Transperitoneal laparoscopic right radical nephrectomy for renal cell carcinoma and end-stage renal disease: a case report
- Christoforos Kosmıdis†1Email author,
- Christoforos Efthimiadis†1,
- Georgios Anthimidis†1,
- Marios Grigoriou†1,
- Kalliopi Vasiliadou†1,
- Georgia Ioannidou†2,
- Sofia Baka†3 and
- Epaminondas Fahantidis†4
© Kosmıdis et al; licensee BioMed Central Ltd. 2009
Received: 20 October 2009
Accepted: 18 November 2009
Published: 18 November 2009
Nephron-sparing surgery (partial nephrectomy) results are similar to those of radical nephrectomy for small (<4 cm) renal tumors. However, in patients with end-stage renal disease, radical nephrectomy emerges as a more efficient treatment for localized renal cell cancer. Laparoscopic radical nephrectomy (LRN) increasingly is being performed. The objective of the present study was to present a case of a patient under hemodialysis who was submitted to LRN for a small renal mass and discuss the current issues concerning this approach. It appears that radical nephrectomy should be the standard treatment in dialysis patients even for small tumors. The laparoscopic technique is associated with acceptable cancer-specific survival and recurrence rate along with shorter hospital stay, less postoperative pain and earlier return to normal activities.
Malignant tumors of kidney account for 3-4% of all new cancer cases each year . Renal cell carcinoma (RCC) comprises 80-85% percent of all primary renal neoplasms . Nephron-sparing surgery (partial nephrectomy) has become the standard treatment for small (<4 cm) renal tumor . However, in patients with end-stage renal disease, radical nephrectomy emerges as an oncologically more sound procedure for localized RCC . Laparoscopic radical nephrectomy (LRN) has been shown to provide equivalent oncologic results for RCC [5–7].
We present herein a case of a patient under hemodialysis who was submitted to LRN for a small renal mass and discuss the current issues concerning this approach.
The lateral line of Toldt was identified and incised with the harmonic scalpel approximately 1 cm from the colon. The thin layer of peritoneum over the anterior surface of the kidney was mobilized from the iliac vessels to the hepatic flexure of the colon, taking care to avoid entering the Gerota fascia. This plane was bluntly dissected by dividing the colorenal ligament until the colon was rolled medially. Any small vessels that were encountered were controlled with the harmonic scalpel. When the colon had rolled medially, the duodenum was also rolled medially allowing identification of the inferior vena cava.
The incidence of RCC is higher in dialysis patients than in the general population. Yet, the prognosis is considered to be favorable in these patients, because routine screening may detect the cancers while they are still small . Partial nephrectomy has become the standard treatment for small (<4 cm) renal tumors. In our case the tumor size was just 2,5 × 2,7 cm. However, it is unlikely that patients with end-stage renal disease would benefit from this minimally invasive approach. In fact, satellite tumors apart from the most evident neoplasm are present in approximately 30% of the patients. Therefore, radical nephrectomy is indicated even when the tumor is small . Additionally, in our case, preservation of renal function was not actually a concern, since our patient suffered from chronic kidney disease stage 5 (Kidney failure; creatinine clearance: 8,32 ml/min and GFR: 4,71 mL/min, less than 15 mL/min/1.73 m2). It did not seem reasonable to jeopardize the oncologic outcome in an attempt to spare nephrons almost not functioning.
Laparoscopic radical nephrectomy (LRN) increasingly is being performed. The kidney can be approached through the peritoneum or retroperitoneally. The transperitoneal approach is familiar to a general surgeon, with easily identifiable anatomy and a large working space. Therefore we preferred the laparoscopic transperitoneal approach.
Routine removal of the ipsilateral adrenal gland is unnecessary, unless the tumor involves a large portion of the upper pole of the kidney or there is suggestion of adrenal gland abnormality on preoperative staging workup . In our case the preoperative workup revealed a small mass at the right adrenal gland, therefore nephrectomy and adrenalectomy was performed en block.
During the mobilization, care is taken to avoid hemorrhage. Small vessels that are encountered can be cauterized or clipped with a 5-mm clip applier. Alternatively the harmonic scalpel or the LigaSure system may be used to control these vessels. Our general policy is to use the harmonic scalpel when performing advanced laparoscopic surgery. Most surgeons clip and divide the renal artery first and then the renal vein. Alternatively a stapler may be used to divide the renal artery and then the vein. In our case hilum bleeding was encountered, so the renal artery and vein were stapled en bloc with the laparoscopic EndoGIA stapler with a vascular load. We felt this was reasonable in order to avoid serious bleeding and open conversion. Actually, renal artery and vein may be stapled en bloc, when necessary . The right adrenal vein was dissected and divided separately.
The postoperative course was uneventful. The laparoscopic approach was associated with well tolerable postoperative pain, quick oral intake, short hospitalization (3 days), and a rapid recovery and return to previous activities.
Nephron-sparing surgery has become the treatment of choice for small (<4 cm) renal tumors. However, in patients with end-stage renal disease, radical nephrectomy appears to be a more efficient treatment for localized RCC. Transperitoneal LRN emerges as an oncologically rational procedure for this special situation.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of his journal.
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