Complications of Laparoscopic Renal Surgery

Introduction

L aparoscopic surgery has emerged as a minimally invasive alternative to open surgery for many urologic pathologies including kidney disease. Laparoscopic procedures on kidneys are performed for both benign and malignant conditions. Laparoscopic techniques must, however, be regarded as a major surgery, because like open procedures these techniques are not free from risks or complications. We report on the complications of laparoscopic renal surgery by one surgeon assisted by resident and fellow staff at the University of Iowa.

Materials and Methods

Upon Institutional Review Board approval, we retrospectively reviewed the records of 421 consecutive laparoscopic renal procedures performed by a single surgeon (H.N.W.) assisted by rotating resident and fellow staff, between August 2001 and November 2008, which included 168 radical nephrectomies, 99 donor nephrectomies, 52 simple nephrectomies, 66 partial nephrectomies, and 36 nephroureterectomies. We gathered operative complication information and compared our results with published series. A modification of the Clavien classification system developed by Leventhal et al ¹ that describes procedure-related complications was used. Briefly, class 1 constitutes non–life-threatening complications; class 2, complications resulting in no residual disability; class 3, complications resulting in residual disability; and class 4, renal failure or death.

Results

We encountered 52 complications associated with 421 procedures, with an overall rate of 12.3% (Table 1). There were two open conversions (0.5%), both of which were elective because of failure to progress. There were two true intraoperative complications (0.5%): one Clavien class 4 (myocardial infarction) and one class 2 (pleurotomy). The patient who suffered an intraoperative myocardial infarction died on postoperative day 1. The patient with pleurotomy received a chest tube at the end of the renal procedure. There were 48 postoperative complications (11.4%). When graded by severity, 17 of 52 (32.7%) were grade 1, 33 of 52 (63.5%) grade 2, 1 of 52 (1.9%) grade 3, and 1 of 52 (1.9%) grade 4.

Simple nephrectomy had the lowest complication rate of 5.8% and all were minor (Clavien class 2). Donor nephrectomy and radical nephrectomy also had low complication rates of 9% and 11.9%, respectively. All donor nephrectomy and the vast majority of radical nephrectomy complications were minor (Clavien class 1 and 2). As mentioned earlier, one radical nephrectomy patient suffered an intraoperative myocardial infarction and died 1 day later (Clavien class 4), whereas another developed an incisional hernia at the kidney extraction site (Clavien class 3).

Although partial nephrectomy and nephroureterectomy patients had the highest complication rates of 18.2% and 22.2%, respectively, all were minor (Clavien class 1 and 2). Most of the partial nephrectomy complications involved delayed bleeding or urine leak. Nephroureterectomy complications involved wound problems, bowel issues, heart and lung comorbidities, and distal ureteral management difficulties.

Discussion

Laparoscopy has greatly changed the landscape in renal surgery worldwide in the past 15 years. Ever since the first laparoscopic nephrectomy by Clayman et al ² in 1991, urologists have strived to offer minimally invasive alternatives to patients for every renal operation previously done in an open fashion. Laparoscopic renal procedures have some definite advantages over their open counterparts, which include decreased postoperative pain, shortened hospital stay, improved cosmesis, quicker return to normal activity, and lower blood loss. ^3,4

Minimally invasive surgery does not, however, mean minimal risk for complications. ⁵ Laparoscopic injuries can have unusual presentations and potentially devastating sequelae. ^{6 –9} Most surgeons embarking on laparoscopic renal procedures begin with nephrectomy for benign and malignant kidney disease. ^{10 –15} Once surgeons gain experience in laparoscopic surgery, more complex renal procedures can be performed safely, including partial nephrectomy and nephroureterectomy. ¹⁶

Laparoscopic partial nephrectomy remains technically challenging; however, good cancer cure and renal function along with an acceptable complication rate are possible in experienced hands. ^{17 –21} Although laparoscopic simple nephrectomies in our series had the smallest complication rate of 5.8%, these cases can sometimes be more challenging than radical or partial nephrectomies because of severe adhesions and distortion from prior infection and scarring. ¹⁵ Our complication rates for simple, donor, and radical nephrectomies were relatively low (6–12%), whereas partial and nephroureterectomy rates were in keeping with larger series (18–22%). When looking at risk factors, it appeared that the type of operation was more closely associated with the complication rate than individual patient comorbidities.

Laparoscopic radical nephrectomy complications were fairly evenly split between wound issues and systemic problems such as ileus, pneumonia, and other medical complaints. Laparoscopic partial nephrectomy complications were mainly related to postoperative bleeding and urine leaks. Laparoscopic donor and simple nephrectomy complications were fairly evenly split between wound issues and gastrointestinal complaints of constipation and gastroenteritis and two occurrences of pulmonary emboli. Laparoscopic nephroureterectomy complications included an assortment of wound, bowel, lung, and heart issues along with problems relating to the management of the distal ureter.

Laparoscopic nephrectomy has been compared favorably with open nephrectomy in many areas including decreased blood loss, quicker convalescence, and lower complications. ^3,5 Large laparoscopic renal surgical series looking at all types of kidney surgery have reported complication rates of 12% to 22%. ^11,16 Laparoscopic nephrectomy for benign and malignant disease has a reported complication rate of 5.6% to 17%. ^{10 –15} Laparoscopic partial nephrectomy series have reported complication rates of 9% to 33%. ^4,17,18

Series comparing laparoscopic and open partial nephrectomies have shown higher complication rates in the laparoscopic group possibly owing to the increased technical challenge of the procedure and the learning curve. ^18,20,21 Robot-assisted technology may have an effect not only on the popularity of minimally invasive nephron sparing surgery but also on the learning curve and potentially decrease complication rates even further. ¹⁸

Careful informed consent is crucial in patients about to undergo any surgical procedure. Frequently, patients associate laparoscopic surgery not only with shortened convalescence and pain, but also with decreased chance for problems, both expected and unexpected. Preoperative counseling should include risks, benefits, options, alternatives, and possible complications of laparoscopic surgery. The discussion should also include the potential need to place a hand port or even open conversion should the need present itself. The vast majority of adverse events related to laparoscopic procedures are minor and leave no residual disability; however, more serious complications can occur. Thorough informed consent leads to more realistic patient expectations and lessens the chance for anger and possibly even claims should an adverse event occur.

Conclusions

Laparoscopic renal procedures have become a standard of care in the surgical treatment of benign and malignant kidney conditions. A minimally invasive technique does not, however, mean that laparoscopy is without the risk of complications. Patients should be thoroughly counseled preoperatively on the potential risks of laparoscopic renal surgery so that realistic patient expectations are maintained and postoperative satisfaction is enhanced. Our complication rates for laparoscopic renal procedures were comparable to that of published series. Most complications were minor and resulted in no residual disability. Although our surgeon was an experienced laparoscopist, favorable outcomes and low complication rates are possible for urologists with adequate training in laparoscopic renal procedures.