Reduced port laparoscopic radical nephrectomy using an umbilical zigzag skin incision for renal cell carcinoma

Abstract

Reduced port laparoscopic radical nephrectomy (RPLRN) is an equivalent approach to conventional laparoscopic radical nephrectomy (LRN). In LRN, one wound generally needs to be extended for specimen extraction; therefore, some ingenuity is needed to achieve a good cosmetic outcome. We herein describe our initial experience of RPLRN using an umbilical zigzag skin incision for renal cell carcinoma (RCC). A 64-year-old female [body mass index (BMI): 20.0 kg/m²] was diagnosed with right RCC, which was 35 mm in diameter (clinical T1aN0M0). Case 2: a 68-year-old male (BMI: 23.2 kg/m²) was diagnosed with right RCC, which was 58 mm in diameter (clinical T1bN0M1), and perinephric fat was relatively thick. The procedure was safely completed in both cases. Total operative times, pneumoperitoneal times, and estimated blood loss in Case 1 and 2 were 90 and 145 min, 49 and 90 min, and 5 and 80 ml, respectively, and the times required to construct umbilical ports and close umbilical wounds were 8 and 9 min and 33 and 46 min, respectively. In Case 1, the specimen was easily extracted without the extension of the umbilical skin incision, whereas it was extended by an additional 2 cm in Case 2. The umbilical wound was inconspicuous in both cases. RPLRN using an umbilical zigzag skin incision for RCC was safely performed without complications, and clashing between instruments was minimized. The high level of cosmesis is advantageous and an umbilical zigzag skin incision may contribute to more widespread use of RPLRN for RCC; however, further studies on long-term oncological outcomes are needed.

Electronic supplementary material

The online version of this article (10.1007/s13691-020-00426-2) contains supplementary material, which is available to authorized users.

Introduction

Laparoscopic radical nephrectomy (LRN) was initially reported by Clayman et al. [1], and has since become the gold standard for clinical T2 renal cell carcinoma (RCC) and localized masses not treatable by partial nephrectomy [2]. To further reduce morbidity and improve cosmetic outcomes, laparoendoscopic single-site radical nephrectomy (LESS-RN) and reduced port laparoscopic radical nephrectomy (RPLRN) have been introduced [3, 4]. And LESS-RN and RPLRN have been reported as feasible and safe surgical options for localized RCC that achieve better cosmetic outcomes than conventional LRN, which is performed using more than 3 ports [5, 6].

In LRN, one wound generally needs to be extended for specimen extraction; therefore, some ingenuity is needed to achieve a good cosmetic outcome. For example, the Pfannenstiel incision was previously reported to be useful for specimen extraction because it is concealed by underwear [7, 8]; however, it is not “scarless”. Transvaginal specimen extraction has also been performed [9], but is not popular due to the associated technical difficulties and safety issues. Hachisuka et al. recently reported laparoendoscopic single-site surgery (LESS) and reduced port surgery (RPS) using an umbilical zigzag skin incision [10]. This incision enlarged the diameter of the fascial and peritoneal opening to 6 cm; therefore, clashing between instruments was minimized and specimen extraction was facilitated. Furthermore, umbilical zigzag skin incisions became almost “scarless” 3 months after surgery.

We herein describe our initial experience of RPLRN using an umbilical zigzag skin incision for RCC with descriptive figures and videos.

Case report

Case 1: a 64-year-old female (body mass index: 20.0 kg/m²) with a history of hemodialysis was diagnosed with a right renal tumor, which was detected by computed tomography in an annual health check-up. The tumor was 35 mm in diameter, located at the upper pole of the right kidney, and was heterogeneously enhanced by contrast medium (Fig. 1a, b). Under the diagnosis of right RCC (clinical T1aN0M0), the patient was referred to Saitama Medical University International Medical Center for curative treatment, and LRN was planned.

Fig. 1.

a, b Computed tomography showed right cell carcinoma that was 35 mm in diameter at the upper pole in Case 1. a Axial section. b Coronal section. c, d Computed tomography showed right cell carcinoma that was 58 mm in diameter at the lower pole in Case 2. c Axial section. d Coronal section (arrow: renal tumor)

Case 2: a 68-year-old male (body mass index: 23.2 kg/m²) presented to his local hospital with macroscopic hematuria, and a right renal tumor was detected by ultrasonography. He was referred to Saitama Medical University International Medical Center for further examinations and treatment. Computed tomography showed that the tumor was heterogeneously enhanced by contrast medium, was 58 mm in diameter, located at lower pole of the right kidney, and perinephric fat was relatively thick (Fig. 1c, d). Multiple lung metastases, mediastinum lymph node metastasis, and pulmonary hilum lymph node metastasis were also detected. He was diagnosed with right RCC (clinical T1bN0M1). In a blood examination, his neutrophil count, hemoglobin level, platelet count, and corrected calcium level were within normal ranges (4589 /μL, 14.1 g/dL, 20.9 × 10⁴/μL, and 9.4 mg/dL, respectively); therefore, he was classified as intermediate risk according to the International Metastatic Renal Cell Carcinoma Database Consortium model. Ultrasound-guided renal biopsy was performed for a histopathological diagnosis of the primary lesion before the initiation of systemic therapy; however, cancer cells were not microscopically included in the specimen. We planned laparoscopic nephrectomy for a definitive histopathological diagnosis and cytoreduction.

Surgical technique

Patients were placed in the lateral position with slight flexion under general anesthesia. After marking a zigzag skin incision in the umbilical region (Fig. 2a), the skin and subcutaneous tissue were incised along this line (Fig. 2b and Supplemental video 1). After incision of the linea alba and peritoneum, a wound retractor (The Alexis Wound Retractor, Applied Medical, Rancho Santa Margarita, CA, USA) was inserted through the incision, which enlarged the diameter of the fascial opening to 6 cm (Fig. 2c). A multichannel port (Free Access, Top Corporation, Tokyo, Japan) was attached to the wound retractor (Supplemental video 2), and two 5-mm trocars were inserted through it. Forceps and a 5-mm flexible laparoscope (Olympus Surgical, Tokyo) were used though the trocars. A 12-mm trocar was then inserted at the exterior edge of the abdominal rectus muscle caudal to the arcus costalis. All of the procedures performed were similar to those of conventional LRN, and only standard straight laparoscopic instruments were used (Supplemental video 3).

Fig. 2.

a Marking for a zigzag skin incision in the umbilical region. b Skin and subcutaneous tissue was incised along the marking for a zigzag skin incision. c The wound retractor was inserted through the umbilical incision, which enlarged the diameter of the fascial opening to 6 cm. d The umbilical wound 1 month after surgery

Peri- and postoperative results

In both cases, the procedure was safely completed without conversion to conventional LRN or open surgery. Interference between forceps and the laparoscope in the umbilical port only occurred a few times. Total operative times, pneumoperitoneal times, and estimated blood loss in Case 1 and 2 were 90 and 145 min, 49 and 90 min, and 5 and 80 ml, respectively. The times required to construct umbilical ports and close umbilical wounds were 8 and 9 min and 33 and 46 min, respectively. In Case 1, the specimen was easily extracted without extension of the umbilical skin incision, whereas it was extended by an additional 2 cm in Case 2.

In Case 1, the histopathological diagnosis of the resected specimen was clear cell RCC that was 35 mm in diameter, Fuhrman Grade 2, v0, ly0, and the surgical margin was negative. The umbilical wound 1 month after surgery is shown in Fig. 2d, and it was inconspicuous 3 months after surgery. Neither local recurrence nor metastasis was detected 5 months after RPLRN. In Case 2, the histopathological diagnosis was clear cell RCC that was 55 mm in diameter, Fuhrman Grade 2, v0, ly0, and the surgical margin was negative. Combination therapy with nivolumab and ipilimumab was administered 19 days after RPLRN, and lung and lymph node metastases both decreased in size after the initiation of combination therapy.

Discussion

We herein described our initial experience of RPLRN using an umbilical zigzag skin incision for RCC. Surgical outcomes were equivalent to those with conventional LRN, and similar procedures to those of conventional LRN were performed. Since interference between forceps and the laparoscope inserted through the umbilical port was minimized, the procedure was safely performed. Furthermore, cosmetic outcomes were excellent.

LESS was developed to improve cosmesis and reduce invasiveness. Single-site laparoscopic surgery was initially reported for retroperitoneoscopic adrenalectomy [11], and LESS is now frequently performed in the urological field [11–16]. In LESS-RN for RCC, surgical outcomes were also reported to be equivalent to those with conventional LRN [5, 6]. However, LESS is now controversial and being performed less because of the challenges associated with maintaining triangulation and clashing between instruments, which are disadvantageous for surgeons and increases risks to patients despite its minimal invasiveness. The European Association of Urology Guidelines for LESS are applicable to cases for which cosmesis is of paramount importance, and LESS is now only recommended for experienced laparoscopic surgeons [18].

RPS was introduced to overcome the disadvantages of LESS, and is now widely performed in many fields of laparoscopic surgery [19, 20]. The additional port in RPS provides a number of benefits over LESS, including the avoidance of internal and external collisions between instruments and the ability to achieve efficient traction; therefore, similar procedures to laparoscopic surgery using multiple ports may be safely performed. The safety and feasibility of RPLRN for RCC with good cosmesis have also been reported [7, 8].

LESS and RPS using an umbilical zigzag skin incision were initially reported by Hachisuka et al. [10]. An umbilical zigzag skin incision in LESS and RPS has two advantages. Collisions between instruments are minimized due to the enlarged diameter of the fascial and peritoneal opening to 6 cm, which reduces the difficulties associated with the procedure and improves safety. Furthermore, relatively large specimens may be extracted without extension of the umbilical skin incision [10, 21, 22]; therefore, a high level of cosmesis is expected. In LRN, the specimen is generally extracted from the abdominal cavity through several incisions, such as umbilical, pararectal, flank, vaginal, and Pfannenstiel incisions [3, 9, 23]. An abdominal skin incision of at least 4 cm in length is required, except for the transvaginal approach [7]; therefore, the port site incision is generally extended. Scars from pararectal, flank, and Pfannenstiel incisions are conspicuous postoperatively, which compromise the concept of a minimally invasive surgery. Similarly, if a straight 4-cm incision is made at the umbilicus for specimen extraction, the scar is not “scarless”. However, when an umbilical zigzag skin incision is mainly made at the edge and depressed area of the umbilicus, the scar is inconspicuous postoperatively. Even in cases in which extracted specimens were relatively large, such as in Case 2, the length of the additional skin incision was short and inconspicuous.

In conclusion, RPLRN using an umbilical zigzag skin incision for RCC was safely performed without difficulties. The high level of cosmesis achieved by this procedure is advantageous and the umbilical zigzag skin incision may contribute to the popularization of RPLRN for RCC; however, further studies on long-term oncological outcomes are needed.

Electronic supplementary material

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Funding

There is no funding to disclose.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflicts of interest.

Ethical approval

All procedures performed herein involving patients were in accordance with the ethical standards of the Institutional and/or National Research Committees and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from the patients.