Retroperitoneal Laparoscopic Partial Nephrectomy for Tumors Larger than 7 cm in Renal Cell Carcinoma: Initial Experience of Single-Institution

Abstract

Background:

To report our initial experience dealing with retroperitoneal laparoscopic partial nephrectomy (LPN) for tumors larger than 7 cm in renal cell carcinoma (RCC).

Materials and Methods:

A total of 15 patients with malignant tumors larger than 7 cm underwent retroperitoneal LPN at our institution. Patient baseline demographics, perioperative outcomes, pathological characteristics, and estimated glomerular filtration rate (eGFR) were analyzed retrospectively in our collected database.

Results:

The tumor size is 7.5 (7.1–9.0) cm. Nine (60.00%) patients, 4 (26.67%) patients, and 2 (13.33%) patients suffered from preoperative chronic kidney disease (CKD) at stage I, II, and III, respectively. The median operating time was 121 (90–330) minutes and the warm ischemia time (WIT) was 29 (12–45) minutes, with the estimated blood loss of 50 (10–1200) mL. The preoperative eGFR was 81.26 mL/min per 1.73 m² (ranging from 56.15 to 140.47), eGFR on 1 and 30 days postoperative was 70.49 mL/min per 1.73 m² (ranging from 50.32 to 137.73) and 75.13 mL/min per 1.73 m² (ranging from 54.07 to 142.99), respectively. At last follow-up, the eGFR was 72.78 mL/min per 1.73 m² (ranging from 51.28 to 137.86); no stage migration for CKD was observed. Major complications included 2 patients requiring blood transfusions and 1 patient performing renal vein suture as well as single leak.

Conclusions:

Our initial experience suggests that retroperitoneal LPN maybe a feasible, safe, and effective procedure for selected tumors larger than 7 cm in RCC, with the advantage of renal function preservation and acceptable major surgical complications. Tumor size might not be the contraindication of LPN in the treatment of selected tumors.

Introduction

Renal cell carcinoma (RCC), which ranks second among the leading causes of deaths in patients with urologic tumors, accounts for 2% of adult malignancies, and ∼116,000 people die from this disease each year, making it one of the most lethal urological malignancies.^1,2 Management of renal tumors has changed significantly in the last two decades, and radical nephrectomy (RN) is no longer the standard treatment for low-stage RCC.³ Furthermore, in studies analyzing RCCs with T1b stage, no differences have been shown for comparable cancer-specific survival rates between partial nephrectomy (PN) and RN.^4–7 Surgical trends have moved toward renal preservation. Currently available evidence suggests that the localized kidney cancer is best managed by PN whenever technically feasible.^8,9 Although open partial nephrectomy (OPN) currently remains the “gold standard” in the surgical therapy of renal tumors,³ increasing evidences have indicated that minimally invasive approaches have quickly gained traction. Laparoscopic partial nephrectomy (LPN) has comparable perioperative outcomes and cancer-specific survival compared with the technique of OPN.^10–12

As the benefits of PN become apparent, the indications and application of nephron-sparing surgery continue to expand. There are several reports of PN for renal tumors larger than 7 cm in size; nevertheless, they are limited to single institution center with small number of patients and conflicting results. There are two studies which reported that, although technically feasible, oncological efficacy may be compromised.^13,14 On the other hand, more recent data have documented that the oncological outcomes are similar to those in RN,^15,16 with the additional benefit of nephron preservation.^17–19 However, the limited studies only focus on OPN, transperitoneal or robot-assisted LPN approach, until now.

Since the information about retroperitoneal LPN for tumors larger than 7 cm in renal tumor is limited, together with the necessity of safe and oncological efficacious evaluation, we retrospectively evaluated and reported the initial experience about using retroperitoneal laparoscopic approach in patients who underwent LPN.

Materials and Methods

Written informed consent was obtained from those patients before the surgery. This study was approved by the Protection of Human Subjects Committee of the Chinese People's Liberation Army (PLA) General Hospital. Patients who were reviewed in our prospectively collected database were treated for renal tumors at Chinese PLA General Hospital. After exclusion of the patients with benign masses, 431 patients with T2 malignant renal masses had radical nephrectomies. Eventually, 15 patients with tumors larger than 7 cm measured preoperatively by computed tomography (CT) scan, who underwent LPN using the retroperitoneal approach, were identified in this study. The procedures were performed by 1 surgeon. All of the 15 patients had a preoperative CT of kidney (Fig. 1A). The preoperative computed tomographic angiography of renal artery was also performed to evaluate the possible anatomic variations (Fig. 1B). Five patients' tumors had further evaluation by magnetic resonance imaging preoperatively. LPN was performed in patients with an absolute indication, that is, a solitary kidney, bilateral disease, or renal insufficiency, to avoid dialysis after surgery. Among them, 2 (13.3%) patients had a solitary kidney or had a solitary kidney from a previous RN, and 4 (26.7%) patients had bilateral tumors. The decision to perform an elective retroperitoneal LPN for patients without imperative indications was based on surgeon discretion after complete evaluation, including preoperative imaging showing a large tumor and a significant portion of the kidney not being involved by tumor, which was amenable to resection, combined with a significant convenient location for the retroperitoneal approach.

FIG. 1.

(A) Preoperative CT of kidney. (B) Preoperative computed tomographic angiography of renal artery. (C) CT scan of kidney after the left partial nephrectomy. (D) The CT scan of kidney 3 months after bilateral partial nephrectomy. CT, computed tomography.

LPN was performed using the retroperitoneal approach with an evolving renorrhaphy technique, which was described previously by our team.^20,21

Certain data were collected, including age at surgery, gender, body mass index (BMI), 2010 TNM stage, tumor size measured by CT scan, surgical characteristics (operative time, warm ischemia time [WIT], estimated blood loss [EBS], and preoperative and postoperative estimated glomerular filtration rate [eGFR]), complications, and pathological data on the surgical specimen, that is, margin status, Fuhrman grade, disease progression, and outcome. Data were given as a median and range or as an absolute value with relative frequencies.

Results

In total, 15 patients were included in this study. Table 1 lists the main demographics of these patients. The median age of this cohort was 55 (34–63) years, with the BMI of 25.4 (19.6–29.3), and the median range of the tumor size was 7.5 (7.1–9.0) cm. Among all the 15 patients, 9 (60.00%) patients, 4 (26.67%) patients, and 2 (13.33%) of them suffered from preoperative chronic kidney disease (CKD) at stage I, II and III, respectively. As objectified by the R.E.N.A.L. nephrometry scoring system,²² 6 patients had medium complexity lesions and 9 patients had high complexity lesions.

Table 1.

Characteristics of Patients and Tumors

Variable	Value
Patients	15
Median age	55 (34–63)
Median body mass index (range)	25.4 (19.6–29.3)
Tumor location (only >7 cm), n (%)
Upper	5 (36)
Middle	2 (14)
Lower	8 (50)
Tumor size (cm), median (range)	7.5 (7.1–9.0)
Indications for nephron-sparing surgery, n (%)
Elective	9 (57)
Bilateral tumors	4 (29)
Solitary kidney	2 (14)
CKD stage (preoperative), n (%)
I–II	13 (86.67)
III	2 (13.33)
IV–V	0
R.E.N.A.L. score
Low complexity (4–6)	0
Medium complexity (7–9)	6
High complexity (10–12)	9

CKD, chronic kidney disease.

All procedures were successfully performed without conversion to RN or open surgery. As shown in Table 2, the median operating time was 121 (90–330) minutes and the WIT was 29 (12–45) minutes, with the EBS of 50 (10–1200) mL. The major complications included 2 patients requiring blood transfusions and 1 patient performing renal vein suture as well as single leak, which was managed with a prolonged retroperitoneal drain. Fourteen tumors were pathologically identified as pT2 and one tumor as pT1b; furthermore, the pathologic examination confirmed clear cell RCC in 14 patients and 1 patient had mixed clear cell and chromophobe. All patients had negative surgical margins. The preoperative eGFR was 81.26 mL/min per 1.73 m² (ranging from 56.15 to 140.47), eGFR on 1 and 30 days postoperative was 70.49 mL/min per 1.73 m² (ranging from 50.32 to 137.73) and 75.13 mL/min per 1.73 m² (ranging from 54.07 to 142.99), and at last follow-up, the eGFR was 72.78 mL/min per 1.73 m² (ranging from 51.28 to 137.86); no stage migration for CKD was observed.

Table 2.

Perioperative and Oncological Outcomes

Variable	Value
Operative time, minutes (range)	121 (90–330)
WIT, minutes (range)	29 (12–45)
Estimated blood loss, mL (range)	50 (10–1200)
Days of hospital stay, days (range)	8 (6–11)
Pathological stage, n (%)
pT1b	1 (6.67)
pT2	14 (93.33)
Pathological characteristics, n (%)
Clear cell carcinoma	14 (93.33)
Mixed clear cell and chromophobe	1 (6.67)
Fuhrman grade, n (%)
I–II	9 (60.00)
III–IV	6 (40.00)
No. of margins, n (%)
Negative	15 (100)
Positive	0 (0)
eGFR, mL/min/1.73 m²
Preoperative	81.26 (56.15–140.47)
Day 1	70.49 (50.32–137.73)
Day 30	75.13 (54.07–142.99)
At last follow-up	72.78 (51.28–137.86)
CKD stage (at last follow-up), n (%)
I–II	13 (86.67)
III	2 (13.33)
IV–V	0
No. of recurrence, n (%)
No	15 (100)
Yes	(0)
No. of metastasis n (%)
No	14 (93.33)
Yes	1 (6.67)

CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; WIT, warm ischemia time.

The median follow-up was 48 (31–84) months, with a mean of 53 months, except for the 1-month oncological follow-up; standardized postsurgical aftercare was performed for patients based on our institution's outpatient procedure; for the first 2 years after surgery, physical examinations, ultrasound, and CT scan were performed every 3 or 6 months; further diagnostic investigations were adjusted individually according to clinical charactors.^23–26 Eventually, there was no recurrence. One metastasized to liver, noted at the sixth month after PN, which was successfully resected and confirmed by pathological examination.

Discussion

Recent studies have shown no differences in oncological outcomes between PN and RN for T2 renal masses.²⁷ PN can be safely performed with acceptable oncological outcomes,²⁸ and it also provided a preservation of renal function when compared to RN for renal masses greater than or equal to 7 cm.¹⁹

The preservation of renal function is intensively needed for patients presenting bilateral renal tumors, solitary kidney, or CKD. The ultimate goal of renal preservation has made the use of PN mandatory. Expanding the elective indication of PN to larger tumors (>7 cm) can be technically challenging, together with negative prognosticators such as higher tumor grades, tumor necrosis, and higher T stages increasing with tumor size.²⁹ Nevertheless, the existing data have shown oncological efficacy and preservation of renal function.^15–17,28

The data regarding technical and oncological outcomes for tumors larger than 7 cm had been reported by several authors.^{5,15–17,28,30,31} However, most of these procedures were performed by OPN, transperitoneal or robotic approach. Although each approach had its inherent advantages and disadvantages, the data, especially about retroperitoneal laparoscopic approach, were still limited. The largest study to date for PN for renal tumors larger than 7 cm was described by Becker et al.¹⁶ Nonetheless, to our knowledge, this study was the largest series to address retroperitoneal LPN for malignant renal tumors larger than 7 cm.

In this cohort, no patient had been faced with dialysis after operation. The preoperative eGFR decreased from 81.26 mL/min per 1.73 m² (ranging from 56.15 to 140.47) to 75.13 mL/min per 1.73 m² (ranging from 54.07 to 142.99) in the renal function assessment at about 30 days after LPN; to our surprise, no stage migration for CKD was observed in this series. Favorably, compared with that of the published reports on PN,³² it can be explained by the following reasons: (1) the tumor size among all selected patients was different. The median tumor size of our series was 7.5 (7.1–9.0) cm compared to a median of 7.5 (7–19) cm reported by Karellas et al.¹⁷ and 8.7 (7–30.0) cm reported by Long et al.,²⁸ respectively. In addition, our series appear to have had a better preoperative CKD stage compared with the previous cohort. (2) The shorter surgical time of retroperitoneal approach has particular advantages,^32,33 which may also contribute to the seemingly shorter WIT in our series.³⁴

Another major concern about LPN for renal tumors larger than 7 cm is the complication. The complication rates of PN for pT2 or higher tumors have been reported by Breau et al., which mainly consist of urinoma (17.9%) in 40 patients with imperative indications,¹⁵ and Long et al. have reported that the complications mainly contain urinary fistulae (12.2%) and blood transfusions (8.2%) in their series of 46 patients undergoing PN.²⁸ In this series, blood transfusion rate was similar to their reports, but only one leak was observed and managed with a prolonged retroperitoneal drain. To our experience, the results benefited from the advantages of the following managements: first, layered parenchymal suture was used in this series (Fig. 2A–D); the renal cortex was sutured first and then the whole renal defect. The layered suture of renal cortex could repair most of the injured collect system and vessels. Second, the preoperative computed tomographic angiography of renal artery was used for preoperative evaluation of possible anatomic variations and eventually confirmed the complete obstruction of renal artery during WIT; hence, a more clear view, combined with the magnified view of laparoscopic lens, made the surgeon mend the injured collect system and vessels precisely.

FIG. 2.

(A) Tumor was excised with at least 5-mm margin of normal renal parenchymal margin around tumor. (B) Injured collect system was constructed when suturing renal cortex. (C) The renal cortex was sutured. (D) The whole renal defect suture is completed.

The limitations of this study included its retrospective, single institution nature without matched controls, the small patient cohort, which maybe the indication of a selection bias. Therefore, further follow-up is still wanted. Moreover, the series only used the retroperitoneal route, and further studies comparing transperitoneal, retroperitoneal, and robot-assisted approach still remain to be performed.

Footnotes

Acknowledgments

The authors gratefully acknowledge the funders and would also like to thank Ms. Yan Li for her support and assistance in data collecting, National High Technology Research and Development Program (“863” Program) of China (2014AA020607), Medical Scientific Research Foundation of Heilongjiang Province, China (2016–214), and Project funded by China Postdoctoral Science Foundation.

Disclosure Statement

No competing financial interests exist.

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