Clinical Analysis Of Retroperitoneal Laparoscopic Radical Nephrectomy In The Treatment Of Renal Cell Carcinoma

BACKGROUND AND OBJECTIVERenal cell carcinoma (RCC) is a kind of malignant tumor originated from uriniparous tubular epithelial system of renal parenchyma, is also called renal adenocarcinoma and renal carcinoma for short, it occupies 80%⁹0% of renal malignant tumors, its morbility rankes in the second position in the malignant tumors of urinary system (only lower than bladder cancer), and occupies 80%⁹0% of the malignant tumors of adult. The proportion of male and female is 1.6²:1. RCC can invade persons at any ages, and high attack ages are 50⁷0. Conventional clear cell renal cell carcinoma is the most common type in pathology (60%⁸5%), moreover, and others are papillary renal cell carcinoma (7%¹4%), chromophobe cell renal cell carcinoma (4%¹0%), collecting duct carcinoma (1%²%) and unclassified renal cell carcinoma (<2%).Radical nephrectomy is the only generally accepted treatment which may cure RCC at present, its standard excision range contains: perirenal fascia, perirenal fat tissues, the kidney of affected side, ipsilateral adrenal gland, reniportal lymph nodes and the part of ipsilateral ureter above the iliac vascular bifurcation. At the past, open radical nephrectomy was the standard therapy of RCC, recently retroperitoneal laparoscopic radical nephrectomy has been used in operation treatment of RCC following the continuous development and application of laparoscopic technique in Urology, and has been accepted widely by vast patients and urologic surgeons because of so many advantages such as minimal invasion, quick recovery and so on. The objective of this research was to discuss the clinical value of application of retroperitoneal laparoscopic radical nephrectomy in the treatment of renal cell carcinoma.METHODSThis research retrospectively analyzed 52 renal cell carcinoma patients received radical nephrectomy in surgical department of Urology of the First Hospital of Jilin University during April 2006 to December 2008, retroperitoneal laparoscopic radical nephrectomy group (retroperitoneal laparoscopic group) contained 18 cases and open radical nephrectomy group (open group) contained 34 cases, all the cases were sporadic unilateral RCC without tumor thrombus in renal vein and vena cava, and no lymphatic and distal metastasis, all the operation were completed through retroperitoneal approach, and 2 cases of retroperitoneal laparoscopic radical nephrectomy group which changed to open radical nephrectomy because of the limited laparoscopic procedural space result by polypionia had been excluded. These patients contained 37 males and 15 females, average age was 56.75(33⁸6), average diameter of the tumors was 4.70cm(1.5¹4.0cm), 24 tumors located in the left and 28 tumors were in the right, the cases which the tumor located in the upper pole, central region and inferior pole of the kidney were 24, 9 and 19. All the cases were diagnosed as renal cell carcinoma by ultrasonography and/or CT scan, and pathological diagnosis were all conventional clear cell renal cell carcinoma, there were 38 T1, 6 T2, 8 T3 in the staging. The two groups had no significant statistical difference in age, sexuality, side, location, staging, tumor diameter and pathological classification (P>0.05). The patients of retroperitoneal laparoscopic group received retroperitoneal laparoscopic nephrectomy: indwelled catheter after effect initiating of general anesthesia, the patient took the contralateral lying position, elevate lumbus with waist bridge, paved aseptic towel after antisepsis of operative region routinely. Made a incision 3.0cm in length at the point 2.0cm below the crossed point of posterior axillary line and costal arch, arrived at retroperitoneal space by incision of skin, subcutaneous tissues and blunt separation of each muscularis and fascia lumbodorsalis, the operator used forefinger to dissociate and expand retroperitoneal space, and pushed the peritoneum to the contralateral side, put the self-made aerocyst into retroperitoneal space, and injected 400ml air into the aerocyst, maintained 3min to expand retroperitoneal space and be favorable for compression hemostasis. Removed the aerocyst, punched at two points: one was 2.0cm below the crossed point of anterior axillary line and costal arch, the other was 2.0cm above iliac crest along midaxillary line by the 5.0mm (first operative hole) and 10.0mm (laparoscopic hole) Trocar under the guidance of operator's finger, and then closed the incision. Connected the pneumoperitoneum apparatus and TV monitor, dissociated the dorsal side of perirenal fascia along lumbar muscle group and perirenal fascia by ultrasonic scalpel and endoscopic aspirator or blunt separator, up to diaphragm and down to the lower part of perirenal fascia. Opened perirenal fascia near the renal hilus, dissociated the renal pedicle bluntly, and then opened the vagina vasorum, dissociated the renal artery and renal vein, clipped the proximal end of renal artery by titanium clamp firstly to lead to the retraction of kidney and decrease intraoperative hemorrhage. Dissociated the upper pole of kidney outside the perirenal fascia and made the decision of adrenalectomy whether or not according the particular situation. Dissociated the medial side of the kidney and the peritoneum, clipped adrenal central vein by titanium clamp at the ventral side of kidney, and cut it off by ultrasonic scalpel, and then disconnected renal vein and renal artery by Endo-GIA. Dissociated the lower pole of kidney outside the perirenal fascia. Removed operative instruments, laparoscope and Trocar after observation of surgical field to make sure no active hemorrhage exist. Prolonged the first incision to about 7.0cm, operator dissociated the lower pole of the kidney outside the perirenal fascia by fingers, took the kidney and perirenal fat tissues out from the incision, and cut off and double ligated the ureter. Indwelled surgical region drainage tube and pulled it out though the operative hole locating at the anterior axillary line, sutured all the incisions and operative holes and fastened drainage tube. Bandaged the incisions and puncture site with aseptic dressing. The patients of open group received open radical nephrectomy: indwelled catheter after effect initiating of general anesthesia, the patient took the contralateral lying position, elevate lumbus with waist bridge, paved aseptic towel after antisepsis of operative region routinely. Selected the 11th intercostal incision 20.0cm in length, and then incised skin and subcutaneous tissues by layers, incised obliquus externus abdominis, obliquus intemus abdominis and transversus abdominis by electrotome layer by layer, used electric coagulation to deal with all the bleeding point of muscles, incised fascia lumbodorsalis, incised external intercostal muscles by electrotome, dissociated internal intercostal muscles and folding of the pleura bluntly from the superior border of the 12th rib, opened the 11th intercostal space. Dissociated perirenal fascia and the space of perirenal tissues to the upper pole of kidney, renal pedicle and the lower pole of kidney outside of the perirenal fascia sharply, disconnected the perirenal fascia at the upper and lower pole of the kidney; dissociated renal artery, then double ligated and transfixed it with silk thread after clamping and disconnection; then dissociated renal vein, then double ligated and transfixed it with silk thread after clamping and disconnection as the same as the disposition of renal artery; dissociated the ureter to the distal surgical field as more as possible, and then double ligated and transfixed it with silk thread after clamping disconnection, moved the resected kidney and tumor out of the surgical region; opened inferior vena cava vasorum from the range between the 2.5cm above inferior vena cava and 2.5cm below renal pedicle, ligated venous vasorum after clamping disconnection by segments at the medial and posterolateral side of inferior vena cava vasorum, dissociated and resected the lymph nodes and connective tissues near the inferior vena cava and renal pedicle, removed loose connective tissues surrounding a region of 2.5cm with the renal pedicle centered; if ipsilateral adrenalectomy was needed, dissociated the ipsilateral adrenal gland, ligated the superior, middle and inferior adrenal arteries after disconnection, then disconnected and ligated the adrenal central vein, removed the resected adrenal gland out of the surgical region; cleaned the surgical field, achieved complete hemostasis, indwelled one surgical region drainage tube and pulled it out near the incision, sutured every muscular layers, subcutaneous tissues and skin interruptedly, fastened drainage tube. Bandaged the incisions and puncture site with aseptic dressing. Compared the intraoperative indicatrixes (length of incision, operation time, intraoperative hemorrhage) and postoperative indicatrixes (postoperative exhaust time, postoperative drainage flow, drainage removal time and the postoperative hospital stay), incident rate of operative complications, and the indicatrixes of follow-up (shot term survival rate and the rate of metastasis of incision, local relapse and distal metastasis). All the data were processed by SPSS 17.0 statistical package, t test was used to compare the measurement data of the two groups, andχ2 test was used to compare the numeration data.RESULTSThe length of incision in posterior laparoscope group were 6.94±0.62cm, was shorten than 15.62±4.66cm in open group obviously (P<0.01); operation time of posterior laparoscope group were 113.06±27.55min, compared with 113.97±27.93min in open group, there was no statistical difference between the two groups(P=0.9106 >0.05); intraoperative hemorrhage of posterior laparoscope group were 127.78±12.11ml, was less than 286.76±55.55ml in open group (P=0.0445 <0.05); the postoperative exhaust time of posterior laparoscope group were 1.67±0.59 days, was less than 2.71±0.97 days in open group obviously (P<0.01); postoperative drainage flow of posterior laparoscope group were 135.83±10.00ml, was less than 192.21±17.80ml in open group (P=0.0324 <0.05); drainage removal time of posterior laparoscope group were 2.89±0.47 days, was shorten than 4.09±2.15 days in open group (P=0.0241 <0.05); the postoperative hospital stay of posterior laparoscope group were 8.28±2.16 days, was shorten than 9.47±1.78 days in open group (P=0.0379 <0.05); the incident rate of intraoperative complications in posterior laparoscope group was 5.56% (1/18), compared with 5.88%(2/34) in open group, there was no statistical difference between the two groups (P=1 >0.05); the incident rate of postoperation complications in posterior laparoscope group was 0% (0/18),was lower than 26.47% (9/34) (P=0.0439 <0.05). The average time of follow-up visit were 14 months (3³3 months), and the lost of follow up rate was 0% (0/52), all the patients in the two groups were survive without tumor (100%, 52/52), and no one suffered local relapse(0%, 0/52), metastasis of incision (0%, 0/52) and distal metastasis(0%, 0/52).CONCLUSIONS1.Compared with open radical nephrectomy, retroperitoneal laparoscopic radical nephrectomy possesses lots of advantages, such as minimal invasion, safety, quick recovery and so on, and is valuable to extend in clinical application as the development tendency of Urological surgery; 2.There are no statistical difference between retroperitoneal laparoscopic radical nephrectomy and open radical nephrectomy in the rate of short term survive, metastasis of incision, local relapse and distal metastasis; 3.Retroperitoneal laparoscopic radical nephrectomy can be hoped to become the primary therapy of local renal cell carcinoma (T₁N₀M₀,T₂N₀M₀).