A Prospective Randomized Study of Pfannenstiel Versus Expanded Port Site Incision for Intact Specimen Extraction in Laparoscopic Radical Nephrectomy

Abstract

Purpose:

To compare intra- and postoperative outcome of patients undergoing laparoscopic radical nephrectomy with intact specimen extraction through a Pfannenstiel (PFN) transverse suprapubic or expanded port site (EPS) incision in a prospective randomized fashion.

Patients and Methods:

Patients undergoing laparoscopic transperitoneal radical nephrectomies for suspected renal tumors were randomized for intact renal specimen extraction via a PFN or EPS incision. Operative, perioperative, 1 week, 6 weeks, and 6 months postoperative parameters were prospectively recorded and analyzed including specimen weight, size in maximum diameter, incision length, total operative time, extraction time, estimated blood loss, length of hospital stay, pain score in the postoperative holding area and on the first post operative day, narcotic consumption, time to fluid intake/full diet intake, unassisted ambulation, cosmesis, and wound-related complications. A postoperative quality-of-life questionnaire was also filled out by all the patients.

Results:

Our series included 51 patients: 26 in the PFN group and 25 in the EPS group. The two groups were similar in demographic characteristics and intraoperative and postoperative parameters apart from a longer PFN incision (P<0.00). First postoperative day pain score was significantly less in the PFN group than in the EPS group (P=0.023). Complication rate was less in the PFN group, although not statistically significant. Hospital stay was significantly shorter in the PFN than in the EPS group (P=0.01). Mean cosmesis and operative satisfaction scores at week 1, week 6, and 6 month visits were not significantly different between both groups. Compared with the EPS group, PFN group patients significantly will choose the same operation if they would do it again (P=0.004).

Conclusions:

PFN incision has less morbidity, pain score, and hospital stay compared with EPS incision for intact specimen extraction after transperitoneal laparoscopic radical nephrectomy. Both incisions are associated with high operative satisfaction, good cosmesis, and a low rate of wound complications.

Introduction

Soon after the introduction of laparoscopic nephrectomy in 1991,¹ laparoscopic techniques were widely applied to different urologic kidney procedures such as simple nephrectomy,² radical nephrectomy,³ radical nephroureterectomy,⁴ and donor nephrectomy.⁵

Two methods can be used for renal specimen extraction after laparoscopic nephrectomy, including in vivo morcellation or whole specimen extraction. Whole specimens have been traditionally extracted through incisions created by expanding a port site, connecting port sites, incising old abdominal surgical scars, or through a new incision. Transverse incisions (such as the Pfannenstiel [PFN]) are preferred cosmetically and have been thought to be less painful than incisions of other orientations.⁶

Currently, no prospective randomized trials are available to compare intact renal specimen extraction in laparoscopic radical nephrectomy using an expanded port site (EPS) versus a PFN incision. Matin and Gill⁷ described the use of a modified PFN incision for specimen retrieval after retroperitoneoscopic renal surgery. Although a formal analysis was not performed, they got the subjective impression that this approach provides increased patient comfort and cosmesis compared with an expanded lateral port site. Tisdale and associates⁶ retrospectively compared intact renal specimen extraction through PFN and EPS incisions after different laparoscopic nephrectomy procedures. They found that a PFN incision is associated with reduced morbidity.

We prospectively compared patients' postoperative recovery (analgesic use, oral intake, ambulation, length of hospital stay, time to work), postoperative extraction site complications (infection, hernia, wound dehiscence, nerve injury), and patients' operative and cosmesis satisfaction after transperitoneal laparoscopic radical nephrectomy with intact specimen extraction through either a PFN or an EPS incision.

Patients and Methods

Laparoscopic radical nephrectomy with intact specimen extraction through either a PFN or EPS incision has been performed in 51 randomized patients with suspected renal cancer. Patients were assigned to either group using a computerized randomization system. The research protocol was approved by the ethics committee of our hospital, and all patients provided written informed consent for the surgery. Data were collected prospectively for subsequent analysis.

Inclusion criteria included all patients over 18 years old with localized renal cancer who would have laparoscopic radical nephrectomy. Exclusion criteria comprised procedures that had conversion to open nephrectomy or used hand-assisted laparoscopic nephrectomy, nephrectomy for noncancerous cases, and the use of epidural analgesia, patient control analgesia, or skin infiltration with local anesthetic agents during or after the surgery.

All patients underwent transperitoneal laparoscopic nephrectomy under general anesthesia. Operative, perioperative, 1 week, 6 weeks, and 6 months postoperative parameters were recorded and analyzed including specimen weight, size in maximum diameter, incision length, total operative time, extraction time, estimated blood loss, length of hospital stay, pain score in the postoperative recovery area and on the first postoperative day (POD), narcotic consumption, time to fluid intake/full diet intake, unassisted ambulation, cosmesis, and wound-related complications. During each follow-up visit, patients' pain score, postoperative complications, and narcotic consumption were recorded. They were also asked to fill out a postoperative quality-of-life questionnaire (Appendix 1; supplementary data are available online at www.liebertpub.com/end). Pain scores were recorded using the visual analogue scale where (0)=no pain, and (10)=worst pain imaginable. Total operative time was defined as the time between the initial port skin incision and the completion of wound closure. Specimen extraction time was defined as the time between the extraction site skin incision and completion of fascial closure. Narcotics consumption was converted to intravenous morphine sulphate equivalents according to standard formula. The primary end point is the difference in hospital stay between the two groups. Secondary end points include any difference in operative, perioperative, and follow-up parameters as well as patients' operative and cosmesis and quality of life.

Surgical technique

We followed our previously published surgical technique.⁸ Briefly, the patient is positioned in the lateral decubitus position with the operative table flexed to open the costophrenic angle. The surgeons stand anterior to the patient while video monitors are at the head of the operating table on both sides. Carbon dioxide pneumoperitoneum is created via a Veress cannula at the apex of the umbilicus or by using a 12-mm Optiview direct laparoscopic access method. Two or three ports, 5 to 12 mm, are placed under direct vision in the subxiphoid region, iliac fossa, and flank as needed. For retraction of the liver in right-sided nephrectomy, an additional 5-mm port may be used at the subxiphoid region. To expose the right kidney, the colon is mobilized toward the midline and the duodenum is kocherized while the descending colon and the splenic flexure are mobilized medially to expose the left kidney. An additional 5-mm port may be inserted in case of a large cancerous kidney. Both the artery and ureter are divided between multiple titanium clips. The renal vein is divided using an EndoGIA device (Covidien). The adrenal gland is preserved whenever possible.

After completing the laparoscopic kidney dissection, the specimen is entrapped in a specimen retrieval bag and then extracted via a PFN or EPS incision according to randomization. In the PFN group, a transverse PFN skin incision is made above the symphysis pubis over skin crease, then the fatty subcutaneous tissues are freed exposing the underlying rectus abdominis muscles. The anterior rectus sheath is opened transversely using sharp dissection. After the cranial-cut aponeurosis is elevated under tension, the rectus muscles are then separated in the midline and the peritoneum is perforated in an identical manner using the vertical midline incision, then the drawstring of the closed bag is grasped, allowing the delivery of the entrapped intact specimen through the PFN incision.

In the EPS group, the most lower and lateral (flank) port is extended transversally and medially for a length sufficient to extract the renal specimen. The skin is incised, followed by the subcutaneous fatty tissue, anterior abdominal musculature, and peritoneum to reach and grasp the drawstring of the closed bag allowing the delivery of the entrapped intact specimen. The extraction incision is then closed in layers and the pneumoperitoneum re-created to inspect for hemostasis. The abdomen is deflated, and the 10 to 12 mm trocar incisions are closed under direct vision with absorbable sutures. The 5 mm ports are closed only at the skin level.

Data analysis

Descriptive statistics are presented as the mean (standard deviation) and percent. For comparative statistics chi-square/Fisher exact tests, Student's t/one-way analysis of variance tests, and the nonparametric methods of Mann-Whitney/Kruskal-Wallis tests were used as appropriate.⁹ A P value of less than 0.05 was considered significant for all tests performed using SPSS statistical software. For the sake of comparison of the hospital stay, two outlier results of 17 and 27 days in the EPS group were excluded. Correlation analysis was performed using the Spearman rho coefficient to assess the association between patients' satisfaction of cosmetic and operative results at the first postoperative week, week 6, and 6 month visits after surgery.

Results

After transperitoneal laparoscopic radical nephrectomy, whole specimen extraction was performed via PFN incision in 26 or EPS incision in 25 patients. The two groups were similar in demographic characteristics (Table 1). Intraoperative parameters including operative time, extraction time, estimated blood loss, number of ports, specimens' weight and size, were also comparable. The incision length was significantly longer in PFN than EPS groups (P=0.000, Table 1). Postoperative parameters were also comparable (Table 1). No differences were found in consumption of narcotics in the recovery room or in the first POD. First POD pain score, however, was significantly less in the PFN group than in the EPS group (P=0.023). No differences in the interval to fluid intake, to full diet intake, or to ambulation were noted between the two groups. Hospital stay was significantly less in the PFN than in the EPS group (P=0.010, Table 1).

Table 1.

Perioperative Patients, Surgery and Specimen Characteristics

Parameter	PFN	EPS	P	Test
Patients (no.)	26	25
Sex
Male	14	17	0.301	Chi-square
Female	12	8
Nephrectomy side
Right	16	12	0.331	Chi-square
Left	10	13
Mean age (years)	55.8 (± 10.1)	59.5 (± 12.7)	0.258	t-test
Mean BMI (kg/m²)	30.9 (± 3.2)	31.8 (± 4.7)	0.469	t-test
Preoperative dialysis
No	25	24	1.000	Fisher exact
Yes	1	1
No. of ports
3	14	7	0.076	Chi-square
4	11	13
5	1	5
Mean specimen weight (g)	631.5 (± 323.7)	685.1 (± 428.9)	0.616	t-test
Mean specimen size (cm)	17.4 (± 3.9)	17.8 (± 5.7)	0.782	t-test
Mean incision length (cm)	10.7 (± 2.4)	8.2 (± 2.2)	0.000	t-test
Mean operative time (min)	152.3 (± 37.6)	160.4 (± 44.8)	0.485	t-test
Mean extraction time (min)	20.4 (± 5.4)	19.7 (± 6.9)	0.688	t-test
Mean estimated blood loss (ml)	90.4 (± 67.5)	158.4 (± 184.1)	0.092	t-test
Mean recovery room narcotics (mg)	15.7 (± 7.5)	17.2 (± 5.8)	0.441	t-test
Mean recovery room pain score	4.3 (± 2.1)	4 (± 2)	0.667	Mann-Whitney
Mean time to fluids (day)	0.15 (± 0.4)	1 (± 2.6)	0.126	t-test
Mean time to diet (day)	2 (± 0.6)	3 (± 3)	0.121	t-test
Mean time to ambulation (day)	1 (± 0.7)	2 (± 3.6)	0.181	t-test
Mean first postoperative day narcotics (mg)	35.8 (± 28.6)	48.5 (± 42.9)	0.215	t-test
Mean first postoperative day pain score	4.4 (± 1.5)	5.3 (± 1.7)	0.023	Mann-Whitney
Mean hospital stay (day)	2.4 (± 0.6)	3 (± 1)	0.010	t-test
Mean first week narcotics (mg)	8.8 (± 12.8)	12.2 (± 16.3)	0.407	t-test
First week complications
Yes (%)	4 (15.4)	6 (24)	0.499	Fisher exact
No (%)	22 (84.6)	19 (76)

PFN=Pfannenstiel; EPS=expanded port site; BMI=body mass index.

Four complications were encountered in the PFN group; three superficial wound infections and one wound gaping after stitch removal. Complications in the EPS group included one wound infection, two wound hematomas, one urine retention necessitating catheterization, one prolonged ileus and one combined retroperitoneal bleeding and prolonged ileus, all managed conservatively. At the last follow-up visits, no tumor recurrence was seen at the operative field or at the extraction site. The rate of complications was not significantly different between both groups (P=0.499, Table 1). No significant differences were found between the two groups for mean cosmesis and operative satisfaction scores at week 1, week 6, and 6 month visits. The overall operative and cosmesis satisfaction increases as time goes postoperatively (Table 2). Operative and cosmesis satisfaction strongly and positively correlated with each other at the first postoperative week, week 6, and 6 month visits (Table 3).

Table 2.

Quality of Life, Cosmesis and Operative Satisfaction Results

Parameter	PFN	EPS	P	Test
Week 1 mean cosmesis satisfaction	91.9 (± 16)	87.2 (± 18)	0.379	Mann-Whitney
Week 1 mean operation satisfaction	84.4 (± 22.6)	82 (± 23.5)	0.746	Mann-Whitney
Week 6 mean cosmesis satisfaction	91.9 (± 16.4)	91.2 (± 14.2)	0.793	Mann-Whitney
Week 6 mean operation satisfaction	88.5 (± 17.4)	89.2 (± 15.3)	0.967	Mann-Whitney
Month 6 mean cosmesis satisfaction	97.3 (± 8.7)	96 (± 6.5)	0.112	Mann-Whitney
Month 6 mean operation satisfaction	98.5 (± 4.6)	96 (± 7.6)	0.145	Mann-Whitney
Q4: Redo same operation
Yes (%)	26 (100)	18 (72)	0.004	Fisher exact
No (%)	0 (0)	7 (28)
Q5: Re: choose same incision
Yes (%)	24 (92.3)	18 (72)	0.075	Fisher exact
No (%)	2 (7.7)	7 (28)
Q6: Recommend same incision
Yes (%)	24 (92.3)	18 (72)	0.075	Fisher exact
No (%)	2 (7.7)	7 (28)

Table 3.

Correlation of Patients' Cosmesis and Operation Satisfaction at Different Visits

Visit	Spearman rho	P
First week visit	0.633	0.000
Sixth week visit	0.597	0.000
Sixth month visit	0.824	0.000

Compared with the EPS group, PFN group patients significantly would choose the same operation if they would do it again (Appendix 1, Question 4; supplementary data are available online at www.liebertpub.com/end). More patients in the PFN group would rechoose the same incision and recommend it to relatives or friends if they encountered a similar problem compared with patients in the EPS group; however, the difference was not statistically significant (Table 2).

Narcotic consumption and pain scores in the recovery room and first POD were not significantly different between males and females in both groups (Table 4). Both male and female patients of the PFN group had statistically significant (P=0.043) shorter hospital stay than their counterparts in the EPS group (Table 4). Male patients of the PFN group demonstrated a significantly higher operative satisfaction at the first week visit (P=0.045) with no differences between both sexes of both groups in later visits. Males of the PFN and females of the EPS groups showed a higher satisfaction of cosmesis than their counterparts at all follow-up visits, although the differences were not statistically significant (Table 4).

Table 4.

Sex Differences in Complications, Hospital Stay, Cosmesis, and Operation Satisfaction

Parameter	PFN	EPS	P	Test
Recovery room mean narcotic consumption in mg (SD)
Male	17.5 (7)	17.2 (5)	0.450	One-way ANOVA
Female	14 (8)	17.3 (8)
First postoperative day mean narcotic consumption in mg (SD)
Male	27.2 (13)	53.3 (49)	0.251	One-way ANOVA
Female	45.8 (38)	38.5 (23)
Recovery room mean pain score (SD)
Male	4.6 (1.8)	4 (2)	0.870	Kruskal-Wallis
Female	3.9 (2.4)	4 (2.1)
Mean hospital stay in days (SD)
Male	2.2 (0.4)	3.1 (1)	0.043	One-way ANOVA
Female	2.6 (0.7)	2.9 (1.1)
First postoperative day mean pain score (SD)
Male	4.3 (1.3)	5.5 (1.9)	0.070	Kruskal-Wallis
Female	4.5 (1.7)	4.8 (1)
First week male patients' complications
No (%)	13 (92.9)	12 (70.6)	0.185	Fisher exact
Yes (%)	1(7.1)	5 (29.4)
First week female patients' complications
No (%)	9 (75)	7 (87.5)	0.619	Fisher exact
Yes (%)	3 (25)	1 (12.5)
Week 1 mean cosmesis satisfaction (SD)
Male	93.6 (16)	85.9 (17)	0.285	Kruskal-Wallis
Female	89.8 (17)	90 (21)
Week 1 mean operation satisfaction (SD)
Male	93 (16)	78 (24)	0.045	Kruskal-Wallis
Female	74 (25)	90 (21)
Week 6 mean cosmesis satisfaction (SD)
Male	93.6 (16)	89 (16)	0.606	Kruskal-Wallis
Female	90 (17)	95 (9)
Week 6 mean operation satisfaction (SD)
Male	88.6 (18)	85 (17)	0.204	Kruskal-Wallis
Female	88.3 (17)	97 (7)
Month 6 mean cosmesis satisfaction (SD)
Male	99 (3)	95.9 (6)	0.344	Kruskal-Wallis
Female	95 (12)	96.3 (7)
Month 6 mean operation satisfaction (SD)
Male	98.6 (4)	95 (8)	0.306	Kruskal-Wallis
Female	98.3 (6)	98 (7)

SD=standard deviation; ANOVA=analysis of variance.

Discussion

Compared with open procedures for renal surgery, the laparoscopic approach results in decreased postoperative pain, narcotic use, and hospital stay. It has been associated with faster recovery and an earlier return to work.^10
–12 In addition, it provides superior cosmetic results.^2,13,14 Renal specimen extraction methods include in vivo morcellation and whole specimen extraction. Specimen morcellation is associated with a smaller incision, better cosmesis, and fewer incision-related complications than open specimen extraction incisions.¹² Questions arise, however, regarding the adequacy of surgical staging, as well as the risk of tumor implantation, when cancer surgery is being performed with specimen destruction.¹⁵

Various incisions are used for whole specimen extraction including extending a port site, connecting port sites, incising old abdominal surgical scars, or through a new incision. Compared with vertical or EPS incisions, transverse abdominal incisions (including PFN incision) are thought to be associated with less pain, improved cosmesis, and minimal risk of postoperative disruption.^6,16,17 The transverse suprapubic scar can be hidden with most types of clothing, including a bathing suit. In addition, the PFN incision is reportedly associated with a decreased rate of incisional hernia.^6,18 Furthermore, because no muscle is cut in an PFN incision, fascial closure can be rapidly performed in a single layer.⁷ Vertical subumbilical midline incisions have the presumed advantage of rapid abdominal entry and less bleeding. Also, the incision may be extended upward if more space is needed for access. The disadvantages of a vertical midline incision include the greater risk of postoperative wound dehiscence and development of incisional hernia and the scar is cosmetically less pleasing.¹⁶

We encountered no bowel complications or incisional hernias in our study cohort. Seven postoperative wound complications were observed: Four superficial wound infections, one wound gaping after stitch removal, and two wound hematomas. They were seen in the first week after surgery, and all were in patients with a body mass index 35 kg/m² or more except in one patient in renal failure under dialysis. The PFN extraction site was associated with a lower complications rate, although not statistically significant (15.4% vs 24%, P=0.499). Similarly, Drosdeck and coworkers¹⁹ performed a multivariate analysis of risk factors for surgical site infection and incisional hernia after laparoscopic colorectal surgery. They found that the use of a PFN extraction site was associated with lower infection rates, although not statistically significant. Samia and associates²⁰ reported an overall incisional hernia rate of 7% after 480 laparoscopic colorectal surgical procedures. Of these, midline incisional hernias accounted for 84% of all hernias. The rates of hernia for muscle-splitting, PFN, and ostomy site extractions were 2.3%, 3.8%, and 4.8%, respectively.

Although PFN incisions were significantly longer than EPS incisions (10.7 vs 8.2 cm, P=0.00), no difference was encountered in extraction times (P=0.688). No significant differences in the interval to fluid intake, to full diet intake, or to ambulation were noted between the two groups, although the PFN group did better in all the parameters (Table 1). Hospital stay was significantly shorter in the PFN group (2.4 vs 3 days, P=0.010). Male patients of the PFN group had the shortest hospital stay among all study patients (Table 4). Similar results were reported by Tisdale and colleagues⁶ in a retrospective study of 104 patients who underwent laparoscopic radical nephrectomy with intact specimen extraction via PFN or EPS incisions.

First POD pain score was significantly less in the PFN group than in the EPS group (P=0.023). The PFN group used fewer narcotics in the recovery room, first POD, and during the first week; however, the difference was not statistically significant (Table 1). Cosmesis satisfaction was high in our study population (Table 2). The PFN patients showed a higher cosmesis and operative satisfaction at all visits compared with patients in the EPS group, although the difference was not statistically significant (Table 2). Moreover, patients in the PFN group were more significantly willing to redo the same operation (Appendix 1, Question 4, supplementary data are available online at www.liebertpub.com/end, P=0.004). They also showed a clear trend of rechoosing the same incision or recommending it to others more than patients of the EPS group, but the difference was not statistically significant (P=0.075). Probably, a larger sample size may increase study power to attain significance.

Similarly, Matin and Gill⁷ got the impression that a modified PFN incision provides increased patient comfort and cosmesis compared with an expanded lateral port site, although a formal analysis was not conducted. Also, Simforoosh and coworkers²¹ reported their series of 50 patients who underwent mini-laparoscopic live donor nephrectomy. Kidney extraction was made through a 6 to 8 cm PFN incision. Better cosmetic results were achieved without jeopardizing donor or graft outcomes. Gupta and colleagues²² compared modified iliac fossa and PFN incisions to retrieve the kidney during laparoscopic transperitoneal donor nephrectomy. PFN incision was found to be superior in terms of cosmesis, although it was longer (7.3 cm vs 5.8 cm).

Cosmesis and operative satisfaction rates were not significantly different between both males and females in both groups except for operative satisfaction in the first week visit (P=0.045, Table 4). During the first week visit, operative satisfaction was highest in males and least in females of the PFN group. This may be because of a higher complication rate in females than in males of the PFN group in the first week visit (25% vs 7.1%, Table 4).

The cosmesis satisfaction rate strongly and positively correlated to the overall operative satisfaction rate, more obviously at longer follow-up (highest at the 6 month evaluation, Table 3). This may be explained by better resolution and more elasticity of scar tissue with time.

The main drawbacks of our study are the limited sample size and the subjective assessment of cosmetic appearance of scars. A validated questionnaire for objective evaluation of cosmesis should be used in future clinical trials. A larger prospective randomized comparative study with other extraction sites in laparoscopic radical nephrectomy will add more outcome insight to help surgeons choosing the appropriate extraction site for malignant nephrectomy specimens considering the patient postoperative quality of life.

Conclusion

The study demonstrates less morbidity, pain score, and hospital stay in patients with a PFN incision compared with patients with an EPS incision for intact specimen extraction after transperitoneal laparoscopic radical nephrectomy. Both incisions are associated with high operative satisfaction, good cosmesis, and a low rate of wound complications. A randomized comparative trial with a larger sample size and longer-term follow-up is necessary for definite outcome evidence.

Footnotes

Acknowledgment

This study was supported by a grant from the College of Medicine Research Center, Deanship of Scientific Research, King Saud University, Riyadh, Saudi Arabia.

Disclosure Statement

No competing financial interests exist.

Abbreviations Used

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