We report our experience with retroperitoneal laparoscopic radical nephrectomy in 2 patients with renal cell carcinoma. In this procedure, a working space in the retroperitoneum is created using the blunt balloon dissection technique. Carbon dioxide insufflation is performed, and 4 trocars are inserted into the retroperitoneal cavity through the lateral abdominal wall. The kidney is removed together with the perirenal fat and Gerota's fascia in a muscle-splitting fashion. Using this procedure, a right nephrectomy was performed in a 65-year-old man with a 2.4-cm tumor and in a 54-year-old woman with a 3.5-cm tumor. Operative time was 220 min and 195 min, respectively, and estimated blood loss was 10 mL and 115 mL, respectively. There were no major perioperative complications. Although a long-term follow-up is necessary to evaluate the efficacy of this procedure, it will probably become a standard treatment modality for localized renal cell carcinoma

Hirakawa, Shinji

Isoyama, Tadahiro

Kadowaki, Hiroyuki

Miyagawa, Ikuo

Sejima, Takehiro

Yonago Acta Medica

Tottori University Research Result Repository

35Abbreviation:  CT, computed tomographyYonago Acta medica 2002;45:35–41Retroperitoneal Laparoscopic Radical Nephrectomy for Renal CellCarcinoma:  A Report on 2 Initial CasesTadahiro Isoyama, Takehiro Sejima, Hiroyuki Kadowaki, Shinji Hirakawaand Ikuo MiyagawaDepartment of Urology, Tottori University Faculty of Medicine, Yonago 683-8504 JapanWe report our experience with retroperitoneal laparoscopic radical nephrectomy in 2patients with renal cell carcinoma.  In this procedure, a working space in the retroperi-toneum is created using the blunt balloon dissection technique.  Carbon dioxide insuffla-tion is performed, and 4 trocars are inserted into the retroperitoneal cavity through thelateral abdominal wall.  The kidney is removed together with the perirenal fat andGerota’s fascia in a muscle-splitting fashion.  Using this procedure, a right nephrectomywas performed in a 65-year-old man with a 2.4-cm tumor and in a 54-year-old womanwith a 3.5-cm tumor.  Operative time was 220 min and 195 min, respectively, and estimatedblood loss was 10 mL and 115 mL, respectively.  There were no major perioperativecomplications.  Although a long-term follow-up is necessary to evaluate the efficacy ofthis procedure, it will probably become a standard treatment modality for localized renalcell carcinoma.Key words:  laparoscopy; nephrectomy; renal cell carcinomaRecently, an increasing number of renal tumorshave been detected incidentally in lower stagesof growth due to the widespread use ofultrasonography and computed tomography(CT).  Radical nephrectomy had previouslybeen the standard treatment modality forlocalized renal cell carcinoma.  In recent yearsthough, laparoscopic nephrectomy has gainedpopularity in treating both benign and malig-nant renal diseases, and is usually performedvia the transperitoneal or retroperitonealapproach.We report on our experience using retro-peritoneal laparoscopic radical nephrectomy in2 patients with renal cell carcinoma.Patient ReportsCase 1A 65-year-old man with a left ureteral stonearrived at our hospital on May 11, 2001.  Heunderwent shock wave lithotripsy on May 14and June 4.  During shock wave lithotripsy, amass 2.4 cm in diameter was found incidentallyin the right kidney by ultrasonography.  CTrevealed a tumor measuring 2.4 cm by 2.1 cm inthe midportion of the right kidney, with no evi-dence of renal hilar lymphadenopathy or hepat-ic metastasis (Fig. 1).  Chest CT and bone scin-tigraphy disproved the probability of metastaticdisease.  The patient was administered a laxa-tive the day before surgery, and an enema themorning of the surgery.  Compression stockingswere applied to both legs and upper thighs.On August 24, under satisfactory generalanesthesia combined with epidural anesthesia,a nasogastric tube and an urethral catheter wereinserted.  The patient was placed in the flankposition, with the kidney bridge elevated, andthe operating table was bent to widen the spacebetween the 12th rib and the iliac crest.  A 1.5-cm incision was made just below the tip of the12th rib for the 1st trocar port.  The flank muscleT. Isoyama et al.36Fig. 1.  Early-phase enhanced computed tomogram demonstrating a renal tumor in theright kidney (case 1).fibers were bluntly separated.  The thoracolum-bar fascia were gently pierced with a fingertip.A space for subsequent balloon dilator place-ment was created by gentle finger dissection ofthe retroperitoneum, anterior to the psoas mus-cle and posterior to Gerota’s fascia.  A workingspace in the retroperitoneum was created by atrocar-mounted balloon device (PDB; UnitedStates Surgical Inc., Norwalk, CT).  The balloonwas inflated with approximately 800 mL of air.The dilation process was monitored laparo-scopically through the transparent balloon.  Fol-lowing the balloon deflation and removal, a sec-ond 12-mm trocar was placed 7 cm dorsal to the1st trocar port under bimanual guidance.  A 12-mm blunt tip trocar was placed at the 1st trocarport.  Carbon dioxide insufflation was perform-ed at a pressure of 8 mmHg to maintain theworking space in the retroperitoneal cavity, anda 10-mm, 0-degree laparoscope was insertedvia the 1st trocar.  The peritoneum was dissect-ed off of the anterior abdominal wall to enable 2additional trocars to be placed.  The 3rd andfourth 5-mm trocars were placed under laparo-scopic vision (Fig. 2).  Dissection and coagula-tion during the laparoscopic procedure were per-formed using the ultrasonically activated scal-pel (Harmonic Scalpel; Ethicon Inc., Cincinnati,OH) via the 3rd trocar.  At first, the lateroconalfascia was incised along the quadratus lumbo-rum muscle, with exposure of the posterior lam-ina of Gerota’s fascia.  The kidney was retract-ed anterolaterally by the surgical assistant, whoused a grasping forceps via the 4th trocar.  Theleading edge of the psoas muscle was tracedcephalad and renal hilar pulsation could beseen.  The renal artery was identified and dis-sected, secured with five 10.5-mm laparoscopicclips (Ligaclip ERCA; Ethicon Inc.), and tran-sected with scissors, while 3 clips were left onthe aorta side.  The inferior vena cava and therenal vein were then identified and dissected.Its adrenal and gonadal branches were trans-ected with the Harmonic Scalpel to prevent themfrom being damaged when the renal vein wasdissected.  The renal vein was mobilized, stapl-ed and divided with a 35-mm laparoscopic sta-pler (Endocutter; Ethicon Inc.).  The posterioraspect of the kidney was dissected upwards, andthe anterior aspect of the kidney surrounded byGerota’s fascia was dissected free from the peri-toneum.  An incision was made in Gerota’s fas-cia at the upper pole of the kidney, and the ipsi-lateral adrenal gland was spared.  The lowerLaparoscopic radical nephrectomy37Fig. 3.  Macroscopic appearance of the specimen (case 1).pole of the kidney was freed, and the ureterisolated during the procedure was secured withfour 8.4-mm clips and transected.  The speci-men was entirely freed upon the completion ofthe circumferential mobilization.  Insufflationwas lowered to confirm proper hemostasis inthe surgical bed.  A 5-mm drainage tube wasthen inserted through the 4th trocar, and left inthe surgical bed.  The trocars were removedunder laparoscopic vision.The specimen was removedin a muscle-splitting fashionthrough an additional skinincision, which was madebetween the 1st and 3rd tro-car ports.  All wounds wereclosed using a synthetic ab-sorbable suture.  Operativetime was 220 min, and esti-mated blood loss was 10 mL.The specimen weighed 275g (Fig. 3).Pathological examination of the kidney re-vealed clear cell-type, grade-2 and stage-pT1arenal cell carcinoma.  Postoperatively, the pa-tient began oral intake on postoperative day 1.He required analgesia for 3 days.  Although asubcutaneous emphysema occurred at the rightflank abdominal wall, it disappeared on post-operative day 2.  Since the patient wanted toreceive adjuvant therapy, he was treated with adaily intramuscular administration of 3 × 106-IU/mL interferon-alpha for 2 weeks.   He wasdischarged from the hospital on postoperativeday 31.Case 2A 54-year-old woman visited our hospital with anasymptomatic gross hematuria on June 26, 2001.Urological examination including ultrasono-graphy and abdominal CT, revealed a tumormeasuring 3.5 cm by 3.5 cm in the lower pole ofthe right kidney, and no evidence of renal hilarlymphadenopathy or hepatic metastasis (Fig.4).  Chest CT and bone scintigraphy showed nosigns of metastatic disease.  Preoperative prepa-ration was as described for case 1.On August 24, retroperitoneal laparoscopicradical nephrectomy was performed undergeneral and epidural anesthesia.  Operative pro-cedure was almost the same as described forcase 1.  Two renal veins directly enter the rightFig. 2.  Trocar placement for retroperitoneal laparo-scopic radical nephrectomy.  , 12-mm trocar; , 5-mm trocar.  The arrow indicates the line of skin inci-sion to remove the specimen.12th ribiliac crestT. Isoyama et al.38Fig. 5.  Cut surface of the specimen (case 2).lateral aspect of the inferior vena cava.  Asmaller vein was clipped and transected, and abigger one was divided with the Endocutter.Operative time was 195 min.  Estimatedblood loss was 115 mL.  The specimen weighed200 g (Fig. 5).  Pathological examination of thekidney revealed chromophobe cell-type, grade-2 and stage-pT1a renal cell carcinoma.  Therewere no postoperative com-plications.  The patient beganoral intake on postoperativeday 1.  She required analgesiafor 2 days.  She was discharg-ed from the hospital on post-operative day 17, since shewas anxious about an earlyhospital discharge despite ouradvice.DiscussionRadical nephrectomy is the standard treatmentfor localized renal cell carcinoma, and was firstdescribed by Robson (1963).  This procedureincludes early ligation of the renal artery andvein before manipulating the renal tumor, enFig. 4.  Contrast-enhanced computed tomogram showing a renal tumor in the right kidney (case 2).Laparoscopic radical nephrectomy39bloc removal of the kidney and ipsilateral adre-nal gland together with the perinephric fatty tis-sue and Gerota’s fascia, and dissection of thelymph nodes.Since the initial report of laparoscopic ne-phrectomy by Clayman et al. (1991), laparo-scopic nephrectomy has become accepted as aminimally invasive procedure for benign, and,more recently, for malignant renal disease.The benefits for patients undergoing alaparoscopic nephrectomy rather than an opennephrectomy include a briefer postoperativecourse with reduced pain and analgesic require-ments, earlier oral intake and mobilization, ashorter hospital stay and convalescence, andbetter cosmetic results (Rassweiler et al., 1998;Abbou et al., 1999; Hemal et al., 1999; Fornara etal., 2001).Laparoscopic radical nephrectomy is mostlydone via the transperitoneal approach becauseof a larger working space and well-recognizedanatomic landmarks.  Gaur (1992) reported thecreation of an adequate working space in the re-troperitoneum using the blunt balloon dissec-tion technique.  This led to an increased interestin the retroperitoneal approach for laparoscopicnephrectomy.  Since the kidney is a retroperito-neal organ, the retroperitoneal approach pro-vides several potential advantages.  In this ap-proach, the renal hilum is initially exposed,allowing for early control of the renal vessels.The risk of intraperitoneal organ injury is verylow compared to the transperitoneal approach.In laparoscopic radical nephrectomy, speci-men removal can be performed 2 differentways; intact removal performed by extendingthe incision at 1 of the port sites, or morcellationafter the specimen has been placed in an entrap-ment sac.  Intact removal of the specimen withor without an entrapment sac requires extensionof the incision (Gill et al., 2000; Cicco et al.,2001).  A larger incision, even in a longitudinalmuscle-splitting fashion (Savage and Gill,2001), may reduce the advantages of laparo-scopic surgery.  Morcellation can be performedwith a high-speed electrical tissue morcellator(Kavoussi et al., 1993) or mechanical clampand forceps (Ono et al., 2001).  However, thismaneuver introduces the risk of seeding of thetumor cell at the port sites, and disseminationinto the working space.  In addition, preciseevaluation of the surgical margins, which isdependent on pathological examination of theintact specimen, may be difficult because of tis-sue morcellation.In our department, simultaneous adrenalec-tomy during open radical nephrectomy is notroutinely performed, except for large, upperpole tumors (Kadowaki and Miyagawa, 2001).Paul et al. (2001) reported a total of 866 con-secutive patients who underwent nephrectomyand ipsilateral adrenalectomy with a solitaryadrenal metastasis of only 6 (0.6%).  They sug-gested that if the maximum tumor size mea-sured by CT is less than 8 cm, and when a stag-ing examination does not show organ or lymphnode metastases, adrenalectomy is not neces-sary.In this series, we did not perform regionallymph node dissection.  Although regionallymph node dissection provides for more pre-cise staging of the disease, its therapeutic valueremains controversial.  Minervini et al. (2001)suggested that there is no clinical benefit interms of overall outcome in undertaking region-al lymph node dissection in the absence of en-larged nodes detected before or during surgery.At present, our policy is to restrict retroperito-neal laparoscopic radical nephrectomy to tu-mors less than 7 cm, and neither regional lymphnode dissection nor ipsilateral adrenalectomy isperformed during the procedure.There are few reports concerning the long-term disease-free outcome of laparoscopicradical nephrectomy (Cadeddu et al., 1998; Onoet al., 2001).  Ono et al. (2001) evaluated theefficacy of laparoscopic radical nephrectomy.One-hundred and three patients who had renaltumors less than 5 cm in diameter underwentlaparoscopic radical nephrectomy.  During amedian follow-up period of 29 months (range 3to 95 months), the seeding of port sites did notoccur in any of the patients.  Metastatic diseasedeveloped in 3 patients, and local recurrence in1 patient.  The 5-year disease-free and patientsurvival rates were 95.1% and 95.0%, respec-tively.  These rates were comparable to those inpatients who underwent open surgery.T. Isoyama et al.40Outcome data were retrospectively com-pared between groups of patients treated bet-ween March 1998 and August 2001 at our de-partment clinic of Tottori University Hospital:the 2 initial patients undergoing laparoscopicradical nephrectomy versus 16 patients with lo-calized disease undergoing open radical ne-phrectomy (Table 1).  Mean tumor size was2.95 cm in the laparoscopic group and 3.50 cmin the open group (P = 0.52).  Outcome analysisrevealed that both groups were comparable inregard to operative time (207.5 min versus210.4 min).  However, the laparoscopic groupshowed lower blood loss (P < 0.05) and earlierpostoperative oral intake (P < 0.05).Although a long-term follow-up is neces-sary to evaluate the efficacy of this procedure, itTable 1.  Results of retroperitoneal laparoscopic versus open radical nephrectomyPa- Age Sex Side Opera- Esti- Tumor Patholog- Anal- Post- Hospitaltient tive mated size ical gesia operative staynumber time blood loss (cm) diagnosis (day) oral intake (day)(min) (mL) (stage/grade)† (day)Retroperitoneal laparoscopic radical nephrectomy  1 65 M Rt 220 10 2.4 pT1a/G2 3 1 31  2 54 F Rt 195 115 3.5 pT1a/G2 2 1 17Mean 59.5 207.5 62.5 2.95 2.5 1 24Open radical nephrectomy  1 63 M Lt 220 235 3 pT1a/G2 17 4 27  2 59 F Lt 185 110 4.5 pT1b/G2 4 2 33  3 73 F Rt 185 260 3 pT1a/G2 7 3 18  4 43 M Rt 142 90 2 pT1a/G2 9 5 31  5 62 M Lt 235 530 3.3 pT1a/G2 2 8 24  6 71 M Lt 180 220 2.9 pT1a/G2 3 4 16  7 59 M Rt 205 385 3.5 pT1a/G2 3 3 56  8 47 F Rt 210 250 3.6 pT1a/G2 2 2 14  9 39 M Rt 180 190 3 pT1a/G2 3 4 1710 77 F Rt 305 145 4.5 pT1b/G2 5 5 1111 72 M Rt 200 220 4.4 pT1b/G2 1 2 1612 63 F Rt 285 220 4 pT1b/G2 4 3 3413 51 F Rt 180 680 6 pT1b/G2 3 3 3514 66 F Lt 260 1150 3 pT1a/G2 4 2 3215 83 M Lt 160 440 3 pT1a/G1 5 2 1616 57 M Lt 235 500 2.3 pT3a/G2 4 3 33Mean 61.6 210.4 351.6 3.5 4.8 3.4 25.8F, female; Lt, left; M, male; Rt, right.*P < 0.05 compared by the Mann-Whitney test.†According to the general rule for clinical and pathological studies on renal cell carcinoma (JapaneseUrological Association, The Japanese Society of Pathology and Japanese Radiological Society, 1999).will probably become a standard treatmentmodality for localized renal cell carcinoma.Acknowledgments:  Special thanks to Drs. YoichiArai and Koji Yoshimura, Department of Urology,Kurashiki Central Hospital, for their kind advice onthe surgical technique.References 1 Abbou CC, Cicco A, Gasman D, Hoznek A,Antiphon P, Chopin DK, et al.  Retroperitoneal lapa-roscopic versus open radical nephrectomy.  J Urol1999;161:1776–1780. 2 Cadeddu JA, Ono Y, Clayman RV, Barrett PH,Janetschek G, Fentie DD, et al.  Laparoscopic ne-* *Laparoscopic radical nephrectomy41phrectomy for renal cell cancer:  evaluation of ef-ficacy and safety:  a multicenter experience.  Urolo-gy 1998;52:773–777. 3 Cicco A, Salomon L, Hoznek A, Saint F, AlameW, Gasman D, et al.  Results of retroperitoneallaparoscopic radical nephrectomy.  J Endourol2001;15:355–359. 4 Clayman RV, Kavoussi LR, Soper NJ, DierksSM, Meretyk S, Darcy MD, et al.  Laparoscopicnephrectomy:  initial case report.  J Urol 1991;146:278–282. 5 Fornara P, Doehn C, Friedrich HJ, Jocham D.Nonrandomized comparison of open flank versuslaparoscopic nephrectomy in 249 patients withbenign renal disease.  Eur Urol 2001;40:24–31. 6 Gaur DD.  Laparoscopic operative retroperito-neoscopy:  use of a new device.  J Urol 1992;148:1137–1139. 7 Gill IS, Schweizer D, Hobart MG, Sung GT,Klein EA, Novick AC.  Retroperitoneal laparo-scopic radical nephrectomy:  the Cleveland clinicexperience.  J Urol 2000;163:1665–1670. 8 Hemal AK, Talwar M, Wadhwa SN, Gupta NP.Retroperitoneoscopic nephrectomy for benigndiseases of the kidney:  prospective nonrandom-ized comparison with open surgical nephrectomy.J Endourol 1999;13:425–431. 9 Japanese Urological Association, The JapaneseSociety of Pathology and Japanese RadiologicalSociety.  General rule for clinical and pathologi-cal studies on renal cell carcinoma.  The 3rd edi-tion.  Tokyo: Kanehara; 1999.10 Kadowaki H, Miyagawa I.  Radical nephrectomy.Rinsho Hinyokika 2001;55:27–32.11 Kavoussi LR, Kerbl K, Capelouto CC, McDougallEM, Clayman RV.  Laparoscopic nephrectomy forrenal neoplasms.  Urology 1993;42:603–609.12 Minervini A, Lilas L, Morelli G, Traversi C,Battaglia S, Cristofani R, et al.  Regional lymphnode dissection in the treatment of renal cell carc-inoma:  is it useful in patients with no suspectedadenopathy before or during surgery?  BJU Int2001; 88:169–172.13 Ono Y, Kinukawa T, Hattori R, Gotoh M, KamihiraO, Ohshima S.  The long-term outcome of laparo-scopic radical nephrectomy for small renal cellcarcinoma.  J Urol 2001;165:1867–1870.14 Paul R, Mordhorst J, Busch R, Leyh H, HartungR.  Adrenal sparing surgery during radical ne-phrectomy in patients with renal cell cancer:  anew algorithm.  J Urol 2001;166:59–62.15 Rassweiler J, Frede T, Henkel TO, Stock C,Alken P.  Nephrectomy:  a comparative study be-tween the transperitoneal and retroperitoneallaparoscopic versus the open approach.  Eur Urol1998;33:489–496.16 Robson CJ.  Radical nephrectomy for renal cellcarcinoma.  J Urol 1963;89:37.17 Savage SJ, Gill IS.  Intact specimen extractionduring renal laparoscopy:  muscle-splitting ver-sus muscle-cutting incision.  J Endourol 2001;15:165–169.Received December 19, 2001; accepted January 17, 2002Corresponding author:  Dr. Tadahiro Isoyama

Retroperitoneal Laparoscopic Radical Nephrectomy for Renal Cell Carcinoma: A Report on 2 Initial Cases

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Retroperitoneal Laparoscopic Radical Nephrectomy for Renal Cell Carcinoma: A Report on 2 Initial Cases

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