Laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell tumor: a large single institution experience.

PURPOSE: Primary laparoscopic retroperitoneal lymph node dissection is done at our institution with therapeutic intent and it technically duplicates the open approach. Controversies associated with the procedure include the thoroughness of dissection, the high rate of chemotherapy exposure and the potential deleterious effects of pneumoperitoneum. We present our experience with laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell tumors. MATERIALS AND METHODS: We queried the Johns Hopkins minimally invasive surgery database from 1995 to 2010 for patients with a clinical stage I nonseminomatous germ cell tumor undergoing laparoscopic retroperitoneal lymph node dissection. Demographic, perioperative, pathological and followup information was collected and analyzed. RESULTS: Of the 91 patients who underwent extended template laparoscopic retroperitoneal lymph node dissection during the study period 60 (66%) had lymphovascular invasion and 55 (60%) had greater than 40% embryonal carcinoma. Median estimated blood loss was 200 cc and mean length of stay was 2.1 days (range 1 to 4). Four patients (4.3%) experienced intraoperative complications and there were 4 open conversions (4.3%). Nine patients (9.8%) experienced postoperative complications. The mean lymph node count was 26.1 (range 7 to 72) and 28 patients (31%) had retroperitoneal metastasis. Followup was available for 55 patients at a median 38.0 months (range 12 to 168). No pN0 case recurred in the retroperitoneum but there were 5 systemic relapses in pN0 cases. Of the 21 patients with pN1 disease 14 elected chemotherapy and 7 elected surveillance. There was no relapse in either group. CONCLUSIONS: Laparoscopic retroperitoneal lymph node dissection appears to be safe, viable and effective for stage I nonseminomatous germ cell tumors. The lack of retroperitoneal recurrence in pN0-N1 cases supports the oncological efficacy of this approach. Its low morbidity and rapid convalescence compare favorably with those in open series.

Long-term oncological and overall outcomes of percutaneous radio frequency ablation in high risk surgical patients with a solitary small renal mass.

PURPOSE: We present long-term outcomes in patients receiving RFA for solitary small renal masses. MATERIALS AND METHODS: We reviewed the overall oncological and survival outcomes of patients with a solitary renal mass treated with radio frequency ablation in whom it had been at least 40 months since treatment. Patients were offered radio frequency ablation due to the high risk of surgical management and surgeon preference. Followup consisted of serum creatinine measurement, physical examination and serial contrast enhanced computerized tomography or magnetic resonance imaging. RESULTS: The 31 patients received a total of 34 radio frequency ablation treatments to a 1.0 to 4.0 cm solitary renal mass (median 2.0). Mean followup in survivors was 61.6 months (median 62.4, range 41 to 80). There was 1 primary treatment failure, which was successfully retreated. There were 3 recurrences 7, 13 and 31 months after radio frequency ablation, respectively. The overall recurrence-free survival rate was 90.3%. There was a 100% metastasis-free and disease specific survival rate in the cohort. Overall patient survival was 71.0% since 9 died of nonrenal cell carcinoma causes. Of the 31 patients 18 had pathologically confirmed renal cell carcinoma. In these 18 cases the actuarial disease specific, metastasis-free, recurrence-free and overall survival rates were 100%, 100%, 79.9% and 58.3%, respectively, at a mean of 57.4 months of followup. In the entire cohort the difference between the pretreatment and the last known serum creatinine level was 0.15 mg/dl (p = 0.06). CONCLUSIONS: In patients who have limited life expectancy or are high risk surgical candidates radio frequency ablation provides reasonable long-term oncological control and it may have a role in the management of small renal masses. Meticulous long-term followup is required in patients receiving radio frequency ablation.

Laparoscopic versus open partial nephrectomy for the treatment of pathological T1N0M0 renal cell carcinoma: a 5-year survival rate.

PURPOSE: We retrospectively compared the oncological adequacy of laparoscopic partial nephrectomy to that of open partial nephrectomy in the treatment of patients with pathological stage T1N0M0 renal cell carcinoma. MATERIALS AND METHODS: A total of 143 patients with stage T1N0M0 renal tumors confirmed by pathological examination of the surgical specimen underwent partial nephrectomy between January 1996 and June 2004 with a followup of at least 1.5 years. Of these patients 85 were treated laparoscopically and the remaining 58 underwent open surgery. Medical and operative records were retrospectively reviewed with emphasis on tumor recurrence and survival. Statistical analysis was performed using Kaplan-Meier analysis. RESULTS: The mean followup for the laparoscopy group was 40.4 +/- 18.0 months. A total of 83 patients survived. Of these patients 2 patients experienced disease recurrence within 18 to 46.2 months, 1 patient died of cancer metastasis to brain within 29.7 months and 1 died of an unrelated cause. Seeding of the port sites did not develop in any of the patients. The 5-year disease-free and actuarial survival rates for this group were 91.4%, and 93.8%, respectively. The 58 patients who underwent open surgery had a mean followup of 49.68 +/- 28.84 months. A total of 53 patients survived without any disease recurrence, 1 survived with recurrence within 8 months, 1 survived with metastasis within 49 months and 3 died of unrelated causes. The 5-year disease-free and patient survival rates for this group were 97.6% and 95.8%, respectively. Kaplan-Meier disease-free survival and patient survival analysis revealed no significant differences between the laparoscopic and open partial nephrectomy groups. CONCLUSIONS: Laparoscopic partial nephrectomy is an alternative technique with mid-range oncological results comparable to open partial nephrectomy in patients with localized pathological stage T1N0M0 renal cell carcinoma.

Long-term survival analysis after laparoscopic radical nephrectomy.

PURPOSE: This report assesses the long-term oncological efficacy of laparoscopic radical nephrectomy compared with open radical nephrectomy in patients with clinically localized renal cell carcinoma. MATERIALS AND METHODS: We analyzed the data from 121 patients who underwent radical nephrectomy between 1991 and 1999 for clinical tumor stage T1/2 N0M0. The medical records of all patients were retrospectively reviewed with emphasis on tumor recurrence and survival. Statistical comparison was performed using Kaplan-Meier analysis. RESULTS: The median followup was 73 months for the laparoscopic group and 80 months for the open group. Of the 67 patients who underwent laparoscopic surgery, 53 survived without any recurrence of disease, 2 are currently alive with metastasis, 2 died of metastatic disease in months 12 and 17, and 10 patients died without any disease recurrence. Laparoscopic port site metastasis did not develop in any patients. Of the 54 who underwent open surgery, 34 survived without any recurrence of disease, 1 currently has metastasis, 6 died of metastasis within 17 to 74 months, and 13 died without any disease recurrence. A comparison of the 5 and 10-year disease-free survival rates of the laparoscopic and open groups revealed no significant differences. In addition, the 5 and 10-year cancer specific and actuarial survival rates were not significantly different. CONCLUSIONS: Based on long-term followup, our evaluation confirmed for clinical tumor stage T1/2 N0M0 that laparoscopic radical nephrectomy is oncologically equivalent to open radical nephrectomy.