated with normal saline. The injury is then repaired by stapling across the pancreas as distally as possible with an EndoGIA stapler;36 alternatively, the pancreas can be plicated in running fashion with absorbable suture on a noncutting needle and then covered with an omental patch. A drain is placed alongside the repair, and serial amylase levels are followed postoperatively. The patient’s diet may be advanced if drain output remains low, enzymes trend toward normal, and peritoneal signs are absent.
To complete medial retraction of the descending colon, the thin colorenal attachments are divided, taking care to avoid violation of the mesentery. The correct plane is followed by staying lateral to the mesenteric fat, which has a brighter hue of yellow compared with retroperitoneal fat. If necessary, a paddle retractor can be inserted through an additional lower midline trocar to assist with medial retraction of the colon, pancreas, and spleen. If a mesenteric rent does occur, closure with an EndoStitch device or surgical clips can be performed by elevating and retracting the colon laterally to expose and repair the defect. Failure to recognize and properly close a mesenteric defect can result in postoperative internal hernia and bowel obstruction or ischemia.37
Right laparoscopic nephrectomy begins with a peritoneal incision along the white line of Toldt to the hepatic flexure. This incision is deviated medially and parallel to the lateral border of the vena cava and duodenum. Visualization can be improved by placing a liver retractor through an additional port in the anterior axillary line or high midline. Injuries to the liver or gallbladder may occur during retraction or instrument insertion and, although injury to the liver is best managed with argon beam coagulation to control bleeding, injury to the gallbladder requires cholecystectomy. To complete medial exposure of the hilum and upper pole, a Kocher maneuver is performed with sharp dissection to mobilize the duodenum; cautery should be avoided at this step to avoid thermal injury. Blunt dissection also carries the risk of tearing the serosa.
The next step for either right or left nephrectomy is localization of the gonadal vessels with the bowel and mesentery retracted medially. Identification of the ureter, which typically lies just posterior to the gonadal vein with a similar course, may then be accomplished. Visualization of peristalsis helps to differentiate the ureter from the gonadal vein. An instrument is passed underneath the ureter but above the gonadal vein and laterally to the abdominal wall to provide anterior traction on the kidney and ureter. Leaving the gonadal vein down will minimize the risk of avulsion, particularly with right nephrectomy. The plane between the posterior Gerota’s fascia and psoas muscle is then developed bluntly, moving from the lower to the upper pole. Care should be taken to avoid disruption of the psoas fascia during this maneuver, which can lead to anterior thigh paresthesia or bleeding. The ureter is left in tact to provide a point of traction during the remainder of the dissection.
If the adrenal gland is to be spared, its lateral edge must be meticulously dissected away from the upper pole. The upper pole is often perfused by a proximal arterial branch that courses along the lateral border of the adrenal gland; failure to identify it can lead to significant hemorrhage and potential loss of the upper pole of the kidney, which is a particularly devastating complication in donor nephrectomy.
Dissection of the renal hilum is facilitated by medial retraction of the viscera and simultaneous elevation of the kidney from the renal fossa. This is best accomplished by inserting a grasper through the subxiphoid trocar beneath the kidney and to the lateral abdominal wall. With the hilum placed on stretch, blunt dissection of the hilar vesselscan be meticulously carried out with the suction-irrigator tip or laparoscopic forceps. Once the inferior attachments and lymphatics are dissected, the renal artery can be identified posterior to the vein. By using an EndoGIA stapler, the main renal artery can be divided first followed by the vein. En block stapling of the hilum may be performed if necessary,38,39 and although a theoretical risk exists of arteriovenous fistula formation, this has not been reported.
Dissection continues to the upper pole once the hilar vessels have been divided. A Ligasure device (Valleylab, Boulder, CO) can be used to release the lateral and posterior renal attachments. The ureter can be clipped and divided at this point, which allows the kidney to be freely rotated anteriorly and retracted superiorly to permit dissection of the remaining superior attachments under direct vision. The specimen is placed in an EndoCatch (Covidien, Mansfield, MA) bag and removed, and port sites are closed.
Vascular injuries are the most common complication of urologic laparoscopy,40 and inadequate hilar dissection and bleeding are the most common causes for open conversion.41 The renal vein has an anterior layer of connective tissue that must often be incised to gain proper exposure. The potential for venous bleeding exists from avulsion injuries or inadequate ligation of venous branches during this step. If a vessel wall defect or inadequately ligated vessels are visualized, clips or sutures may be used. Alternatively, direct pressure with gauze is often adequate to control venous bleeding and minimizes blood loss. Gonadal, lumbar, and accessory venous branches can be clipped and divided as necessary. Bleeding from an avulsed lumbar vessel must be identified early, because it often retracts into the paraspinal tissue, making subsequent vascular control difficult.
Appropriate use of the EndoGIA stapler is critical to avoiding complications while dividing the renal artery and vein. A multi-institutional study42 on endovascular stapler malfunction showed that 70% of stapling complications were due to preventable errors, such as stapling over a previously placed clip or incomplete transection due to incorrect placement. The stapler should be placed perpendicularly across the vessel to allow visualization of the stapler tips; this ensures that the entire vessel is being divided without incorporating other structures. The use of torque should be avoided when firing the stapler, because it carries the risk of vascular avulsion.
A laparotomy pad should be placed inside the abdomen before stapling so it may be quickly accessed and used for compressing the hilum in case of vascular injury. A fourth port can be added in the midline below the umbilicus for placement of an additional retractor or suction device if needed. If bleeding is adequately controlled, laparoscopic management of the injury can be attempted with free hand suturing or clips, if a sufficient portion of the transected vessel is accessible. Conversion to open surgery may be indicated for exploration and control of a major vascular injury, and therefore, a laparotomy set with vascular instruments should be available at all times.
Bowel injury can be one of the most devastating complications of laparoscopic surgery. It is of paramount importance to dissect at a safe distance away from the bowel to avoid injury or even unintended transmission of thermal energy to the bowel wall.
Laparoscopic bowel injury occurs in approximately 0.65% of abdominal urologic procedures, and blunt, sharp, and thermal dissection account for the vast majority (unpublished data). The transperitoneal approach results in a higher incidence of bowel injury in comparison with the retroperitoneal approach, but intraoperative recognition and management are the pivotal factors in determining outcome. Continuous vigilance in field inspection on the part of the surgeon will help to maximize recognition, and particular attention should be given to cases of nephrectomy with inflammatory pathology where ambiguous tissue planes can easily result in anatomic disorientation. When bowel injury does occur, superficial or small transmural injuries should be oversewn while more significant injuries may require bowel resection. Addressing the injury may be accomplished laparoscopically or converted to an open procedure if necessary.
Postoperatively, the patient’s diet should be advanced after the return of bowel function.
Unrecognized bowel injury is particularly devastating, because it almost always results in high-grade complications requiring additional procedures to manage. Patients with unrecognized bowel injuries can present in a delayed fashion, but generally within 3 days to 5 days from surgery. Signs and symptoms may be atypical and a high index of suspicion should be maintained in any patient with unexplained abdominal complaints in the postoperative period.43 Fever and leukocytosis are uncommon, while the more common signs and symptoms include trocar-site pain and edema, nausea, leukopenia, generalized abdominal pain, or diarrhea. Patients may deteriorate to hemodynamic instability and death if not recognized and treated in a timely fashion.43 CT scan with oral contrast is the diagnostic modality of choice for a patient with suspicion of bowel injury in the postoperative period.44
Diaphragmatic injury can occur during dissection of the spleen or upper pole and can most often be identified visually or indirectly due to billowing of the diaphragm. In the case of inconspicuous injury, an acute rise in ventilation pressures may be the only indication. To avoid a tension pneumothorax, a central line catheter may be placed in the second intercostal space while the injury is located and repaired. Of note, surgeons using a valveless trocar system45 may not see a rise in ventilation pressure if diaphragmatic injury occurs (Cinman et al, personal communication, 2010). Once the injury is recognized, the patient should be placed in the Trendelenburg position to facilitate evacuation of air while the diaphragm is closed by free-hand suturing or with an EndoStitch device (Tyco, Norwalk, CT). The pneumothorax can be evacuated by placing a suction tip in the defect during closure, with the addition of a thoracostomy tube if necessary.46,47 Chest X-ray should be performed following surgery and serially thereafter if a chest tube is placed.
Insensible losses are far less with the laparoscopic approach relative to open surgery. As such, fluid resuscitation should be modified to prevent intravascular volume overload and associated complications, such as postoperative congestive heart failure or arrhythmias.
The exception is for donor nephrectomy when the renal perfusion is of paramount importance, and fortunately, the incidence of significant cardiac disease in this patient population is exceedingly low. Because of oliguria induced by the pneumoperitoneum required for laparoscopic renal surgery, the urine output should not serve as an indicator of fluid status during the procedure, and intravenous fluids should be minimized.
Patient positioning for laparoscopic nephroureterectomy is similar to that of laparoscopic nephrectomy. Port placement is also similar, with the addition of a lower midline port between the umbilicus and pubic symphysis to facilitate dissection of the distal ureter.
The procedure follows that of nephrectomy, with the notable exception being that the ureter is completely dissected distally and divided just proximal to its hiatus in the bladder. To release the ureter, a peritoneal incision is carried inferiorly into the paracolic gutter, over the iliac bifurcation, and medial to the umbilical ligaments. Potential pitfalls when freeing the ureter include injury to the iliac vessels, superior vesical artery, vas deferens (males), or round ligament (females). The ureteral hiatus may be managed in several ways. An EndoGIA stapler may be used to transect the ureter with a cuff of bladder, ensuring complete resection while avoiding tumor spillage. The distal uretermay also be managed with an open approach following laparoscopic nephrectomy, cystoscopic detachment and ligation, transurethral resection of the ureteral orifice, and ureteral intussusception;48 no prospective randomized trial has compared these techniques.
ROBOTIC-ASSISTED LAPAROSCOPIC NEPHRECTOMY AND NEPHROURETERECTOMY
Robotic-assisted laparoscopic surgery has been applied to extirpative renal surgery and shown to be a feasible approach.49-54 Although there are no clearly demonstrated benefits to robotic renal surgery with respect to conventional laparoscopy, use of the robot does allow for a larger cohort of surgeons to offer their patients an alternative to open surgery with less morbidity, albeit at a significantly higher cost than conventional laparoscopy.
The sequence of steps for a robotic-assisted laparoscopic nephrectomy is identical to that described above for laparoscopic nephrectomy,49,55,56 with the exception of port placement and patient positioning. The patient is positioned in a 45º to 60º ipsilateral flank-up position with the table flexed, and a 12-mm periumbilical camera port is placed. One 8-mm robot port is placed 8cm lateral to and below the level of the umbilicus. The second 8-mm robot port is placed 8cm superior to the camera port in the midline. One to 3 assistant ports are placed for the purposes of suction, irrigation, retraction, and passage of sutures or clips. The location may be infraumbilical, supraumbilical, or the ipsilateral upper quadrant.52 Alternatively, the 12-mm camera port can be placed 2cm below the subcostal margin at the anterior axillary line and the 8-mm robotic ports triangulated 8cm toward the diseased kidney. A 12-mm infraumbilical assistant port can then be inserted, and a 5-mm port is placed for liver retraction.55 A fourth arm can be used to retract the kidney and place the hilum on stretch.56 Control of the hilum has been described with suture ligation, stapling, and hemolock clips.
Port placement for robotic nephroureterectomy is similar to that of robotic nephrectomy: 12-mm camera port at the umbilicus, 8-mm robotic port 8cm superior in the midline, 8- mm robotic port 8cm lateral, and 12-mm infraumbilical assistant port. The procedure closely follows that of laparoscopic nephroureterectomy.57
For both nephrectomy and nephroureterectomy, there have been no reported complications specific to utilization of robotic assistance. Notable differences between the robotic and conventional laparoscopic approach include markedly increased cost and the requirement for a second surgeon skilled in laparoscopic techniques to assist at the bedside with passage of sutures, clips, and stapling devices.
LAPAROENDOSCOPIC SINGLE SITE (LESS) SURGERY
Attempts to further reduce morbidity and improve cosmetic outcomes have led to the development of laparoendoscopic single site (LESS) surgery. This approach has been shown to be feasible for a wide variety of urologic applications for both upper and lower urinary tract pathology. However, comparative studies to date have failed to demonstrate any significant advantages of LESS over conventional laparoscopy. Cosmetic outcome may be the exception, but no objective studies have measured differences to date.58-60
Positioning for LESS nephrectomy is similar to that of laparoscopic nephrectomy. The surgery may be performed through a periumbilical incision or via a mini Pfannenstiel approach. There are several purpose-built devices for single-site surgery with multiple instrument ports within a larger sleeve or port apparatus. Alternatively, multiple conventional ports may be placed through a single incision after raising subcutaneous tissue flaps, which allows for a small degree of triangulation. A flexible-tipped laparoscope (LTF Series, Olympus Surgical, Orangeburg, NY) is inserted through one of the ports and allows for the camera operator to keep the scope from clashing with the other instruments. Conventional laparoscopic or flexible instruments may be used to perform nephrectomy in standard laparoscopic fashion.58
Positioning and port placement are similar for LESS nephroureterectomy, which is performed in standard laparoscopic fashion. Division of the distal ureter has been performed through cystoscopic resection and laparoscopic stapling.59 Open bladder cuff repair through the same Pfannenstiel incision has also been described.61 For both nephrectomy and nephroureterectomy, there have been no reported complications specific to utilization of the LESS approach.
Minimally invasive extirpative surgery of the kidney offers significant advantages over the traditional open approach. As technology evolves, surgical techniques improve, and experience grows, morbidity is expected to continue to decline. However, these perioperative advantages can only be realized with a thorough knowledge of the prevention and management of complications.
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