Abstract

Introduction: Laparoscopic radical nephrectomy has become one of the most innovative challenges to the

conventional and traditional gold standard of the open approach. Currently, this option is preferred over

surgery in many uro-oncological centers all over the world, particularly focused towards T1 tumors.

Numerous experiences world wide have demonstrated very good surgical results and low peri-operative

morbidity, at least comparable to or better in many aspects to open surgery. Additionally, a few published

series with long-term follow-up show now a similar oncological result than the open counterpart. The basic

oncological surgical principles applied to laparoscopic surgery are exactly the same as for open surgery.

Moreover, the criteria used for diagnosis, staging, follow-up, and general management are identical as well.

Thus, the objective of this communication is to focus more on the technical aspects of the procedure rather

than on the aspect of the disease. Additionally, we present a review of the current state of the art of

laparoscopic radical nephrectomy including a review of long term follow-up data based on own experience and

on the literature.

Materials and Methods: Since 1992, we performed 80 laparoscopic radical nephrectomies in 78 patients (48

male, 30 female) with localized renal cell carcinoma. All relevant peri-operative data were recorded,

concerning operative time, complications, conversion and reintervention rate as well as hospital stay.

Outcomes were determined by local recurrence, regional progression, development of metastases and disease

specific survival.

Results: The operating time averaged 150 (65-410) minutes, there was no difference whether a

transperitoneal (n:18) or retroperitoneal (n:62) approach was used. In 25 cases the specimen was entrapped in

an organ bag and retrieved after digital morcellation, whereas in 55 instances the intact organ was removed

via a 6-8 cm incision in the lower abdomen. The mean estimated blood loss was 135 (100 - 700) cc. There was

no conversion to open surgery.

The tumor was right sided in 33 (41%) patients, left sided in 43 (54%), and bilateral in two (5%) patients.

The tumor was located at the upper pole in 21 (26%), at the central area in 40 (50%) and at the lower pole in

19 (24%) of the cases. Mean tumor size was 4.1 cm (range 0.5 to 8). The pathological examination revealed

renal cell carcinoma in 78 (97.5%) and an oncocytoma in two (2.5%) specimens. In the renal cell carcinoma

group, the tumor stage was pT1 in 61 (76%), pT2 in 12 (15%), pT3a in 3 (4.5%), and pT3b in 2 (2.5%) of the

specimens. The surgical margins were negative in all cases. The mean observation time of 43 patients was 65

months (36-85). There was no port-site metastasis. The cumulative overall disease-free survival rate after 5

years is 91%, revealing 96% for pT1/pT2 and 80% for pT3 tumors.

Conclusion: The role of laparoscopic radical nephrectomy for malignancies of kidney and ureter is still

under debate. Primary concerns focused on the safety of the procedure, the reproducibility of the technique

compared to open surgery, and the risk of tumor cell spillage leading to port site metastases. Further concerns

have been related to cost-effectiveness and the steep learning curve of the procedure. Despite some technical

modifications by different groups, laparoscopic radical nephrectomy can be regarded as a standardized and

safe procedure, which allows the transmission and reproduction of the surgical principles of the open

procedure. Additionally, the peri-operative morbidity of the patients can be reduced significantly by use of

laparoscopy. Much more important, however, is the long-term oncological outcome of the procedure. The

overall five year disease free survival rate is excellent with 91% and does not differ from contemporary series

of open surgery. Despite the risk of understaging the tumor on preoperative CT-Scan, morcellation can be

safely done without compromising survival. According to our own experience, with fragmentation rather than

complete morcellation of the kidney, adequate tumor staging had never been a problem.