Research Article: Laparoscopic Partial Nephrectomy: Is It Worth Still Performing the Retroperitoneal Route?

Date Published: June 12, 2012

Publisher: Hindawi Publishing Corporation

Author(s): Idir Ouzaid, Evanguelos Xylinas, Géraldine Pignot, Arnaud Tardieu, Andras Hoznek, Clément-Claude Abbou, Alexandre de la Taille, Laurent Salomon.

http://doi.org/10.1155/2012/473457

Abstract

Objective. The objective of this study was to compare perioperative, oncologic, and functional outcomes of TLPN (transperitoneal
laparoscopic partial nephrectomy) versus RLPN (retroperitoneal).
Patients and Methods. From 1997 to 2009, a retrospective study of 153 consecutive patients who underwent TLPN or RLPN for suspicious renal masses was performed. Complications, functional and oncological outcomes were compared between the 2 groups.
Results. With a mean followup of 39 and 32 months, respectively, 66 and 87 patients had TLPN and RLPN, respectively. Tumor location was more often posterior in the RLPN and more often anterior in the TLPN. Mean operative time and mean hospital stay were longer in the TLPN group with 190 ± 85 min versus 154 ± 47 (P = 0.001) and 9.2 ± 6.4 days versus 6.2 ± 4.5 days (P < 0.05), respectively. Transfusion and urinary fistulas rates were similar in the 2 groups. After 3-year followup, chronic kidney failure occurred in 6 and and 4% (P = 0.67) in after TLPN and RLPN, respectively. After 3-year followup, recurrence free survival was 96.7% and 96.6% (P = 0.91) in the TLPN and RLPN groups, respectively. Conclusion. Our study confirmed that TLPN had longer operative time and hospital stay than RLPN. The complication rates were similar. Furthermore, mid-term oncological and functional outcomes were similar.

Partial Text

Renal cell carcinoma (RCC) represents 2-3% of all cancers. It is the most lethal urologic cancer. Traditionally, more than 40% of patients with RCC have died of their cancer, in contrast with the 20% mortality rates associated with prostate and bladder carcinomas [1]. In 2008, there were an estimated 88 400 new cases and 39 300 kidney cancer-related deaths from RCC in Europe [2]. Etiological factors include lifestyle factors such as smoking, obesity, and hypertension. Having a first-degree relative with kidney cancer is also associated with an increased risk of RCC. The most effective prophylaxis is to avoid cigarette smoking and obesity [3]. Due to the increased detection of tumors by imaging techniques, such as ultrasound (US) and computed tomography (CT), the number of incidentally diagnosed RCCs has increased. Currently, more than 50% of RCCs are detected incidentally. These tumors are more often smaller and of lower stage [4]. Surgery is the gold standard treatment for localized RCC [3]. Nephron sparing surgery (NSS) emerged as a new surgical approach for T1 RCC. The rationale for NSS is twofold. First, it has been clearly reported that radical nephrectomy (RN) is associated with higher mortality in pT1 RCC tumors [5] and more renal failure [6]. Chronic kidney failure is independently associated with higher mortality [7]. Second, NSS has the same oncological outcomes than RN. Indications for NSS are absolute in cases with an anatomic or functional solitary kidney, relative when the functioning opposite kidney is affected by a condition that might impair renal function in the future, and elective in the presence of a healthy contralateral kidney. Another indication is patients with hereditary RCCs, who carry a high risk of developing additional kidney tumors [3]. NSS can be performed in opened (OPN), laparoscopic (LPN), or with robotic-assisted surgery. The first retroperitoneal laparoscopic partial nephrectomy (RLPN) was reported by Gill et al. in 1994 [8]. The transperitoneal laparoscopic partial nephrectomy (TLPN) was first reported by Winfield et al. in 1993 [9]. NSS can also be performed with robotic assistance [10]. Compared to OPN, LPN is associated with similar renal function outcomes, decreased postoperative narcotic use, shorter hospital stay, and improved convalescence [11]. Only few comparative TLPN and RPLN studies have been reported. The objective of our study was to compare perioperative, oncologic, and functional outcomes of TLPN versus RLPN at our institution.

NSS was indicated electively in 84% and 91%, for solitary kidney in 11% and 6%, and for bilateral tumors in 5% and 3% in the TRLP and RLPN groups, respectively. Preoperative data are shown in Table 1. Tumor location was statistically different. In the TLPN and RLPN tumor groups, 60% and 28% (P < 0.001) were anterior and 13% and 49% (P < 0.001) were posterior, respectively. Conversely, tumor size, location pole, and the depth of the tumor in the renal parenchyma were not significatively different. By 2000, because of the emerging data supporting elective PN, several minimally invasive surgery groups began concerted efforts to develop LPN techniques intending to closely simulate the open laparoscopic nephrectomy (OPN) procedure. Among LPN, RLPN is less popular than TLPN. Concerns about the continuing RLPN have been then arisen, and many centers stopped performing this approach. In our center, we usually use the laparoscopic retroperitoneal route for various procedures including LPN [17]. However, our staff surgeons tend to prefer the transperitoneal approach. Thus, we wanted to assess the surgical, functional, and oncologic outcomes of the two procedures. Our study confirmed the reported data that TLPN and RLPN were similar except for the operative time and the hospital stay longer in the TLPN. However, even if the RLPN is not as popular as TLPN, this approach should be considered for few patients with past history of intraperitoneal procedures that may turn the TLPN to be more difficult than RLPN.   Source: http://doi.org/10.1155/2012/473457

 

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