Hand-assisted laparoscopic nephrectomy for stage T1 and large stage T2 renal tumors

Standard laparoscopic nephrectomy (LN) has been shown to be as effective oncologically as open surgery for both stage T1 and stage T2 renal tumors. While much has been published regarding the increasing indications for laparoscopic nephrectomy, there is little in the literature regarding the advantages of hand-assisted laparoscopy (HAL) for the treatment of large (>7-cm) stage T2 renal tumors. To our knowledge, this study is the first to directly compare the results in pathologic stage T1 and stage T2 tumors. Our aim was to assess whether HAL nephrectomy for these larger tumors maintains the same advantages enjoyed by HAL for the smaller ones (<7 cm).

One hundred HAL renal extirpative procedures were performed over a 3-year period. Of these, 60 were radical nephrectomies for malignant disease, of which 50 tumors were stage T1 and 10 stage T2. Standard HAL nephrectomy was performed through a vertical midline or paramedian incision, and the specimen was sent for histologic examination and tumor staging. We retrospectively analyzed our charts to determine if HAL nephrectomy for T2 tumors was as advantageous as for T1 tumors. We collected data on patient age, ASA score, average tumor size, estimated blood loss, operative time, conversion rate, rate of complications, and length of hospital stay. Follow-up ranged from 4 to 26 months with a mean of 11 months.

The mean size was 4.68 and 9.22 cm for stage T1 and T2 tumors, respectively. Intraoperatively, stage T2 tumors were associated with less blood loss than were T1 tumors (105 mL v 190 mL). Operative times were equivalent, at 190 and 185 minutes for stage T1 and T2, respectively. No open conversions were required in the T2 group v four (8.7%) in the T1 group. Three of these open conversions were seen in the first 25 HAL cases. No complications or conversions were seen in the stage T2 patients. Of note, the majority of the operations for stage T2 disease were performed after the learning curve had been surpassed.

The HAL nephrectomy maintains the benefits associated with standard LN. Stage T1 and T2 tumors are equally amenable to HAL nephrectomy, enjoying the same perioperative advantages. The larger size of the higher-stage tumors does not appear to hinder intact organ removal via a 7-cm hand incision. For the novice laparoscopist, we recommend approaching smaller tumors first with HAL nephrectomy, as there is a learning curve. As surgical expertise with HAL nephrectomy increases, larger tumors (stage T2) can be removed safely and expeditiously with little blood loss and a low complication rate. In the short term, patients with stage T2 cancers appear to enjoy the same disease-free survival rate as those with tumors of lower stage. Longer-term follow-up is clearly needed; however, we anticipate the same excellent results as have been demonstrated by others performing conventional radical LN.