Laparoscopic Cytoreductive Nephrectomy

Definition:
Laparoscopic cytoreductive radical nephrectomy is the exact same operation as a laparoscopic radical nephrectomy. However, the laparoscopic cytoreductive nephrectomy is done in the setting of kidney cancer that has extended outside of the kidney and its surrounding tissues. The extent of the cancer may be limited to tissues in the area around the kidney known as the lymph nodes, or the kidney cancer may have more extensively spread to other organs such as the lung or liver.

Considering a laparoscopic cytoreductive radical nephrectomy implied that, prior to the surgery, your doctor already knows that the cancer has spread outside the kidney to another organ and therefore removal of the kidney alone is not going to result in cure. After the laparoscopic cytoreductive radical nephrectomy, other systemic treatment strategies will be needed to increase the chance of cure and to extend life as much as possible.

Laparoscopic cytoreductive nephrectomy is the same operation as an open cytoreductive nephrectomy. Any cytoreductive nephrectomy is very challenging and the laparoscopic approach should be utilized only in selected cases in which the risk of the kidney cancer having grown into surrounding organs is limited. Only very experienced surgeons dedicated to advanced laparoscopy should be performing this procedure, and it should often be scheduled in conjunction with a surgeon who specializes in open cytoreductive nephrectomy.

In the past, open and laparoscopic cytoreductive nephrectomy were not performed unless the patient required the procedure to treat symptoms such as pain or bleeding. However, it has been proven in two separate large clinical trials that a cytoreductive nephrectomy affords healthy patients with advanced kidney cancers a slight improvement in survival, and will extend life for a period of time that is usually in the range of three months to a year.

The laparoscopic cytoreductive radical nephrectomy uses a minimally invasive approach (laparoscopy) to perform exactly the same procedure that is done in open cytoreductive radical nephrectomy. In any radical nephrectomy (open or laparoscopic) the entire kidney including the kidney cancer is removed. With the cytoreductive radical nephrectomy, it is possible that other involved organs will have to be removed as well.

The laparoscopic approach to cytoreductive radical nephrectomy means that no large incisions are required to perform the procedure. Instead of a large incision, three or four 1/2 cm to 1 cm incisions (less than 1/2 inch) are made. The spaces in the body are gently filled with gas to make working space and a small camera is placed into the body through one of the incisions. The other small incisions are used to place working instruments which can be used to perform the procedure.

Technique:
Laparoscopic cytoreductive radical nephrectomy for kidney cancer is performed by a Urologist (kidney surgeon) in an operating room. Only laparoscopic surgeons with tremendous experience with advanced laparoscopy and the laparoscopic treatment of kidney cancer should perform laparoscopic cytoreductive radical nephrectomy as the procedure is very challenging. Prior to scheduling the procedure, each patient should have an extensive consultation with their Urologist regarding the nature of their kidney disease as well as all of the available treatment options. This discussion should review all the advantages and limitations of each surgical and non-surgical approach.

Once you and your Urologist have decided on laparoscopic cytoreductive radical nephrectomy, a date for surgery is chosen. Typically, a patient goes to the hospital on the day of surgery. General anesthesia (you are completely asleep) is required. The Procedure is then done through three or four small incisions which are either ½ a centimeter or 1 cm in length (less than ¼ to ½ an inch). The kidney is then identified but never actually seen, as it is surrounded by both fat and the leathery layer known as Gerota’s fascia. The surgeon identifies and controls the renal artery (blood supply to the kidney). Once the artery is controlled, attention is turned to the vein, which is also controlled. The entire specimen is then separated from all of its attachments to the body and put into a sack while still inside of the body.

Often tissues around the kidney known as lymph nodes are involved in this type of advanced kidney cancer. In laparoscopic cytoreductive nephrectomy, the surgeon will often take the lymph nodes around the area as a specimen in an effort to remove as much of the kidney cancer that is in the body as possible. Any other organs that are involved such as the liver, pancreas and spleen are also removed. While, in the hands of very experienced experts, the removal of other organs is possible, advanced kidney cancer involving other organs will often require the conversion from the laparoscopic approach to an open approach to maximize the patient’s safety and minimize the risk of complications.

Candidates:
There are a number of important patient and tumor parameters that are critical in deciding the type of treatment that is best for kidney cancer. Considerations are numerous but include: the size and general radiographic appearance of the mass, the local anatomy of the mass, the overall age and health condition of the patient, overall kidney function, the number of lesions in the kidney, patient personal preference, etc. The decision on a proper strategy for the treatment of kidney cancer is challenging and should be made by each patient in conjunction with a Urologist who is experienced in managing kidney cancer.

Candidates for laparoscpopic cytoreductive radical nephrectomy include relatively healthy patients with kidney cancer that has extended beyond the kidney and its immediate surrounding tissues (metastatic kidney cancer). The operation tends to benefit patients who can perform basic activities of daily living by themselves and who do not have symptoms from their kidney cancer. Before undergoing this type of surgery, patients should discuss their situation with a Urologist who specializes in advanced kidney cancer and who has extensive experience with this laparoscopic radical cytoreductive nephrectomy.

Advantages / Disadvantages:
Laparoscopic cytoreductive radical nephrectomy has the advantages intrinsic to any laparoscopic or minimally invasive procedure in that patients recover more quickly and with less pain. However, in the setting of advanced kidney cancer, the minimally invasive advantages of recovery are more important than ever as a rapid recovery may allow patients the strength to receive the additional systemic treatments that are required more quickly. While there is no proven benefit to getting treatment more quickly, it is possible that expediting the systemic treatment could improve the overall outcome.

Typically, with laparoscopic cytoreductive radical nephrectomy patients get all the benefits of a minimally invasive procedure. Blood loss is less with laparoscopic cytoreductive radical nephrectomy compared to open cytoreductive radical nephrectomy. Pain is also significantly less with laparoscopic cytoreductive radical nephrectomy. The decreased blood loss, pain, and trauma to the body also result in faster overall recovery from the operation which, as previously stated, could be very important to outcome by allowing systemic treatment to be initiated more rapidly.

The major disadvantages of laparoscopic cytoreductive radical nephrectomy are that the procedure can only be safely performed by surgeons with special training and extensive experience with advanced kidney cancer laparoscopic procedures. Additionally, while pre-operative imaging will currently provide surgeons with a good understanding of the disease, it is impossible to determine the exact extent of the kidney cancer until the time of surgery. As such, there is a significant chance that a laparoscopic radical cytoreductive nephrectomy will require “open conversion” (change of approach to open cytoreductive radical nephrectomy) to optimize the control of the cancer and minimize the risk of complications.

Follow-up:
Pathology Results – The tissue that is removed during the lapraroscopic cytoreductive radical nephrectomy (entire kidney with the kidney cancer and surrounding tissues) is sent to a pathologist who must “fix” (preserve) the specimen, prepare slides, and evaluate the tissue under the microsope. The “final pathology” reveals the type of kidney cancer that has been treated, and also stages the kidney cancer (determines how extensive the local spread of the disease has been).

Activity after surgery - While patients will typically be able to do routine activities such as eating and taking care of every day needs, it is generally suggested that no heavy lifting or vigorous activity be performed for four to six weeks to allow the body to recover. While it is surgeon dependent, most surgeons will suggest only light lifting (less than 10lbs), gentle activity, and no driving for one to two weeks after surgery. It is typical for patients to feel drained or lack energy for several weeks after surgery, and complete and full return to activity will usually take four to six weeks. However, every patient is different and recovery is somewhat variable. Generally, the patient will feel better day by day.

Wound care and bandages - With laparoscopy, wound care is generally very easy. The dressings (bandages) are usually removed by the patient at home the second day after surgery. Under the bandages there are small pieces of surgical tape. Once these start to peel off on their own, the patient may remove them. Removing the tape in the shower may be helpful and the adhesive will soften and allow the tape to be removed gently and without pain. Under the tape are the small wounds. The stitches are below the skin and do not have to be removed as they absorb by themselves.

Bathing - Swimming and bathing in a tub should not be done for one week after surgery, but showering is usually permitted any time after the second day after surgery. The shower should be with regular soap and water. An effort should be made not to allow the shower to directly hit the wounds for the first several days. The wounds should be cleaned with a dry and clean towel and left uncovered. A small amount of oozing is possible for the first few days after surgery, and a clean gauze with surgical tape can be used to keep clothing dry. However, if there is any significant leakage from the wound or if the would should become red, hot, tender, or swollen, you should contact your doctor immediately.

Follow-up visit – Your doctor will typically call with the final pathology report results one week after the surgery has been performed. A follow-up visit with the surgeon is usually scheduled approximately four weeks after the procedure has been done. With cytoreductive radical nephrectomy of any type, the combined efforts of urologic surgeons and medical oncologists who provide systemic treatments must be carefully coordinated to provide each patient the best timing for treatment.

Copyright 2006 Kidney Cancer Institute            

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