Laparoscopic upper pole partial nephrectomy with concomitant en bloc adrenalectomy

doi:10.1016/S0090-4295(03)00366-2

Urology

Volume 62, Issue 2, August 2003, Pages 223-226

https://doi.org/10.1016/S0090-4295(03)00366-2 Get rights and content

Abstract

Objectives

To report our experience with laparoscopic partial nephrectomy for renal tumor with concomitant adrenalectomy. An upper pole renal tumor may contiguously involve the adrenal gland, requiring concomitant adrenalectomy. Although commonly performed in the setting of laparoscopic radical nephrectomy, concomitant adrenalectomy has not been described during laparoscopic partial nephrectomy.

Methods

Four patients with an upper pole renal tumor and suspected adrenal involvement underwent laparoscopic partial nephrectomy with concomitant ipsilateral adrenalectomy. Preoperative three-dimensional computed tomography revealed the renal tumor to be closely abutting the adrenal gland in 3 patients and a 4-cm adrenal mass in 1 patient. The mean renal tumor size was 3.2 cm (range 1.4 to 6.6). To maintain oncologic principles, our transperitoneal laparoscopic technique excises the adrenal gland en bloc with the renal tumor. As such, adrenalectomy is performed first, followed by partial nephrectomy, incorporating hilar control, tumor excision, and sutured renal reconstruction.

Results

All four procedures were performed without open conversion or intraoperative complications. The mean renal warm ischemia time was 36 minutes, estimated blood loss 169 mL, total operating time 3.9 hours, and hospital stay 3.2 days. One patient developed a transient urinary leak postoperatively. Pathologic examination of the renal tumor revealed renal cell carcinoma (n = 1), dystrophic calcification with ectopic bone formation (n = 1), adult mesoblastic nephroma (n = 1), and subcapsular heterotopic adrenal cortex with cyst (n = 1), all with negative surgical margins. Pathologic examination of the adrenal gland revealed adenoma in 1 case and a normal adrenal gland without malignant involvement in 3 cases. All patients were disease free at last follow-up (mean 6.2 months, range 2 to 12).

Conclusions

In patients with an upper pole renal tumor and radiologically suspected adrenal involvement, laparoscopic partial nephrectomy with concomitant adrenalectomy can be performed efficaciously respecting oncologic principles.

Section snippets

Material and methods

Since August 1999, laparoscopic partial nephrectomy for tumor has been performed in 185 patients at our institute by the senior author (I.S.G.). Of the 185 patients, 46 (24.8%) had an upper pole renal tumor. Of these 46 patients, only 4 were suspected to have potential involvement of the adrenal gland on preoperative computed tomography (CT) scanning.

These 4 patients underwent ipsilateral adrenalectomy at the time of laparoscopic partial nephrectomy. All 4 patients had an upper pole renal

Results

The mean warm ischemia time was 35 minutes (range 29 to 48), the mean blood loss was 169 mL (range 75 to 300), and the mean operative time was 3.9 hours (range 2.5 to 5.0). The mean hospital stay was 3.2 days (range 2 to 4). Intraoperative ultrasonography was performed in all cases to demarcate the renal tumor from normal tissue. All 4 patients had entry into the collecting system during partial nephrectomy, which was repaired with suture intracorporeally. The mean tumor size was 3.2 cm (range

Comment

Complete surgical resection remains the cornerstone of treatment of organ-confined renal cell carcinoma. Radical nephrectomy historically includes excision of the tumor, along with perirenal fat, Gerota’s fascia, and the ipsilateral adrenal gland.8 Ipsilateral adrenal gland involvement by either direct extension or vascular embolization occurs in only 1% to 2% of patients.4, 5 Tumors that involve the adrenal gland by direct extension are classified as pT3a and those that involve the gland by

Conclusions

Laparoscopic partial nephrectomy with concomitant adrenalectomy is feasible in carefully selected candidates having a small upper pole renal tumor with radiologically suspected ipsilateral adrenal involvement. From a technical standpoint, laparoscopic adrenalectomy should be performed before partial nephrectomy, thus maintaining an en bloc specimen and minimizing intraoperative handling of the reconstructed renal remnant. We believe that such a minimally invasive nephron-sparing strategy may be

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Cited by (18)

Expanding Indications for Laparoscopic Partial Nephrectomy
2008, Urology
Citation Excerpt :
These carefully expanded indications are summarized in Table 2. Ramani et al.26 published their results in 4 patients undergoing transperitoneal LPN and concomitant adrenalectomy for upper pole tumor with adrenal involvement. The adrenal gland was maintained en bloc with the partial nephrectomy specimen and the overlying fat and fascia.
Operative Outcomes of Upper Pole Laparoscopic Partial Nephrectomy: Comparison of Lower Pole Laparoscopic and Upper Pole Open Partial Nephrectomy
2007, Urology
The intraoperative complexity of laparoscopic partial nephrectomy (LPN) for upper pole renal tumors is recognized. We report on the technical feasibility and operative outcomes of LPN for upper pole tumors (UPLPN) and lower pole tumors (LPLPN), and open partial nephrectomy (UPOPN) for upper pole tumors.
We retrospectively reviewed our database of LPNs performed by a single surgeon from October 2002 to February 2006. All solitary, upper and lower pole tumors in patients with a normal contralateral kidney were included. The perioperative outcomes were assessed. UPOPNs performed in the same institution by a separate surgeon were analyzed and compared separately with the UPLPN group.
Three groups, UPLPN (20 patients), LPLPN (33 patients), and UPOPN (24 patients), were analyzed. The UPLPN and LPLPN groups had similar perioperative outcomes. The intraoperative and postoperative major complications were also comparable between the UPLPN and LPLPN groups (17% versus 12%, P = 0.68 and 22% versus 6%, P = 0.07, respectively). The mean pathologic tumor size was larger (3.2 versus 2.3 cm, P = 0.05) and the mean operative time significantly shorter (187 versus 244 minutes, P = 0.02) in the UPOPN group than in the UPLPN group. The UPOPN group had a trend toward fewer intraoperative complications compared with the UPLPN group (4% versus 17%, P = 0.17). The final pathologic surgical margins were negative in all three groups.
LPN for upper pole renal tumors is technically feasible and may have comparable outcomes to LPN for lower pole tumors. However, performing open nephron-sparing surgery is still the standard of care because it may offer fewer complications and reduce the risk of ischemic damage to the kidney.
Minimally Invasive Nephron-Sparing Surgery (MINSS) for Renal Tumours{A figure is presented}. Part I: Laparoscopic Partial Nephrectomy
2007, European Urology
Citation Excerpt :
After a mean follow-up of 16.4 mo (range: 1–54), there were no recurrences. Ramani et al. [44] reported adrenalectomy during LPN in 4 patients with an upper pole tumour and suspected adrenal involvement. Using a transperitoneal approach, they first performed adrenalectomy, followed by LPN.
To review the evolution and current status of extirpative methods (laparoscopic partial nephrectomy [LPN]) of minimally invasive nephron-sparing surgery (MINSS) for renal tumors.
The English language literature of the past 10 yr was reviewed by using the National Library of Medicine database and the following keywords: kidney, laparoscopic partial nephrectomy, minimally invasive, nephron-sparing surgery, renal, and tumor. Over 275 papers were identified. Of these, 55 papers were selected for this review on the basis of their contribution in advancing the field with regards to (1) evolution of concepts, (2) development and refinement of techniques, and (3) intermediate- and long-term clinical outcomes of LPN.
Open partial nephrectomy (OPN) is the reference standard for nephron-sparing surgery against which all MINSS techniques should be measured. With available skills for time-sensitive intracorporeal suturing, LPN provides perioperative results and long-term oncologic and functional outcomes comparable to the reference standard, with significantly decreased patient morbidity. The initial 5-yr data of 50 patients has just become available, and shows overall and cancer-specific survival of 84% and 100%, respectively. As global experience with this technique increases, data need to be prospectively accrued, and long-term cancer cure rates should be compared with the reference standard.
As of this writing, the technique and global acceptance of LPN is evolving, although it remains restricted by the complexity of laparoscopic renal reconstruction. In expert hands, cancer cure and renal function outcomes are similar to OPN.
Laparoscopic partial nephrectomy for incidental stage pT2 or worse tumors
2006, Urology
Citation Excerpt :
In this series, one pT3b tumor invading a branch of renal vein was detected laparoscopically during excision, with conversion to laparoscopic radical nephrectomy. Increasing experience has allowed LPN to be performed for tumor invading into the deep parenchyma up to the collecting system or renal sinus, tumor in a solitary kidney, a hilar tumor, an upper pole tumor requiring concomitant adrenalectomy, and tumor requiring heminephrectomy (30% or more excision of renal parenchyma).12–15 This study had certain limitations.
To present our experience with laparoscopic partial nephrectomy (LPN) in patients with an incidentally detected Stage pT2, pT3a, or pT3b renal mass.
Of 525 patients undergoing LPN, 21 (4%) had pT2 or worse disease. LPN routinely involved en bloc excision of the overlying perirenal fat, along with the tumor and a healthy parenchymal margin. The preoperative computed tomography scans of these 21 patients were reviewed again by an unblinded radiologist to determine whether any suspicious radiologic signs of clinical Stage T2 or worse disease were present.
The tumors were Stage pT2 in 1 (0.2%), pT3a in 19 (3.6%), and pT3b in 1 (0.2%). The mean pathologic tumor size was 3.7 cm (range 1.8 to 7.4). In the patient with pT3b disease, a tumor thrombus invading a renal vein branch was detected laparoscopically. The renal parenchymal and perirenal fat surgical margins were negative for cancer in all 21 patients (100%). The repeated nonblinded review of the preoperative computed tomography scans suggested definitive evidence, equivocal evidence, and no evidence of pT3a disease in 0, 5 (26%), and 14 (74%) patients, respectively, and suspicion for pT3b disease in the 1 patient. One patient with a 2.5-cm pT3a sarcomatoid renal cell carcinoma with negative surgical margins developed distant metastasis and died. During a mean follow-up of 29 months (range 1 to 58), the cancer-specific survival rate was 95%.
The results of our study have demonstrated that adherence to surgical principles allows LPN to be performed for occult Stage pT2 and pT3 tumors with negative surgical margins and good oncologic outcomes. We have highlighted the importance of routine en bloc laparoscopic excision of the overlying perirenal fat along with the tumor, and intact specimen extraction, mirroring open surgery.
Laparoscopic heminephrectomy for tumor
2005, Urology
To present our experience with laparoscopic heminephrectomy. We defined heminephrectomy as excision of 30% or more of the renal parenchyma. Laparoscopic partial nephrectomy has typically been performed for smaller, exophytic tumors. With growing experience, we have performed more extensive resections for larger tumors, when indicated.
Since August 1999, we have performed laparoscopic partial nephrectomy in more than 300 patients. Of these, 41 patients were deemed to have undergone laparoscopic heminephrectomy (group 1). A contemporary group of 41 consecutive patients who underwent laparoscopic partial nephrectomy (less than 30% resection) were retrospectively identified for comparison (group 2).
The preoperative patient demographics were similar, except for a greater body mass index (P = 0.02) in group 1. Group 1 had larger tumors (3.7 cm versus 2.3 cm, P <0.001) that were more commonly centrally located (41% versus 9.8%, P = 0.001) and more deeply infiltrating (P <0.001) compared with group 2. Group 1 underwent larger parenchymal resections (P <0.001) and routine pelvicaliceal suture repair (P = 0.002). The warm ischemia time was longer in group 1 (39 versus 33 minutes, P = 0.02); however, the amount of blood loss (150 versus 100 mL, P = 0.28) and total operative time (220 versus 190 minutes, P = 0.09) were comparable between the groups. The analgesic requirements, hospital stay, overall complications, and postoperative serum creatinine were comparable between the groups. Histopathologic examination showed that all 82 surgical margins were negative.
Laparoscopic heminephrectomy is an advanced procedure that can be performed efficaciously with equivalent outcomes to those of less substantial resections. To our knowledge, experience with laparoscopic heminephrectomy has not been previously described.
Simultaneous robotic-assisted adrenalectomy and partial nephrectomy: technical aspects
2016, Journal of Robotic Surgery

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Adult urologyLaparoscopic upper pole partial nephrectomy with concomitant en bloc adrenalectomy

Abstract

Objectives

Methods

Results

Conclusions

Section snippets

Material and methods

Results

Comment

Conclusions

J Urol

J Urol

J Urol

J Urol

Adult urology
Laparoscopic upper pole partial nephrectomy with concomitant en bloc adrenalectomy