Pure Retroperitoneoscopic Surgery Versus Minimal Incision-Assisted Retroperitoneoscopic Surgery for Upper Urinary Tract Diseases

Abstract

Objectives:

We developed minimal incision-assisted retroperitoneoscopic surgery (MARP) in an attempt to pursue optimized patient-related benefits. We evaluated the clinical value of MARP for upper urinary tract diseases compared with pure retroperitoneoscopic surgery (PRPS).

Patients and Methods:

Between January 2003 and September 2008, PRPS and MARP were carried out in 338 and 85 patients, respectively. The upper urinary tract surgical procedures were defined as simple and complex procedures. We defined our experience from January 2003 to December 2005 as our early stage of PRPS learning curve. Our experience from January 2006 to September 2008 was defined as our late stage of PRPS learning curve. Patients' perioperative details were compared.

Results:

MARP was associated with shorter operative time for each complex procedure and with less frequent conversion to open surgery (2.4% vs. 11.3%, p = 0.023). A significantly greater proportion of MARP patients underwent complex procedures (81.2% vs. 49.1%, p < 0.001), and a significantly greater proportion of MARP were carried out at the early stage of PRPS learning curve (62.4% vs. 44.1%, p = 0.003). Estimated blood loss, hospital stay, the amount of analgesic use (diclofenac sodium suppository), and intraoperative and postoperative complications were comparable.

Conclusions:

MARP maintains the patient-related benefits of PRPS while allowing surgeons to perform more complex cases of upper urinary tract diseases and shortening the relevant operative time. It can be useful for cases in which the specimen is going to be extracted intact, when starting out learning retroperitoneoscopy, or when unable to progress the case using laparoscopic techniques.

Introduction

T he retroperitoneal approach provides a shorter and more direct access to the upper urinary tract lesions without interference from intra-abdominal structures.¹ In our unit we preferred to perform laparoscopic procedures through retroperitoneal access to treat upper urinary tract diseases. However, retroperitoneoscopic surgery requires a high degree of skill and extensive experience and therefore presents additional challenges over open surgery. Therefore, hand-assisted laparoscopy (HAL) has been introduced to urology in an attempt to combine the benefits of laparoscopy and open surgery. But HAL through a retroperitoneal route (HAR) with the patient in full flank position has been seldom reported in the literature. The main reason for preventing surgeons from performing HAR may be the limited advantage with this technique over other approaches. We therefore developed minimal incision-assisted retroperitoneoscopic surgery (MARP) for upper urinary tract diseases. The purpose of this study was to evaluate the clinical value of MARP and perform a comparative analysis with pure retroperitoneoscopic surgery (PRPS). To our knowledge, such a study has not yet been done.

Patients and Methods

The study protocol was approved by the author's institutional review board or ethics committee. Between January 2003 and September 2008, data were collected prospectively for all patients found to have upper urinary tract diseases and who underwent PRPS or MARP. We divided these upper urinary tract surgical procedures into two categories: simple and complex procedures. The former included cyst decortication, simple nephrectomy, and ureterolithotomy; the latter included complex nephrectomy because of giant hydronephrosis, infective nonfunctioning kidney, and renal-cell carcinoma, and reconstructive surgeries such as pyeloplasty and partial nephrectomy. We defined our experience of PRPS as two stages: from January 2003 to December 2005 as our early stage of PRPS learning curve and from January 2006 to September 2008 as our late stage of PRPS learning curve.

The selection for PRPS or MARP was determined by surgeon's experience, patients' characteristics, and disease and operative factors. In general, MARP was selected over PRPS when intact specimen removal was desired or when a difficult manipulation was anticipated. A three-port, balloon-dissecting, retroperitoneal approach, as previously described,² was used in both groups. The MARP technique differed from the PRPS in that the difficult dissection and anastomosis were performed using surgeon hands under endoscopic guidance. Briefly, the position of the patient, retroperitoneal space establishment, trocar site selection, and endoscopic manipulations were similar in both groups. In the MARP group, the most challenging manipulation thought by surgeons remained behind when most of surgical steps had been completed. Consequently, a 7–8-cm incision was made at the site where it was the shortest distance to the surgical field of interest. Laparoscope was still placed in the primary port or the other two ports. In other words, MARP procedure was divided two parts. The first part was the same as pure retroperitoneoscopy, whereas the second part was similar to conventional open surgery. The procedures in the second part were carried out under the guidance of both endoscopic and direct vision. Through the minimum incision, wide surgical fields were created by dissecting anatomical planes using specialized long retractors and spatulas. We can carry out the remaining procedures more efficiently and quickly under the control of our hands, which seemed to be difficult to be completed by laparoscopy.

Patients' details including age, height, weight, and sex were collected prospectively, starting at the initial clinic assessment. Details during and after surgery, including operative time, intraoperative estimated blood loss, postoperative hospital stay, analgesic requirements, and complications, were recorded prospectively. The operative time was recorded from the time of the initial skin incision to the final skin suture. Postoperatively, patients were given diclofenac sodium suppository for pain control. Analgesic use was described in terms of total cumulative milligrams of diclofenac sodium suppository administered as required. Major postoperative complications were those requiring significant intervention or hospital readmission. Minor postoperative complications did not lead to such interventions.

All statistical analyses were performed with SPSS 13.0 statistical software package. Numerical data from a normal distribution were expressed as a group mean and compared using Student's t-test. Numerical data from a nonnormal distribution were expressed as a group median and evaluated using Mann–Whitney rank sum test. Pearson's chi-square test was used to compare categorical data. Statistical significance was defined as p < 0.05.

Results

A total of 338 patients underwent PRPS and 85 underwent MARP. The two groups were comparable in terms of age, sex, and body mass index. Table 1 lists the intraoperative and postoperative details of the two study groups. There was no significant difference between the two groups with respect to estimated blood loss, hospital stay, the amount of analgesic use (diclofenac sodium suppository), and intraoperative and postoperative complications. Although each simple procedure required similar operative time in the two groups, each complex procedure in the MARP group required significantly shorter operative time than that in the PRPS group.

Table 1.

Patients' Perioperative Details

		No. of patients		No. of conversion to open surgery		Duration of surgery (minutes)		Estimated blood loss (mL)		Hospital stay (days)		No. (%) of complications
Procedure		PRPS	MARP	PRPS	MARP	PRPS	MARP	PRPS	MARP	PRPS	MARP	PRPS	MARP
Simple procedures	Cyst decortication	50	4	0	0	50 (40–70)	52 (45–68)	22 (10–35)	25 (15–50)	5.6 (5–7)	6.2 (6–7)	0	0
	Simple nephrectomy	37	5	2	0	90 (75–118)	87 (65–100)	40 (20–100)	42 (15–110)	7.2 (7–8)	7.2 (7–8)	3 (8.1)	0
	Ureterolithotomy	85	7	2	0	86 (70–120)	83 (72–105)	31 (10–80)	30 (10–75)	6.8 (6–7)	7.1 (6–7)	10 (11.8)	0
Complex Procedures	Complex nephrectomy
	Renal-cell carcinoma	38	18	4	1	160 (120–210)^a	130 (100–180)^a	90 (60–125)	93 (75–130)	7.3 (7–8)	7.3 (7–8)	6 (15.8)	3 (16.7)
	Infective nonfunctioning kidney	32	15	7	1	155 (125–200)^a	120 (110–150)^a	120 (100–180)	124 (90–160)	7.2 (7–9)	7.5 (7–9)	7 (21.9)	3 (20.0)
	Giant hydronephrosis	21	10	3	0	110 (80–160)^a	90 (70–120)^a	180 (90–260)	176 (100–220)	6.5 (6–7)	7.1 (6–7)	2 (9.5)	1 (10.0)
	Reconstructive surgery
	Pyeloplasty	36	12	4	0	165 (140–180)^a	126 (100–148)^a	56 (20–80)	50 (30–65)	7.2 (7–8)	7.3 (7–8)	5 (13.9)	1 (8.3)
	Partial nephrectomy	29	14	5	0	180 (120–335)^a	150 (110–180)^a	150 (110–205)	155 (100–200)	7.6 (7–9)	7.5 (7–9)	3 (10.3)	2 (14.3)

Values are the mean or median (range) unless otherwise indicated.

Statistically significant difference.

MARP = minimal incision-assisted retroperitoneoscopic surgery; PRPS = pure retroperitoneoscopic surgery.

Of the 338 patients with PRPS, 172 (50.9%) underwent simple procedures and 166 (49.1%) underwent complex procedures. Of the 85 patients with MARP, 16 (18.8%) underwent simple procedures and 69 (81.2%) underwent complex procedures (Table 2). A significantly greater proportion of MARP patients underwent complex procedures (81.2% vs. 49.1%, p < 0.001). The overall rate of conversion to open surgery for PRPS and MARP was 11.3% and 2.4%, respectively (p = 0.023).

Table 2.

Association of Pure Retroperitoneoscopic Surgery and Minimal Incision-Assisted Retroperitoneoscopic Surgery with Procedure Type

Variable	Overall	PRPS	MARP	p
No. of patients	423	338	85
Simple procedures	188	172 (50.9%)	16 (18.8%)
Complex procedures	235	166 (49.1%)	69 (81.2%)	<0.001

A total of 149 (44.1%) and 189 (55.9%) PRPS were performed at early and late stages of PRPS learning curve, respectively. A total of 53 (62.4%) and 32 (37.6%) MARP were performed at early and late stages of PRPS learning curve, respectively (Table 3). A significantly greater proportion of MARP were carried out at the early stage of PRPS learning curve (62.4% vs. 44.1%, p = 0.003).

Table 3.

Association of Pure Retroperitoneoscopic Surgery and Minimal Incision-Assisted Retroperitoneoscopic Surgery with Learning Curve

Variable	Overall	PRPS	MARP	p
No. of patients	423	338	85
2003–2005	202	149 (44.1%)	53 (62.4%)	0.003
2006–2008	221	189 (55.9%)	32 (37.6%)

Discussion

Although PRPS could reduce risks associated with traditional transperitoneal laparoscopy, this technique has been criticized for limited working place.³ Especially when peritoneum tears occurred and gas entered the abdominal cavity, the retroperitoneal working place became more limiting and resulted in difficulty in manipulation. With an aim to combine the benefits of hand assistance and retroperitoneal route, hand-assisted retroperitoneoscopy was introduced. This technique created working space through anterior retroperitoneal approach and needed special hand-access devices.⁴ However, hand-assisted retroperitoneoscopy did not gain the same popularity as HAL.

Herein, we developed MARP. The main characteristic of MARP was that PRPS and hand assistance were used successively in one surgery. The hand assistance differed from hand-assisted retroperitoneoscopy, in that this approach needed no retropneumoperitoneum and special hand access device while the hand was inserted through the same long incision as HAR. On the other hand, MARP is not another term for conversion to open surgery for failure to progress. MARP is an initiative procedure according to preoperative planning, whereas the latter is a passive procedure according to a temporary decision. It should be emphasized that our goal was to pursue optimized patient-related benefits using MARP.

Our study demonstrated that the MARP group with complex procedures had a significantly shorter median operative time compared with the PRPS group. This difference may be attributable to the fact that the most challenging and time-consuming manipulations by endoscopy during PRPS were undergone by hands during MARP. If these procedures were performed by retroperitoneoscopy, it would require longer time. The incision used in MARP was 7–8 cm, which is large enough to insert a hand to complete the remaining procedures. Moreover, studies have shown that the small 7–8-cm incision was not significantly more morbid than the standard laparoscopic approach with respect to return to normal activity and work.⁵ In addition, we noted in this study that MARP was not associated with a greater amount of analgesic use (diclofenac sodium suppository) for pain control postoperatively compared with PRPS.

The most common reason reported for converting a laparoscopic operation into open surgery was vascular injury.⁶ Major bleeding was difficult to handle with laparoscopic instruments alone. However, during MARP the surgeon's finger can compress a bleeding vessel immediately. This increased the safety of this technique and decreased the open conversion rate. Our results confirmed that the overall rate of conversion to open surgery in the MARP group was significantly lower than that in the PRPS group.

We found that patients in the MARP group underwent more complex procedures. This may be attributed to the aforementioned similar fact that the more challenging procedures can be performed more efficiently by hand. This technique has advantages of tactile sensation for dissection of blood vessels and obscured organs, spatial orientation, as well as the use of the hand for dissection, retraction, and suturing. In addition, MARP can allow the surgeon to perform complex procedures with greater confidence.

In this study, greater proportion of MARP were carried out at the early stage of PRPS learning curve, suggesting that MARP approach had the potential to decrease the learning curve of PRPS.

Conclusions

Footnotes

Disclosure Statement

No competing financial interests exist.

Abbreviations Used

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