Laparoscopic Radical Nephrectomy with Transperitoneal Approach for Large Renal Tumors: Standardized Surgical Technique and Outcomes

Abstract

Background:

Minimally invasive surgery is used only in selected cases of renal masses greater than 7 cm, and few studies exist in this setting. This study aimed to evaluate the safety and effectiveness of a laparoscopic surgical approach for the treatment of large renal tumors using a standardized technique.

Materials and Methods:

Data of patients who underwent laparoscopic nephrectomy (LN) using the transperitoneal approach were retrospectively evaluated from December 2019 to September 2022. The study population was divided into two groups: patients with renal masses <7 cm (Group A) and those with renal masses ≥7 cm in diameter (Group B). The intraoperative and postoperative outcomes were compared.

Results:

Forty patients were enrolled (16 in Group A and 24 in Group B) in this study. Although significant difference in terms of age and American Society of Anesthesiologists score were detected, the two groups did not differ in mean operative time (130 minutes standard deviation [SD] ± 64 versus 148 minutes DS ± 56; P = .376), intraoperative complications (0% versus 8.3%; P = .508), need for postoperative transfusion (12% versus 12%; P > .999), and length of stay (3.38 DS ± 0.62 days versus 3.92 DS ± 2.47; P = .313). One patient had a local recurrence and died ∼13 months after surgery. Furthermore, 2 patients developed trocar-site incisional hernia in Group B.

Conclusion:

In this cohort of patients, LN for large renal tumors appeared to be safe and feasible. Larger mass dimension does not appear to influence the outcomes when the surgery is performed using a standardized technique by experienced surgeons.

Introduction

Laparoscopic nephrectomy (LN) was first reported by Clayman et al. in 1991.¹ The minimally invasive approach has been widely accepted and recommended for selected cases of stage T1 (<7 cm in diameter) renal cell tumors, providing clear benefits in terms of safety, intraoperative blood loss, length of hospital stay, less pain, and faster recovery. Similarly, the oncological equivalence of LN to the open technique has been confirmed in several studies.^2–4 Currently, few studies have evaluated the safety and efficacy of LN for renal masses >7 cm in size. However, two of these studies exclusively used a manual-assisted technique.^5,6 For renal tumors >7 cm, surgeons generally prefer minimally invasive surgery because of technical difficulties associated with the alternative options. In addition, no trials suggest that laparoscopic and open radical nephrectomies are comparable with the laparoscopic approach in terms of oncological outcomes and morbidity.⁷

Furthermore, as the laparoscopic approach is considered challenging for renal lesions >7 cm, the feasibility and generalizability of the procedure are questionable. Surgeons with limited experience in minimally invasive procedures may be faced with this type of lesions frequently opting for open surgery.

In our institution, a standardized technique for LN has been adopted for tumors of all sizes. Therefore, this study aimed to assess the safety and efficacy of a standardized technique for LN with a transperitoneal approach for large renal masses (>7 cm) comparing the outcomes with those of a control group (renal tumors <7 cm).

Materials and Methods

We retrospectively reviewed the medical records of all patients scheduled to undergo nephrectomy for both malignant and benign renal tumors at our institution between December 2019 and September 2022. All patients who underwent laparoscopic radical nephrectomy with a transperitoneal approach were included and categorized into two cohort groups based on the maximum diameter of the renal tumor on pathologic examination: <7 cm (Group A) and ≥7 cm (Group B). The patients' demographic and pathological data were recorded. Perioperative outcomes, such as operative time, need for blood transfusion, length of hospital stay, recurrence, incisional hernia, and death rates, were compared between the two groups.

Surgical technique

Surgery was performed by two general surgeons, F.C. and U.B., who had been trained to perform laparoscopic surgery with >200 advanced laparoscopic surgical procedures/year. The patient was placed in the lateral decubitus position, and the operative table was flexed to extend the costophrenic angle. The surgeon and assistant stand anterior to the patient, facing the monitors located at the head of the operating table on both sides. Pneumoperitoneum is induced using the open Verres-assisted technique.⁸ The Verres needle is placed in the right iliac fossa and left hypochondrium (Palmer's point) for right and left nephrectomy, respectively. Four trocars were typically used.

For laparoscopic right nephrectomy, the hepatic flexure of the colon is mobilized, and the lateral border of the inferior vena cava is considered a landmark for identification of the right renal vein. Dissection was carried out using blunt maneuvers to identify the right renal artery, which was sectioned between clips. The artery-first approach allows a decrease in blood flow to the kidney and, thus, to venous return. In this way, a reduction in the caliber of the vein was achieved, making it easier to ligate with absorbable threads and clips. Occasionally, veins were divided using a vascular stapler. The ureter was exposed medially to the inferior renal pole, clipped, and sectioned.

Finally, mobilization of the kidney is conducted from the bottom up in the avascular plane above the psoas muscle. Adrenal glands are usually spared. The specimen was positioned in an endobag and was extracted through a suprapubic incision. A drain was usually placed and removed on the first postoperative day (Supplementary Video S1).

For laparoscopic left nephrectomy, the descending colon and splenic flexure were mobilized. The spleen and tail of the pancreas were moved to the right. After exposure of the retroperitoneal region, the left renal vein can be reached either by following the gonadal vein, which drains directly into the left renal vein, or by directly approaching the renal hilum. Although it includes sectioning of the gonadal vessels and middle adrenal vein, the vascular approach is the same as for right nephrectomy, as well as the mobilization of the kidney and surrounding adipose tissue.

Statistical analyses

Data are presented as frequencies (percentages) for categorical variables or as means (standard deviations) for continuous variables. Comparisons between the two groups for continuous variables were performed using the Student's t-test or Mann–Whitney U test, as appropriate. Comparisons between groups for categorical variables were performed using the chi-squared test or Fisher's exact test, as appropriate. For all analyses, a P value <.05 was considered significant. All analyses were performed using R statistical software version 4.0.3.

Results

A total of 44 patients underwent nephrectomy for renal tumors between December 2019 and September 2022. Four patients were excluded because an open approach was used. Sixteen and 24 patients had tumors <7 cm (Group A) and ≥7 cm (Group B), respectively. The two groups were homogeneous for all baseline characteristics, except that patients in Group A were older (P = .033), had a lower American Society of Anesthesiologists score (P = .037), and a higher Radius, Exophytic/endophytic, Nearness to collecting system or sinus, Anterior/posterior, Location score (P < .001) than those in Group B (Table 1).

Table 1.

Preoperative Characteristics of the Study Population

	Total, N = 40	Group A <7 cm (n = 16)	Group B ≥ 7 cm (n = 24)	P
Sex
Male	23 (57.5%)	11 (69)	12 (50)	.396
Female	17 (42.5%)	5 (31)	12 (50)
Mean age (±SD)	59 (12)	64 (10)	56 (13)	.033
Median ASA
II	30 (75)	9 (56)	21 (88)	.037
III	9 (22)	6 (38)	3 (12)
IV	1 (2.5)	1 (6.2)	0 (0)
Mean BMI (±SD)	27.2 (4.2)	26.9 (3.9)	27.3 (4.5)	.736
Operative side
Left	15 (38)	7 (44)	8 (33)
Right	25 (62)	9 (56)	16 (67)
Mean preoperative creatinine (mg/dL) (±SD)	1.00 (0.28)	1.04 (0.34)	0.98 (0.23)	.495
Mean preoperative e-GFR (mL/min/1.73 m²) (±SD)	78 (19)	76 (22)	80 (18)	.598
Mean preoperative hemoglobin (g/L)	13.56 (1.63)	13.75 (1.40)	13.43 (1.78)	.529
PADUA score	9.10 (1.35)	8.44 (1.15)	9.54 (1.32)	.008
RENAL score	6.90 (1.57)	6.00 (1.10)	7.50 (1.56)	<.001

ASA, American Society of Anesthesiologists; BMI, body mass index; e-GFR, estimated glomerular filtration rate; RENAL, Radius, Exophytic/endophytic, Nearness to collecting system or sinus, Anterior/posterior, Location; SD, standard deviation.

Concomitant adrenalectomy was more frequent in Group B versus Group A (38% versus 12%; P = .006). Two minor intraoperative injuries of the inferior vena cava occurred in Group B: both were repaired with laparoscopic sutures (Table 2). One patient in Group B underwent conversion to open surgery due to technical difficulties. However, no statistically significant difference was found between the two groups in terms of operative time (median 130 [±64] versus 148 [±56] minutes; P = .376).

Table 2.

Intraoperative Findings

	Total, N = 40	Group A <7 cm (n = 16)	Group B ≥ 7 cm (n = 24)	P
Mean duration of procedure (minutes) (±SD)	140 (±59)	130 (±64)	148 (±56)	.376
Type of intervention
Surrenalectomy	9 (22%)	0 (0)	9 (38%)	.006
Linfoadenectomy	3 (7.5%)	0 (0)	3 (12%)	.262
Conversion (n)	1	0	1
Intraoperative complications	2 (5)	0 (0)	2 (8.3)	.508
Abdominal drain	24 (60)	7 (44)	17 (71)	.167

Malignant disease occurred in 80% of the cases. Pathological findings are presented in Table 3. The mean specimen size was 17.0 (±6.2) cm in Group A and 20.6 (±3.7) cm in Group B (P = .048). Similarly, the mean tumor size was 4.3 (±1.9) cm in the Group A and 10.0 (±2.7) cm in the Group B (P < .001) (Table 3). An R0 rate of 100% was achieved.

Table 3.

Pathology Details

	Total, N = 40	Group A <7 cm (n = 16)	Group B ≥ 7 cm (n = 24)	P
Pathology
Malignant	32 (80%)	11 (69%)	21 (87%)	.229
Clear cell	21	7	14
Papillary	3	1	2
Chromophobe	5	3	2
Liposarcoma	1	0	1
Transitional cell	2	0	2
Benign	8 (20%)	5 (31%)	3 (13%)
Oncocytoma	3	3	0
Angiomyolipoma	5	2	3
Staging
T1	11 (34)	11 (100)	0 (0)	<.001
T2	17 (53)	0 (0)	17 (81)
T3	4 (13)	0 (0)	4 (19)
T4	0
Grading				.430
G1	14 (44)	7 (63)	7 (33)
G2	5 (16)	1 (9)	4 (19)
G3	10 (31)	2 (18)	8 (38)
G4	3 (9)	1 (9)	2 (9)
Mean specimen size (cm)	19.2 (±5.1)	17.0 (±6.2)	20.6 (±3.7)	.048
Mean tumor size (cm)	7.7 (±3.7)	4.3 (±1.9)	10.0 (±2.7)	<.001

In Group B, 1 patient developed recurrence and died for reasons unrelated to the primary disease ∼5 months after surgery, and 2 patients developed trocar-site incisional hernia (Table 4).

Table 4.

Postoperative Outcomes

	Total, N = 40	Group A <7 cm (n = 16)	Group B ≥ 7 cm (n = 24)	P
Mean creatinine at POD1	1.45 (0.54)	1.44 (0.51)	1.45 (0.57)	.904
Mean hemoglobin at POD1	11.66 (1.46)	11.69 (1.35)	11.64 (1.56)	.951
Mean length of stay (days)	3.70 (1.95)	3.38 (0.62)	3.92 (2.47)	.313
Mean drain remove (days)	1.23 (1.66)	0.75 (1.13)	1.54 (1.89)	.105
Mean first full diet (days)	2.00 (0.320)	2.062 (±0.250)	1.958 (±0.359)	.199
Mean urinary catheter removal (days)	1.80 (1.44)	1.50 (±1.03)	2.00 (±1.64)	.245
Postoperative blood transfusion	5 (12)	2 (12)	3 (12)	>.99
Postoperative chemotherapy	2 (5)	0 (0)	2 (8.3)	.508
Recurrence	1 (2.5)	0 (0)	1 (4.2)	>.999
Death	1 (2.5)	0 (0)	1 (4.2)	>.999
Trocar-site incisional hernia	2 (5)	0 (0)	2 (8.3)	.508
Follow-up mean (days) (±SD)	411 (±253)	348 (±250)	454 (±251)	.199

POD, postoperative day.

Discussion

In the present study, we found that LN for renal tumors >7 cm is as safe and effective as LN <7 cm when performed by experienced surgeons using a standardized surgical technique.

LN has an acceptably low complication rate compared with open radical nephrectomy,⁹ and it has become the preferred surgical technique for patients with localized stage T1 renal masses (diameter <7 cm). In a cohort of 112 T2N0M0 patients, Hemal et al.¹⁰ reported similar long-term oncologic outcomes between the open and laparoscopic groups. Furthermore, the minimally invasive approach has advantages such as blood loss, shorter hospital stay, decreased analgesic requirement, and rapid recovery. Similarly, in a multicenter Korean study,¹¹ 88 patients with renal tumors >7 cm who underwent LN were compared with 167 patients who underwent open nephrectomy. Despite the longer operative time and higher blood loss rate, there were no differences in the overall and disease-free survival rates.

Based on these findings, laparoscopy has progressively gained popularity for the treatment of renal tumors >T1 to obtain the same benefits as those of smaller tumors. However, similar to other complex urologic procedures,¹² LN for masses >7 cm is considered technically demanding. Technical difficulties include decreased working space, challenging access to the renal ileum, and displacement of surrounding organs. Intraoperative complications include major vascular injuries, which may also endanger the patient's life.

In the present study, we converted to open surgery only in 1 case and 2 minor bleeding from the vena cava were treated laparoscopically. Our findings are in contrast with those of previous studies that showed significantly longer operative time, greater estimated blood loss, higher intraoperative complications, and conversion to open surgery rates when T2 renal tumors were compared with smaller lesions.^13,14 We found that a standardized surgical technique based on rigorous steps and accurate recognition of anatomical landmarks was fundamental for reducing morbidity. Furthermore, our findings are consistent with those of surgeons who have gained sufficient experience to operate on large masses with a minimally invasive approach and successful outcomes.¹⁵

The present study has several limitations. A small sample size and potential selection bias could affect the outcomes. In addition, we included both benign and malignant tumors. The limited follow-up time for some patients could influence long-term oncological efficacy.

Conclusions

This study provides support for implementing minimally invasive surgical treatment of large renal tumors. In our cohort of patients, LN for large renal tumors appeared safe and feasible. Larger dimensions of the masses do not seem to influence the outcomes when the surgery is performed using a standardized technique by experienced surgeons. Although the surgical outcomes are comparable, further multi-institutional studies with larger sample sizes are warranted to confirm these findings.

Footnotes

Authors' Contributions

Conceptualization and writing by R.P., B.I., M.I., and U.B.; data collection by B.I., M.I., A.T., D.S., A.G., and M.M.; statistical analysis: D.P.; supervision by U.B. and F.C.; revision of the final draft by R.P., U.B., and F.C.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Supplementary Material

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