Laparoscopic Nephrectomy versus Open Radical Nephrectomy in uremic patients with end-stage renal disease
Uremic patients with end-stage renal disease (ESRD), who have undergone continuous peritoneal dialysis (PD) and hemodialysis (HD) treatment, require a minimally invasive approach when undergoing a surgical approach. This is due to the fact that they are at high risk for intraoperative and postoperative complications due to comorbidities such as immunosuppression, platelet dysfunction, anemia, and electrolyte abnormalities. In this study we analysed the feasibility and safety of laparoscopic radical nephrectomy (LRN) versus (vs) open radical nephrectomy (ORN), in terms of perioperative and postoperative outcomes, in uremic patients with ESRD.
Materials and Methods
Between September 2007 and December 2013, 19 patients with ESRD, who underwent LRN or ORN for chronic pyelonephritis, renal calculi leading to recurrent urinary tract infection or hydronephrosis, renal tumors, complicated cyst or polycystic kidney associated, were retrospectively analysed. All operations were performed by three experienced surgeons of our Department. All patients (14 men and 5 women) with complete preoperative clinical and intraperioperative parameters including age at surgery, gender, Body Mass Index (BMI), ASAscore, surgical approach, operation time, intraoperative complications, immediate postoperative complications, tumor-size, tumor grade and pTNM stage were available for further analyses. The 30-day complication rate in both groups was retrospectively review and graded according to the modified Clavien System in five grades. Postoperatively, patients with renal tumors were followed every 3-4 months in the first year, every 6 months in the second year, and annually thereafter. All statistical analyses were conducted on Microsoft Excel 2010 platform. Statistical analysis of the mean values of continuous variables was performed using the Student’s t-test and analysis of the significance of the categorical variables was performed using the chi-square and Fisher tests. A p < 0.05 was considered to indicate statistical significance.
Overall, 9 (47.3%) vs 10 (52.7%) patients underwent LRN vs ORN, respectively. The mean age found was 67.34 ± 14.54 years in LPN group (G1), and 68.18 ±13.41 years in ORN group (G2) (p=0.247). The mean BMI [22.3±4.3Kg/m2 (13.5-31.1) vs 27.1±5.3Kg/m2 (13.1-42.3), p=0.001] of patients in G1 were lower relative to G2. The mean ASA score [2.7±0.8(G1) vs 2.9±0.7(G2)] did not show significant statistically differences in both groups respectively (p=0.632). The patients of G1 underwent nephrectomy: 4(44.5%) for renal cell carcinoma (RCC), 3(33.3%) for complicated cyst and 2(22.2%) for calculi infected and hydronephrosis, while the patients of G2: 5 patients (50%) for RCC, 2(20%) for chronic pyelonephritis, 1(10%) for infected hydronephrosis and 2(20%) for polycystic kidney. There was no significant difference between the two groups in terms of mean tumor size and tumor stages (p=0.364). The estimated blood loss was 223±155mL in G1 and 455±134mL in G2 (p<0.005). Both groups were comparable with regard to mean operation time [145±54 min (89-203) in G1 vs 135±67 min (87-215) in G2; p=0.753]. The mean hospital stay was 5.95 ± 1.85 days in G1, and 8.10 ± 1.67 days in G2 (p<0.001). After an early post-operative period pain necessitating analgesics was observed in all patients (100%) of G2 and only in 3 patients of G1 (Grade 1 complications). Blood transfusions were required in 4 patients (44.4%) in G1, and in 8 (80%) patients in G2. (Grade 2 complications) (p =0.01). Grade 3 complications was not observed in both groups. Grade 4 complications occurred in 3 (30%) patients (1 pulmonary embolism, 2 atrial fibrillation) in G2, and in 1 (11.1%) patient (atrial fibrillation) in G1. One patient of G2 died within 30 days of surgery (Grade 5 complications).
Since its introduction by Clayman et al. in 1991, LRN has been an accepted treatment modality for several kinds of renal disease. Laparoscopic surgery is a minimally invasive treatment, it results in reduced blood loss, a shorter postoperative hospital stay, minimal wound pain, reduced need for analgesics, an earlier return to normal activity, quick oral intake, and improved cosmesis. However, there are few studies focusing on the out-comes of LRN for dialysis-dependent ESRD patients and the number of patients in these reports is small. Many conditions concerning mainly the anaesthesia procedures do affect the laparoscopic success of uremic patients. It is important to emphasize the uremic patients is associated with metabolic acidosis that can be aggravated with CO2 insufflation during LRN. Hypercapnia consequently may deteriorate the underlying chronic metabolic acidosis of the uremic patients leading to cardiovascular collapse and dysrhythmias as in two patients in G1. However the present study revealed that LRN is not associated with increased operative and postoperative morbidity in terms of metabolic acidosis in the hands of an experienced anesthesiology team (p=0.347).
For uremic patients, the indications for using a retroperitoneal approach vs transperitoneal approach for LRN is still much discussed. Okegawa et al. showed no statistically significant difference between a retroperitoneal or transperitoneal approach for LRN in ESRD patients. We have always performed LRN by using a transperitoneal approach, which allows a large working space and possibility removing a large tumor or fragile tissue (eg. cysts). According our opinion a retroperitoneal approach caused cyst rupture and tumor cell dissemination.
Laparoscopic surgical techniques were developed to reduce the morbidity of the surgical management. Little is know about renal laparoscopy in uremic patients, and to date, there are only a small number of cases series reported in the literature regarding management of surgery in ESRD patients . The present study revealed that laparoscopic surgery in uremic patients might be performed safely under experienced of laparoscopy team. This surgical technique is a minimally invasive treatment, it reduces blood loss, shortens the postoperative hospital stay, minimizes wound pain, and results in an earlier return to normal activity. However, long-term follow-up and multicentre studies suggest that LRN in uremic patients does not compromise life expectancy and oncologic efficacy in treatment of tumors as in our study.
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