HAND-ASSISTED LAPAROSCOPIC RADICAL NEPHRECTOMY: COMPARISON TO OPEN RADICAL NEPHRECTOMY STEPHEN Y. NAKADA, PAUL FADDEN, DAVID F. JARRARD,
TIMOTHY D. MOON
ABSTRACT Objectives. Hand-assisted laparoscopic surgery is easier to learn than standard laparoscopy and simplifies intact specimen removal. We present our experience performing hand-assisted laparoscopic radical nephrectomy (HALRN) and compare it with contemporary open radical nephrectomy performed at our institution. Methods. We performed 18 HALRNs for renal tumors ranging in size from 2 to 11 cm (average 4.5). Patients ranged in age from 40 to 83 years (average 62.9). All patients underwent HALRN with intact removal through a 7 to 8-cm vertical midline incision through an impermeable wound protector. Two or three working ports were used. We retrospectively compared our results with the results of 18 open radical nephrectomies performed during the same period, with the patients matched for age, body mass index, and American Society of Anesthesiologists’ score. Results. In the HALRN group, the average operating room time was 220.5 minutes, average length of stay 3.9 days, average time to return to normal activity 15.8 days, and average time to return to work 26.8 days. The median time to return to 100% normal was 28.0 days. No conversions or re-explorations were necessary in the HALRN series. The final pathologic examination revealed renal cell carcinoma in 15, oncocytoma in 1, angiomyolipoma in 1, and a complex cyst in 1. At a maximum of 48 months of follow-up (average 12.2), no recurrences were identified. Three deaths occurred in the series; 2 patients died with no evidence of disease and 1 patient died of metastatic disease (the nephrectomy was palliative). In the open group, the average operating room time was 117.8 minutes, average length of stay 5.1 days, average time to return to normal activity 23.5 days, and average time to return to work 52.2 days. The median time to return to 100% normal was 150 days, with 3 patients never returning to 100% normal. Conclusions. Our series demonstrated that HALRN is a safe, effective, minimally invasive option for treating renal cell carcinoma and provides a shorter hospital stay (P ⫽ 0.02), earlier return to work (P ⫽ 0.04), and earlier return to 100% normal (P ⫽ 0.0002) than open radical nephrectomy. UROLOGY 58: 517–520, 2001. © 2001, Elsevier Science Inc.
e first reported on hand-assisted laparoscopic radical nephrectomy (HALRN) performed using the PneumoSleeve (Dexterity, Blue Bell, Pa) in 1997, with the belief that hand assistance would be a useful adjunct to renal organ ablative laparoscopy.1 Since then, urologists have reported series of hand-assisted laparoscopic surgery (HALS) for radical nephrectomy, partial nephrec-
From the Department of Surgery, Division of Urology, University of Wisconsin Medical School, Madison, Wisconsin Reprint requests: Stephen Y. Nakada, M.D., Department of Surgery, Division of Urology, University of Wisconsin Medical School, 600 Highland Avenue, G5/343 Clinical Science Center, Madison, WI 53792-3236 Submitted: April 3, 2001, accepted (with revisions): June 13, 2001 © 2001, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
tomy, nephroureterectomy, and donor nephrectomy.2–9 We believe that HALS probably adds little morbidity to standard laparoscopy when a specimen is removed intact, because an incision must be made regardless of the approach. Although several longterm series have shown the efficacy and safety of morcellating laparoscopic radical nephrectomy specimens in situ in an entrapment sack, the development of HALS simplified intact removal of renal tumors.10,11 HALS has also simplified laparoscopic management of larger renal tumors while maintaining the benefits of a minimally invasive procedure.5,8 We present a retrospective comparison of 18 HALRN and 18 open radical nephrectomy (ORN) cases at our institution during the same period. 0090-4295/01/$20.00 PII S0090-4295(01)01321-8 517
TABLE I. Preoperative data, HALRN vs. ORN Age (yr) Sex (M/F) Side (L/R) BMI ASA score Tumor size (cm) Specimen weight (g)
62.9 10/8 9/9 29.8 2.6 4.5 402.2
61.2 12/6 9/9 30.4 2.5 6.4 601.3
NS NS NS NS NS 0.02 0.02
KEY: HALRN ⫽ hand-assisted laparoscopic radical nephrectomy; ORN ⫽ open radical nephrectomy; NS ⫽ not significant; M/F ⫽ male/female; L/R ⫽ left/right; BMI ⫽ body mass index; ASA ⫽ American Society of Anesthesiologists’.
MATERIAL AND METHODS PATIENT DATA AND DATA ANALYSIS The patient age, body mass index, American Society of Anesthesiologists’ score, and tumor size were reviewed in 18 patients undergoing HALRN and compared with 18 patients who underwent ORN; all patients underwent surgery at our institution during the same period (April 1997 to October 2000). The 18 ORN patients were from selected from a total of 60 patients undergoing open nephrectomy. Eighteen patients (10 men and 8 women) underwent HALRN for renal tumors ranging in size from 2 to 11 cm (average 4.5) (Table I). All patients underwent computed tomography and were found to have a clinically localized functioning renal mass in all cases but one. In this case, the patient had metastatic disease, and nephrectomy was performed for palliative purposes, because the patient had flank pain and gross hematuria. Eighteen patients (12 men and 6 women) underwent ORN for renal tumors ranging from 3 to 11 cm (average 6.4). The operating room time, amount of blood loss, length of hospital stay, analgesic use, and complication incidence were verified from the patient records (Table II). All the patients were contacted retrospectively by telephone by a nonbiased researcher unaware of the type of procedure performed and asked when they returned to normal, nonstrenuous activity, to work, and when they felt 100% recovered. The comparisons of age, blood loss amount, operating room time, hospital stay length, and time to return to normal, nonstrenuous activity, driving, and work were performed using the Wilcoxon ranksum test. Because certain patients did not feel 100% recovered at the time of follow-up, a log-rank test was used to determine whether any differences in the time to reach 100% recovery existed between the two groups. All analyses were performed using Statistical Analysis System statistical software (SAS Institute, Cary, NC).
METHODS HALRN was performed as described previously.3 We used a modified lateral position, with minimal kidney rest elevation, mild table flex, and ample padding of all pressure points. A vertical, 7 to 8-cm supraumbilical incision was made, and a hand-assist device, either the PneumoSleeve (Dexterity) or the Handport (Smith and Nephew), was used (Fig. 1). Two to three additional trocars were placed, as previously described (Fig. 2). Right-handed surgeons inserted their left hand for a left HALRN. The right HALRNs were performed either by left-handed surgeons inserting their right hand or righthanded surgeons inserting their left hand and adding a trocar in the upper midclavicular line. In brief, after attaining the pneumoperitoneum and placing the trocars, the colon was reflected medially, and the upper pole attachments, including either the splenic or hepatic at518
tachments to the kidney, were taken down. The lateral attachments were freed and the lower pole and ureter identified. After control and division of the ureter and gonadal vein, these structures were traced to the renal vein. The renal vein was identified and dissected free anteriorly, and then the kidney was flipped medially to facilitate dissection of the renal artery. We either divided the artery between multiple clips or more recently, used a single application of the endoscopic gastrointestinal stapler, vascular load (Ethicon Endosurgery, Cincinnati, Ohio). The kidney was then reflected back laterally, and the renal vein was divided using the endovascular stapler. The specimen was removed intact through the vertical hand port device without using an entrapment sac. Open radical nephrectomy was performed through either a standard flank approach or a subcostal approach. Patients undergoing partial nephrectomy, rib resection, caval exploration, or the thoracoabdominal approach were excluded from this study.
RESULTS In the HALRN group, the average operating room time was 220.5 minutes, average length of stay 3.9 days, average time to return to normal activity 15.8 days, and average time to return to work 26.8 days. The median time to return to 100% normal was 28.0 days, with 1 patient never returning to 100% normal (Table II). No conversions or re-explorations were required in the HALRN series. The final pathologic examination revealed renal cell carcinoma in 15 patients, oncocytoma in 1, angiomyolipoma in 1, and a complex cyst in 1 patient. At a maximum follow-up of 48 months (average 12.2), no recurrences had been identified, excluding the 1 patient undergoing palliative nephrectomy. Three patients in the series died; 2 patients had no evidence of disease and died at least 6 months postoperatively of causes unrelated to the procedure, and 1 patient died of metastatic disease (the nephrectomy was palliative). In the open group, the average operating room time was 117.8 minutes, average length of stay 4.7 days (P ⫽ 0.02), average time to return to normal activity 23.5 days, and average time to return to work 53.3 days (P ⫽ 0.04). The median time to return to 100% normal was 150 days, with 3 patients never returning to 100% normal (P ⫽ 0.0002). All patients had renal cell carcinoma in the open group. In the HALRN group, 3 patients had incomplete return to work and 100% recovery data because of a lack of follow-up (deaths). In the open group, 6 patients did not have return to work data because they were retired. No recurrences or deaths were identified at an average follow-up of 8.2 months in this group. In the HALRN group, 1 patient developed an incarcerated inguinal hernia of the omentum postoperatively and required surgical repair. One patient developed mild congestive heart failure postoperatively, and one had difficulty voiding and required a Foley catheter for 1 week postoperatively. No patients in the HALRN group required transfusion. UROLOGY 58 (4), 2001
TABLE II. Intraoperative and postoperative data, HALRN vs. ORN HALRN OR time (min) 220.5 (52.7) EBL (mL) 170.8 (130.9) Hospital stay (days) 3.9 (1.6) Time to normal, nonstrenuous activity 15.8 (8.6) (days) Time to return to work (days) 26.8 (23.4) Time to 100% recovered (days) 28.0† Follow-up period (mo) 12.2 (14.6)
118.2 (41.8) 237.50 (152.4) 4.7 (0.9) 22.7 (14.9)
0.0001* 0.2708 0.0174* 0.1897
53.3 (32.0) 150.0† 8.2 (6.2)
0.0350* 0.0002* 0.9616
KEY: OR ⫽ operating room; EBL ⫽ estimated blood loss; other abbreviations as in Table I. Data in parentheses are the standard deviation. * Significantly different. † Median, log-rank test.
FIGURE 2. PneumoSleeve and two trocars during left hand-assisted radical nephrectomy.
epidural catheter for pain control. The remaining 10 patients used an average of 245 mg intravenous morphine equivalents and 3.9 mg oral morphine equivalents during hospitalization. FIGURE 1. Hand device placement and trocar positions for left hand-assisted radical nephrectomy, with a right-handed surgeon. LMCL ⫽ lower mid-clavicular line; LAAL ⫽ lower anterior axillary line.
Although the hand-assist devices did leak routinely, it was not enough to limit the operation in any case. In the open group, 1 patient had a wound infection and required wet-to-dry dressings for 2 weeks, and one had a prolonged ileus. One patient complained of significant flank muscle weakness, which had not completely resolved at last followup. One patient in the open group also required a transfusion. HALRN patients used on average 32.4 mg intravenous morphine equivalents and 4.5 mg oral morphine equivalents during hospitalization. In the open group, 8 (44%) of the 18 patients used an UROLOGY 58 (4), 2001
COMMENT Since the initial report of laparoscopic nephrectomy in 1991, urologists’ enthusiasm for laparoscopic renal surgery has been less than anticipated.12 The lack of adequate training cases, the steep learning curve, the prolonged operating room time, and limited reimbursement have all hindered the growth of laparoscopic urology. However, the ease of the skill transfer of HALS has been such that 45% of urologists attending an HALS course have already performed hand-assisted nephrectomy.13 Early posterior control of the renal artery has been a useful technical maneuver when performing HALS radical nephrectomies and is simplified by hand assistance because the kidney can be easily flipped.3 Hand assistance has also proved effective in managing larger renal lesions.5,8 We have preferred to used a vertical midline incision in all cases to allow a more secure closure. Other investigators have used other hand port and trocar locations with 519
good success.4,5 The handedness of the surgeon, as well as the hand and arm length of the surgeon, play a role in the placement of the hand device. In our series, HALRN took longer than ORN (P ⫽ 0.0001); however, the HALRN patients had a shortened hospital stay (P ⫽ 0.03). The HALRN patients returned to work sooner (P ⫽ 0.04) and felt “back to 100% normal” significantly (P ⫽ 0.0002) earlier than patients undergoing ORN. Although not statistically significant, a trend toward an earlier return to normal activity (15.8 days versus 23.8 days) was identified in the HALRN group. Although our follow-up data were limited for both groups, no evidence has been found to suggest a difference in the oncologic efficacy between the two operations. Significant advantages in the time to return to work and to return to 100% recovery were demonstrated in the HALRN group compared with the ORN group. We believe that the use of hand assistance in renal laparoscopy has benefits whenever intact removal of a specimen is indicated. In fact, hand assistance has benefits for the operating surgeon whenever laparoscopic nephrectomy is considered. In time, the precise relationship between HALS and standard laparoscopy will become clearer. ACKNOWLEDGMENT. To Glen Leverson for statistical analysis, Joy Schluckebier for data acquisition, and Nick Weber for figure preparation. REFERENCES 1. Nakada SY, Moon TD, Gist M, et al: Use of the PneumoSleeve as an adjunct in laparoscopic nephrectomy. Urology 49: 612– 613, 1997.
2. Tanaka M, Tokuda N, Koga H, et al: Hand assisted laparoscopic radical nephrectomy for renal carcinoma using a new abdominal wall sealing device. J Urol 164: 314 – 318, 2000. 3. Nakada SY: Techniques in endourology— hand-assisted laparoscopic nephrectomy. J Endourol 13: 9 –14, 1999. 4. Stifelman MD, Sosa RE, Andrade A, et al: Hand-assisted laparoscopic nephroureterectomy for the treatment of transitional cell carcinoma of the upper urinary tract. Urology 56: 741–747, 2000. 5. Stifelman MD, Sosa ER, and Shichman SJ: Hand-assisted laparoscopic radical nephrectomy for large (⬎5 cm) and very large (⬎10 cm) renal tumors. J Endourol 14(suppl 1): A30, 2000. 6. Seifman BD, Montie JE, and Wolf JS: Prospective comparison between hand-assisted laparoscopic and open surgical nephroureterectomy for urothelial cell carcinoma. Urology 57: 133–137, 2001. 7. Wolf JS, Seifman BD, and Montie JE: Nephron sparing surgery for suspected malignancy: open surgery compared to laparoscopy with selective use of hand assistance. J Urol 163: 1659 –1664, 2000. 8. Wolf JS Jr, Moon TD, and Nakada SY: Hand assisted laparoscopic nephrectomy: comparison to standard laparoscopic nephrectomy. J Urol 160: 22–27, 1998. 9. Wolf JS, Marcovich R, Merion RM, et al: Prospective, case matched comparison of hand assisted laparoscopic and open surgical live donor nephrectomy. J Urol 163: 1650 –1653, 2000. 10. Ono Y, Katoh N, Kinukawa T, et al: Laparoscopic radical nephrectomy: the Nagoya experience. J Urol 158: 719 – 723, 1997. 11. Dunn MD, Portis AJ, Shalhav AL, et al: Laparoscopic versus open radical nephrectomy: a 9-year experience. J Urol 164: 1153–1159, 2000. 12. Clayman RV, Kavoussi LR, Soper NJ, et al: Laparoscopic nephrectomy: initial case report. J Urol 146: 278 –282, 1991. 13. AUA News 2001; 6(1).
UROLOGY 58 (4), 2001