Laparoscopic radical nephrectomy in T3 tumors
Article published in Urologia Polska 2008/61/Supl. 1.

authors

Marcin Słojewski, Piotr Petrasz, Adam Gołąb, Andrzej Sikorski

Katedra i Klinika Urologii PAM w Szczecinie

summary

Introduction.

Principles of surgical management of kidney cancer were established by Robson in1963 and despite changes of operative techniques they are still obligatory today. The development of laparoscopic technologies allowed employment of this method in treatment of kidney tumors with strict oncological principles. Radical laparoscopic nephrectomy (RLN) is considered as a standard method in patients with T1-T2 tumors. Laparoscopic removal of kidney with tumor larger than 7cm in diameter is technically difficult but feasible and results from literature are encouraging. RLN is been also performed in patients with stage T3. One group are patients with preoperatively downstaged disease (pT3) in whom tumor pathological stage is much higher than evaluated before surgery. In centers experienced in laparoscopy of the upper urinary tract, to RLN are also

qualified patients with cT3 disease. The indications are cytoreductive in advanced disease, or radical in patients with tumor confined to the organ. Patients with renal thrombus belong to the particular group because of high operative risk and technical problems. There are several paper which proof that nowadays T3b stage can be considered, in selected cases, as an indication for laparoscopic intervention. Despite that, patients with highly advanced disease should be qualified for laparoscopy very carefully.

Objectives.

The aim of the study is to present our experience with laparoscopic surgery in patients with T3 kidney cancer.

Materials and methods.

During 4 years (01.2004-01.2008) we have performed 105 laparoscopic radical nephrectomies due to upper urinary tract neoplasms, including 6 nephroureterectomies. Among operated patients in 15 (14.3%) pathology report revealed extracapsular infiltration of the tumor (T3)(Group 1). In one case the involvement of the renal vein and vena cava was preoperatively diagnosed. In remaining patients (n=90) stage T1 and T2 was confirmed (Group 2). Mean age in both groups were 61 and 64 years respectively. In group 1 tumor size in CT examination was measured from 35 to 90 mm (mean 57mm). In group 2 mean tumor size was 50mm (23-95mm). 94 (89.5%) patients were operated with retroperitoneal approach, and in 11 cases (10.5%) transperitoneal approach was applied.

Results.

There were no deaths in perioperative period. Mean operative time in patients with T3 tumors was 143 minutes (min. 90, max. 200), and blood loss was evaluated for 373 ml (min. 0, max. 1200). In 5 cases (33%) operations were converted to open surgery due to advancement of disease (hilar infiltration, pathological vasculature). Weight of removed specimens in this group was 230 to 730 g (mean 622 g). In patients with T1/T2 tumors operative time was from 45 to 240 minutes (mean 105min.), and blood loss was evaluated for 0 to 2000ml (mean 180 ml). Mean weight of specimen was 452g (min. 153, max. 984g). In three cases (3.3%) decision about conversion was minded. In group 2 five (5.5%) serious complications was noted, mostly bleeding from hilar vessels and from adrenal area. In group 1 two cases (13.3%) of

serious complications occurred (patients converted because of the reasons listed above not included).

Conclusions.

1. RLN is a safe method of treatment in patients with stage T1 and T2 kidney tumors. 2. In cases of T3 cancer RLN is burdened with much higher risk of conversion to open surgery, longer operative time and greater intraoperative blood loss. 3. Indications for laparoscopic nephrectomy in T3 cases should be set carefully and selectively. Basic criterion should be safety of the patient and the necessity of oncological radicality. This study has been financed by 2007-2010 scientific grant for research projects.