Operative Techniques and Outcomes in Laparoscopic Radical Nephrectomy

Abstract

Laparoscopic Radical Nephrectomy (LRN) is one of the commonest minimal access urological surgical procedures for renal malignancies. The procedure involves the complete removal of the affected kidney, together with the adrenal gland and surrounding Gerota’s fascia along with the ureter as distal as possible. Advantages of LRN includes decreased intra-operative blood loss, decreased post operative pain, speedy recovery and decreased duration of hospital stay. This chapter aims to describe all the operative steps in an illustrated manner and also to highlight the difficulties which may be encountered by beginners and how to troubleshoot the various difficulties and complications during the procedure.

1. Introduction

Renal malignancy is amongst the 10 most commonly diagnosed cancers in both males and females [1]. It is twice more common in men than in women [2]. Surgery is the mainstay of management for localized renal cell carcinoma (RCC). Open radical nephrectomy (ORN) was first described in the 1960s [3, 4]. But the first report of laparoscopic radical nephrectomy (LRN) for a small renal mass was published in 1991 [5]. Since this initial report in 1991, minimal access urological surgery has revolutionized the surgical management of renal cancer [5]. Laparoscopic Nephrectomy (LRN) has now become the mainstay of management of renal masses.

2. Indications

Initially, LRN was preferred for small renal tumors (<4 cm); however, with increasing experience, LRN has been adopted as the standard of care for larger renal tumors as well with good perioperative and oncological outcomes [1].

LRN is now also considered for large or central renal masses where a nephron-sparing surgery is not possible [1].

Other indications are Cytoreductive nephrectomy for metastatic renal carcinoma and RCC with IVC thrombus [1].

Traditionally, radical nephrectomy involved removal of the entire kidney along with Gerota’s fascia and the perinephric fat and ipsilateral adrenal gland. The modern radical nephrectomy now allows for adrenal-sparing radical nephrectomy if there is no clinical evidence of adrenal gland invasion or metastasis [1].

3. Preoperative evaluation

Initial evaluation is done with Ultrasonography (USG) and Contrast enhanced Computed Tomography (CECT) for the exact site, size of renal cell carcinoma, extension beyond Gerota’s fascia, liver secondaries, Inferior Vena cava (IVC) involvement and hilar lymphadenopathy. Routine blood investigations – complete blood counts, liver function tests and renal function tests is necessary to assess the contralateral renal function and fitness for surgery. X ray or CT of the chest is required for the assessment of pulmonary metastasis. A bone scan is done for patients with elevated serum calcium or alkaline phosphatase levels and in those with symptomatic bone pain. If renal vein/IVC tumor thrombus is suspected, it needs appropriate evaluation by Magnetic Resonance Imaging (MRI), or three-dimensional CT preoperatively [6].

4. Operative steps

4.1 Patient positioning and port placement

The patient is kept nil by mouth for 8 hours before the scheduled surgery. Under General Anesthesia, nasogastric tube is placed and the bladder is catheterized. Preoperative injectable antibiotics, preferably third generation Cephalosporins are given.

The patient is placed in ipsilateral kidney position at an angle of 45 degrees and the kidney bridge of the operating table is raised. The patient is secured to the table with upper leg kept extended while lower leg flexed with a pillow between the legs. The arms rest comfortably with padding. The operating surgeon and camera person are on the left side of the patient and the monitor is kept on the right side of the patient at the level of eyes of the surgeons.

Following ports are placed as shown in Figure 1 for right side and in Figure 2 for left side LRN:

• 10-mm camera port is placed 3–4 cm cranial and lateral to umbilicus depending on patient habitus.

• 2 working ports 10 mm and 5 mm as shown in Figure 1.

• One 5-mm port is placed distal to xiphisternum for liver retraction in right side radical nephrectomy.

Figure 1.

Port placement for right side laparoscopic radical nephrectomy (Hollow circles: 10 mm ports and Solid circles: 5 mm ports).

Figure 2.

Port placement for left side laparoscopic radical nephrectomy (Hollow circles: 10 mm ports and Solid circles: 5 mm ports).

4.2 Transperitoneal approach

1. Reflection of the colon: Along the white line of Toldt, the colon is reflected medially across the midline for adequate visualization of anterior surface of Gerota’s fascia (Figures 3 and 4). On right side, duodenum is kocherized until IVC is clearly visualized.

2. Dissection of renal hilum:

   1. Right side: Liver is retracted by atraumatic grasper placed through an extra 5-mm port distal to xiphisternum followed by isolation and dissection of lower pole of kidney with ureter. This is followed by creation of plane between upper pole of kidney and adrenal gland thereby creating an upper window proximal to renal vein (Figure 5). Dissection of right renal vein in relation to IVC is then done by blunt and share dissection using energy source (Figure 6). Thus the right renal vein is dissected circumferentially. The right renal artery which lies inferior and posterior to the right renal vein is then dissected (Figure 7) and clipped with two haem-o-lok clips proximally and two distally. After clipping of renal artery, renal vein is clipped with two haem-o-lok clips proximally and two distally.

   2. On the Left side: On left side, after the lower pole is isolated gonadal vein is identified and dissected cranially to find the left renal vein (Figure 8). After the renal vein is seen, lumbar vein is identified and clipped for identification renal artery which lies posterior to it. This is followed by creation of upper window proximal to renal vein by clipping of adrenal vein. The right renal artery which lies inferior and posterior to the right renal vein is dissected (Figure 9) and clipped with two haem-o-lok clips proximally and with two distally. After clipping of renal artery, renal vein is clipped with two haem-o-lok clips proximally and two distally.

3. This is followed by dissection of all fibro fatty tissues with lymph nodes around the renal hilum.

4. The kidney is then mobilized with Gerota’s fascia from surrounding structures. The separation of kidney from lateral abdominal wall is done at last so that specimen does not fall in the operative field.

5. Dissection of the ureter: The gonadal vein and ureter are both identified over ipsilateral psoas muscle. The ureter is elevated from the psoas muscle, clipped and divided. Hemostasis is assured and a drain is kept at renal hilum.

6. Specimen is kept in an endobag for retrieval to prevent port site metastasis and delivered through a small muscle-splitting incision in the right iliac fossa or through an incision between two port-sites.

7. All port sites are irrigated with normal saline and closed with Vicryl and Ethilon sutures.

Figure 3.

Intra-operative image depicting mobilization of colon on left side.

Figure 4.

Intra-operative image depicting the Gerota’s fascia on left side.

Figure 5.

Intra-operative image depicting the dissection of right renal superior pole from liver.

Figure 6.

Intra-operative image depicting dissection of right renal vein from IVC.

Figure 7.

Intra-operative image depicting right hilar dissection.

Figure 8.

Intra-operative image depicting dissection of left renal vein and its branches.

Figure 9.

Intra-operative image depicting left renal artery with psoas window.

4.3 Retroperitoneoscopic LRN

Retroperitoneoscopic radical nephrectomy may be considered in selected patients – history of multiple transperitoneal open surgical procedures, peritoneal dialysis, pregnancy and morbid obesity. In pregnancy, a retroperitoneoscopic surgery may minimize peritoneal and uterine irritation and the risk of preterm labour [7]. In morbidly obese patients, the retroperitoneoscopic approach may help by avoiding abdominal pannus and voluminous visceral fat encountered during transperitoneal approach [8].

Under general anesthesia with end tidal CO₂ monitoring under cover of prophylactic antibiotics, the patient is positioned in the same way as above. The surgeon and camera person stand on ipsilateral side of the patient while the assistant on opposite side of the patient. Initial access is obtained by open (Hasson’s technique). A 10–12 mm incision is made in the lumbar (Petit’s) triangle below the 12th rib at the lateral border of paraspinal muscle [9]. The muscle fibers are carefully separated and retroperitoneum is entered by gently piercing the thoracolumbar fascia with tip of an artery forceps. A balloon dilator is then inserted into the opening. Distention of the balloon with air rapidly and atraumatically displaces the adjacent fat and peritoneum, thereby creating an adequate working space for retroperitoneoscopic surgery within that area. A 10 mm port is then placed in this opening and used as camera port. The 2nd and 3rd ports were then inserted under direct vision. The psoas muscle acts as a landmark and the posterior aspect of the kidney is reached first and the pulsating renal artery is identified at the hilum. The renal hilum is dissected, the renal vein and renal artery cleared of fat and clipped using haem-o-lok clips and vessels divided. Further dissection of kidney is then continued separating it from the surrounding fat. The ureter is then clipped and divided; the specimen is retrieved by incising one of the port sites and increasing it to 2.5–3 cm. A drain is left in the retroperitoneum.

5. Post-operative recovery

The nasogastric tube is removed after the procedure. Postoperatively, the patient’s vitals, urine and drain output are monitored. Orals are started the next day and Foley’s catheter is removed once the patient is comfortably ambulating. The drain is then removed and patient is discharged. An unrestricted activity is usually resumed according to the patient’s comfort.

6. Technical considerations

6.1 Transperitoneal vs. retroperitoneal laparoscopic nephrectomy

The advantages of a transperitoneal approach include a wider working space and more easily identifiable anatomical landmarks. However, it also requires bowel mobilization and adhesiolysis in cases of previous transperitoneal abdominal surgery. The retroperitoneal approach, on the other hand, allows extra-peritoneal dissection and direct access to the renal hilum while avoiding the need for bowel mobilization and adhesiolysis. Limitations of this approach include the smaller working area in the retroperitoneal space, and reduced traction and instrument mobility.

A few technical considerations are particularly important with the retroperitoneoscopic approach. Proper balloon dilation in avascular plane between the psoas fascia posteriorly and Gerota’s fascia anteriorly is necessary to mobilize the Gerota’s fascia and expose the psoas muscle, the ipsilateral peritoneal reflection, the ureter, the IVC on the right side and the aortic pulsations on the left side. After balloon dilation, the renal hilum is readily accessible and thus the size of the renal mass or kidney is not a significant issue during the hilar dissection. Mobilization of the specimen along avascular planes is important to further develop and enlarge the retroperitoneal space as the dissection proceeds.

6.2 The lower pole approach in retroperitoneoscopic radical nephrectomy

In routine retroperitoneal LRN, renal vessels at the hilum are accessed by the latero-posterior space (LPS). Using this approach, the dissection of latero-conal fascia and quadratus lumborum fascia allows the entry into avascular area, bounded by the quadratus lumborum, the psoas major, and Gerota’s fascia for the purpose of renal pedicular control [10]. However, the narrow space of manipulation is intrinsically subject to poor anatomical identification and a greater risk of renal pedicle injury especially in patients with obesity, larger tumors, or renal pedicle adhesions. Yuan et al., in 2018, published a new technique, the lower pole (LP) approach for the control of renal pedicular vessels in retroperitoneal LRN [11]. In this approach, The dissection of the renal latero-anterior space preceded that of the LPS. Upon the establishment of the working space the anterior and posterior renal fasciae were transected 3.0 cm below the lower pole [11].

While a retrospective comparative study suggested improved operation times, blood loss, and time to commencement of diet with retroperitoneal LRN [12]; Recently published articles with prospective randomized series demonstrated no statistically difference in the overall operative morbidity in transperitoneal versus retroperitoneal radical nephrectomies [13, 14, 15, 16]. Nevertheless it is remarkable that the retroperitoneal group, compared to the transperitoneal approach, was associated with a shorter total time to control the renal artery and quicker control of the renal vein [13]. Most studies have demonstrated equal efficacy for both techniques and the choice of the retroperitoneal or transperitoneal approach depends mostly on surgeon’s experience and choice [13].

6.3 Removal of dissected specimen

This is another area of continued controversy -whether to morcellate or to remove the intact specimen with additional incision. We retrieve the specimen by additional incision using an endobag at our institute.

The major concern with morcellation is pathological interference and tumor spillage [17, 18, 19]. Although, Ono et al. have reported that proper morcellation does not hamper the pathological stage [20]. In a recent study, Varkarakis et al. stated that, intact extraction and morcellation are both acceptable options for specimen removal, and the choice should depend on surgeon and patient preferences [21].

6.4 Lymph node dissection

Lymphadenectomy has been reported to have no beneficial therapeutic effects in the treatment of renal cell carcinoma [13]; however, Ono et al. have reported the results of ipsilateral para-aortic lymph nodes in 25 patients with renal cell carcinomas of 5 cm or more in diameter [22] and they concluded that extended lymph node dissection could be conducted safely by the laparoscopic procedure [22].

6.5 Oncological results of laparoscopic radical nephrectomy: long-term cancer control

The concerns about oncological safety of LRN were expressed initially, as the initial published series had a limited mean follow-up of only 2 years. Nevertheless, the overall five-year disease free survival rates of laparoscopic radical nephrectomy in recent series were found to be over 90% [1]. All of the series at least confirmed the oncological efficacy of LRN as compared with open surgical approach [1].

7. Special scenarios

7.1 LRN for locally advanced tumors

LRN is effective for selected patients with locally advanced renal tumors with longer term data establishing oncological equivalence [23, 24].

7.2 Cytoreductive radical nephrectomy

LRN is also the effective modality for CRN for metastatic renal carcinoma as a part of multi-modality therapy.

7.3 Minimally invasive IVC tumor thrombectomy

Patients with Venous tumor thrombus (VTT) have a guarded prognosis with an estimated 1-year survival of 29% without surgery [25]. Aggressive surgical management with complete resection of tumor thrombus is the only treatment option that offers the potential for cure in these patients which is a technically and physically demanding procedure, and has traditionally been performed open surgically with significant associated risks of perioperative morbidity and mortality [1]. LRN has been used predominantly for level I–II thrombi [26, 27, 28, 29, 30, 31, 32, 33]. The procedure is technically demanding even in the hands of experienced laparoscopic surgeons in view of rigid instrumentation, restricted movements, transmitted physiological tremor, prolonged learning curve and more specifically difficulty in suture repair of the IVC and controlling major intra- abdominal bleeding [1].

8. Future perspectives

With increasing expertise in complex partial nephrectomy for large renal masses, the utility of LRN is likely to encompass now new and expanded indications due to the incremental clinical benefit provided by the robotic platform over pure laparoscopy. The excellent exposure provided by laparoscopy combined with the improved vision, magnification, dexterity and maneuverability of the robotic platform allows experienced surgeons to perform more complex and technical demanding procedures in a minimally invasive manner. The beginning of widespread availability of robotic technology is likely to drive utilization of robotic radical nephrectomy for complex renal malignancy cases including locally advanced renal cancer invading adjacent structures, cytoreductive surgery in metastatic renal cancer, retroperitoneal LND for bulky regional lymphadenopathy, and tumor thrombectomy for venous tumor thrombus extending to the vena cava [1].

9. Conclusion

The widespread uptake of minimally invasive approaches combined with ongoing evolution and refinement of surgical technique have resulted in significant improvements in peri-operative outcomes over the last three decades. Numerous studies confirm lower operative morbidity and improved perioperative outcomes with LRN compared to Open Radical Nephrectomy, specifically in terms of reduced post-operative pain, analgesic requirements, estimated blood loss, need for transfusions, length of hospital stay and more rapid convalescence and return to daily activities [34, 35, 36] without hampering the long-term oncological efficacy [37, 38]. LRN will thus continue to play a major role in renal malignancies till the robotic surgeries become widespread.

Conflict of interest

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