Laparoscopic Radical Nephrectomy: Morcellate or Leave Intact? Definitely Morcellate!

W NE ON I T C SE POINT-COUNTERPOINT Laparoscopic Radical Nephrectomy: Morcellate or Leave Intact? Definitely Morcellate! Jay T. Bishoff, MD Endourology Section, Department of Urology, Wilford Hall Medical Center, Lackland AFB, TX Eleven years after the first laparoscopic radical nephrectomy (LRN), which was performed with morcellation, the best approach to the procedure remains controversial. Concerns include tumor seeding, recurrence, accuracy of staging, histopathological diagnosis, and longer surgery time. Enclosing the kidney in an impermeable sac prior to morcellation helps prevent seeding. Pathological review of morcellated LRN specimens has been shown to be as accurate as that of intact specimens. Ten-year survival data for LRN with morcellation are not available yet, but 5-year rates are as good as those for open nephrectomy. The utility of morcellation in LRN is supported by the results of clinical practice. [Rev Urol. 2002;4(1):34–37] © 2002 MedReviews, LLC Key words: Laparoscopic radical nephrectomy • Nephrectomy • Morcellation • Renal cell carcinoma he first laparoscopic radical nephrectomy (LRN), performed in 1990 by Clayman and co-workers, included morcellation and extraction of the kidney specimen through an 11-mm trocar site.1 This accomplishment was one of the greatest milestones in minimally invasive surgery, as it provided the solution for removing a large solid organ without an incision of equal or greater size. Since the initial report, many institutions have verified the utility of a laparoscopic approach to address benign and malignant diseases of the kidney, with far less morbidity to the patient than open surgery. Consequently, LRN is rapidly becoming the standard of care, and surgeons who perform LRN with morcellation continue to experience results similar to those in Dr. Clayman’s original report. Patients T 34 VOL. 4 NO. 1 2002 REVIEWS IN UROLOGY Laparoscopic Radical Nephrectomy: Morcellate who undergo LRN with morcellation have less pain and shorter hospital stays than those who have LRN with intact removal.2,3 Nevertheless, for some surgeons the preferred means of organ removal remains controversial. Although more and more renal masses are being treated with LRN, many kidneys are removed intact, primarily due to concerns over tumor disease suffered a solitary recurrence at one trocar site 25 months after radical nephrectomy.5 In the second case, a patient with a T1N0M0 renal cell carcinoma (Fuhrman Grade II) underwent transperitoneal laparoscopic radical nephrectomy with morcellation of the specimen. Ascites with a large amount of fluid was noted at the time of surgery, but no To date there are no reports of peritoneal seeding or local tumor recurrence in the renal fossa following LRN. seeding, recurrence, pathological staging, histopathological diagnosis, and additional time required for organ entrapment and morcellation. Tumor Seeding Fear of tumor seeding in the peritoneal cavity, renal fossa, or trocar sites leads many laparoscopic surgeons to remove kidney specimens intact. However, to date there are no reports of peritoneal seeding or local tumor recurrence in the renal fossa following LRN. Recurrence of renal carcinoma in surgical wounds from open and laparoscopic surgery is rarely seen. Nevertheless, the spread of cancer to trocar sites is of concern, because trocar site seeding has been reported with some frequency in nonurologic cancers. In a broad survey of over 1050 European general surgery programs, port site recurrence occurred in 17% of laparoscopic cholecystectomies performed for incidental gallbladder carcinoma and 4.6% of laparoscopic procedures for colorectal cancer.4 In the case of LRN with morcellation, there have been only two reports of port site seeding. In a series of 94 patients undergoing LRN with specimen morcellation, one patient with T3N0M0 (Fuhrman Grade IV) cytological evaluation was performed. Five months later, the patient developed disseminated metastatic renal cell carcinoma, carcinomatosis, and recurrence at all of the trocar sites.6 When the cases of port site seeding for all malignancies are evaluated, several common elements emerge. Many of the reported cases involve malignancy that was unexpected or whose presence was being determined with a biopsy. In such cases, basic principles of cancer surgery were violated. Moreover, in other patients the specimen is to be morcellated, a LapSacTM (Cook Urological, Inc., Spencer, IN), fabricated from a double layer of plastic and nondistensible nylon, must be used. This device has been shown to withstand morcellation and remain impermeable to bacteria and tumor cells. During LRN, attempts should be made to perform a wide en bloc dissection to ensure an adequate surgical margin. The field is draped prior to morcellation and all potentially cancerous tissue entrapped in an impermeable sac prior to extraction from a trocar site Grade and Stage Morcellation of radical nephrectomy specimens for extraction has also raised concerns about accurate pathological staging. Computed tomography (CT) has been proven to be an effective tool for planning surgery and predicting pathological findings. The overall accuracy of CT in staging renal cell carcinoma ranges from 72% to 90%. In a review of 172 renal tumors treated with open radical nephrectomy, Shalhav and colleagues correlated the preoperative Computed tomography alone is effective in staging renal cancers. metastatic disease or malignant ascites was already present at the time of surgery. The majority of cases involved removal of tissue either directly through a trocar site or through a small incision without the protection of an entrapment sac. To prevent port site seeding and tumor spillage, several steps need to be taken in order to follow the basic principles of cancer surgery. Direct handling of the tissue must be minimized and all attempts made to prevent violation of the tumor until it is contained in an impermeable sac. If CT-based clinical stage with the final pathological tumor stage. They found one patient (0.6%) to be understaged and seven (4%) overstaged by preoperative CT. They concluded that clinical CT staging of low-stage renal tumors is reliable and tends to overstage rather than understage renal tumors.7 Thus, CT alone is effective in staging renal cancers. Despite the gross appearance of the morcellated specimen, accurate histopathogical and staging information can be obtained. Several institutions have performed intact removal VOL. 4 NO. 1 2002 REVIEWS IN UROLOGY 35 Laparoscopic Radical Nephrectomy: Morcellate continued Table 1 Published Reports of Laparoscopic Radical Nephrectomy with the Majority of Specimens Morcellated Authors N Chan et al 200111 67 36 (12–111) 0 95% Dunn et al 20002 61 25 (3–73) 0 91% Ono et al 2000 125 28 (1–87) 0 97% Janetschek et al 200013 75 13 0 100% Fentie et al 20005 57 33 (14–70) 1.2% 95% 12 Follow-Up Months (range) of renal tumors and, after representative sections of the tumor were removed for pathologic diagnosis and staging, had the entire intact specimen morcellated. The morcellated tissue was processed and returned, in a blinded fashion, to a different pathologist for review. In each case the pathologist was able to accurately determine the diagnosis, grade, stage, and presence or absence of vascular invasion from the morcellated specimens. Only the size of the tumor could not be determined from the morcellated tissue.8,9 The use of India ink prior to morcellation has further refined pathological staging during LRN. When India ink is placed in the morcellation bag, the excess ink washed from the bag, and the specimen then morcellated, the India ink consistently endures fixation, embedding, and sectioning with the black, inked margins of the specimen visible under the microscope.10 Long-Term Survival Adequate treatment of renal cancer is of greatest concern when recommending LRN. Long-term follow-up demonstrating overall and cancerspecific survival of patients treated with LRN and morcellation is the final proof needed to establish the effectiveness of LRN for the treatment of renal cancer. Currently, 10-year 36 VOL. 4 NO. 1 2002 REVIEWS IN UROLOGY Port Site Seeding survival data are not available. However, 5-year data now show that early cancer-specific survival rates for LRN with morcellation are the same as those for open nephrectomy (Table 1). Review of Technique In the past, one of the greatest barriers to morcellation was the difficulty of organ entrapment. Without automatic deployment engineering for Disease-Free Survival fixed position. Once the kidney is entrapped, the wire can be pulled from the holes in the sac and the mouth of the sac brought out through a trocar site. The neck of the morcellation sac is pulled though the trocar site, enlarged to approximately 1.5–2 cm to allow tissue to protrude from the opening. Because deep, blind passes with morcellation instruments may damage the bag or grasp surrounding Early cancer-specific survival rates for LRN with morcellation are the same as those for open nephrectomy. the LapSac, placing the kidney into the bag required practice, perseverance, and occasionally plain old good fortune. However, with several simple tricks the bag can now be modified to allow rapid entrapment of the kidney. A stiff hydrophilic wire can be double-passed through the holes in the Lap Sac, creating a rigid opening. The bag and wire can be rolled up and inserted through an 11-mm trocar site once the trocar is removed. Replacing the trocar alongside the protruding ends of the wire allows the pneumoperitoneum to be reestablished. The modified LapSac opens easily, and the rigid wire keeps the mouth of the sac open and in a structures, only the tissue crowning from the opening of the morcellation sac is grasped during extraction. Morcellation is performed with the abdomen insufflated while a 30° laparoscope is used to monitor the morcellation process and inspect the integrity of the bag. All possibly contaminated instruments are removed from the operative field. Ascitic fluid suspicious for malignancy is sent for cytology. A number of high-speed morcellators have been developed, and most have been disappointing in their ability to rapidly and safely morcellate the kidney. We have found that alternating bites between a Kocher Laparoscopic Radical Nephrectomy: Morcellate clamp (or a small bone rongeur) to disrupt the collecting system and a ring forceps to break up the parenchyma is as fast as or faster than commercially available morcellators. These instruments are inexpen- Conclusion LRN is an effective treatment for localized renal cell carcinoma, with disease-free survival similar to that of open radical nephrectomy. Concerns over tumor recurrence, port site seed- 3. 4. 5. The entire procedure of entrapment, morcellation, and closure of the trocar site is routinely done in less than 30 minutes. 6. 7. sive, reusable, and readily available as standard equipment in most operating rooms. At our institution the use of these simple techniques allows us to entrap the kidney in a mean time of 4 minutes. With manual morcellation the entire kidney specimen is removed through a trocar site enlarged to 2 cm in a mean time of 12 minutes. A Carter Thomason closure device (Inlet Medical Inc., Eden Prairie, MN) is used to close the trocar site. The entire procedure of entrapment, morcellation, and closure of the trocar site is routinely done in less than 30 minutes. ing, histopathology, staging, and time required for morcellation have caused a regression in the technique toward larger incisions for intact removal. However, these fears have not been realized in clinical practice. Morcellation of the kidney specimen was an integral part of the first LRN, performed over 10 years ago, and its utility continues to be supported in the literature today. References 1. 2. Clayman RV, Kavoussi LR, Soper NJ, et al. Laparoscopic nephrectomy: initial case report. Urology. 1991;146:278–282. Dunn MD, Portis AJ, Shalhave AL, et al. Laparoscopic vs open radical nephrectomy: a 9- 8. 9. 10. 11. 12. 13. year experience. J Urol. 2000;164:1153– 1159. Walther MM, Lyne JC, Libutti SK, Linehan WM. Laparoscopic cytoreductive nephrectomy as preparation for administration of systemic interleukin-2 in the treatment of metastatic renal cell carcinoma: a pilot study. Urology. 1999;53:496– 501. Paolucci V, Schaeff B, Schneider M, Gutt C. Tumor seeding following laparoscopy: international survey. World J Surg. 1999;23:989– 995. Fentie DD, Barrett PH, Taranger LA. Metastatic renal cell cancer after laparoscopic radical nephrectomy: long-term follow up. J Endourol. 2000;14:407– 411. Castilho LN, Fugita OE, Mitre AI, et al. Port site tumor recurrences of renal cell carcinoma after videolaparoscopic radical nephrectomy. J Urol. 2001;165:519. Shalhav AL, Leibovitch I, Lev R, et al. Is laparoscopic radical nephrectomy with specimen morcellation acceptable cancer surgery? J Endourol. 1998;12:255–257. Landman J, Lento P, Hassen W, et al. Feasibility of pathological evaluation of morcellated kidneys after radical nephrectomy. J Urol. 2000;164:2086–2089. Piper N, Bishoff JT, Eliason S, et al. Does morcellation of renal specimens affect diagnosis, grade, stage or margin status? Abstract presented at the Society of Government Service Urologists Annual Kimbrough Urology Seminar; November 4–9, 2001; Seattle, WA. Meng MV, Koppie TM, Duh Q-Y, Stoller ML. Novel method of assessing surgical margin status in laparoscopic specimens. Urology. 2001;58:677–682. Chan DY, Cadeddu JA, Jarrett TW, et al. Laparoscopic radical nephrectomy for cancer control in renal cell carcinoma. J Urol. 2001;166:2095–2100. Ono Y, Kinukawa T, Hattori R, et al. Long-term outcome of laparoscopic radical nephrectomy for renal cell carcinoma. J Urol. 2000;19(suppl):163 Janetschek G, Jeschke K, Peschel R, et al. Laparoscopic surgery for stage T1 renal cell carcinoma: radical nephrectomy and wedge resection. Eur Urol. 2000;38:131–138. Main Points • Laparoscopic radical nephrectomy (LRN) is rapidly becoming the standard of care in kidney surgery. • Early cancer-specific survival rates for LRN with morcellation equal those for open nephrectomy. • Peritoneal seeding and local tumor recurrence in the renal fossa have not been reported following LRN. • Use of India ink prior to morcellation has made pathological staging during LRN more accurate. • Morcellation allows use of a smaller incision than intact kidney removal. • Patients have less pain and shorter hospital stays after LRN with morcellation than after LRN with intact removal. VOL. 4 NO. 1 2002 REVIEWS IN UROLOGY 37