OBJECTIVE: To evaluate the clinical efficacy of posterior laparoscopic radical kidney cancer surgery for stage T1 kidney cancer.
Methods: 352 patients with stage T1 renal cancer were treated by the same group of surgeons, among which 185 patients underwent radical posterior laparoscopic kidney cancer surgery (posterior laparoscopic group) and 167 patients underwent radical open kidney cancer surgery (open surgery group), and there were no statistically significant differences in age, gender, tumor stage size, and blood Scr values between the two groups. The differences in surgical complications and survival rate were analyzed and compared between the 2 groups.
RESULTS: In the posterior laparoscopic group compared with open surgery: operative time was 55-130 (75.6±11.2) min versus 50-140 (68±10.6) min, with no statistically significant difference (P>0.05); intraoperative bleeding was 50-1200 (110.6±32.3) ml versus 50-1500 (160.8±38.1) ml (P< 0.05); 8 versus 132 cases requiring postoperative analgesia (P < 0.05), 1 to 2 (1.3 ± 0.5) days versus 2-5 (2.9 ± 1.2) days of postoperative feeding (P < 0.05), and 3 to 7 (4.6 ± 1.2) days versus 7 to 14 (8.9 ± 1.6) days of postoperative hospitalization (P < 0.05) , all with statistically significant differences. The median postoperative follow-up time was 25 months (6 to 42 months), and the difference in survival rate was not statistically significant (P > 0.05).
CONCLUSION: Compared with open radical kidney cancer surgery, posterior laparoscopic radical kidney cancer surgery with less bleeding, faster recovery, and fewer postoperative complications has become the gold standard for the surgical treatment of stage T1 kidney cancer.
We retrospectively analyzed the clinical data of 352 patients who underwent radical posterior laparoscopic kidney cancer surgery or open radical kidney cancer surgery from 2003 to 2007 to evaluate the clinical efficacy of radical posterior laparoscopic kidney cancer surgery for stage T1 kidney cancer. The results are reported as follows.
Clinical data
There were 352 cases in this group. Patients were randomly divided into 2 groups with tumor diameter ≤7 cm and WHO 2002 stage T1, except for patients with cancer embolus, local lymph node metastasis and patients who underwent partial nephrectomy. Patients were diagnosed preoperatively by ultrasound and CT/MRI examination. Postoperative outpatient follow-up review was performed every 3-6 months with a follow-up of 6 to 42 months.
There were 185 cases in the retroperitoneoscopic group. There were 102 male cases and 83 female cases. Age ranged from 20 to 78 years, mean (60.4±17.5) years, body mass 65.6 (47-87) kg. tumor was located on the left side in 98 cases and on the right side in 87 cases; upper pole of the kidney in 63 cases, lower pole in 59 cases, and central part in 64 cases. The tumor imaging diameter ranged from 1.5 to 7 cm, with a mean of (4.3±2.1) cm. serum Scr value was 81.2 (46-134) umol/L. All cases underwent posterior laparoscopic radical nephrectomy for renal cancer.
There were 167 cases in the open surgery group. The tumor was located on the left side in 92 cases and on the right side in 75 cases; 57 cases were in the upper pole, 52 cases in the lower pole and 58 cases in the middle of the kidney. The tumor imaging diameter ranged from 1.5 to 7 cm, with a mean of (4.4±1.9) cm, and the serum Scr value was 78.6 (51-129) umol/L. Open radical nephrectomy for renal cancer was performed through a lumbar 11-rib incision.
There were no statistically significant differences in age, gender composition, clinical stage of tumor, preoperative imaging tumor size, serum Scr value and tumor location between the 2 groups (P > 0.05).
Treatment methods
1.Rective posterior laparoscopic nephrectomy for renal cancer: general anesthesia. The patient was placed in the healthy-side position, and three 10-mm trocar operating channels were established in the lumbar region. First, the lumbar major fascia was separated from the posterior layer of Gerota’s fascia in the gap toward the midline, and then freed medially. The vena cava is found first on the right side of the operation, and the gonadal vein or ureter is found first on the left side, which is used as an anatomic landmark to separate upward to find the renal hilum. The connective tissue and vascular sheath around the renal tip are separated, and the renal artery is freed by 2 to 3 cm, two on the proximal end of the renal artery and one on the distal end of the Hem-O-lok. after cutting the renal artery, the renal vein and its branches are freed on its deep surface, and the renal vein is clamped and cut with the Hem-O-lok. The perirenal fascia was separated and the anterior wall of the kidney was freed. The perirenal fascia was separated and cut medially at the upper pole of the perirenal fascia to the tip of the kidney using an ultrasonic knife. The perinephric fascia was separated outside the perinephric fascia to the level of the iliac vessels, the perinephric fascia was dissected, the ureter was separated, and the kidney was dissected after double titanium clamping treatment. The kidney specimen was put into the homemade specimen bag and removed from the first operation hole.
2.Open radical nephrectomy for renal cancer: general anesthesia. The patient was placed in the healthy side position. Take the 11-rib incision approach, free upward to reveal and push away the pleura, push away the peritoneum medially to reveal the perirenal fascia. The perirenal fascia was separated along the psoas major muscle, and the upper pole (including the adrenal gland), middle and lower pole of the kidney were released outside the perirenal fat capsule. The ureter was located and freed in front of the psoas major muscle at the lower pole of the kidney to the bifurcation of the abdominal aorta, and was cut and ligated. The kidney was retracted ventrally to reveal the renal hilum, the renal artery and vein were separated and severed by double ligation with a No. 7 silk suture plus a No. 4 silk suture. The kidney specimen was removed.
Statistical methods
The data were processed using sas8.0 statistical software, and the t-test for independent samples was used for comparison between groups of continuous variables, and the χ2 test was used for comparison between groups of categorical variables.
Results
There were 164 cases of renal clear cell carcinoma, 17 cases of renal papillary cell carcinoma, and 4 cases of granular cell carcinoma in the posterior laparoscopic group; 145 cases of renal clear cell carcinoma, 19 cases of renal papillary cell carcinoma, and 3 cases of granular cell carcinoma in the open surgery group.
In the posterior laparoscopic group, one case of left paramedian renal artery injury occurred intraoperatively, and Hem-O-lok clamping was given after gauze compression to stop bleeding, and 6 cases of peritoneal rupture, and titanium clamps were used to close the rupture. Subcutaneous emphysema was observed in 3 cases. The operation time was 55-130 min, average (75.6±11.2) min; intraoperative bleeding was 50-1200 ml, average (110.6±32.3) ml. 8 cases required postoperative analgesic drugs, and the incisions were free of infection and fat liquefaction. 4 cases had delayed healing of the first operation hole incision. Postoperative feeding was performed from 1 to 2 days, with a mean of (1.3±0.5) days, and postoperative hospitalization was performed from 3 to 7 days, with a mean of (4.6±1.2) days. The median time of postoperative follow-up was 25 months (6-42) months, with 3 cases of death due to other reasons, 24 cases of loss of follow-up, and 1 case of bone metastasis, with a survival rate of 85.4% and no perforation hole implantation metastasis.
Intraoperative pleural injury occurred in 8 cases in the open surgery group, of which 7 cases had pleural fissures sutured closed after aspiration and 1 case had closed chest drainage. Three cases of peritoneal laceration were treated with sutures. The operative time ranged from 50 to 140 min, with an average of (68±10.6) min; intraoperative bleeding ranged from 50 to 1500 ml, with an average of (160.8±38.1) ml. 12 cases had incisional fat liquefaction, which delayed healing; 132 cases required postoperative pain medication; postoperative feeding ranged from 2 to 5 d, with an average of (2.9±1.2) d; postoperative hospitalization ranged from 7 to 14 d, with an average of (8.9±1.6) d. The median postoperative follow-up time was 25 months (6-42 months), with 2 deaths due to other reasons, 21 cases lost to follow-up, and 2 cases of pulmonary metastasis, with a survival rate of 86.2%.
The amount of intraoperative bleeding, postoperative gastrointestinal function recovery time, and postoperative hospitalization time were significantly less in the post-laparoscopic group than in the open surgery group, and the difference was statistically significant (P < 0.01); the number of intraoperative and early postoperative complications was significantly less in the laparoscopic group than in the open surgery group, and the difference in survival rate at follow-up between the two groups was not statistically significant (P > 0.05).
Discussion
With the improvement of surgical methods, surgical techniques and instruments, laparoscopic radical surgery for kidney cancer has gradually become popular.Taari et al. In James’ opinion, compared with open surgery, there is no statistically significant difference in 5-year survival rate and recurrence and metastasis rate of kidney cancer patients, and patients with advanced kidney cancer or even local lymph node metastasis can also undergo laparoscopic radical nephrectomy. .
In general, the tumor diameter for radical laparoscopic nephrectomy should be ≤5 cm, but there are reports that all stage T1 and some stage T2 renal cancers can be treated by radical laparoscopic nephrectomy, Colombo et al. reported that stage T2 renal cancer with diameter ≤15 cm can also be treated by radical laparoscopic nephrectomy. However, most of them are performed by hand-assisted laparoscopy or transabdominal approach. The transabdominal approach has large operating space and obvious anatomical landmarks such as liver and spleen, and is suitable for laparoscopic radical kidney cancer surgery for larger kidney cancers, but intraoperative intra-abdominal organ damage may occur and the incidence of postoperative intestinal complications is higher; while the retroperitoneal approach has small operating space, but it can quickly control the kidney tip and has reliable anatomical landmarks such as the psoas major muscle and renal artery, and is suitable for retroperitoneal kidney cancer surgery for stage T1 kidney cancer. Compared with the transabdominal route, patients are less traumatized and recover more quickly.
The results of our group showed that radical surgery for posterior laparoscopic stage T1 kidney cancer had significant advantages over open surgery in terms of intraoperative bleeding, hospitalization time, recovery of gastrointestinal function and postoperative complications, etc. There was no significant difference in survival rate between the two groups at follow-up. Therefore, we believe that stage T1 (≤7 cm) renal cancer is suitable for radical retroperitoneoscopic kidney cancer surgery. However, the degree of adhesion between the tumor and surrounding tissues and organs, the proximity to the renal tip, the need for skilled operating techniques in obese patients, and the history of posterior laparotomy on the affected side should be evaluated preoperatively, and the history of posterior laparotomy is listed as a contraindication to radical retroperitoneoscopic renal cancer surgery. ＜Whether to perform laparoscopic radical nephrectomy or partial nephrectomy for kidney cancer <4 cm is still controversial. We believe that with the improvement of technology and further optimization of laparoscopic surgical instruments, laparoscopic partial nephrectomy for kidney cancer <4 cm is feasible.
This study confirms that posterior laparoscopic radical nephrectomy for renal cancer is a minimally invasive and safe method. Compared with open surgery, it has become the gold standard for radical surgery of stage T1 kidney cancer because of less tissue damage, less bleeding, no significant difference in operation time and postoperative recovery, fewer perioperative complications, and no significant difference in distant metastasis and recurrence rate compared with open surgery.