Left Laparoscopic Radical Nephrectomy with Direct Access to the Renal Artery: Technical Advantages

european urology 49 (2006) 1004 1010 available at www.sciencedirect.com journal homepage: www.europeanurology.com Surgery in Motion Left Laparoscopic Radical Nephrectomy with Direct Access to the Renal Artery: Technical Advantages Francesco Porpiglia *, Julien Renard, Michele Billia, Ivano Morra, Cesare Scoffone, Cecilia Cracco, Roberto Tarabuzzi, Carlo Terrone, Roberto Mario Scarpa Department of Urology, University of Turin, San Luigi Hospital, Orbassano (TO), Italy Article info Article history: Received 22 December 2005 Accepted February 14, 2006 Published online ahead of print on March 6, 2006 Keywords: Radical nephrectomy Laparoscopy Renal cancer Abstract Objectives: To evaluate the technical advantages of early ligature of the renal artery at the level of the Treitz ligament during left laparoscopic radical nephrectomy (LRN). Material and methods: Twenty-six patients underwent LRN for organconfined lesions. We grouped measured parameters (see Results) on the basis of the first 13 and last 13 patients, and compared both subgroups. All parameters were correlated to stage of disease (pt1 vs pt2-3). The Student t test was used for statistical analysis. Results: The mean (range) for measured parameters are as follows: age: 56.5 11.6 (41 77) years; American Society of Anesthesiologists score: 2.4 1 (1 3); body mass index: 23.4 3.4 (21.1 33); lesion size at computed tomography: (6.2 2.4 (4 12) cm; operative skin to skin time: 130 20 (125 170) minutes; blood loss: 255 120 (100 800) ml; hospital stay: 6.5 2.0 (4 15) days; analgesic consumption (Tramadol 100 mg): 2.5 1 (2 4) vials; follow up time: 30.5 5.6 (3 48) months. No intraoperative complications occurred. Pathologic analysis showed 12 pt1n0, five pt2n0, eight pt3an0 and one pt3b N2 with mean lesion size of 6.2 1.6 (4 13) cm. Mean number of removed lymph nodes was 9.8 1.6 (7 17). No statistical difference was observed between the two subgroups ( p > 0.05), and between pt1 and pt2 3 stage ( p > 0.05) groups. Conclusions: Early ligature using direct access to the renal artery at the Treitz ligament permits the surgeon to follow the classic steps and principles of radical nephrectomy. # 2006 Elsevier B.V. All rights reserved. * Corresponding author. Department of Urology, San Luigi Hospital, Regione Gonzole 10, 10043, Orbassano, Torino, Italy. Tel.: +39 0119026558; fax: +39 0113082428. E-mail address: porpiglia@libero.it (F. Porpiglia). 0302-2838/$ see back matter # 2006 Elsevier B.V. All rights reserved. doi:10.1016/j.eururo.2006.02.038

european urology 49 (2006) 1004 1010 1005 1. Introduction Radical nephrectomy has been the gold standard for treatment of renal cell carcinoma (RCC) since 1963 when Robson [1] first published his landmark article. The oncologic principles on which radical nephrectomy surgery are based are the en block resection of the kidney, the ipsilateral adrenal gland, the Gerota capsule and the lymph nodes. Moreover, early ligature of the renal artery was required as the first step of the procedure. After the introduction of laparoscopic radical nephrectomy (LRN) by Clayman [2] in 1991, many centres throughout the world have demonstrated the real advantages of the laparoscopic approach over the open technique for this kind of procedure [3]; the advantages include reduced analgesic requirements, improved cosmetics, shorter hospital stay, and a faster convalescence [4]. Other authors [5] have proved, after a long follow-up, that the oncologic efficacy of LRN is similar to that of open procedures. Nevertheless, despite the demonstrated safety and effectiveness of LRN, the technique has not yet been standardized completely. One particular step in LRN needs to be clarified: the management of the renal pedicle. In fact, even though several authors consider the early control of renal hilum vessels useful, regardless of whether the transperitoneal, retroperitoneal or hand-assisted approach is employed, this phase, which implies a minimum manipulation of the kidney and its tumor, is often not performed [4,5]. This aspect is more evident in the management of the left renal vascular pedicle during the transperitoneal approach. In fact, the renal artery usually is ligated after severing the gonadal vessels and the ureter, with mobilization of the lower pole of the kidney. In this study, after accurately describing the entire technique, we have evaluated the advantages of early ligature of the renal artery at the level of the Treitz ligament during left LRN. stage) and median follow-up. To evaluate the difficulty of the technique and its learning curve, we divided all parameters on the basis of the first 13 and last 13 patients, and correlated them with the stage of the disease (pt1 vs pt2 3). Statistical analysis was performed with the Student t-test. 2.1. Technique Fig. 1 Position of trocars. The patient is placed in the extended 45-degree lateral decubitus position. Four to five trocars are placed: the first one (12 mm) is placed just to the left of or inside the umbilicus, the second (12 mm), at the midclavicular line 2 cm below the costal margin, and the third (12 mm), on the anterior axillary line 3 cm above the umbilicus. The fourth trocar (5 mm) is positioned 2 3 cm laterally and below the third trocar. An optional 5-mm port can be inserted just under the xyphoid (Fig. 1). The procedure begins with the identification of the fourth portion of the duodenum and the inferior mesenteric vein (Fig. 2). In some cases, the left colic flexure can cover the duodenum. In this configuration, it is necessary to lift the colic flexure upwards, using forceps through the optional trocar. The procedure begins with the incision of the posterior 2. Materials and methods From February 2001 to November 2005, we performed 53 left LRN for organ-confined renal lesions at our institution. We introduced early ligature of the renal artery at the level of the Treitz ligament LRN starting in July 2003. Twenty-six consecutive patients, the subject of this study, were treated using this technique. The patients were all evaluated according to gender, age, American Society of Anesthesiologists (ASA) score, body mass index (BMI), duration of intervention, blood loss, intra- and post-operative complications, need of conversion to open surgery, hospital stay, size and weight of lesions, number of lymph nodes removed, pathologic examination of specimen (according to TNM Fig. 2 Identification of inferior mesenteric vein.

1006 european urology 49 (2006) 1004 1010 Fig. 3 Incision of peritoneal duodenum ligaments. Fig. 5 Incision of pre-aortic peritoneum. peritoneum, laterally to the duodenum (Fig. 3). The Treitz ligament, which suspends the duodenum to the diaphragm pillars, is evidenced and incised (Fig. 4). This method allows the duodenum to be medialized entirely. At this point, two methods can be used, depending on the characteristics of the patient. If the patient is thin, the aorta wall and the left renal vein generally are evident. However, if the patient is obese, it is necessary to dissect the sclerolipomatous and lymphatic tissue surrounding the aorta wall, starting from the lowest point of incision and going upwards (Fig. 5). The dissection must be blunt and very careful with the tip of the suction. Tedious bleeding from the lymphatic tissue vessels should, in fact, be controlled with bipolar electrocoagulation. When the tissue is removed, the gonadal artery can be identified and sectioned at its origin. Continuing the dissection upwards, the left renal vein is retracted (Figs. 6 and 7) withforcepsat the point it crosses over the aorta; then the left renal artery is identified and its overlying lymphatic tissue carefully dissected to expose its origin (Fig. 7). The renal artery is Fig. 6 Identification of left renal vein and gonadal artery after lymph node dissection. Fig. 4 Identification and section of Treitz ligament. Fig. 7 Left renal artery at its origin.

european urology 49 (2006) 1004 1010 1007 Fig. 8 Positioning of Hem-o-lock 1 clip at level of renal artery. Fig. 9 Aorta cleaned of lymph nodes. secured with a suture or Hem-o-lock 1 clips (Teleflex Medical, Research Triangle Park, NC, USA) without interruption of the vessel at this phase (Fig. 8). The inferior mesenteric vein, which describes a vascular arch, can impede adequate exposure. In this case, it can be sectioned, or the assistant can lift it upwards and laterally through the fourth trocar. This way, the surgeon feels he is working in a tunnel that is made up of the aorta inferiorly (which represents the main route that should be followed), by Gerota s capsule laterally, by the duodenum and cava vein medially and by the vascular arc of the mesenteric vein superiorly. When ligature of the renal artery is performed, the procedure continues as described in the standard technique with medialization of the descending colon and left colic flexure, spleen, and pancreas tail. The hilar, pre-aortic and latero-aortic lymph nodes were removed (Fig. 9) from all patients in the same step, in a single block along with the specimen. 3. Results The subject group was composed of 11 women and 15 men. The mean age was 56.5 11.6 (range, 41 77) years. The mean ASA score was 2.4 1 (range, 1 3); the mean BMI was 23.4 3.4 (range, 21.1 33). The mean size of lesions on the computed tomography (CT) scan was 6.2 2.4 (range, 4 12) cm. The mean operative skin-to-skin time was 130 20 (range, 125 170) minutes. The mean time required to find the renal artery was 18 4 (range, 15 32) minutes. In terms of varied anatomy, in one case we encountered two principal renal arteries that originated from the aorta side by side. In another case, we observed an accessory artery at the lower pole of the kidney. In 23 of 26 (89%) patients, the renal artery was identified directly. In three (11%) of the first 13 operated patients, it was necessary to revert to the standard laparoscopic approach because of abundant sclerotic tissue surrounding the aorta, which caused tedious bleeding. The mean blood loss was 255 120 (range, 100 800) ml. No intra-operative complications were encountered. We observed one episode (4%) of post-operative haemorrhagy that required transfusion and further Table 1 Results of the comparison between the first 13 patients and the last 13 patients Parameter First 13 patients Last 13 patients p value Intraoperative complications 0 0 ns Absence of early artery ligature 3/13 0 ns Number of lymph nodes removed 7.38 3.45 9 4.62 ns Postoperative complications 0 1/13 ns Mean hospital stay (d) 5.54 4.3 6.92 3.4 ns Mean operative skin to skin time (min) 141.4 26.5 125 15.7 ns Mean blood loss (ml) 260.3 112.2 245.5 93.6 ns Mean weight (g) 313.46 119.15 243.84 136.78 ns Mean size (cm) 6.1 5.6 6.3 4.7 ns ns = not significant.

1008 european urology 49 (2006) 1004 1010 Table 2 Results of the comparison between stage pt1 and pt2 3 patients Parameter 12 stage pt1 patients 14 stage pt2 T3 patients p value Intraoperative complications 0 0 ns Absence of early artery ligature 1 2 ns No. of lymph nodes removed 8.5 1.7 8.3 2.1 ns Post-operative complications 0 1 ns Mean hospital stay (d) 5.8 3.4 6.5 4.2 ns Mean operative skin to skin time (min) 125 34.6 127 43.8 ns Mean blood loss (ml) 255.3 103.4 260.6 113.5 ns Mean weight (g) 270.46 109.15 287.13 136.78 ns Mean size (cm) 6.3 2.4 6.8 3.6 ns ns = not significant. surgical intervention. The bleeding originated from an adrenal artery. The mean hospital stay was 6.5 2.0 (range, 4 15) days. The mean analgesic consumption (Tramadol 100 mg) was 2.5 1(range, 2 4) vials. No statistical difference was observed for any of the considered parameters between the first 13 patients and the last 13 patients ( p > 0.05; Table 1). Nevertheless, we observed in the first 13 patients, three cases in whom early ligature of the renal artery was impossible. Moreover the operative time of this subgroup was longer (260 min vs 245 min). There was no statistical difference for any of the parameters between the groups with stage pt1 and stage pt2 3 ( p > 0.05; Table 2). The pathologic analysis showed 12 pt1n0, 5 pt2n0, eight pt3an0 and one pt3b N2. The grading according to Furhman was eight G1, nine G2 and nine G3. The mean lesion size was 6.2 1.6 (range, 4 13) cm. The mean weight was 278.6 130.5 (range, 150 650) g. The mean number of lymph nodes removed was 9.8 1.6 (range, 7 17). The mean follow up time was 30.5 5.6 (range, 3 48) months. One patient died after 2 months from an acute cardiac disorder, not from renal disease. One patient, who was already M1 before the procedure, presented progression of the disease. The other 23 patients did not present any local recurrence or metastasis. 4. Discussion Radical nephrectomy is considered to be the gold standard for the treatment of RCC and laparoscopy, with the transperitoneal or retroperitoneal approach now being accepted widely as the therapy for RCC confined to the kidney [6 18]. Conventionally, this technique is based on the oncologic principles declared by Robson in 1963, and early ligature of the renal artery represents one fundamental step. Even though this procedure is now controversial [19], this principle is routinely applied. The transperitoneal approach implies that the renal artery usually is ligated after severing the gonadal vessels and the ureter, with mobilization of the lower pole of the kidney. Moreover, it is possible to ligate the renal artery after having exposed the renal pedicle (on the right side, after medialization of duodenum; on the left side, after medialization of the left colic flexure, spleen and pancreas tail). Retroperitoneoscopy seems to permit a faster access to the renal artery than the transperitoneal approach [5]. The transperitoneal access, especially with ligature of the artery after severing of the ureter and gonadal vessels, implies minimum manipulation of the kidney, which, however, does not seem to reduce the oncologic efficacy with respect to open surgery [4,20]. Although these techniques are widely used and have been the subject of many variations, there is still a wide margin for further development with the aim of standardizing it definitively, without losing the principles declared by Robson [1], even though some of these aspects are still controversial (eg, the role of lymphadenectomy when no lymph nodes are shown on a CT scan). When we perform a laparoscopic procedure, our purpose is to try to replicate the principles of open surgery, especially when an oncologic treatment is considered. For this reason, especially when performing left LRN, the early ligature of the renal artery at the level of the Treitz ligament with en block lymphadenectomy is a step of the procedure that replicates what is performed in open surgery. That is why we have chosen this option since July 2003. Even though the advantages that can derive from this technique are subject to discussion, we have here highlighted some important factors such as its feasibility, its safety and some technical advantages. The feasibility of the technique had been shown already in a previous paper [5]. In terms of safety, we can confirm that in the 26 cases reported in

european urology 49 (2006) 1004 1010 1009 this study, no intra-operative complications were recorded, the blood loss and the transfusion rate were minimal (one underwent transfusion) and the post-operative complications were similar to those encountered during procedures with the standard approach to the renal vascular pedicle, as reported by various authors [4,5,21]. What are the real advantages? The advantages attributable to early ligature with direct access at the level of the Treitz ligament of the renal artery are represented by a lower risk of bleeding during later portions of the dissection, especially when peri-tumoral vessels are present, and the potential of minimizing cancer cell release because of the absolute absence of manipulation of the kidney before renal artery ligature. Moreover, the medial approach to the renal artery allows the surgeon to preventively ligate the artery in the presence of anatomic variations. In our experience, we encountered one case of a double renal artery that had the same origin; thanks to this technique, we were able to see both arteries at their origin, which would have been less probable if the traditional approach had been used. This technique also allows early ligature of the artery for large renal masses (in our experience up to 7 cm) [22] and also for stage pt3 tumors, which often can interfere or create problems for the correct dissection of the renal hilum. These two characteristics of the lesions, in our experience, did not interfere with the safety of the procedure; in fact, there was no difference between the pt1 and pt2 3 stages of tumors. This type of ligature also consents the en block resection of all the lymph nodes. In fact, to reach the origin of the renal artery, it is essential to clean the aorta wall and renal hilum of all lymphatic tissue. These lymph nodes are then removed together with the Gerota capsule. As far as lymph nodes are concerned, to our knowledge, the type and dimension of performed lymphadenectomy have not yet been clarified in literature. Many authors [23] report only hilar lymph nodes, while others [3] performed lymph node dissection during the nephrectomy. Still others have not explained whether the lymph node dissection is performed during a later step. Moreover, it also is common to find in literature that many authors do not specify the number of lymph nodes removed when lymphadenectomy was performed during LRN, a number that is necessary for a correct stadiation, according to TNM. This access enables the hilar, pre-aortic and latero-aortic lymph nodes to be removed en block along with the specimen, permitting the minimum lymph nodes necessary foranaccuratestadiationtoberemoved.inour experience, the mean number of lymph nodes removed was 9.8 1.6 (only one patient had fewer than eight lymph nodes removed). While these are the advantages, the critical points of this technique can be the intrinsic difficulty of performing this approach, which requires a skilled laparoscopist. In fact, after incision of the Treitz ligament and dissection of the lymphatic tissue that surrounds the aorta, the surgeon has the feeling of working in a tunnel, in which errors, and as a consequence, bleeding are not permitted if one wants to reach his goal. In our experience, we had to revert to the standard technique in three of the first 13 operated patients. This means, that even though the laparoscopist was skilled, specific experience in this approach must be taken into account. Moreover, the potential risk of this technique is the ligature of the superior mesenteric artery, a mistake that would be fatal for the patient. In order to prevent this event, it is fundamental to identify the wall of the aorta, the gonadal artery and the renal vein that must be lifted upwards by forceps to dissect the renal artery carefully at its origin from the lateral wall of the aorta. It is evident that, to dissect only the renal artery, it is fundamental to work under the renal vein, which is used as a landmark, the superior mesenteric artery always being located above the renal vein. 5. Conclusion Early ligature using direct access to the renal artery at the level of the Treitz ligament is a technique that must be performed after acquiring adequate experience in laparoscopy. This technique permits the surgeon to follow the classic steps and principles of radical nephrectomy, which have driven open surgery techniques for several years. It also ensures ligature of the renal artery for anatomic variations, in the presence of large renal masses, and ensures an adequate lymphadenectomy, which is mandatory for a correct stadiation. A major number of cases and a longer follow-up of patients treated with this technique will surely contribute in demonstrating its utility. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/ j.eururo.2006.02.038 and via www.europeanurology.com. Subscribers to the printed journal will find the supplementary data attached (DVD).

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