Abstract ... Objective
To present the complications from our first 100 cases of laparoscopic nephrectomy, a technically demanding procedure requiring lengthy experience, and to define the risk factors.
Patients and methods
Indications for laparoscopic nephrectomy included patients requiring nephrectomy for benign pathology and those requiring nephroureterectomy for upper tract transitional cell carcinoma confined to the upper ureter and/or renal pelvis. All patients were operated on by one surgeon (D.A.T.) via a transperitoneal route and data on diagnosis, outcome and complications collected prospectively.
Results
The overall complication rate was 18%, of which 3% were major and 15% minor complications. Five cases were converted to open surgery electively. Complications and conversions were associated with a history of pyonephrosis, previous renal surgery, staghorn calculi, polycystic kidney disease, and xanthogranulomatous pyelonephritis. While there was no discernible decline in the decrease in complications with experience, operative duration decreased from a mean of 204 min for the first 20 cases to 108 min for the last 20. Complications and conversions were more closely associated with diagnosis than with the surgeon's experience.
Conclusion
Laparoscopic nephrectomy and nephroureterectomy can be undertaken for a variety of indications with reasonable complication and conversion rates. Although inflammatory conditions increase the difficulty of these procedures, we feel that patients requiring nephrectomy for benign disease should be offered a trial of laparoscopic surgery.
Introduction
Laparoscopic nephrectomy is a demanding procedure requiring extensive experience. Several investigators have noted the advantages to the patient inherent in the laparoscopic approach, including less need for postoperative narcotics and a faster return to normal activities [ 1, 2]. We previously reported that laparoscopic nephrectomy and nephroureterectomy compare well with the open procedures in terms of overall morbidity, length of stay and operative duration [ 3]. Laparoscopic nephrectomy also compares well with open nephrectomy in terms of cost, as measured in the UK National Health Service [ 2].
The complications reported for laparoscopic nephrectomy are generally similar to those of open nephrectomy, but a few are unique to the laparoscopic approach, including injuries related to trocar placement, and carbon dioxide retention or embolization. In addition, the technical difficulty of laparoscopic nephrectomy has led to musculoskeletal injuries related to prolonged operation [ 4].
Several risk factors have been associated with complications and conversions. In a large multicentre study, laparoscopic tumour nephrectomy had a higher complication rate than laparoscopic simple nephrectomy [ 4]. In addition, complications were most likely to occur in the first 20 cases, suggesting that this reflected sufficient experience and training to minimize the rate. We present the complications from the first 100 cases at our institution, all performed by one surgeon, and attempt to identify risk factors for complications and for conversion to open surgery.
Patients and methods
Between September 1992 and March 1997, 100 patients (38 male, 62 female; mean age 50.5 years, range 15–91) underwent laparoscopic nephrectomy (n=79) or nephroureterectomy (n=21) at our institution. The indications for nephrectomy are listed in Table 1. Our policy has been to offer a trial of laparoscopy to all patients with benign pathology, including those with inflammatory conditions and previous surgery. We have also offered laparoscopic nephroureterectomy to patients with TCC in the upper ureter and/or renal pelvis. All the present patients were operated on by one surgeon (D.A.T.).
The steps of the technique used for laparoscopic nephrectomy were: the patient is placed in the flank position, the first trocar placed at the edge of the rectus level with the umbilicus, and the second and third trocars placed in an anterior axillary line. The colon is reflected medially, Gerota's fascia entered and when required, a fourth trocar is placed in the mid-axillary line. The hilum is dissected while the kidney is retracted laterally. Endoclips are used for the artery and EndoGIA staples (Autosuture Inc, USA) for the vein. Peri-renal dissection is used to free the kidney and the ureter divided last. The specimen is then removed in an organ-retrieval bag.
Initial access to achieve pneumoperitoneum was performed under direct vision, using the Hasson technique, to minimize the risk of injury from the Veress needle. For nephroureterectomy, the initial step was to resect the ureteric orifice transurethrally. After repositioning the patient, the ureter was clipped before laparoscopic dissection of the kidney and ureter, which were removed intact by extension of the inferior port site.
Data were collected prospectively; the clinical records of all patients were reviewed, noting either complications or conversion to open surgery, to identify any potential risk factors.
Results
The overall complication rate was 18% ( Table 2), of which 3% were major and 15% minor. Three patients had major complications; the first, aged 59 years, had bilateral TCC and a previous history of percutaneous resection, underwent nephroureterectomy, and sustained an aortic injury, treated by open repair. The second, aged 52 years, had hypertension and no renal function, underwent nephrectomy, sustained a vena caval injury, that was treated by open repair. The third patient, aged 77 years, had a history of obesity, coronary artery disease and transient ischaemic attacks. He underwent nephroureterectomy lasting 180 min for renal pelvic TCC, which had previously been resected percutaneously. Postoperatively, he developed a haematoma in the renal bed, a bleeding diathesis and a fatal myocardial infarction 3 days after surgery.
Table 2. Minor complications 
Ten patients required transfusions; the number of units transfused per procedure was 0.38. There was one complication with a delayed presentation, in a patient who presented with a superficial wound infection 12 days after surgery. There were no intra-operative port-related complications and no injuries to bowel. Compared with a contemporary series of open nephrectomies performed for benign indications at our institution, the complication (18% vs 28%) and transfusion rates (0.38 vs 0.89 units per procedure) were lower for laparoscopy [ 3].
Patients with minor complications had a similar mean operative duration (141 vs 143 min) but a longer hospital stay (6.2 vs 4.8 days) than patients with no complications. In contrast, patients who required conversion to open surgery or who had a major complication had a longer mean operative duration (315 min) and length of stay (11.8 days).
The complication rate was similar for both laparoscopic nephrectomy (17.5%) and nephroureterectomy (18%). However, when patients with inflammatory conditions such as pyonephrosis, staghorn calculi, xanthogranulomatous pyelonephritis (XGP) and those with previous renal surgery were excluded, there was a higher incidence of minor complications and conversions to open surgery ( Table 3). All but one of the local infectious complications occurred in this group of patients. Overall, 29 of 42 patients with inflammatory conditions (69%) underwent laparoscopic nephrectomies without complication or conversion to open surgery, compared with 87% in those patients without these risk factors. The mean operative duration was longer in the inflammation group, but the mean length of stay was only marginally longer ( Table 3).
Table 3. Conversions and complications in patients with transitional cell carcinoma and inflammatory conditions, compared with those without
In addition to the two cases of vascular injury noted earlier, five cases were electively converted to open surgery; four for failure to progress (two with staghorn calculi/pyonephrosis, one with locally advanced TCC and one with XGP), and one to remove a large polycystic kidney, where entrapment of the kidney failed. All cases requiring elective conversion were in patients with underlying inflammatory conditions or previous surgery.
Even with accumulating experience, there was no discernible trend over time in complications and conversions ( Table 4), with the exception of the last 20 cases, which we attribute to the relative paucity of inflammatory conditions in this group of patients (three of 20). The effect of experience was more evident in the decreasing operative duration (Table 4).
Discussion
There were 18 complications and five elective conversions in this series of 100 patients undergoing laparoscopic nephrectomy and nephroureterectomy. Our policy has been to offer a trial of laparoscopy to all patients with benign conditions and selected patients with TCC. The series included 42 patients with a variety of inflammatory conditions, e.g. XGP, pyonephrosis and previous surgery, all of which proved to be significant risk factors for complications and conversion to open surgery. Nevertheless, we believe that the overall benefits of a laparoscopic approach usually outweigh the risks, even in this difficult group of patients. We do not presently offer laparoscopic nephrectomy to patients with suspected RCC or XGP.
Several technical points should be detailed for the avoidance of complications: strict attention to basic surgical principles; trocars should be placed under direct vision; extra care should be taken to avoid even minor haemorrhage, as blood in the field obscures vision dramatically; the renal hilum should be approached before perirenal or ureteric dissection if at all possible; adequate exposure and retraction are essential; early conversion to open surgery for failure to progress; appropriate selection of patients, including preoperative CT in patients with suspected XGP or known upper tract TCC, to exclude tumour extension; and finally, a regular team of surgeons and nurses, to reduce unnecessary delays and frustration.
The present complication and conversion rates are broadly similar to those published previously. Complication rates in the largest reported series were 2.8–37% [ 1, 5] and conversion rates 2.8–10.3% [ 6, 7]. Gill et al. [ 4] reported a 6% rate of conversion to open surgery and a 16% rate of complications in a multi-institutional study. Complications in that series tended to occur in the first 20 cases and were more common in patients undergoing laparoscopic radical nephrectomy. Rassweiler et al. [ 7] recently reported a 5.8% complication rate and a 10.3% rate of conversion to open surgery. However, a more detailed analysis of these series is limited by their multi-institutional nature, given the wide range of operative techniques used.
The nature of complications encountered in the present series was similar to that of other series [ 1, 4, 7[8]–9], with a few minor exceptions. We encountered no bowel injuries or intra-operative complications related to trocar access, which we attribute to our use of the open-access (Hasson) technique and strict adherence to basic surgical principles. In addition, there were no postoperative musculoskeletal complications, possibly because of the shorter operative duration. There were several minor infectious complications in patients with a history of staghorn calculi, XGP and pyonephrosis, despite the prophylactic use of broad-spectrum antibiotics. Perhaps this can be attributed to the limited irrigation of the operative field through the laparoscopic approach.
The relatively long operative duration reported by most investigators [ 1, 6, 10] for laparoscopic nephrectomy and nephroureterectomy has been used by critics to argue against the widespread adoption of these techniques. The present mean duration was 153 min, which compares well with a contemporary open surgical series [ 3]. The current mean is 111 min in our last 40 cases. By maintaining the operative duration in line with that for open surgery, we support those reports rating laparoscopic nephrectomy as less expensive than open nephrectomy [ 2].
As shown in Table 4, increased experience shortens operative duration but does not necessarily reduce complication and conversion rates, which appear to be more closely related to the patient's underlying disease process. Most of these complications were minor and had little or no effect on the patients' recovery. Peters [ 11], in a survey of the laparoscopic experience of paediatric colleagues, reported that complication rates diminished significantly only after 100 cases. Given the greater difficulty involved in performing laparoscopic nephrectomy compared with diagnostic laparoscopy, a longer period of training and experience should perhaps be expected. This requirement for extensive experience of laparoscopic nephrectomy may have contributed to earlier reports which tended to overestimate its cost [ 12] and may mask some of its inherent advantages [ 13].
Laparoscopic nephrectomy can be performed safely and efficiently, but thus far has been limited to few referral centres. The way forward is to simplify the techniques and improve training, thereby making it more accessible to the general urologist. To this end, hand-assisted laparoscopy may bridge the gap between the experts and the novice by reducing the necessary experience required [ 14].
1
Kerbl K, Clayman RV, McDougall EM et al. Transperitoneal nephrectomy for benign disease of the kidney: a comparison of laparoscopic and open surgical techniques. Urology 1994; 43: 607 13
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Wilson BG, Deans GT, Kelly J, McCrory D Laparoscopic nephrectomy: initial experience and cost implications. Br J Urol 1995; 75: 276 80
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3
Sharma NK, Stephenson R, Tolley DA Should laparoscopic nephrectomy/nephroureterectomy be the preferred treatment option for most renal pathology? A comparative study. J Urol 1996; 155: 491A, abstract 722
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Gill IS, Kavoussi LR, Clayman RV et al. Complications of laparoscopic nephrectomy in 185 patients: a multi-institutional review. J Urol 1995; 154: 479 85
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Ono Y, Katoh N, Kinukawa T, Matsuura O, Ohshima S Laparoscopic radical nephrectomy: Nagoya experience. J Urol 1997; 158: 719 24
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Rassweiler JJ, Fornara P, Fahlenkamp D et al . Laparoscopic nephrectomy — the Austro-German experience. J Urol 1997; 157: 403A abstract 1582
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Cadeddu JA, Regan F, Kavoussi LR, Moore RG The role of computerized tomography in the evaluation of complications after laparoscopic urological surgery. J Urol 1997; 158: 1349 52
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Eraky I, El-Kappany HA, Ghoneim MA Laparoscopic nephrectomy: Mansoura experience with 106 cases. Br J Urol 1995; 75: 271 5
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Keeley FXJr , Sharma NK, Tolley DA Hand-assisted laparoscopic nephroureterectomy. J Urol 1997; 157: 399A abstract 1565
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