According to the 2010 European Association of Urology (EAU) guidelines, laparoscopic radical nephrectomy (RN) has been the recommended standard of care for patients with T2 tumors and smaller renal masses not treatable by nephron-sparing surgery.1 Laparoscopic RN is performed with the use of several (three to four) access ports inserted trans or retroperitoneally, which minimize the need for the long incisions of open surgery and the associated morbidity. And the oncologic results of this procedure are comparable to those of open RN.2,3 A further development of laparoscopy is directed towards reducing the number of access ports in an attempt to minimize portoperation related morbidity and to improve the cosmetic outcome.
The concept of “scarless surgery” led to the development of laparoendoscopic single-site (LESS) surgery. LESS can be performed via a single incision that is nearly invisible if placed within the umbilicus, which improves postoperative recovery and cosmetic outcomes.4 This approach has been successfully used for benign etiology nephrectomy, donor nephrectomy, and radical nephrectomy.5-7 In the current report, we present our preliminary experience with transperitoneal LESS-RN using a home-made single-port device in China.
Between July 2010 and November 2011, 11 patients underwent transperitoneal LESS-RN for renal tumor using a home-made single-port device (Patent number: ZL 2011 2 0274364.0) in a single center. A single laparoscopic surgeon (Ma Lulin), with experience of >200 cases of transperitoneal laparoscopic RN, performed all procedures. Preoperatively, all patients gave written informed consent to LESS-RN after being informed on the relative merits of LESS and laparoscopic RN, and that additional incisions might be necessary for patient safety. Patient characteristics, perioperative variables and postoperative outcomes were recorded.
Indications of LESS-RN were represented by renal tumors ≤T2a stage without evidence of lymphadenopathy or renal vein involvement. Additional selection criteria were body mass index (BMI) <35 kg/m2 and absence of health conditions, for example cardiovascular and respiratory comorbidities that would preclude laparoscopy. None of the patients had previous abdominal surgery. All procedures were performed in patients who were not eligible for partial nephrectomy (localization in hilum, involvement of pelvicalyceal system) or the cases that decided to undergo radical procedure for oncologic safety.
All patients were diagnosed with renal tumor by sonography with no symptom. Preoperative imaging included high-resolution computed tomography (CT) with contrast medium in all cases, or magnetic resonance imaging (MRI), if deemed necessary. Renogram was for the assessment of differential renal function, and in our study, only in one case the contralateral glomerular filtration rate (GFR) was a little lower (29.6 ml/min). After being informed of the higher risk of renal failure after RN, this patient also chose this operation. The characteristics of patients included in this study are shown in Table 1.
Transperitoneal LESS-RN was performed with the patient under general anesthesia. A urethral catheter and a nasogastric tube were placed immediately before anesthesia to decompress bladder and stomach. The patient was placed in a 60-degree lateral decubitus position with the table in slight flexion on the patient's waist. When the patient was positioned securely, we made the skin preparation as required for the transperitoneal laparoscopic RN. We used a surgical glove and an inverted cone device of polycarbonate as the home-made single-port device.8 Three fingers of the glove were cut, and one 13 mm trocar, one 11 mm trocar, and one 5 mm trocar were placed. The home-made single-port device was constructed by securing the fingers of the glove to the end of the three trocars with a silk suture (Figure 1).
The surgeon and the assistants stood contralateral to the affected side, and a 5-cm minilaparotomy was performed at the umbilicus. The inner ring of the single-port was inserted into the umbilical skin incision, and the outer ring, in which there were many pinholes, was fixed to the skin by seaming (Figure 2). After insufflation of the peritoneum with CO2 to 12-15 mmHg (1 mmHg=0.133 kPa), a 10-mm rigid 30° Olympus laparoscope was inserted through the 13 mm trocar and a harmonic scalpel was inserted through the 11 mm trocar. A combination of standard and articulating laparoscopic instruments was used.
In the case of a left nephrectomy, the white line of Toldt was incised from the level of the iliac vessels inferiorly, extending above the spleen superiorly. The splenocolic ligament was released to maximize exposure of the kidney. The colon was retracted medially and away from the operating field. During the performance of right nephrectomy, the peritoneal incision began at the hepatic flexure and was carried cephalad above the hepatic flexure, including the right triangular and right anterior coronary ligaments. The mobilization of the liver and colon allowed for adequate exposure of the kidney. Further retraction of the liver required a needlescopic forceps inserted directly (without trocar) in the anterior axillary line below the 12th rib. This incision did not need suturing with an inconspicuous scar.
Once the colon had been freed, the ureter was identified within the retroperitoneal fat medial to the psoas muscle and mobilized up to the level of ureteropelvic junction. The ureter alone on the right side or both the ureter and gonadal vessels together on the left side were elevated and followed proximally to the lower pole of the kidney. A long straight needle was inserted through the abdominal wall directly into the midaxillary line below the 12th rib, around the ureter and through the abdominal wall again. The continuous retraction of the ureter was provided by the stay suture tied to the skin, which facilitated the exposure and dissection of the renal hilum.
The sequence of steps of LESS-RN was similar to transperitoneal laparoscopic RN. Once the lower pole had been lifted laterally, the renal artery and vein were identified, prepared, and then dissected with Hem-o-lok clips. And regional lymphadenectomy was performed if there were enlarged lymph nodes. The kidney was removed along with the perirenal fat in the intact Gerota's fascia and placed inside a home-made endo-catch bag, which was made by stitching two layers of polyester together (Figure 3). The adrenal-sparing approach was implemented in all patients. Then the single-port was removed, and the intact specimen was retrieved through the umbilicus without morcellation. The fascia was closed with interrupted 1-0 Vycril suture to avoid a subsequent umbilical hernia, while the skin was closed with an intracutaneous suture (Figure 4). No drainage catheter was placed generally.
Except for two transperitoneal laparoscopic conversions and one hand-assisted laparoscopic conversion, the other procedures were completed successfully, without conversion to open surgery. Table 2 lists the detail perioperative outcomes and histopathologic results. The mean operative time was 224.5 (155-297) minutes, estimated blood loss (EBL) was 270.9 (50-900) ml, and only one case was transfused with 2 units of blood during the operation. The perioperative mean haemoglobin (Hg) decrease was 17.3 (2-36) g/L and creatinine (Cr) increase was 35.2 (21-59) μmol/L. The mean visual analogue pain scale (VAPS) on the first postoperative day was 4.0/10, and for only one patient 100 mg of Tramadol was used once for postoperative pain management. The mean days to postoperative ambulation and oral intake respectively were 1.8 (1-3) days and 2.7 (2-5) days, and hospital stay was 10.4 (5-15) days. Only one case had a paralytic ileus that was resolved on the fifth postoperative day after fasting, fluid replacement, and gastrointestinal decompressing. No other postoperative complications occurred.
Histopathological examination of the specimens, according to the 7th American Joint Committee on Cancer (AJCC) cancer staging, revealed renal cell carcinoma in all cases with a stage distribution of three pT1aN0M0, five pT1bN0M0, and three pT2aN0M0 tumors. All tumors were organ-confined with negative surgical margins. In the mean follow-up period of 21.4 (12-28) months, all patients were alive without evidence of tumor recurrence or metastasis, and were satisfied with the appearance of the scars.
Since the first laparoscopic nephrectomy was introduced as a less invasive alternative by Clayman et al9 in 1991, laparoscopic techniques have become the major approach for renal surgery and they continue to evolve. Rane et al10 were the first to perform LESS nephrectomy in 2007, followed shortly with a more detailed discussion by Raman et al11 in the same year. LESS, one of the advancements in the field of urology, has been developed to further reduce the morbidity and scarring associated with surgical intervention. After Raman et al7 reported the first LESS-RN in 2009, this technique has gained widespread acceptance and provided a further minimal invasive surgery option for renal tumor.
In the present series, LESS-RN was performed on patients with renal tumors ≤T2a stage without evidence of lymphadenopathy or renal vein involvement, and patients who could be treated by partial nephrectomy were excluded.12 There was one case with renal tumor of T1a stage, while the tumor was in the hilum of kidney and accompanied with a renal cyst, as a result, we choose RN, not partial nephrectomy, for this patient. It's worth mentioning that because of the measurement error of tumor diameters by preoperative imaging, two cases of T1b tumor changed to pT1a after the histopathological examination.
Stolzengurg et al13 reported 30 cases of LESS-RN for renal tumor, with a mean operative time of 156.6 minutes, EBL 122.3 ml, and VAPS on the first postoperative day 2.9/10. Greco et al14 presented their initial experience of 33 cases of LESS-RN. In their series, there was one transperitoneal laparoscopic conversion, with a mean operative time of 143.7 minutes and EBL 122.3 ml. The perioperative mean Hg decrease was 22.6 g/L, and Cr increase was 15.7 μmol/L. The mean days to oral intake was 1 day, hospital stay was 3.8 days, and VAPS at discharge was 1.9/10. Compared to the literatures, the operative time, EBL and postoperative recovery was a little higher in our series, associated with the reason that our cases of LESS-RN were less and we were still in the learning-curve with lack of experience. The longest operative time was 297 minutes, with the EBL 500 ml in this case, and the tumor's diameter was 8.8 cm, the largest one. In our opinion, the tumor size could affect the effect of LESS-RN. As a result, the tumor size should be considered for the choice of LESS-RN with preliminary experience, although with the accumulation of experience, tumor size would be not so important to perform LESS-RN.
There was one hand-assisted laparoscopic conversion with the addition of one port in our series, because the renal tumor was located in the dorsal center of the kidney with a severe adhesion. The EBL of this case was 900 ml, the maximum one, and he was transfused with 2 units of blood. The perioperative Hg decrease and Cr increase were comparable with the literature.14 Although the VAPS in our series was a little higher on the postoperative first day, there was only one patient who took an analgesic once, which represented a mild postoperative pain.
There were two transperitoneal laparoscopic conversions in our series, and these patients' BMI, respectively, were 30.4 kg/m2 and 27.2 kg/m2, the first and second obese cases in our series. During the operation, the thick abdominal wall interfered with the instruments and made their movement even more challenging, as a result, we added two ports to make a transperitoneal laparoscopic conversion. An obese patient represents an additional challenge for LESS, especially during early experience. In some literatures, BMI ≤30 kg/m2 or <35 kg/m2 has been used14,15 as a selection criterion for LESS because of the difficulty in the placement of the multiport in the umbilicus and the increased distance to the target organ in these patients. In our opinion, we are still in the learning-curve of LESS-RN, so the BMI criterion should be considered now. However, an obese patient is not the absolute contraindication of LESS-RN, and with the accumulation of experience, BMI would be a secondary criterion of LESS.
In our experience with LESS-RN, we used a combination of standard and articulating laparoscopic instruments to solve the lack of instrument triangulation because of the absence of separate port sites, as in the literature.16 The sequence of steps of LESS-RN was similar to transperitoneal laparoscopic RN with minor modifications: the umbilical incision was extended to 5.0 cm in the cranial direction to be more close to the kidney, the ureter was ligated during the procedure to facilitate the retraction of the kidney, and when the liver affected the operative filed, we used a needlescopic forcep inserted directly for further retraction of the liver.
Raman et al7 were the first to present a case-control study comparing LESS nephrectomy with transperitoneal laparoscopic nephrectomy. According to the authors' experience, the operative results of LESS, including operative time, EBL, perioperative complications, postoperative pain management, and recovery, were comparable to those of transperitoneal laparoscopic nephrectomy, while the superiority of LESS was limited to a mere cosmetic advantage. A comparative series between LESS and transperitoneal laparoscopic nephrectomy was also performed in the study by Seo et al,17 and this series also suggested that LESS was not inferior to transperitoneal laparoscopy. To investigate the surgical trauma after LESS-RN and transperitoneal laparoscopic RN, Greco et al18 measured the serum concentrations of acute-phase markers, and the results represented that LESS-RN did not add any significant advantage in systemic stress response and surgical trauma. However, the low population and retrospective review of these series did not allow us to draw any scientific conclusions.
There are several commercial trocar options for LESS including the R-port, Uni-X, and Triport single laparoscopic port system. However, these systems are expensive and have small operative space. As a result, we used our home-made single-port device (Patent number: ZL 2011 2 0274364.0) in LESS, which has several merits. First, this device consists of common equipments and materials, and is more cost-effective than current commercial ports. Second, the elasticity of the surgical glove minimizes the interference of the instruments with the laparoscope and magnifies the range of motion. These advantages may make it easier to control the instruments and shorten the learning-curve of LESS. Third, it can prevent subcutaneous emphysema and bleeding, caused by the effect of tamponade of the inverted cone device and the surgical glove. Lastly, the conventional surgical equipments can be used, and moreover, different numbers and sizes of instruments can be accommodated to this home-made device with little difficulty. Additionally, compared with the standard 15-mm Endo-Catch bag, our home-made endo-catch bag is cost-effective, impervious and collapsible without the introducer and metal ring, which can be inserted through the 13-mm trocar easily.
This operation has a learning-curve, including coordination between the surgeon and the camera holder, and navigating the instruments within a limited range of motion and counterintuitive movements. The initial oncologic results have been approved through the single-site. At the average 21.4 months of follow-ups, all patients were alive without evidence of tumor recurrence or metastasis. However, more large and long-term studies are needed to determine the advantages of LESS-RN over transperitoneal laparoscopic nephrectomy.
It is a limitation of our current report that there is an absence of a valid questionnaire when we assessed the cosmetic results of the scars. Nevertheless, all the patients expressed that they were satisfied with their surgical scars during scheduled office visits. And we will adopt a valid questionnaire to gather cosmetic results for later patients.
Transperitoneal LESS-RN using a home-made single-port device is technically feasible and safe in a selected group of patients (low BMI and stage tumor) and has led to satisfactory cosmetic results. Although preliminary oncologic outcome is not compromised, the long-term evaluation of these patients is awaited.
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