Laparoscopic Radical Nephrectomy: Morcellate or Leave Intact? Leave Intact

W NE ON I T C SE POINT-COUNTERPOINT Laparoscopic Radical Nephrectomy: Morcellate or Leave Intact? Leave Intact Jihad H. Kaouk, MD, Inderbir S. Gill, MD, MCh Section of Laparoscopic and Minimally Invasive Urology, Urologic Institute, The Cleveland Clinic Foundation, Cleveland, OH At specialized centers worldwide, laparoscopic radical nephrectomy is now routine practice for management of indicated patients with localized renal cell carcinoma. Although the various intraoperative technical steps and maneuvers have been standardized for both the retroperitoneal and the transperitoneal laparoscopic approaches, controversy persists regarding the method of extraction of the nephrectomized cancerous specimen. Opinion is divided between intact extraction and morcellation. Clearly, the larger skin incision used for intact extraction is a cosmetic compromise. However, available data suggest that patient morbidity is not adversely impacted to any significant degree. Intact specimen extraction does build confidence into this procedure by respecting scientifically established oncologic guidelines, and it provides a specimen identical to that obtained in open surgery. This facilitates accurate pathologic staging, including assessment of surgical margins, which allows formulation of individualized, patient-specific follow-up protocols. For these reasons, intact extraction for renal cell cancer is preferred at our institution and multiple others worldwide. [Rev Urol. 2002;4(1):38–42] © 2002 MedReviews, LLC Key words: Renal cell carcinoma • Laparoscopy • Nephrectomy • Morcellation • Radical nephrectomy, laparoscopic D uring radical nephrectomy for renal cell carcinoma, the classic procedure is to remove the intact kidney covered by Gerota’s fascia, with or without the ipsilateral adrenal gland.1 Concomitant dissection of renal hilar lymph nodes is controversial and not performed routinely at most centers. In recent years, laparoscopic nephrectomy has gained in popularity for both benign and malignant disease. Laparoscopic radical nephrectomy (LRN) for cancer can be performed equally effectively and efficaciously by either the transperitoneal or the retroperitoneal approach. Although the individual technical steps of LRN have been standardized, debate persists regarding whether the specimen should be extracted intact or by morcellation. 38 VOL. 4 NO. 1 2002 REVIEWS IN UROLOGY Laparoscopic Radical Nephrectomy: Leave Intact Table 1 Impact of the Size of the Extraction Incision on Patient Morbidity Variable Incision length (cm) CT size of renal mass (cm) Incision ≤ 6 cm (n = 50) Incision > 6 cm (n = 50) Mean SD Mean SD 4.7 1.1 8.2 1.3 P Value N/A 4.4 1.5 6.1 3.0 .003 363.5 194.5 806.8 299.4 <.001 MSO4 equivalent (mg) 14.9 10.4 15.9 10.9 .80 Hospital stay (hr) 35.0 22.5 35.1 19.6 Complications (%) 15.6 11.4 .79 Readmissions (%) 4.0 4.0 1.00 Specimen weight (g) .04 Adapted from Gill et al 2001.4 Cancer Vol. 92, No. 7, 2001, pp. 1843-1855. © 2001 American Cancer Society. Reprinted by permission of Wiley-Liss, Inc., a subsidiary of John Wiley & Sons, Inc. CT, computed tomography; N/A, not applicable; SD, standard deviation; MSO4, morphine sulfate. Why Intact Specimen Extraction? For any minimally invasive technique to achieve widespread acceptance, we believe that it must at a minimum equal, and preferably improve on, open surgical outcomes without compromising the technical and oncological principles underpinning the open procedure. The primary purpose of LRN is to excise the tumor-bearing kidney in a minimally invasive manner while affording the patient the best chance for long-term cancer cure. Cosmetic outcomes, although important, are clearly somewhat secondary. Intact extraction of the cancerous renal specimen following a LRN satisfies the stringent requirements proposed by the American Joint Committee on Cancer (AJCC) and the Union Internationale Contre le Cancer (UICC).1 Morcellation does not. Surgical Margin Status Pathological confirmation of a negative surgical margin is important for documentation of the technical adequacy of LRN. Inking of the specimen surface followed by histological examination of its surgical margins is not possible after tissue morcellation. In a study by Landman and colleagues,2 pathological evaluation of radical nephrectomy specimens was performed before and after morcellation to determine whether the morcellation process compromised the histological diagnosis. Morcellation was performed ex vivo within a mock synthetic abdominal wall that may only four were fresh. Pathological tumor size could not be assessed in any case due to morcellation. Following morcellation, perirenal fat invasion was documented in four specimens and renal vein involvement in one. Importantly, however, of the four fresh renal cell carcinoma specimens, in one case (25%) fat invasion and renal vein involvement was felt to be artifactual due to mor- Cosmetic outcomes, although important, are clearly somewhat secondary. not have represented the technical difficulties during an actual clinical case. The morcellation technique was modified to allow specimen extraction through a 2-cm incision, the reason being “to preserve as much pathological information as possible since tissue obtained after morcellation and removal through a standard 12 mm port site is too fragmented to enable accurate staging." The study included only 11 renal cell carcinomas (mean tumor size 4.2 cm, range 2–7 cm), of which seven were formalin fixed and cellation. In another case, the laparoscopic sac was grossly perforated during morcellation, risking tumor spillage and port site recurrence. No information could be provided on the status of the surgical margins of the specimen.2 Precise Pathological Staging The UICC and the AJCC recommend that the radical nephrectomy specimen allow precise pathological staging, thus providing detailed information about capsular penetration, vascular VOL. 4 NO. 1 2002 REVIEWS IN UROLOGY 39 Laparoscopic Radical Nephrectomy: Leave Intact continued Table 2 Morcellation vs Intact Specimen Extraction: A Literature Review Total Barrett et al 19986 Ono et al 19997 Dunn et al 19998 Abbou et al Morcellation Morcellation Morcellation Intact extraction Intact extraction Morcellation Intact extraction No. of patients 72 34 61 29 100 167 129 Laparoscopic approach Transperitoneal Transperitoneal Transperitoneal Retroperitoneal Retroperitoneal Transperitoneal Retroperitoneal Surgical time (hr) 2.9 5.1 5.5 2.4 2.8 4.5 2.6 Complication rate (%) 10 9 5 major, 8 3 major, 24 11 Method of organ 9 Gill et al 20014 Morcellation Intact Extraction retrieval 48 minor 11 minor Specimen weight (g) 402.5 281 N/A N/A 554.3 342 554.3 Analgesia (mg MSO4 N/A 29 27 8.6 22 28 15.3 Hospital stay (d) 4.4 N/A 3.6 4.8 1.6 4 3.2 Convalescence (wk) N/A 3.2 8.4 N/A 4.2 5.8 4.2 Port site recurrence 1 0 0 0 0 1 0 Local recurrence 0 0 1 1 0 1 1 equivalent) Adapted from Gill et al 2001.4 Cancer Vol. 92, No. 7, 2001, pp. 1843-1855. © 2001 American Cancer Society. Reprinted by permission of Wiley-Liss, Inc., a subsidiary of John Wiley & Sons, Inc. N/A, not applicable; MSO4, morphine sulfate. and lymphatic invasion, and involvement of perirenal tissue.1 Obviously, precise pathological staging of kidney cancer is compromised during morcellation, and the time-consuming examination of fragmented tissue usually requires an experienced pathologist. In an effort to improve pathological examination after specimen morcellation, limited enlargement of the primary port site incision has been described in some series to retrieve larger fragments for better pathological examination. It has been argued that the precision of current computed tomographic (CT) scanning technology provides clinical staging information that is as reliable as histopathological evaluation. Preoperative radiological staging of 40 VOL. 4 NO. 1 2002 REVIEWS IN UROLOGY renal cell carcinoma by CT scanning has an excellent overall accuracy, ranging from 82% to 91%.3 However, especially for larger tumors, CT scan may not be completely reliable for the individual patient. We compared clinical staging by CT scanning with histopathological staging of the intact extracted surgical specimen in 125 cases of renal tumors at the Cleveland Clinic.4 Notably, the CT scan understaged 9% of the renal tumors by failing to detect tumor invasion into the perirenal fat (4), renal vein (3), and adrenal gland (2). Had morcellation been performed in these cases, this important prognostic information would have been lost, thus compromising follow-up management of these patients. Individualized Follow-up Protocol per Patient Currently available systemic therapy for treatment of metastatic renal cell carcinoma is of limited efficacy; aggressive surgical treatment of local recurrence or localized metastatic lesions provides somewhat superior results. Therefore, early detection of recurrent or metastatic disease is important, because a delay in diagnosis may compromise long-term outcomes. Individualized follow-up protocols based on accurate pathological staging of the primary lesion, as provided by intact extraction, maximize chances of timely treatment of recurrent cancer.5 Builds Confidence into the Procedure Currently, long-term follow-up of Laparoscopic Radical Nephrectomy: Leave Intact Table 3 Laparoscopic Radical Nephrectomy: Morcellation vs Intact Extraction, Advantages and Disadvantages cost of the morcellator and $133 for the morcellator blade, morcellation may prolong operative time by 30 to 45 minutes. Morcellation Intact Extraction Why Specimen Morcellation? Operative time Inferior Superior Analgesia Comparable Comparable Hospital stay Comparable Comparable Morbidity Comparable Comparable Cosmesis Superior Inferior Cost-effectiveness Inferior Superior Pathological staging Inferior Superior There can be only two rationales for specimen morcellation: 1) to extract the specimen without adding to the port site incisions, thus minimizing patient morbidity and hospital stay; and 2) to achieve a superior cosmetic result. Let us examine these two aspects in more detail. Surgical margins Inferior Superior Follow-up prognostication Inferior Superior Port site recurrence Inferior Superior LRN is lacking. In the absence of such long-term follow-up, the negative surgical margins achieved routinely in intact specimens in our series provide encouraging surrogate evidence attesting to the technical efficacy of laparoscopy from an oncological standpoint.4 Further, examination of the whole specimen allows precise comparison to various open surgical series. We believe that reliable histopathological evaluation of the excised specimen, as obtained by intact extraction, has been one of the key factors in building confidence in the oncologic adequacy of LRN. Complications Associated with Morcellation Serious complications that have actually occurred in clinical practice due to morcellation include local tumor spillage, trocar site recurrence, and major morcellation injury to a loop of bowel or colon. Barrett and Fentie6 reported a port site recurrence 25 months following radical nephrectomy and specimen morcellation. Spillage may occur through tiny or gross defects made in the fabric of the entrapment sac by the morcellator blades following prolonged morcellation of a large specimen. Additionally, serious bowel injury has occurred following unsuspected rupture of the entrapment sac, leading to morcellation of an adjacent bowel loop. Cost-Effectiveness There is a cost factor to specimen morcellation. In addition to the $1975 Minimize Patient Morbidity and Hospital Stay Intuitively, it seems logical that “the smaller the incision, the less the morbidity." Although a larger incision is necessary for intact specimen extraction, this incision can be located and created in such a manner as to minimize morbidity. In our singleinstitution report of 100 consecutive LRNs, key patient morbidity parameters were evaluated to determine whether the length of the skin incision employed for intact specimen extraction had a significant impact on them (Table 1). Upon comparing 50 patients with skin incisions 6 cm or less in length with 50 patients who had skin incisions more than 6 cm long, no significant difference in narcotic analgesia requirements, hospital stay, complication rates, or potential readmission was noted.4 A literature review of patient morbidity following intact extraction versus morcellation from multiple institu- Main Points • Intact extraction of the cancerous kidney satisfies proposed American Joint Committee on Cancer and Union Internationale Contre le Cancer requirements; morcellation does not. • Inking of the specimen surface followed by histological confirmation of negative surgical margins is not possible after tissue morcellation. • Precise pathological staging of kidney cancer may be compromised during morcellation. • The muscle-splitting larger extraction incision, cosmetically located, does not appear to increase patient morbidity significantly. • Serious complications have occurred, albeit rarely, in clinical practice due to morcellation. VOL. 4 NO. 1 2002 REVIEWS IN UROLOGY 41 Laparoscopic Radical Nephrectomy: Leave Intact continued tions worldwide corroborates our single-institution data (Table 2).4,6–9 examination for staging and followup protocols. Superior Cosmetic Result Clearly, morcellation provides a superior cosmetic result. However, our current routine practice for specimen Conclusion Intact specimen extraction after LRN follows the classic oncological guidelines established in open sur- 3. 4. 5. Intact specimen extraction after LRN follows the classic oncological guidelines established in open surgery and provides critical pathologic information. 6. 7. extraction in male patients is a low muscle-splitting Pfannensteil incision, at or below the pubic hair line. In suitable female patients, intact specimen extraction per vaginum has proved most efficacious.10 In any event, we believe that cosmetic considerations should not outweigh established oncological principles that allow accurate pathological 42 VOL. 4 NO. 1 2002 REVIEWS IN UROLOGY gery and provides critical pathologic information. These important advantages accrue without significant collateral disadvantages in regard to patient morbidity (Table 3). 8. 9. References 1. 2. Guinan P, Sobin LH, Algaba F, et al. TNM staging of renal cell carcinoma: work group no. 3. Cancer. 1997;80:992–993. Landman J, Lento P, Hassen W, et al. Feasibility of pathological evaluation of morcellated kid- 10. neys after radical nephrectomy. J Urol. 2000;164:2086–2089. Kopka L, Fischer U, Zoeller G, et al. Dual phase helical CT of the kidney: value of the corticomedullary and nephrogenic phases for evaluation of renal cell carcinoma. J Urol. 1998;160:1586–1587. Gill IS, Meraney AM, Schweizer DK, et al. Laparoscopic radical nephrectomy in 100 patients: a single center experience from the United States. Cancer. 2001;92:1843–1855. Levy DA, Slaton JW, Swanson DA, et al. Stage specific guidelines after radical nephrectomy for localized renal cell carcinoma. J Urol. 1998;159:1163–1167. Barrett PH, Fentie DD, Taranger LA. Laparoscopic radical nephrectomy with morcellation for the renal cell carcinoma: the Saskatoon experience. Urology. 1998;52:23–28. Ono Y, Kinukawa T, Hattori R, et al. Laparoscopic radical nephrectomy for renal cell carcinoma: a five year experience. Urology. 1999;53:280–286. Dunn MD, Portis AHJ, Shalhav AL, et al. Laparoscopic vs. open radical nephrectomy for renal tumor: the Washington University experience [abstract 638]. J Urol. 1999;161:166. Abbou CC, Cicco A, Gasman D, et al: Retroperitoneal laparoscopic versus open radical nephrectomy. J Urol. 1999;161:1776-1780. Gill IS, Cherullo EE, Meraney AM, et al: Vaginal extraction of the intact specimen following laparoscopic radical nephrectomy. J Urol. In press.