Abstract
At specialized centers worldwide, laparoscopic radical nephrectomy is now routine practice for management of indicated patients with localized renal cell carcinoma. Although the various intraoperative technical steps and maneuvers have been standardized for both the retroperitoneal and the transperitoneal laparoscopic approaches, controversy persists regarding the method of extraction of the nephrectomized cancerous specimen. Opinion is divided between intact extraction and morcellation. Clearly, the larger skin incision used for intact extraction is a cosmetic compromise. However, available data suggest that patient morbidity is not adversely impacted to any significant degree. Intact specimen extraction does build confidence into this procedure by respecting scientifically established oncologic guidelines, and it provides a specimen identical to that obtained in open surgery. This facilitates accurate pathologic staging, including assessment of surgical margins, which allows formulation of individualized, patient-specific follow-up protocols. For these reasons, intact extraction for renal cell cancer is preferred at our institution and multiple others worldwide.
Key words: Renal cell carcinoma; Laparoscopy; Nephrectomy; Morcellation; Radical nephrectomy, laparoscopic
During radical nephrectomy for renal cell carcinoma, the classic procedure is to remove the intact kidney covered by Gerota’s fascia, with or without the ipsilateral adrenal gland.1 Concomitant dissection of renal hilar lymph nodes is controversial and not performed routinely at most centers. In recent years, laparoscopic nephrectomy has gained in popularity for both benign and malignant disease. Laparoscopic radical nephrectomy (LRN) for cancer can be performed equally effectively and efficaciously by either the transperitoneal or the retroperitoneal approach. Although the individual technical steps of LRN have been standardized, debate persists regarding whether the specimen should be extracted intact or by morcellation.
Why Intact Specimen Extraction?
For any minimally invasive technique to achieve widespread acceptance, we believe that it must at a minimum equal, and preferably improve on, open surgical outcomes without compromising the technical and oncological principles underpinning the open procedure. The primary purpose of LRN is to excise the tumor-bearing kidney in a minimally invasive manner while affording the patient the best chance for long-term cancer cure. Cosmetic outcomes, although important, are clearly somewhat secondary. Intact extraction of the cancerous renal specimen following a LRN satisfies the stringent requirements proposed by the American Joint Committee on Cancer (AJCC) and the Union Internationale Contre le Cancer (UICC).1 Morcellation does not.
Surgical Margin Status
Pathological confirmation of a negative surgical margin is important for documentation of the technical adequacy of LRN. Inking of the specimen surface followed by histological examination of its surgical margins is not possible after tissue morcellation. In a study by Landman and colleagues,2 pathological evaluation of radical nephrectomy specimens was performed before and after morcellation to determine whether the morcellation process compromised the histological diagnosis. Morcellation was performed ex vivo within a mock synthetic abdominal wall that may not have represented the technical difficulties during an actual clinical case. The morcellation technique was modified to allow specimen extraction through a 2-cm incision, the reason being “to preserve as much pathological information as possible since tissue obtained after morcellation and removal through a standard 12 mm port site is too fragmented to enable accurate staging.” The study included only 11 renal cell carcinomas (mean tumor size 4.2 cm, range 2–7 cm), of which seven were formalin fixed and only four were fresh. Pathological tumor size could not be assessed in any case due to morcellation. Following morcellation, perirenal fat invasion was documented in four specimens and renal vein involvement in one. Importantly, however, of the four fresh renal cell carcinoma specimens, in one case (25%) fat invasion and renal vein involvement was felt to be artifactual due to morcellation. In another case, the laparoscopic sac was grossly perforated during morcellation, risking tumor spillage and port site recurrence. No information could be provided on the status of the surgical margins of the specimen.2
Precise Pathological Staging
The UICC and the AJCC recommend that the radical nephrectomy specimen allow precise pathological staging, thus providing detailed information about capsular penetration, vascular and lymphatic invasion, and involvement of perirenal tissue.1 Obviously, precise pathological staging of kidney cancer is compromised during morcellation, and the time-consuming examination of fragmented tissue usually requires an experienced pathologist. In an effort to improve pathological examination after specimen morcellation, limited enlargement of the primary port site incision has been described in some series to retrieve larger fragments for better pathological examination.
It has been argued that the precision of current computed tomographic (CT) scanning technology provides clinical staging information that is as reliable as histopathological evaluation. Preoperative radiological staging of renal cell carcinoma by CT scanning has an excellent overall accuracy, ranging from 82% to 91%.3 However, especially for larger tumors, CT scan may not be completely reliable for the individual patient. We compared clinical staging by CT scanning with histopathological staging of the intact extracted surgical specimen in 125 cases of renal tumors at the Cleveland Clinic.4 Notably, the CT scan understaged 9% of the renal tumors by failing to detect tumor invasion into the perirenal fat (4), renal vein (3), and adrenal gland (2). Had morcellation been performed in these cases, this important prognostic information would have been lost, thus compromising follow-up management of these patients.
Individualized Follow-up Protocol per Patient
Currently available systemic therapy for treatment of metastatic renal cell carcinoma is of limited efficacy; aggressive surgical treatment of local recurrence or localized metastatic lesions provides somewhat superior results. Therefore, early detection of recurrent or metastatic disease is important, because a delay in diagnosis may compromise long-term outcomes. Individualized follow-up protocols based on accurate pathological staging of the primary lesion, as provided by intact extraction, maximize chances of timely treatment of recurrent cancer.5
Builds Confidence into the Procedure
Currently, long-term follow-up of LRN is lacking. In the absence of such long-term follow-up, the negative surgical margins achieved routinely in intact specimens in our series provide encouraging surrogate evidence attesting to the technical efficacy of laparoscopy from an oncological standpoint.4 Further, examination of the whole specimen allows precise comparison to various open surgical series. We believe that reliable histopathological evaluation of the excised specimen, as obtained by intact extraction, has been one of the key factors in building confidence in the oncologic adequacy of LRN.
Complications Associated with Morcellation
Serious complications that have actually occurred in clinical practice due to morcellation include local tumor spillage, trocar site recurrence, and major morcellation injury to a loop of bowel or colon. Barrett and Fentie6 reported a port site recurrence 25 months following radical nephrectomy and specimen morcellation. Spillage may occur through tiny or gross defects made in the fabric of the entrapment sac by the morcellator blades following prolonged morcellation of a large specimen. Additionally, serious bowel injury has occurred following unsuspected rupture of the entrapment sac, leading to morcellation of an adjacent bowel loop.
Cost-Effectiveness
There is a cost factor to specimen morcellation. In addition to the $1975 cost of the morcellator and $133 for the morcellator blade, morcellation may prolong operative time by 30 to 45 minutes.
Why Specimen Morcellation?
There can be only two rationales for specimen morcellation: 1) to extract the specimen without adding to the port site incisions, thus minimizing patient morbidity and hospital stay; and 2) to achieve a superior cosmetic result. Let us examine these two aspects in more detail.
Minimize Patient Morbidity and Hospital Stay
Intuitively, it seems logical that “the smaller the incision, the less the morbidity.” Although a larger incision is necessary for intact specimen extraction, this incision can be located and created in such a manner as to minimize morbidity. In our single-institution report of 100 consecutive LRNs, key patient morbidity parameters were evaluated to determine whether the length of the skin incision employed for intact specimen extraction had a significant impact on them (Table 1). Upon comparing 50 patients with skin incisions 6 cm or less in length with 50 patients who had skin incisions more than 6 cm long, no significant difference in narcotic analgesia requirements, hospital stay, complication rates, or potential readmission was noted.4 A literature review of patient morbidity following intact extraction versus morcellation from multiple institutions worldwide corroborates our single-institution data (Table 2).4,6–9
Table 1.
Impact of the Size of the Extraction Incision on Patient Morbidity
| Incision ≤ 6 cm (n = 50) | Incision > 6 cm (n = 50) | ||||
|---|---|---|---|---|---|
| Variable | Mean | SD | Mean | SD | P Value |
| Incision length (cm) | 4.7 | 1.1 | 8.2 | 1.3 | N/A |
| CT size of renal mass (cm) | 4.4 | 1.5 | 6.1 | 3.0 | .003 |
| Specimen weight (g) | 363.5 | 194.5 | 806.8 | 299.4 | <.001 |
| MSO4 equivalent (mg) | 14.9 | 10.4 | 15.9 | 10.9 | .80 |
| Hospital stay (hr) | 35.0 | 22.5 | 35.1 | 19.6 | .04 |
| Complications (%) | 15.6 | 11.4 | .79 | ||
| Readmissions (%) | 4.0 | 4.0 | 1.00 | ||
Adapted from Gill et al 2001.4 Cancer Vol. 92, No. 7, 2001, pp. 1843–1855. © 2001 American Cancer Society. Reprinted by permission of Wiley-Liss, Inc., a subsidiary of John Wiley & Sons, Inc.
CT, computed tomography; N/A, not applicable; SD, standard deviation; MSO4, morphine sulfate.
Table 2.
Morcellation vs Intact Specimen Extraction: A Literature Review
| Total | |||||||
|---|---|---|---|---|---|---|---|
| Barrett et al | Ono et al | Dunn et al | Abbou et al9 | Gill et al | Morcellation | Intact Extraction | |
| 19986 | 19997 | 19998 | 20014 | ||||
| Method of organ | Morcellation | Morcellation | Morcellation | Intact extraction | Intact extraction | Morcellation | Intact extraction |
| retrieval | |||||||
| No. of patients | 72 | 34 | 61 | 29 | 100 | 167 | 129 |
| Laparoscopic approach | Transperitoneal | Transperitoneal | Transperitoneal | Retroperitoneal | Retroperitoneal | Transperitoneal | Retroperitoneal |
| Surgical time (hr) | 2.9 | 5.1 | 5.5 | 2.4 | 2.8 | 4.5 | 2.6 |
| Complication rate (%) | 10 | 9 | 5 major, | 8 | 3 major, | 24 | 11 |
| 48 minor | 11 minor | ||||||
| Specimen weight (g) | 402.5 | 281 | N/A | N/A | 554.3 | 342 | 554.3 |
| Analgesia (mg MSO4 | N/A | 29 | 27 | 8.6 | 22 | 28 | 15.3 |
| equivalent) | |||||||
| Hospital stay (d) | 4.4 | N/A | 3.6 | 4.8 | 1.6 | 4 | 3.2 |
| Convalescence (wk) | N/A | 3.2 | 8.4 | N/A | 4.2 | 5.8 | 4.2 |
| Port site recurrence | 1 | 0 | 0 | 0 | 0 | 1 | 0 |
| Local recurrence | 0 | 0 | 1 | 1 | 0 | 1 | 1 |
Adapted from Gill et al 2001.4 Cancer Vol. 92, No. 7, 2001, pp. 1843–1855. © 2001 American Cancer Society. Reprinted by permission of Wiley-Liss, Inc., a subsidiary of John Wiley & Sons, Inc.
N/A, not applicable; MSO4, morphine sulfate.
Superior Cosmetic Result
Clearly, morcellation provides a superior cosmetic result. However, our current routine practice for specimen extraction in male patients is a low muscle-splitting Pfannensteil incision, at or below the pubic hair line. In suitable female patients, intact specimen extraction per vaginum has proved most efficacious.10 In any event, we believe that cosmetic considerations should not outweigh established oncological principles that allow accurate pathological examination for staging and follow-up protocols.
Conclusion
Intact specimen extraction after LRN follows the classic oncological guidelines established in open surgery and provides critical pathologic information. These important advantages accrue without significant collateral disadvantages in regard to patient morbidity (Table 3).
Table 3.
Laparoscopic Radical Nephrectomy: Morcellation vs Intact Extraction, Advantages and Disadvantages
| Morcellation | Intact Extraction | |
|---|---|---|
| Operative time | Inferior | Superior |
| Analgesia | Comparable | Comparable |
| Hospital stay | Comparable | Comparable |
| Morbidity | Comparable | Comparable |
| Cosmesis | Superior | Inferior |
| Cost-effectiveness | Inferior | Superior |
| Pathological staging | Inferior | Superior |
| Surgical margins | Inferior | Superior |
| Follow-up prognostication | Inferior | Superior |
| Port site recurrence | Inferior | Superior |
Main Points.
Intact extraction of the cancerous kidney satisfies proposed American Joint Committee on Cancer and Union Internationale Contre le Cancer requirements; morcellation does not.
Inking of the specimen surface followed by histological confirmation of negative surgical margins is not possible after tissue morcellation.
Precise pathological staging of kidney cancer may be compromised during morcellation.
The muscle-splitting larger extraction incision, cosmetically located, does not appear to increase patient morbidity significantly.
Serious complications have occurred, albeit rarely, in clinical practice due to morcellation.
References
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