Laparoscopic surgery offers the benefits of a less invasive surgery, often with fewer side effects but the procedure is technically more difficult to perform. With the addition of robotic technology to laparoscopic surgery, certain limitations of laparoscopic surgery may be overcome and the surgical options for RCC continue to expand.
Researchers from the Urologic Institute at the Cleveland Clinic proposed that laparoscopic radical nephrectomy should become the standard of care for patients with early stage renal cancer.
Patients with stages T1 – T3 renal cell cancer have small cancers that are confined to the kidney and historically, patients with these early stage renal cell cancers underwent a radical nephrectomy through an extensive surgical procedure. The extensiveness of this procedure prohibited some elderly patients and/or patients with other medical complications from receiving optimal care.
During the procedure, small, one-centimeter incisions are made in the abdomen and side. Then, a very small tube that holds a video camera is inserted through the incisions, creating a live picture of the inside of the patient’s body. This picture is continually displayed on a television screen, so that physicians can perform the entire surgery by watching the screen. Before the kidney containing the cancer is removed from the body, the incision through which it will be removed is enlarged to allow its passage with minimal contact.
Laparoscopic Nephrectomy for Early Stage Disease
Early stage renal cell cancer is typically treated with one of two surgical options, depending on the extent of spread of disease: 1) surgery to remove the entire kidney, local lymph nodes, and any cancer in the area surrounding the kidney (radical nephrectomy); or 2) less aggressive surgery to remove only the part of the kidney affected with cancer (partial nephrectomy). Surgery is the standard treatment for RCC because the disease is typically resistant to radiation and chemotherapy. Patients who are unable to tolerate surgery, however, will not undergo either radical or partial nephrectomy.
Both radical nephrectomy and partial nephrectomy may be conducted using laparoscopy. In the case of a radical nephrectomy, the incision is enlarged to allow passage of the kidney. With a partial nephrectomy, a small bulk of tissue is removed and the incision can remain small.
Researchers initially evaluated the outcomes of 100 patients with renal cell cancer that underwent laparoscopic surgery at the Cleveland Clinic Foundation. These patients had stage T1-T3a renal cell carcinoma with an average cancer width of 5.2 centimeters. The average surgical time was 2.8 hours and the average hospital stay was 1.6 days. Major complications occurred in only 3 patients. There were no deaths during surgery. All surgical specimens had no cancer detected in their outer margins. An average of 16 months following surgery, there were no local recurrences and only one death had occurred from distant cancer spread.
Laparoscopic surgery offers the benefits of a less invasive procedure but is also technically more difficult to perform. With the addition of robotic technology to laparoscopic surgery, certain limitations of laparoscopic surgery can be overcome and the surgical options for RCC continue to expand.
Inferior Vean Cava Thrombectomy
Advanced kidney cancer may invade the body’s biggest vein, the inferior vena cava (IVC), which carries blood out of the kidneys back to the heart.
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Part of the treatment is an IVC thrombectomy (removal of cancer from the inferior vena cava). This is highly effective, and the affected kidney is removed along with the tumor.
The open surgery requires an incision that begins 2 inches below the ribcage and extends downward on both sides of the ribcage. Next, organs that surround the IVC, such as the liver, are mobilized, and the IVC is clamped above and below the cancer. In this way, surgeons gain control of the inferior vena cava for cancer resection.
To compare open to robotic surgery researchers combined data from 28 studies that enrolled 1,375 patients at different medical centers. The 439 patients that had robotic IVC thrombectomy were compared with the 936 who had open surgery.
The robotic approach in comparison with open was associated with:
- Fewer blood transfusions: 18% of robotic patients required transfusions compared to 64% of open patients.
- Fewer complications: 5% of robotic patients experienced complications such as bleeding compared to 36.7% of open thrombectomy patients.
Robotic technology offers an additional option in laparoscopic surgery for RCC. Its potential advantages include requiring less extensive surgeon experience than non–robotic laparoscopic procedures, allowing a greater number of surgeons to perform the procedure with high accuracy, which could bring laparoscopic radical and partial nephrectomy into more-widespread use.
Laparoscopic surgery is now the standard of care for patients with renal cell cancer requiring surgery at many cancer centers. This procedure is effective and well-tolerated and patients who might otherwise be excluded from undergoing a radical nephrectomy may now receive optimal treatment.
- Cancer, Vol 92, Issue 7, pp 1843-1855, 2001