european urology 49 (2006) 1004–1010
available at www.sciencedirect.com
journal homepage: www.europeanurology.com
Surgery in Motion
Left Laparoscopic Radical Nephrectomy with Direct Access
to the Renal Artery: Technical Advantages
Francesco Porpiglia *, Julien Renard, Michele Billia, Ivano Morra, Cesare Scoffone,
Cecilia Cracco, Roberto Tarabuzzi, Carlo Terrone, Roberto Mario Scarpa
Department of Urology, University of Turin, San Luigi Hospital, Orbassano (TO), Italy
Article info
Abstract
Article history:
Received 22 December 2005
Accepted February 14, 2006
Published online ahead of
print on March 6, 2006
Objectives: To evaluate the technical advantages of early ligature of the
renal artery at the level of the Treitz ligament during left laparoscopic
radical nephrectomy (LRN).
Material and methods: Twenty-six patients underwent LRN for organconfined lesions. We grouped measured parameters (see Results) on the
basis of the first 13 and last 13 patients, and compared both subgroups.
All parameters were correlated to stage of disease (pT1 vs pT2-3). The
Student t test was used for statistical analysis.
Results: The mean (range) for measured parameters are as follows: age:
56.5 11.6 (41–77) years; American Society of Anesthesiologists score:
2.4 1 (1–3); body mass index: 23.4 3.4 (21.1–33); lesion size at computed tomography: (6.2 2.4 (4–12) cm; operative skin to skin time:
130 20 (125–170) minutes; blood loss: 255 120 (100–800) ml; hospital
stay: 6.5 2.0 (4–15) days; analgesic consumption (Tramadol 100 mg):
2.5 1 (2–4) vials; follow–up time: 30.5 5.6 (3–48) months. No intraoperative complications occurred. Pathologic analysis showed 12 pT1N0,
five pT2N0, eight pT3aN0 and one pT3b N2 with mean lesion size of
6.2 1.6 (4–13) cm. Mean number of removed lymph nodes was 9.8 1.6
(7–17). No statistical difference was observed between the two subgroups
( p > 0.05), and between pT1 and pT2–3 stage ( p > 0.05) groups.
Conclusions: Early ligature using direct access to the renal artery at the
Treitz ligament permits the surgeon to follow the classic steps and
principles of radical nephrectomy.
# 2006 Elsevier B.V. All rights reserved.
Keywords:
Radical nephrectomy
Laparoscopy
Renal cancer
* Corresponding author. Department of Urology, San Luigi Hospital, Regione Gonzole 10,
10043, Orbassano, Torino, Italy. Tel.: +39 0119026558; fax: +39 0113082428.
E-mail address: [email protected] (F. Porpiglia).
0302-2838/$ – see back matter # 2006 Elsevier B.V. All rights reserved. doi:10.1016/j.eururo.2006.02.038
european urology 49 (2006) 1004–1010
1.
Introduction
Radical nephrectomy has been the gold standard
for treatment of renal cell carcinoma (RCC) since
1963 when Robson [1] first published his landmark
article. The oncologic principles on which radical
nephrectomy surgery are based are the ‘‘en block’’
resection of the kidney, the ipsilateral adrenal
gland, the Gerota capsule and the lymph nodes.
Moreover, early ligature of the renal artery was
required as the first step of the procedure. After the
introduction of laparoscopic radical nephrectomy
(LRN) by Clayman [2] in 1991, many centres
throughout the world have demonstrated the real
advantages of the laparoscopic approach over the
open technique for this kind of procedure [3]; the
advantages include reduced analgesic requirements, improved cosmetics, shorter hospital stay,
and a faster convalescence [4]. Other authors [5]
have proved, after a long follow-up, that the
oncologic efficacy of LRN is similar to that of open
procedures. Nevertheless, despite the demonstrated safety and effectiveness of LRN, the
technique has not yet been standardized completely. One particular step in LRN needs to be
clarified: the management of the renal pedicle. In
fact, even though several authors consider the
early control of renal hilum vessels useful, regardless of whether the transperitoneal, retroperitoneal
or hand-assisted approach is employed, this phase,
which implies a minimum manipulation of the
kidney and its tumor, is often not performed [4,5].
This aspect is more evident in the management
of the left renal vascular pedicle during the transperitoneal approach. In fact, the renal artery
usually is ligated after severing the gonadal vessels
and the ureter, with mobilization of the lower pole
of the kidney. In this study, after accurately describing the entire technique, we have evaluated the
advantages of early ligature of the renal artery at
the level of the Treitz ligament during left LRN.
2.
1005
Fig. 1 – Position of trocars.
stage) and median follow-up. To evaluate the difficulty of
the technique and its learning curve, we divided all
parameters on the basis of the first 13 and last 13 patients,
and correlated them with the stage of the disease (pT1 vs
pT2–3). Statistical analysis was performed with the Student
t-test.
2.1.
Technique
The patient is placed in the extended 45-degree lateral
decubitus position. Four to five trocars are placed: the first
one (12 mm) is placed just to the left of or inside the umbilicus,
the second (12 mm), at the midclavicular line 2 cm below the
costal margin, and the third (12 mm), on the anterior axillary
line 3 cm above the umbilicus. The fourth trocar (5 mm) is
positioned 2–3 cm laterally and below the third trocar. An
optional 5-mm port can be inserted just under the xyphoid
(Fig. 1). The procedure begins with the identification of the
fourth portion of the duodenum and the inferior mesenteric
vein (Fig. 2). In some cases, the left colic flexure can cover the
duodenum. In this configuration, it is necessary to lift the colic
flexure upwards, using forceps through the optional trocar.
The procedure begins with the incision of the posterior
Materials and methods
From February 2001 to November 2005, we performed 53 left
LRN for organ-confined renal lesions at our institution. We
introduced early ligature of the renal artery at the level of the
Treitz ligament LRN starting in July 2003. Twenty-six
consecutive patients, the subject of this study, were treated
using this technique. The patients were all evaluated
according to gender, age, American Society of Anesthesiologists (ASA) score, body mass index (BMI), duration of
intervention, blood loss, intra- and post-operative complications, need of conversion to open surgery, hospital stay, size
and weight of lesions, number of lymph nodes removed,
pathologic examination of specimen (according to TNM
Fig. 2 – Identification of inferior mesenteric vein.
1006
european urology 49 (2006) 1004–1010
Fig. 3 – Incision of peritoneal duodenum ligaments.
Fig. 5 – Incision of pre-aortic peritoneum.
peritoneum, laterally to the duodenum (Fig. 3). The Treitz
ligament, which suspends the duodenum to the diaphragm
pillars, is evidenced and incised (Fig. 4). This method allows
the duodenum to be medialized entirely. At this point, two
methods can be used, depending on the characteristics of the
patient. If the patient is thin, the aorta wall and the left renal
vein generally are evident. However, if the patient is obese, it
is necessary to dissect the sclerolipomatous and lymphatic
tissue surrounding the aorta wall, starting from the lowest
point of incision and going upwards (Fig. 5). The dissection
must be blunt and very careful with the tip of the suction.
Tedious bleeding from the lymphatic tissue vessels should, in
fact, be controlled with bipolar electrocoagulation. When the
tissue is removed, the gonadal artery can be identified and
sectioned at its origin. Continuing the dissection upwards,
the left renal vein is retracted (Figs. 6 and 7) with forceps at
the point it crosses over the aorta; then the left renal artery
is identified and its overlying lymphatic tissue carefully
dissected to expose its origin (Fig. 7). The renal artery is
Fig. 6 – Identification of left renal vein and gonadal artery
after lymph node dissection.
Fig. 4 – Identification and section of Treitz ligament.
Fig. 7 – Left renal artery at its origin.
1007
european urology 49 (2006) 1004–1010
Fig. 8 – Positioning of Hem-o-lock1 clip at level of renal
artery.
secured with a suture or Hem-o-lock1 clips (Teleflex Medical,
Research Triangle Park, NC, USA) without interruption of
the vessel at this phase (Fig. 8). The inferior mesenteric vein,
which describes a vascular arch, can impede adequate
exposure. In this case, it can be sectioned, or the assistant
can lift it upwards and laterally through the fourth trocar. This
way, the surgeon feels he is working in a tunnel that is made
up of the aorta inferiorly (which represents the main route that
should be followed), by Gerota’s capsule laterally, by the
duodenum and cava vein medially and by the vascular arc of
the mesenteric vein superiorly. When ligature of the renal
artery is performed, the procedure continues as described in
the standard technique with medialization of the descending
colon and left colic flexure, spleen, and pancreas tail.
The hilar, pre-aortic and latero-aortic lymph nodes were
removed (Fig. 9) from all patients in the same step, in a single
block along with the specimen.
3.
Results
The subject group was composed of 11 women and
15 men. The mean age was 56.5 11.6 (range, 41–77)
Fig. 9 – Aorta cleaned of lymph nodes.
years. The mean ASA score was 2.4 1 (range, 1–3);
the mean BMI was 23.4 3.4 (range, 21.1–33). The
mean size of lesions on the computed tomography
(CT) scan was 6.2 2.4 (range, 4–12) cm. The mean
operative skin-to-skin time was 130 20 (range,
125–170) minutes. The mean time required to find
the renal artery was 18 4 (range, 15–32) minutes.
In terms of varied anatomy, in one case we
encountered two principal renal arteries that
originated from the aorta side by side. In another
case, we observed an accessory artery at the lower
pole of the kidney. In 23 of 26 (89%) patients, the
renal artery was identified directly. In three (11%) of
the first 13 operated patients, it was necessary to
revert to the standard laparoscopic approach
because of abundant sclerotic tissue surrounding
the aorta, which caused tedious bleeding. The mean
blood loss was 255 120 (range, 100–800) ml. No
intra-operative complications were encountered.
We observed one episode (4%) of post-operative
haemorrhagy that required transfusion and further
Table 1 – Results of the comparison between the first 13 patients and the last 13 patients
Parameter
Intraoperative complications
Absence of early artery ligature
Number of lymph nodes removed
Postoperative complications
Mean hospital stay (d)
Mean operative skin to skin time (min)
Mean blood loss (ml)
Mean weight (g)
Mean size (cm)
ns = not significant.
First 13 patients
Last 13 patients
0
3/13
7.38 3.45
0
5.54 4.3
141.4 26.5
260.3 112.2
313.46 119.15
6.1 5.6
0
0
9 4.62
1/13
6.92 3.4
125 15.7
245.5 93.6
243.84 136.78
6.3 4.7
p value
ns
ns
ns
ns
ns
ns
ns
ns
ns
1008
european urology 49 (2006) 1004–1010
Table 2 – Results of the comparison between stage pT1 and pT2–3 patients
Parameter
12 stage pT1 patients
14 stage pT2–T3 patients
Intraoperative complications
Absence of early artery ligature
No. of lymph nodes removed
Post-operative complications
Mean hospital stay (d)
Mean operative skin to skin time (min)
Mean blood loss (ml)
Mean weight (g)
Mean size (cm)
0
1
8.5 1.7
0
5.8 3.4
125 34.6
255.3 103.4
270.46 109.15
6.3 2.4
0
2
8.3 2.1
1
6.5 4.2
127 43.8
260.6 113.5
287.13 136.78
6.8 3.6
p value
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns = not significant.
surgical intervention. The bleeding originated
from an adrenal artery. The mean hospital stay
was 6.5 2.0 (range, 4–15) days. The mean analgesic
consumption (Tramadol 100 mg) was 2.5 1 (range,
2–4) vials. No statistical difference was observed
for any of the considered parameters between the
first 13 patients and the last 13 patients ( p > 0.05;
Table 1). Nevertheless, we observed in the first
13 patients, three cases in whom early ligature
of the renal artery was impossible. Moreover the
operative time of this subgroup was longer (260 min
vs 245 min). There was no statistical difference
for any of the parameters between the groups
with stage pT1 and stage pT2–3 ( p > 0.05; Table 2).
The pathologic analysis showed 12 pT1N0, 5 pT2N0,
eight pT3aN0 and one pT3b N2. The grading
according to Furhman was eight G1, nine G2 and
nine G3. The mean lesion size was 6.2 1.6 (range,
4–13) cm. The mean weight was 278.6 130.5
(range, 150–650) g. The mean number of lymph
nodes removed was 9.8 1.6 (range, 7–17). The
mean follow–up time was 30.5 5.6 (range, 3–48)
months. One patient died after 2 months from an
acute cardiac disorder, not from renal disease.
One patient, who was already M1 before the
procedure, presented progression of the disease.
The other 23 patients did not present any local
recurrence or metastasis.
4.
Discussion
Radical nephrectomy is considered to be the gold
standard for the treatment of RCC and laparoscopy, with the transperitoneal or retroperitoneal
approach now being accepted widely as the therapy
for RCC confined to the kidney [6–18]. Conventionally, this technique is based on the oncologic
principles declared by Robson in 1963, and early
ligature of the renal artery represents one fundamental step. Even though this procedure is now
controversial [19], this principle is routinely
applied. The transperitoneal approach implies that
the renal artery usually is ligated after severing the
gonadal vessels and the ureter, with mobilization of
the lower pole of the kidney. Moreover, it is possible
to ligate the renal artery after having exposed the
renal pedicle (on the right side, after medialization
of duodenum; on the left side, after medialization
of the left colic flexure, spleen and pancreas tail).
Retroperitoneoscopy seems to permit a faster
access to the renal artery than the transperitoneal
approach [5]. The transperitoneal access, especially
with ligature of the artery after severing of the
ureter and gonadal vessels, implies minimum
manipulation of the kidney, which, however, does
not seem to reduce the oncologic efficacy with
respect to open surgery [4,20].
Although these techniques are widely used and
have been the subject of many variations, there is
still a wide margin for further development with the
aim of standardizing it definitively, without losing
the principles declared by Robson [1], even though
some of these aspects are still controversial (eg, the
role of lymphadenectomy when no lymph nodes are
shown on a CT scan). When we perform a laparoscopic procedure, our purpose is to try to replicate
the principles of open surgery, especially when an
oncologic treatment is considered. For this reason,
especially when performing left LRN, the early
ligature of the renal artery at the level of the Treitz
ligament with en block lymphadenectomy is a step
of the procedure that replicates what is performed in
open surgery. That is why we have chosen this
option since July 2003. Even though the advantages
that can derive from this technique are subject to
discussion, we have here highlighted some important factors such as its feasibility, its safety and
some technical advantages.
The feasibility of the technique had been shown
already in a previous paper [5]. In terms of safety,
we can confirm that in the 26 cases reported in
european urology 49 (2006) 1004–1010
this study, no intra-operative complications were
recorded, the blood loss and the transfusion rate
were minimal (one underwent transfusion) and the
post-operative complications were similar to those
encountered during procedures with the standard
approach to the renal vascular pedicle, as reported
by various authors [4,5,21].
What are the real advantages? The advantages
attributable to early ligature with direct access at
the level of the Treitz ligament of the renal artery
are represented by a lower risk of bleeding during
later portions of the dissection, especially when
peri-tumoral vessels are present, and the potential
of minimizing cancer cell release because of the
absolute absence of manipulation of the kidney
before renal artery ligature. Moreover, the medial
approach to the renal artery allows the surgeon
to preventively ligate the artery in the presence
of anatomic variations. In our experience, we
encountered one case of a double renal artery that
had the same origin; thanks to this technique, we
were able to see both arteries at their origin, which
would have been less probable if the traditional
approach had been used. This technique also
allows early ligature of the artery for large renal
masses (in our experience up to 7 cm) [22] and also
for stage pT3 tumors, which often can interfere or
create problems for the correct dissection of the
renal hilum. These two characteristics of the
lesions, in our experience, did not interfere with
the safety of the procedure; in fact, there was no
difference between the pT1 and pT2–3 stages of
tumors. This type of ligature also consents the en
block resection of all the lymph nodes. In fact, to
reach the origin of the renal artery, it is essential to
clean the aorta wall and renal hilum of all
lymphatic tissue. These lymph nodes are then
removed together with the Gerota capsule. As far
as lymph nodes are concerned, to our knowledge,
the type and dimension of performed lymphadenectomy have not yet been clarified in literature.
Many authors [23] report only hilar lymph nodes,
while others [3] performed lymph node dissection
during the nephrectomy. Still others have not
explained whether the lymph node dissection is
performed during a later step. Moreover, it also is
common to find in literature that many authors do
not specify the number of lymph nodes removed
when lymphadenectomy was performed during
LRN, a number that is necessary for a correct
stadiation, according to TNM. This access enables
the hilar, pre-aortic and latero-aortic lymph nodes
to be removed en block along with the specimen,
permitting the minimum lymph nodes necessary
for an accurate stadiation to be removed. In our
1009
experience, the mean number of lymph nodes
removed was 9.8 1.6 (only one patient had fewer
than eight lymph nodes removed).
While these are the advantages, the critical points
of this technique can be the intrinsic difficulty of
performing this approach, which requires a skilled
laparoscopist. In fact, after incision of the Treitz
ligament and dissection of the lymphatic tissue that
surrounds the aorta, the surgeon has the feeling of
working in a tunnel, in which errors, and as a
consequence, bleeding are not permitted if one
wants to reach his goal. In our experience, we had
to revert to the standard technique in three of the
first 13 operated patients. This means, that even
though the laparoscopist was skilled, specific
experience in this approach must be taken into
account. Moreover, the potential risk of this technique is the ligature of the superior mesenteric
artery, a mistake that would be fatal for the patient.
In order to prevent this event, it is fundamental to
identify the wall of the aorta, the gonadal artery
and the renal vein that must be lifted upwards by
forceps to dissect the renal artery carefully at its
origin from the lateral wall of the aorta. It is evident
that, to dissect only the renal artery, it is fundamental to work under the renal vein, which is used
as a landmark, the superior mesenteric artery
always being located above the renal vein.
5.
Conclusion
Early ligature using direct access to the renal artery
at the level of the Treitz ligament is a technique that
must be performed after acquiring adequate experience in laparoscopy. This technique permits the
surgeon to follow the classic steps and principles of
radical nephrectomy, which have driven open
surgery techniques for several years. It also ensures
ligature of the renal artery for anatomic variations,
in the presence of large renal masses, and ensures
an adequate lymphadenectomy, which is mandatory for a correct stadiation. A major number of
cases and a longer follow-up of patients treated
with this technique will surely contribute in
demonstrating its utility.
Appendix A. Supplementary data
Supplementary data associated with this article
can be found, in the online version, at doi:10.1016/
j.eururo.2006.02.038 and via www.europeanurology.com. Subscribers to the printed journal will find
the supplementary data attached (DVD).
1010
european urology 49 (2006) 1004–1010
References
[1] Robson CJ. Radical nephrectomy for renal cell carcinoma. J
Urol 1963;89:37–42.
[2] Clayman RV, et al. Laparoscopic nephrectomy: initial case
report. J Urol 1991;146:278–82.
[3] Fenn NJ, Gill IS. The expanding indications for laparoscopic radical nephrectomy. BJU Int 2004;94:761–5.
[4] Permpongkosol S, et al. Laparoscopic radical nephrectomy: long-term outcomes. J Endourol 2005;6:628–33.
[5] Porpiglia F, Terrone C, Cracco C, et al. Direct access to the
renal artery at the level of Treitz ligament during left
radical laparoscopic transperitoneal nephrectomy. Eur
Urol 2005;48:291–5.
[6] Dunn MD, Portis AJ, Shalhav AL, et al. Laparoscopic versus
open radical nephrectomy: a 9 year experience. J Urol
2000;164:1153–9.
[7] Mc Dougall EM, Clayman RV, Elashry OM. Laparoscopic
radical nephrectomy for renal tumor: the Washington
University experience. J Urol 1996;155:1180–5.
[8] Clayman RV. Laparoscopic radical nephrectomy. J Urol
2002;168:872.
[9] Ono Y, Kinukawa T, Hattori R. The long term outcome of
laparoscopic radical nephrectomy for small renal cell
carcinoma. J Urol 2001;165:1867–70.
[10] Gill IS. Laparoscopic radical nephrectomy for cancer. Urol
Clin North Am 2004;27:707.
[11] Lang H, Jacqmin D. Laparoscopic surgical treatment for
localized renal cell carcinoma. EAU Update Ser 2003;1:226.
[12] Portis AJ, Clayman RV. Should laparoscopy be the standard approach used for radical nephrectomy? Curr Urol
Rep 2001;2:165.
[13] Portis AJ, et al. Long term follow–up after laparoscopic
radical nephrectomy. J Urol 2002;167:1257–62.
[14] Portis AJ, et al. Laparoscopic radical/total nephrectomy: a
decade of progress. J Endourol 2001;15:345–54.
[15] Dunn MD, Mc Dougall EM, Clayman RV. Laparoscopic
radical nephrectomy. J Endourol 2000;14:849–55.
[16] Janetschek G, et al. Laparoscopic surgery for stage T1
renal cell carcinoma: radical nephrectomy and wedge
resection. Eur Urol 2000;38:131–8.
[17] Wille AH, Roigas J, Chan DY, Cadeddu JA, Jarret TW.
Laparoscopic radical nephrectomy: cancer control for
renal cell carcinoma. J Urol 2001;166:2095–100.
[18] Wille AH, Roigas J, Deger S, Tullmann M, Turk I, Loening
SA. Laparoscopic radical nephrectomy: techniques,
results and oncological outcome in 125 consecutive cases.
Eur Urol 2004;45:483–8.
[19] Battaglia M, Ditonno P, Martino P, Palazzo S, Annunziata
G, Selvaggi FP. Prospective randomized trial comparing
high lumbotomic with laparotomic access in renal
cell carcinoma surgery. Scand J Urol Nephrol 2004;38:
306–14.
[20] Abbou CC, et al. Retroperitoneal laparoscopic versus open
radical nephrectomy. J Urol 1999;13:A63.
[21] Porpiglia F, et al. Early ligature of renal artery during radical
laparoscopic transperitoneal nephrectomy: description of
standard technique and direct access. J Endourol 2005;
19:623–7.
[22] Steinberg AP, et al. Laparoscopic radical nephrectomy for
large (greater than 7 cm, T2) renal tumors. J Urol 2004;
172:2176–81.
[23] Permpongkosol S, et al. Long-term survival analysis after
radical nephrectomy. J Urol 2004;174:1222–5.