Objective To summarize the experience of radical nephrectomy via abdominal approach for the treatment of giant kidney cancer (tumor diameter ≥12 cm). Methods Forty-five patients with giant kidney cancer were admitted from May 2002 to May 2009. A subcostal oblique incision was chosen for the transabdominal approach, and a liver puller was used to reveal the operative field; the renal artery was ligated first, and the non-tumor side tissues were freed after blocking the renal blood supply; minimally invasive techniques (such as titanium clamps and Hem-o-lock) were applied intraoperatively when separating the tumor; when a cancerous thrombus in the inferior hepatic vena cava was encountered, the vena cava surrounding the cancerous thrombus was blocked with a heart ear clamp and the thrombus was removed. The operative time, intraoperative complications, estimated intraoperative bleeding, postoperative hospitalization time, and postoperative pathology were retrospectively summarized. Results Tumor diameter ranged from 12.2 to 28.3 cm, with an average of 14.5 cm. operative time (150±58) min, estimated intraoperative bleeding volume (350±180) ml, blood transfusion in 3 cases (6.7%), and hospitalization time (12±5.6) d. There was no intraoperative injury to duodenum, liver, colon and large vessels in this group, and no postoperative abdominal infection or postoperative intestinal obstruction. There was one case each of splenic injury due to tumor invasion of the peritoneum involving close adhesion of the splenic peritoneum and exposure of the superior pole of the kidney, and two cases (4.4%) of spleen were resected; postoperative pathological stage, 13 cases were T2N0-1M0-1 stage, 23 cases were T3 N0-1M0-1 stage, and 9 cases were T4N0-1M0-1 stage. Three cases (6.7%) of renal bed tumor recurrence were followed up for 3 to 63 months. Conclusion Radical nephrectomy via abdominal approach for the treatment of giant renal cancer is a safe and effective procedure. The intraoperative application of liver pulling hooks for good surgical visualization and the application of titanium clips and Hem-o-lock to block the peritumor vessels can reduce intraoperative bleeding. Intraoperative attention should be paid to protect the spleen and avoid or reduce splenic injury as much as possible.
Kidney tumor, giant, radical kidney cancer surgery, experience summary
Surgical treatment is preferred for patients with limited and locally invasive and T4 stage renal cancer in good physical status [1]. Laparoscopic radical nephrectomy or transumbilical open radical nephrectomy can be chosen for kidney cancer with tumors around 7 cm [2], while transabdominal (or combined transthoracic) is generally recommended for kidney tumors larger than 7 cm. 45 cases of large-volume kidney cancer were treated with radical nephrectomy using a subcostal transabdominal approach from May 2002 to May 2009, and we have achieved a good experience, which is reported as follows.
Subjects and methods
I. Subjects
There were 45 cases in this group, 36 males and 9 females. Age 21-79 years old, average 64 years old. 28 cases were seen for lumbar discomfort or pain, 14 cases were hospitalized for carnal hematuria, and 3 cases were found by ultrasound and CT examination due to other systemic diseases. The tumors were located in the upper pole of the kidney in 15 cases, in the middle of the kidney in 6 cases, in the lower pole of the kidney in 19 cases, and in multiple cases in 5 cases. The preoperative clinical stage (AJCC 2002) was cT2 N0M0-119 cases, cT3a N0M0-18 cases, cT3b N0M0-110 cases (with inferior hepatic vena cava or renal vein thrombosis), cT4 N0-2M0-18 cases; among them, there were 6 cases with enlarged hilar lymph nodes, 4 cases with lung metastasis, 3 cases with bone metastasis and 1 case with liver metastasis.
II. Surgical methods and techniques
General anesthesia was routine, and a gastric tube was left in place before surgery, with the affected side elevated 20-30 degrees in the supine position. All cases were operated through a subcostal margin oblique incision, i.e., a parallel rib margin incision 2 cm below the rib, with the upper margin starting from the glabella and the lower margin ending at the mid-axillary line (about 25-30 cm long). The skin, subcutaneous tissue and various layers of muscles are incised to enter the abdominal cavity, and the liver pulling hook pulls up the rib arch to reveal more space.
When removing the right kidney tumor, the hepatic colonic ligament was detached, the retroperitoneum on the surface of the tumor was cut, and the right renal hilum was medially located, and the interstitial space between the duodenum and the right kidney was subconsciously free, and the vena cava beneath it could be found after gently pushing away the duodenum, and the left renal vein was revealed on the left side of the vena cava, and the lower edge of the left renal vein was free enough to expose the right renal artery (Photo 1), and “Mee’s clamp “The right renal artery will be ligated by freeing the right renal artery and drawing through the No. 7 silk; freeing the kidney and tumor surrounding tissues, ligating the thicker vessels with Hem-o-lock when encountering them, and adding titanium clips for the finer vessels, the renal vein can be ligated during or at the end of freeing the whole renal tumor, and in case of cancerous thrombus in the renal vein or inferior hepatic vein, the heart ear clamp will block the vena cava around the cancerous thrombus and remove it.
When the left kidney tumor is removed, the lateral peritoneum is incised on the lateral side of the descending colon, the splenic colonic ligament is cut, the colon is freed downward and the pancreas and spleen are freed upward and inward to reveal the left renal portal. Most of the tumors are too large beyond the midline and it is not easy to expose the renal vein, then start to free from the normal side (most of the lower pole of kidney) toward the renal hilum. The left renal vein is longer and can be moderately pulled up to remove the connective tissue, gonadal vein and lymphatic vessels under the renal vein and reveal the left renal artery (Photo 2), which is treated the same as the right renal artery.
III. Observation items and postoperative follow-up
The operation time, estimated intraoperative bleeding, intraoperative complications, and the number of days of hospitalization were recorded. Ultrasound, renal area CT, X-ray chest radiograph, liver and kidney function, and blood and urine routine were reviewed on an outpatient basis at 3, 6, 9, and 15 months after surgery, and once every six months after 1 year, and all patients were adhered to long-term follow-up.
IV. Statistical methods: mean and standard deviation were calculated using the spss 11.5 package, and survival rate was calculated using the Kaplan-Meier method.
Results
1. Surgical results: The tumor diameter of this group ranged from 12.2 to 28.3 cm, with a mean of 14.5 cm, mean operative time (150±58) min, estimated intraoperative bleeding (350±180) ml, and 3 patients (6.7%) received 400-600 ml of red blood cell suspension transfusion. The duration of hospitalization was (12±5.6) d. Postoperative pathological staging, T2N0-1M0-1 stage in 13 cases, T3 N0-1M0-1 stage in 23 cases, and T4N0-1M0-1 stage in 9 cases. Postoperative pathology report: 36 cases of clear cell carcinoma, 5 cases of sarcomatoid carcinoma, 2 cases of suspicious cell carcinoma, and 2 cases of papillary carcinoma.
2. Perioperative complications: intraoperatively, the spleen was damaged by tumor invasion of peritoneum and close adhesion between peritoneum and splenic peritoneum and exposure of suprarenal pole in 1 case each, and the spleen was resected in 2 cases (4.4%); the tail of pancreas was resected in 1 case because of tumor adhesion invasion with pancreas; there was no injury to duodenum, liver, colon and large blood vessels in this group, and there was no postoperative abdominal infection and intestinal obstruction.
3. Follow-up results: 3 to 63 months, average 26.5 months. 2 cases (4.4%) had renal insufficiency and 3 cases (6.7%) had recurrence of renal fossa tumor. Among them, 2 cases died 1 year after surgery, another case with bone metastasis died at 23 months; 2 cases of lung metastasis died at 27 and 31 months, the survival rate of 1 and 3 years after surgery in this group was 78.5% and 55.7%, respectively, in patients with metastasis in immune or molecular targeted therapy.
Discussion
Foreign literature usually refers to renal cancer tumor diameter greater than 7 cm as large renal cell carcinoma [3,4,5], and the larger the renal cancer, the richer the tumor blood supply, and the corresponding complication rate is 20-27% when choosing a combined thoracoabdominal incision or abdominal L-shaped incision [6,7]. Therefore, the management of giant kidney cancer requires certain strategies to successfully complete the surgery and reduce complications. To summarize our experience, the characteristics of our group include (1) exposure of the operative field: our group chose a subcostal oblique incision and used a liver pull hook to pull up the rib arch by 3-6 cm, which could clearly reveal the lower edge of the liver, the lower edge of the spleen and the upper pole of the kidney. The lower edge of the abdomen is soft, and the renal hilum and the lower pole of the kidney can be revealed with a general pulling hook. (2) Reasons and methods for ligating the renal artery first: Conventional radical kidney cancer surgery found that after ligating the renal artery first, the kidney tissue and tumor tissue become smaller and softer, and there is a certain gap around the tumor which is not easily loosened. In giant kidney cancer, tumor ambassador kidney structure disorder or tumor covering renal hilum, or renal hilum combined with enlarged lymph nodes make it complicated and difficult to find renal artery and ligate renal artery. For right kidney giant renal cancer, we mostly choose to deal with the right renal artery under the left renal vein, which controls the right renal blood supply before freeing the right kidney tumor, and then when freeing the right kidney, the kidney and tumor surface vessels are easy to deal with, and the operation field can be kept clear, which makes the operation safe and smooth. When dealing with the left kidney tumor, although there is no special structure of right renal artery, we can always remove the kidney and tumor at the normal kidney tissue (especially at the lower pole of kidney) after patiently freeing and ligating the blood vessels and tissues under the renal vein, then appropriately pull up the longer renal vein, find the left renal artery and ligate it with thick lines, which can also achieve the purpose of controlling the blood supply of the left kidney first. (3) Application of minimally invasive techniques: There are many branches of perirenal vessels and rich lumbar vessels, and silk ligation is easy to tear the vessels, plus blunt free tissues, which can easily lead to bleeding in the operation field. The development of modern minimally invasive techniques can provide good surgical instruments, such as titanium clamps and Hem-o-lock. In this group, small vessels are ligated with titanium clamps and large deeper tissues are clamped with Hem-o-lock clamps without pulling blunt free, which ensures the clarity of the operative field and is not easy to damage the surrounding organs and large vessels.
Complications of radical surgery for giant kidney cancer mainly include accidental hemorrhage, spleen injury, liver injury, pancreatic injury, duodenal injury, and misligation of the superior mesenteric artery, with an incidence of about 27% reported in the literature [6]. We found that inadvertent hook pulling during radical surgery for renal cancer in Plain can lead to splenic peritoneal injury, and suturing the splenic peritoneum to stop hemorrhage is mostly unsuccessful, and decisive removal of the spleen is an effective method to avoid secondary surgery. Therefore, when exposing the superior pole of the kidney, gauze is padded under the pulling hook and the pulling is moderate. Some literature reported that in order to prevent liver and spleen injury, the right triangular ligament, coronary ligament and hepatic colonic ligament of the liver, gastrocolic ligament, splenic colonic ligament and splenorenal ligament should be free intraoperatively, while we believe that the ligaments and ligaments should be free depending on the exposure according to the degree of exposure. In our group, one case of kidney cancer invaded the tail of the pancreas, and instead of forcible dissection, the tail of the pancreas was resected, as reported in the literature [6]. Using the method of this group, we were able to complete the freeing of the kidney and tumor under direct vision, without operating in a blinded state, so there was no 1 case of hemorrhage or duodenal injury.
The preoperative clinical staging of our group was cT2 N0M0-119 cases, cT3a N0M0-18 cases, cT3b N0M0-110 cases, cT4 N0-2M0-18 cases; postoperative pathological staging, T2N0-1M0-1 stage 13 cases, T3 N0-1M0-1 stage 23 cases, T4N0-1M0-1 stage 9 cases, there existed preoperative evaluation earlier than postoperative, the possible reason The possible reason is that the preoperative imaging examination cannot determine whether there is invasion of perirenal fat and/or adipose tissue of the renal sinus. For tumors larger than 7 cm without renal vein carcinoma thrombus, most of them are classified as T2 stage, and in fact those with perirenal fat invasion belong to T3 stage. In our group, three cases of renal fossa tumor recurrence were related to perirenal lymph node metastasis; two cases died one year after surgery, one case died 23 months after bone metastasis, and two cases died 27 months after lung metastasis, all of which were related to late stage at the time of consultation. The average operating time of radical resection of kidney cancer in this group was 2.5 h, the estimated bleeding volume at operation was about 400 ml, the postoperative complications were controlled at about 10%, and the survival rates at 1 and 3 years were the same as those reported in the relevant literature [7], indicating the rationality and practicality of our method, which provides an effective open procedure for the radical resection of large kidney cancer.