Day Case Laparoscopic Nephrectomy

Introduction

S ince first reported by Clayman and associates ¹ 20 years ago, laparoscopic nephrectomy (LN) has become more and more popular. As experience and technique have improved, urologists have expanded indications for LN to larger tumors (>7 cm, pT₂), level I renal vein tumor thrombus, cytoreductive nephrectomy, limited locally invasive tumors into psoas or diaphragm, concomitant lymphadenectomy, and more. ^2,3 Laparoscopic simple nephrectomy has been established as the standard of care in the management of most benign renal diseases in which permanent loss of renal function has occurred. ⁴ Laparoscopic radical nephrectomy is the standard of care for patients with T₂ tumors and smaller renal masses that are not treatable by nephron-sparing surgery according to the latest guideline for renal-cell carcinoma published by the European Association of Urology. ⁵

As expertise in laparoscopic technique has increased, many procedures have been performed as day case surgery (DS): Cholecystectomies, hernia repair, appendectomy, Nissen fundoplication, adrenalectomy. ^{6 –10} We have also developed laparoscopic DS at our center for a number of procedures, including laparoscopic pyeloplasties, adrenalectomies, and nephrectomies. We report our case series of LN performed as DS. To our knowledge, this would be the first series of DS LN reported in the medical literature. The aim of this retrospective study is to report our initial experience with DS LN and to assess its feasibility and safety.

Patients and Methods

We retrospectively studied the initial series of consecutive patients who were considered for DS LN between January 2006 and December 2009 in a single urologic center. The inclusion criterion in the present study consisted of LN patients who had been planned to be treated as a DS. Our selection criteria for DS LN were similar to those for other day surgery procedures. In general, fit and well-motivated patients with acceptable comorbidities and in whom an uncomplicated surgery was anticipated by the senior author were offered the option of LN as DS. Medical criteria included the requirement that any coexisting medical conditions were stable and optimally treated.

When selecting patients for DS LN, certain social criteria have to be considered: The patient must be willing to undergo DS; after the procedure, there should be a responsible adult/carer/parent able and willing to care for the patient for at least 24 hours postsurgery; patients/parents must have access to a private telephone; the journey home should not take longer than 1 hour; and an escort must be available to drive or accompany the patient home in a taxi.

Data regarding demographic information, medical comorbidities, preoperative diagnosis, preoperative and postoperative symptoms, admission as well as discharge date and hour and pathologic result were acquired. The success rate of DS and reasons for unplanned overnight admission and for readmission were collected and evaluated.

All patients followed a standard pathway of care for the DS laparoscopic procedure. Invitations for admission were sent with instructions to fast from midnight for solids and 6.30 AM for clear fluids. A confirmation phone call was been arranged the day before the procedure. The patients were admitted at around 7:30 AM. The procedure was performed in the morning session, usually as the first case. A standardized anesthetic technique was used. All patients received 1600 mg of slow-release ibuprofen orally an hour before surgery. Anesthesia was induced with midazolam-alfentanil-propofol and maintained with sevoflurane in air with controlled ventilation via a tracheal tube. Intraoperative opioids were avoided, and patients received 1 g of intravenous paracetamol toward the end of the procedure. Multimodal antiemesis was provided with dexamethasone and ondansetron.

The LN was performed using a standard transperitoneal approach with four ports on the left side and five ports on the right side. The specimen was removed intact in an Endo Catch bag for tumors and extracted piecemeal for benign diseases. Urethral catheterization was performed at the beginning of the procedure, and the catheter was removed before recovery from anesthesia. After the initial few cases, an urethral catheter was not inserted at all.

Levobupivacaine 0.5% was instilled around the port sites before trocar placement and at the conclusion of the procedure to minimize postoperative pain.

Postoperatively, patients were monitored in the recovery ward and then in the day surgery ward. Hourly parameters—pulse rate, blood pressure, temperature, consciousness level, and pain scores—were recorded. Oral fluids and diet were introduced postoperatively as tolerated. All patients were reviewed by a senior member of staff and were discharged between 6 PM and 8 PM if discharge criteria were met—ie, controlled pain and nausea, stable observation, mobilizing, and tolerating diet. Patients were provided with written and verbal information regarding the procedure, especially with regard to observing important signs: Increased pain despite analgesia, nausea, increase in temperature and pulse, dizziness, and increasing abdominal distention. They were provided with direct access to the urology ward and to the surgical admissions unit by telephone, and both wards were informed about the patient. The patients were prescribed a 5-day course of ibuprofen and co-codamol to be taken regularly. The district nurse visited the patient on the evening of surgery, days 1 and 2 postoperatively, and thereafter at the nurse's discretion to monitor temperature, pulse, blood pressure, and wound sites.

Results

Twenty-six cases of LN were planned as DS during the study period. There were 12 female (46.15%) and 14 male (53.84%) patients. The mean age was 46.22 years (range 11–77 y). The LN was on the left side in 15 (57.7%) patients and on the right side in 11 (42.3%) patients. Fifteen (57.7%) patients had benign diseases associated with nonfunctioning kidney, and 11 (42.3%) patients had renal masses. Six (23.07%) patients had a small scar in a different quadrant from the planned port sites, and two (7.69%) patients had scars in the same quadrant. Both patients with scars in the same quadrant, one secondary to cholecystectomy and the other from both appendectomy and hysterectomy, failed to be discharged on the same day. Thirteen (50%) patients in this series had cardiac or respiratory comorbidities. There were two notable successful DS patients. One had concomitant LN and cholecystectomy and the other had previously been treated with chemotherapy and radiotherapy for left testicular cancer. Both cases were straightforward.

The pathology reports for the patients with tumor masses are shown in Table 1. There was one benign tumor, an oncocytoma, which was suspected before the operation, but the patient was very keen to have it removed because malignancy could not be definitely ruled out. The other 10 patients had renal-cell carcinoma with a tumor stage pT₁, pT₂, and pT₃, of which two had cystic renal-cell carcinoma.

Twenty-two patients were discharged on the same day. The success rate of DS was 84.61%. The average length of stay for those patients was 11 hours and 1 minute, with a maximum stay of 12 hours and 30 minutes and a minimum stay of eight hours and 50 minutes. Three of four patients who failed to be discharged on the same day were women and all of them underwent a radical LN for tumor. The reason for overnight admission was uncontrolled pain in two patients. One patient returned from the theater late in the afternoon, and the surgeon considered it was safer to admit her on the ward. The male patient, 61 years old, was not able to pass urine until late evening, so he was admitted overnight. Three patients of this latter group of patients were in the first half of the present series (Table 1). They were discharged on days 1 (three patients) and 2. Their ages ranged from 42 to 61 years with a medium age of 55.25 years.

Any patient who was admitted within 30 days of operation was considered as a readmission. Six of the patients who were successfully discharged as a DS were readmitted on a later date. There were five men and one woman. All of those were from the simple LN group. One was readmitted for 1 day, 3 days after the procedure, because of a minor wound infection at the epigastric port. The second and third patient came on the first postoperative day because of wound pain. One was reassured and discharged the same day; the other stayed 1 day. A fourth patient came on the third postoperative day with nausea and vomiting. The symptoms disappeared after he recovered his intestinal transit.

The fifth and sixth patients, 41 and 42 years old, were wheelchair bound, because of cerebral palsy and C4 tetraplegia, respectively, and had long-term suprapubic catheters. Both were diagnosed with staghorn calculi in a nonfunctioning left kidney. These are not our typical DS patients, but DS was chosen for them at the patient's and their families' request. One of them presented on the fourth postoperative day, and the diagnosis was left lower lobe pneumonia and adynamic ileus. Treatment was conservative with a slow recovery. The other patient was readmitted on the fifth postoperative day with adynamic ileus; he was also treated conservatively, and the recovery was slow.

Discussion

LN has been established as the standard of care for the management of most benign renal diseases in which permanent loss of renal function has occurred and also in tumors and some smaller renal masses that are not deemed suitable for nephron-sparing surgery. ^4,5

As experience and technique have improved, the indications for LN have expanded—ie, pT₂ tumors, level I renal vein tumor thrombus, cytoreductive nephrectomy, morbidly obese patients, previous surgery. ^2,11 In our small series, there are two patients with pT₂ and three patients with pT₃ tumors.

The debate regarding superiority of LN over an open procedure regarding perioperative morbidity, reduced blood loss, duration of convalescence, reduced analgesia requirements, and length of hospital stay is over. ^{12 –14} The issue now is whether LN is minimally invasive enough to be successfully performed as a DS. Laparoscopic DS is a natural evolution of minimally invasive surgery. Many procedures have been performed as DS with good results: Cholecystectomies, hernia repair, appendectomy, Nissen fundoplication, adrenalectomy, and pyeloplasty. ^{6 –10,15} DS LN should have the same well-established advantages as any other DS when compared with inpatient LN—ie, it allows the patient to recuperate at home and reduces hospitalization costs. ¹⁶

With this philosophy in mind, the first LN as DS was performed in our unit in January 2006 by AG. With increasing experience, more and more patients have been admitted for DS. Currently, approximately 15% of all nephrectomies performed in our unit are deemed suitable for DS.

Of the 26 patients, 22 were discharged on the same day. The success rate of DS in this series is 84.61%. Early experience of DS laparoscopic cholecystectomy had a success rate of 56%. ¹⁷ Our results are comparable with those published for modern series of laparoscopic cholecystectomies, which are between 86% and 95%. ^{16,18 –20} In our series, 75% of the patients who failed to be discharged on the same day were in the first half of the present series (Table 1). Two of those four patients had previous surgery in the same quadrant. All patients had radical nephrectomy for tumor, which results in a bigger extraction scar.

Total readmission rate was 23.07%. Five of six of the readmitted patients had comorbidities. Among them were the two patients with cerebral palsy and tetraplegia in whom adynamic ileus developed postoperatively, which was complicated further in one case with pneumonia. As mentioned, these are not our typical DS patients, but DS was chosen for them at the patient's and their families' request. Also, they presented at postoperative days 4 and 5, a typical timing for ileus. We believe that even as inpatients, they would have been discharged on postoperative day 1, and their outcome would have been no different. One may argue, however, that perhaps these are comorbidities that may contraindicate DS. If we exclude the above mentioned two patients, the readmission rate would be 15.38%. Further analyzing the readmitted patients, we do not think that the minor wound infection or the slow intestinal transit recovery would have had a different outcome had these patients been inpatients. Of the two patients reassessed because of wound pain on the first postoperative day, one was discharged immediately and the other one was admitted overnight. This last patient could have had a different postoperative management as an inpatient.

The readmission rate strictly caused by DS was 3.84%, which is not different from those published in modern series of laparoscopic cholecystectomies (between 1.5% and 8%). ^{16,18 –20} In the last 10 DS LN, there was no readmission.

In the DS laparoscopic cholecystectomy, some studies have identified criteria that could predict an increased risk for failing the DS procedure: Age of over 65 years, American Society of Anesthesiology status >2, and having other medical problems. ^16,21 To improve the DS rates, however, the National Health Service Institute for Innovation along with the British Association of Day Surgery advocate a default approach as DS for cholecystectomies. Encouraged by our initial experience, we propose to follow a similar approach for DS LN.

Is DS LN safe? Patient safety is of paramount importance. To assure a standard of care for DS LN, all patients are following a standard pathway similar to DS cholecystectomy. Strict discharge criteria, close postoperative support, earlier mobilization of the patient, the information provided, and immediate contact ability ensures that the initial warning signs of postoperative complications are likely to be reported at an earlier stage. In this modest case series, we have not come across any critical incident as a result of LN being a DS.

This is a retrospective and nonrandomized case series, and this is the weakness of this study. To our knowledge, however, this is the only case series of LN as DS in an adult population.

Conclusions

The DS LN is feasible and safe. We believe that the results should be easily reproducible. Increasing experience may help to develop more rigorous preoperative, intraoperative, and discharge criteria to increase the success rate and to decrease the readmission rate for DS LN.