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Definition:
Laparoscopic radical nephrectomy uses a minimally invasive
approach (laparoscopy) to perform exactly the same procedure
that is done in open radical nephrectomy. In any radical nephrectomy
(open or laparoscopic) the entire kidney including the kidney cancer
is removed. The operation involves removal of the kidney along with
the fat around the kidney. All of this tissue is contained in a
leathery layer known as Gerota's fascia. If the kidney cancer is
quite large and near the adrenal gland which is adjacent to the
kidney, the operation can include removal of the adrenal gland as
well. The operation also often includes removal of the lymph nodes
which are around the kidney.
The laparoscopic approach to partial 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.
The entire kidney with the cancer within and with
the surrounding fat and the layer known as Gerota’s fascia
are removed. Once the entire specimen has been separated from the
surrounding tissues, it is placed in a bag while still inside the
body. The bag is then removed by making an incision.
Technique:
Laparoscopic
radical nephrectomy for kidney cancer is performed by a Urologist
(kidney surgeon) in an operating room. 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
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 1/2 a centimeter
or 1cm in length (less than 1/4 to 1/2 and 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.
There are two means for removal of the kidney. Intact
extraction means that an incision is made and the entire kidney
(while still inside the sack) is removed. Usually, the incision
is just smaller than the size of the kidney and the kidney cancer
as the body’s tissues are flexible and will stretch slightly
to allow removal of the specimen. Another technique for removal
of the specimen is known as morcellation. Morcellation involves the fragmentation of the kidney including the kidney cancer within the body so that it can be removed through a smaller incision. The goal of morcellation is to maximize the minimally invasive nature of the kidney surgery by removing the kidney and kidney cancer through the smallest cut possible. A smaller cut is usually associated with less pain and a more rapid recovery. An additional benefit of the smaller cut for removal of the kidney and kidney cancer is that there is usually a better cosmetic result.
The process of “morcellation” must be done with great care using well-defined techniques as the breaking up of the kidney and the cancer is associated with risks when not performed very meticulously. These risks should be discussed with your surgeon prior to the procedure.
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.
Laparoscopic radical nephrectomy is a very effective
procedure for the treatment of kidney cancers. Typically, it is
preferable to have a procedure that spares the kidney such as a
laparoscopic partial nephrectomy or cryoablation, but tumors greater
than 7cm (approximately 2 3/4 inches) are usually best treated by
removal of the entire kidney. In the hands of an experienced laparoscopic
surgeon, a laparoscopic radical nephrectomy is a routine operation
that induces minimal trauma in the patient and results in minimal
blood loss. As such, patients that can tolerate general anesthesia
and have good overall kidney function are good candidates for laparoscopic
radical nephrectomy.
In patients with compromised renal function (such
as patients with only one kidney) Even the larger tumors are considered
candidates for kidney sparing procedures such as the laparoscopic
partial nephrectomy or cryoablation.
Advantages / Disadvantages:
Laparoscopic
radical nephrectomy has the advantages intrinsic to any procedure
in which the cancer is completely removed. After the procedure,
an experienced pathologist can carefully review the kidney itself,
the kidney cancer, and the fat and other tissues that are around
the kidney to confirm that all the cancer cells have been extracted.
Additionally, even though laparoscopic partial nephrectomy is a
relatively new procedure, there is well established information
that the procedure has kidney cancer cure rates equal to those of
open radical nephrectomy.
As laparoscopic radical nephrectomy, by definition,
uses a laparoscopic approach, patients get all the benefits of a
minimally invasive procedure. Blood loss is significantly less with
laparoscopic radical nephrectomy compared to open radical nephrectomy.
Pain is also significantly less with laparoscopic radical nephrectomy.
The decreased blood loss, pain, and trauma to the body also result
in faster overall recovery from the operation. With laparoscopic
radical nephrectomy, patients return to full activity in less than
half the time it takes to recover from open radical nephrectomy.
As laparoscopic radical nephrectomy is a relatively
new and somewhat technically challenging operation, it is not offered
at all centers. A disadvantage of the procedure is that only few
doctors offer this procedure to their patients, so the procedure
is not available to all patients.
Follow-up:
Pathology
Results – The tissue that is removed during the lapraroscopic
radical nephrectomy (entire kidney with the kidney cancer and surrounding
tissues) 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. At the follow-up visit wounds are checked and follow-up
radiographic imaging is scheduled. Typically, an MRI or CT scan
is scheduled for six months after the procedure has been performed.
Depending on the final pathology report which establishes the type
of cancer which was removed, a future follow-up regimen is then
established.
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