Laparoscopic Renal Surgery for Benign Disease

Joseph C. Liao, MD, Alberto Breda, MD, and Peter G. Schulam, MD, PhD

Corresponding author fibrosis could pose immense challenges toward surgical dis- Joseph C. Liao, MD section. Patients with xanthogranulomatous pyelonephritis Department of Urology, Stanford University School of Medicine and VA Palo Alto Health Care System, 3801 Miranda Avenue, (XGP), tuberculous nephritis, and prior renal surgery should MC112, Palo Alto, CA 94304, USA. be reserved for the most experienced laparoscopic surgeons. E-mail: [email protected] These patients should be counseled regarding the increased Current Urology Reports 2007, 8:12–18 likelihood of complications and possible open conversion. Current Medicine Group LLC ISSN 1527-2737 With improvement in instrumentation and dissemina- Copyright © 2007 by Current Medicine Group LLC tion of skills, laparoscopic renal surgery is now routinely practiced in many centers around the world. Since the last review [10], there has been continued improvement in Fifteen years after the first report, laparoscopic nephrec- instrumentation including smaller scopes (5 mm), visual tomy has demonstrated proven efficacy and safety obturator trocars, and a new generation of digital cameras comparable with an open approach, with a significant [11,12]. The use of a morcellator for specimen removal advantage of a faster recovery. Wide dissemination of does not lead to reduction in operating or recovery time these surgical techniques and continued improvement and remains as the surgeon’s preference [13]. in instrumentation has made laparoscopy the preferred In this review, the current state of laparoscopic renal approach for treating benign pathologic conditions of surgery for benign disease, with particular emphasis the . In this review, the expanding indications of on simple , is discussed. We cover patient laparoscopic simple nephrectomy and the outcomes selection, technical aspects of transperitoneal and retro- of the larger clinical series are examined. We discuss peritoneal nephrectomy, and review the outcomes of the the technical aspects of both transperitoneal and larger clinical series to date. Other applications including retroperitoneal approaches. Finally, laparoscopic cyst laparoscopic cyst decortication and some of the newer decortication and some of the novel applications of procedures are highlighted. Reconstructive procedures laparoscopic renal surgery are highlighted. such as pyeloplasty are not covered in this review.

Introduction Patient Selection Since the first report of transperitoneal laparoscopic Laparoscopic simple nephrectomy should be considered nephrectomy by Clayman et al. [1] in 1991 and the report for any benign pathologic conditions of the kidney indi- of retroperitoneal approach using a dissecting balloon by cated for removal (Table 1). Indications for nephrectomy Gaur et al. [2] in 1993, laparoscopy has emerged as the include refractory pain, bleeding, chronic infection, or standard of care for benign renal disease requiring surgical hypertension. Absolute contraindications are similar to intervention. More than 1200 cases have been reported those for open nephrectomy, which include uncorrected in the literature. The advantages of reduced postoperative coagulopathy, active peritonitis, and severe cardiopulmo- pain, a shorter hospital stay, earlier return to normal nary disease. Renal anatomic anomalies, such as horseshoe activities, and improved cosmesis compared with the open [14–16] or ectopic kidney [17], do not preclude the laparo- approach are well-documented [3,4,5•,6–9]. scopic approach, provided adequate preoperative imaging The most common indication for laparoscopic renal is obtained. Relative contraindications are directly related surgery for benign disease is simple nephrectomy. Although to the surgeon’s experience and comfort level. With expe- laparoscopic removals of small atrophic kidneys are ideally rience, obese patients and patients with enlarged kidneys suited for the less experienced surgeon, simple nephrectomy such as autosomal dominant polycystic kidney disease remains as one of the great misnomers in urologic surgery. (ADPKD), which are more challenging to mobilize, may be Simple by no means equates to uncomplicated nephrectomy, attempted. In obese patients, initial access may be challeng- particularly in situations in which dense inflammation and ing due to the thickened abdominal wall. In experienced Laparoscopic Renal Surgery for Benign Disease Liao et al. 13

Table 1. Indications for laparoscopic with only one open conversion. Similar favorable results have simple nephrectomy also been observed by others [5•,27]. The authors argue that Renovascular disease laparoscopic nephrectomy should be the first-line treatment for renal TB. Ureteropelvic junction/ureteral obstruction As part of the preoperative work-up, all patients need Reflux nephropathy a complete history and physical examination. Standard Stone disease laboratory studies including complete blood count, serum Renal dysplasia chemistries, coagulation studies, and urine culture are obtained. Chest radiograph, electrocardiogram, and addi- Renal tuberculosis tional cardiac work-up (if warranted) are also obtained. Xanthogranulomatous pyelonephritis All patients are required to have an abdominal imaging Polycystic kidney disease study to visualize the renal pathology. Our imaging study Native nephrectomy before renal transplant of choice is CT of the abdomen with and without intrave- nous contrast with delay phase, which provides excellent visualization of the renovascular and collecting system hands, laparoscopic renal surgery in obese patients results anatomy. The CT scan is also helpful to delineate the in similar operative times and complication rates but is relationship among the kidney and the surrounding organs associated with less blood loss and faster recovery when and presence of perinephric stranding as a sign of inflam- compared with the open approach [18]. Others have found mation. If there are concerns regarding the residual renal longer operative times and increased estimated blood loss function, a MAG-3 nuclear scan with differential function but similar complication and conversion rates and recovery is useful. We generally place the patients on a clear liquid period compared with the nonobese cohort [19•,20]. diet 2 days before the surgery. The day before the surgery, The most difficult cases are related to the presence patients are instructed to take two bottles of magnesium of severe scarring and fibrosis, which may completely citrate and are placed on nothing by mouth after midnight. obliterate normal anatomic planes for capsular and hilar dissection. Examples include XGP, renal tuberculosis (TB), and prior open abdominal/renal surgeries. These Surgical Technique situations are typically associated with higher complica- Laparoscopic nephrectomy may be performed either by tion and conversion rates [21,22] and should be reserved transperitoneal (“pure” or hand-assisted) or retroperitoneal for the most experienced laparoscopic surgeons. XGP is approaches. The hand-assisted approach is useful to bridge a severe, chronic bacterial infection of the renal paren- the steep learning curve needed to transition from open to chyma that results in significant inflammatory changes pure laparoscopic surgery. Some have advocated its use if within the kidney and the surrounding tissues. XGP has severe fibrosis is anticipated [28]. The technical aspect of been called the “great imitator” because it may mimic the hand-assisted approach is well-described elsewhere [29] other inflammatory or neoplastic conditions of the kid- and is not further commented on here. The transperitoneal ney. Nephrectomy is the treatment of choice. Given its approach offers the advantage of more intuitive anatomic challenging nature, XGP has been considered as a rela- landmarks and greater working space. The retroperitoneal tive contraindication for laparoscopic removal. There approach offers faster access to the renal hilum without have been few laparoscopic case series in the literature the need to mobilize intra-abdominal structures and may [23,24]. Khaira et al. [24] compared a small series of be advantageous in patients with prior abdominal surgery. patients who underwent laparoscopic (n = 3) versus We describe the technical aspects of both approaches, with open (n = 8) nephrectomy for XGP. Major complications particular emphasis on the transperitoneal approach, our rates were 33% for the laparoscopic group (vascular preferred choice. injury requiring open conversion) and 25% for the open group (unrecognized bowel injury, pneumothorax). The Transperitoneal nephrectomy authors concluded that a laparoscopic approach, albeit We have developed a generalized transperitoneal approach challenging, does not necessarily pose a greater risk in for renal surgery in which near-identical trocar configura- selected XGP patients by an experienced surgeon. tions (Fig. 1) are used for both extirpative and reconstructive Similarly to XGP, renal TB results in dense perinephric procedures. Using this standard approach, we have success- fibrosis, which makes laparoscopic dissection very challeng- fully performed more than 600 laparoscopic renal surgery ing, with prolongation of the operative time and increased cases, including simple nephrectomy, donor nephrectomy, risks of open conversion. An early series reported up to an radical nephrectomy, partial nephrectomy, adrenalectomy, 80% open conversion rate [25]. More recently, Lee et al. [26] renal cyst decortication, nephropexy, and pyeloplasty. We compared 31 cases of laparoscopic simple nephrectomy for believe the adaptation of a standard approach simplifies TB versus 44 cases for non-TB benign processes and found surgical planning and facilitates transferring of laparoscopic only prolonged operative time (244 minutes vs 216 minutes) techniques to the trainee. 14 Kidney Diseases

Figure 1. Port placement for laparoscopic Patient’s right Patient’s left transperitoneal renal surgery.

5 mm camera port 5 mm camera port

3 mm 5 mm working port working port (optional) 5 mm working port (optional) 5 mm working port 5 mm working port

Veress needle 12 mm working port 12 mm working port

Specimen extraction site

The patient is placed in a modified flank position at a 45° pole and carried caudally with continued medial retrac- angle. The table is gently flexed, but the kidney rest is not tion on the colon, thereby identifying and exposing the used in order to minimize the risk of rhabdomyolysis and psoas muscle. The triangular ligament of the liver is next because we have not found it to enhance our exposure [30]. incised to allow medial retraction of the liver, which can Pneumoperitoneum is achieved with the Veress needle placed be achieved through a lateral port by an assistant or with at the superior margin of the umbilicus and the position the use of a 3 or 5 mm trocar just below the xiphoid with verified with a saline drop test. We normally insufflate the a locking grasping instrument. With the liver elevated, the abdomen to 15 mm Hg. In obese patients, the pressure may posterior peritoneum is incised from the white line across need to be increased to 18 to 20 mm Hg to provide adequate the lower pole toward the inferior vena cava and cephalad working space. In children and in situations in which excess toward the incised triangular ligament.

CO2 absorption is of concern (eg, hypercarbia in patients For a left nephrectomy, the white line of Toldt is simi- with chronic obstructive pulmonary disease), the pressure is larly incised for medial reflection of the descending colon lowered to 10 to 12 mm Hg. If the Veress needle cannot be and the mesentery. The dissection is carried out caudally placed satisfactorily, we use the visual obturator with a 0° until the psoas muscle is exposed. The gonadal vein is laparoscope to gain access. usually easily identified traversing along the psoas. The Once the abdomen is insufflated, the costal margin, posterior peritoneum overlying the kidney is next incised to the lateral rectus edge, the iliac crest, and the entry site of mobilize the spleen medially. The incision is carried on up the trocars are marked (Fig. 1). For the right side, the first to the crus of the diaphragm. With aggressive mobilization 5 mm trocar site is at two to three fingerbreadths from the of the spleen and development of the plane between the costal margin on the rectus muscle edge. Two additional spleen and the upper pole, the spleen, pancreas, and colon working ports (5 mm and 12 mm) are then placed under will fall medially and usually require no active retraction. direct visualization caudal to the camera port four finger- The Gerota’s fascia is incised near the lower pole to iden- breadths apart along the lateral rectus border. For the left tify the . The gonadal vein is identified at this time and side, we use the same configuration, but the insertion of left intact. The plane of dissection is lateral to the gonadal the first trocar for the camera is at one fingerbreadth from vein, which we do not routinely divide. Particularly on the the costal margin along the rectus edge. The lowermost left side, by staying lateral to the gonadal, unnecessary dis- trocar is usually at or above the level of the umbilicus. section of the lumbar vein(s) is obviated. The ureter and the With this port configuration, the laparoscope is held by lower pole are now elevated with a blunt instrument and the assistant through the most cephalad trocar, leaving the the Gerota’s fascia is swept off the capsule. Alternatively, two lower ports for the surgeon’s left and right hands. By if significant inflammation and fibrosis are encountered, not having the working ports straddling the laparoscope, Gerota’s fascia can be used as the plane of dissection and the working envelopes for the surgeon and the assistant are be swept free from the psoas muscle, as in radical nephrec- separated. This trocar configuration makes for improved tomy. With the ureter elevated along with the lower pole of ergonomics for the surgeon and the assistant. In addition, the kidney, the dissection marches towards the renal hilum. the cephalad laparoscope location allows for a top-down After identifying the renal vein, a plane between the vein view of the kidney analogous to the dictum in open renal and artery is developed. With adequate elevation on the surgery in which one’s “incision can never be too high.” kidney, the endoscopic vascular stapler can be safely placed For a right nephrectomy, the white line of Toldt is across the artery using the 12 mm port followed by the renal identified and incised starting at the level of the lower vein in a similar fashion. Laparoscopic Renal Surgery for Benign Disease Liao et al. 15

The adrenal gland is gently dissected off the kidney, and The ureter is then secured and transected with the use of the upper pole is freed off of the muscle. It is useful to divide the endovascular stapler. The remaining retroperitoneal the small perforating vessels between the adrenal and kidney attachments are now divided, and the specimen is secured with the ultrasonic dissector. The final plane of dissection is in an endoscopic retrieval bag. the lateral attachments. Finally, the ureter is either clipped or transected with the endovascular stapler. The specimen is harvested through a Pfannestiel or low midline incision Clinical Outcomes with an endoscopic retrieval bag through an 18 mm trocar. The improvement in laparoscopic nephrectomy over open We generally do not morcellate the specimen. surgery with respect to intraoperative parameters, length of stay, and recovery time (while maintaining low and compa- Retroperitoneal nephrectomy rable complication rates) have been reviewed [3,4,5•,6–9]. The techniques of retroperitoneal nephrectomy have To date, more than 1200 cases of laparoscopic nephrec- been detailed elsewhere [31,32]. The patient is placed in tomy for benign disease have been reported in the literature a full lateral decubitus position. Access to the retroperi- (Table 2). Among these, approximate equal numbers have toneal space and port position are identical for the left been done via the transperitoneal and retroperitoneal and the right procedures. The open Hasson technique is approaches. Review of retrospective studies comparing the the most commonly employed technique for access. The two approaches did not demonstrate significant differences initial access is a 15 to 20 mm incision at the tip of the in most outcome measures [10]. There is no randomized 12th rib at the midaxillary line. The lumbodorsal fascia study comparing transperitoneal with retroperitoneal is incised, and the muscle fibers are split. The retroperi- simple nephrectomy, as has been done for radical nephrec- toneal space is entered, and blunt dissection is performed tomy. The radical nephrectomy study indicated shorter with the index finger. A space is created for the insertion operative time with the retroperitoneal approach, with no of a trocar-mounted balloon dilator anterior to the psoas other differences in postoperative parameters [33•]. In our muscle and posterior to the Gerota’s fascia. The balloon review of the published series, we included only series since may be inflated up to 800 mL depending on the amount of 1996 with more than 30 patients. Overall, no consistent retroperitoneal fat and the size of the patient. Progression advantages for either approach with respect to operative of the dilation process can be endoscopically monitored time, estimated blood loss, conversion rate, and major com- because the laparoscope can be passed inside the balloon plications are observed across the different series. Whereas during the inflation. there are theoretical advantages and disadvantages for The primary balloon-tip port is secured in the retroper- either approach depending on patient characteristics and itoneum, and insufflation is established (10–15 mm Hg). A specific indication, surgeon experience and preference posterior secondary 12 mm port is inserted at the lateral remains the primary driving force. border of the paraspinus muscle along the inferior border Gupta et al. [5•] recently reported the largest single- of the 12th rib, and an additional 5 mm port may be placed center series of laparoscopic simple nephrectomy with on the midaxillary line at the level of the superior iliac crest 363 cases over a 7-year period and compared with 83 to be used for retraction and suction. The anterior 12 mm cases of open simple nephrectomy during the same port is placed at the intersection of the inferior border of period. Retroperitoneal approach (n = 351) was favored the 12th rib and a perpendicular line drawn to it from the over the transperitoneal approach (n = 12). Among the anterior superior iliac spine. Care should be taken to avoid retroperitoneal cases, 29 patients had history of surgery traversing through the peritoneal cavity with this port. and pyonephrosis, and 31 patients had history of After dilation of the working space has been achieved, percutaneous tube placement. There were the kidney is displaced anteriorly. The psoas muscle is 22 (6%) conversions due to failure to progress, XGP, identified, and dissection is carried out in the cephalad and history of ipsilateral renal surgery. direction. The pulsation of the hilum is identified with the Prevention of complications requires careful atten- artery presenting first. On the left side only, a posterior tion to patient selection, positioning, access, intraoperative lumbar vein may be encountered first. When this is the fluid balance, vascular injury, exiting the abdomen, and case, the lumbar vein should be clipped and divided. At postoperative abdominal pain [34]. Several large series this point, the Gerota’s fascia must be incised to gain access of laparoscopic renal surgery have addressed the issue of to the renal hilum. Dissection is initiated around the renal complications [35–39]. A recent meta-analysis compared hilum, and the artery and vein are taken separately with the complication rates related to different laparoscopic renal pro- use of clips or an endovascular stapler. The Gerota’s fascia cedures and techniques [40••]. Major complications include is (at this point) further incised, and dissection is continued bleeding, vascular injury, injury to surrounding organs, on the renal capsule to circumferentially isolate the kidney. embolism, open conversion, and death. Minor complications When dissecting the upper pole of the kidney, care must be include ileus, wound cellulites, diaphragmatic irritation, taken in order to precisely find the right plane between the urinary retention, and subcutaneous emphysema. The over- adrenal gland and the kidney in order to spare the adrenal. all major and minor complication rates for all laparoscopic 16 Kidney Diseases d Mean Mean convalescence, d of stay, Mean length length Mean ) % Major Major complications, ( ) % Conversions ( Conversions mL Mean EBL, Mean min time, time, Mean OR OR Mean TP and RP 190 150 RPTP and 188 7 (6.7%) — 2 (1.9%) 46 (9.4%) 4 (6%) 29 — 5.4 — ‡ † 1996 33 RP TP and 320 — 2 3 (9%) 2.9 14.7 Clayman [7] Clayman Series also included 38 radical for malignancy. Series nephrectomies radical 38 included also for malignancy. Series also included 39 radical nephrectomies radical Series 39 included nephroureterectomies also and 23 for malignancy. Poulsen et al. [48] et al. Poulsen 2005 103 Gupta et al. [5•]Gupta et al. Gaur [49] [21] 2004 Tolley and Keeley 1998Gill [31] [25] et al. Rassweiler 351 1998 79 2000 [50] et al. Doublet and McDougall 1997 482 1998 38 RP TP 36 36 98 147 RP RP RP 65 132 — 95 263 84 4 (1%) 5 (3.4%) — 117 6 (1.6%) 1 (1.3%) 4 (1%) 2 (5.6%) 0 4.8 — 3 0 1 (3%) — 2.7 3.7 2.9 13.3 14 16.1 Table 2. Outcomes of contemporaryTable series of laparoscopic nephrectomy benign for disease* Study Year cases of Number Approach *Only series*Only with greater cases than 30 were included. after 1996 † ‡ EBL—estimated blood loss; OR—operating blood RP—retroperitoneal; loss; room; TP—transperitoneal. EBL—estimated Laparoscopic Renal Surgery for Benign Disease Liao et al. 17 renal surgery were 9.5% and 1.9%, respectively. Of the 300 retroperitoneal approach is a matter of surgeon preference. patients included in the analysis who underwent laparoscopic Sound surgical judgment needs to be applied judiciously, simple nephrectomy, the major and minor complication particularly in situations in which significant inflammation rates were 13.7% and 5.7%, respectively. Interestingly, the may be encountered. major and minor complication rates were higher for both laparoscopic radical nephrectomy (10.7%, 3.3%) and donor nephrectomy (10.6%, 0.5%), respectively, highlighting the References and Recommended Reading challenging nature of “simple” nephrectomy. Papers of particular interest, published recently, have been highlighted as: • Of importance Other Laparoscopic Renal Surgeries •• Of major importance Renal cyst decortication is indicated in situations in 1. Clayman RV, Kavoussi LR, Soper NJ, et al.: Laparoscopic which conservative management of symptomatic renal nephrectomy: initial case report. J Urol 1991, 146:278–282. cysts has failed. The majority of the simple renal cysts 2. Gaur DD, Agarwal DK, Purohit KC: Retroperitoneal are incidental findings, and the patients are asymp- laparoscopic nephrectomy: initial case report. J Urol 1993, 149:103–105. tomatic. Large cysts that are associated with flank 3. 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