Laparoscopic nephrectomy for adult polycystic kidney disease: safety, feasibility, and early outcomes.

BACKGROUND AND PURPOSE: Indications for laparoscopic renal surgery are increasing; however, benefits in adult polycystic kidney disease (APKD) remain uncertain. Our objective was to systematically synthesize the reported literature on safety, feasibility, complications, and early outcomes of laparoscopic nephrectomy in APKD to determine clinical benefits for surgical practice. METHODS: We conducted a meta-analysis of the published literature reporting on laparoscopic nephrectomy in APKD between 1991 and 2013. The criteria from the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) study were used to assess the quality of reported literature. RESULTS: One prospective and 15 retrospective studies of low to modest quality (according to the STROBE checklist) were identified, reporting on 293 patients who underwent laparoscopic nephrectomy for APKD. None of the studies was a randomized clinical trial (RCT). The transperitoneal approach was the most commonly used technique. Body mass index ranged from 16 to 57 (mean 26.2 kg/m(2); 53% of patients were dialysis dependent, and 31% had a previous or simultaneous transplant. Kidney length ranged from 8 to 50 cm (mean 34.5cm), and the mean mass of affected kidneys was 1647 g (range 132 g-7200 g). Duration of hospital stay ranged from 2.6 to 11 days (mean 4.9 days). Operative time ranged from 90 to 568 minutes, with 16.2% of patients needing blood transfusion. There were 24 intraoperative complications and 68 postoperative complications, a rate of 8% and 24%, respectively. A total of 16 (5%) cases were converted to an open technique. No mortality was reported in any of the included studies. CONCLUSION: The quality of the included studies is poor, and it is difficult to argue for or against change in clinical practice because the evidence included is of level 3 and 4 only. Higher quality studies are needed to demonstrate that the technique is generalizable across all populations.

Mitomycin C instillation following ureterorenoscopic laser ablation of upper urinary tract carcinoma.

INTRODUCTION: Instillation of Mitomycin C (MMC) should prevent implantation of cancer cells released during endoscopic treatment and prevent recurrences as seen in carcinoma of the bladder. AIM: TO DEVELOP AND EVALUATE A PROTOCOL FOR A SINGLE DOSE MMC INSTILLATION FOLLOWING HOLMIUM: YAG laser ablation of upper urinary tract transitional cell carcinoma (UUT-TCC). SETTING AND DESIGN: A single institute prospective study. MATERIALS AND METHODS: MMC instillations protocol was designed and offered to patients between August 2005 and April 2011. Following tumor ablation, MMC was instilled into upper urinary tract (UUT) over 40 minutes. All the patients were regularly followed up. RESULTS: Twenty UUT units (19 patients) were managed for UUT-TCCs using our MMC protocol. Two UUT units had G1pTa tumors, 14 had G2pTa, 2 had G3pTa, and 2 had G3pT1. At a mean follow-up of 24 months (range 1-72 months), 13/20 (65%) of the UUT units remained cancer-free, 3 (15%) UUT units developed stricture and were treated with endoscopic dilatation, only 1 (5%) of these developed long-term complications. None of the patients developed postoperative renal impairment or systemic side-effects. CONCLUSIONS: Using a set standard protocol, MMC can safely be instilled into the UUT after TCC ablation with minimal complications or side effects, good preservation of renal function, and with a low recurrences rate comparable to the literature.

Laparoscopic en bloc resection of ureter with a cuff of bladder during radical nephroureterectomy for lower ureteric tumors: a matched-paired analysis.

BACKGROUND: Surgical management of the lower end of the ureter during laparoscopic nephroureterectomy remains a matter of debate. The commonest method during laparoscopic nephroureterectomy-endoscopic incision-has been shown to have a higher recurrence rate compared with open surgical excision with a cuff of bladder. In addition, the literature still lacks comparative studies between different approaches to support and guide the current clinical practice. PATIENTS AND METHODS: Three consecutive series of patients undergoing laparoscopic radical nephrectomy for transitional cell carcinoma located in the lower one-third of the ureter with different methods (laparoscopic en bloc resection of ureter with a cuff of bladder, open surgical excision, and endoscopic incision) of dealing with the lower end were compared in their short-term surgical and oncological outcomes. The primary outcome was recurrence at 12 months of follow-up. The secondary outcomes were hospital stay, positive surgical margins, and duration of catheterization. RESULTS: Analysis of perioperative and postoperative outcomes revealed laparoscopic en bloc resection of the lower end of the ureter with a cuff of bladder is a safe and feasible approach with the advantages of the laparoscopic approach such as less hospital stay compared with the open approach. The analysis of oncological outcomes in this feasibility study showed a higher rate of recurrences in the endoscopic approach. CONCLUSIONS: Laparoscopic en bloc resection of the lower end of the ureter with a cuff of bladder during nephroureterectomy for tumors located in the lower one-third of ureters is safe and feasible in terms of perioperative outcomes and early oncological results. We acknowledge that the small sample size and the nonrandomized design are a limit of the study. Thus, prospective randomized controlled trials are recommended to prove the superiority of one approach over the others.

Long-term oncologic outcomes of laparoscopic radical nephrectomy for kidney cancer resection: Dundee cohort and metaanalysis of observational studies.

BACKGROUND: The long-term oncologic outcome of laparoscopic radical nephrectomy compared with that of open radical nephrectomy remains unclear. A few case series with follow-up periods longer than 5 years are reported in the literature. The existing literature is focused primarily on early and intermediate outcomes of laparoscopic radical nephrectomy. This study aimed to assess the outcome of laparoscopic radical nephrectomy for localized disease compared with open surgery. METHODS: The search strategy was designed to identify observational and experimental studies conducted in any country that investigated the long-term oncologic outcomes of laparoscopic radical nephrectomy compared with open surgical resection, published in any language. We searched the MEDLINE (1996 to May 2010), EMBASE (1996 to May 2010), and Cochrane databases using the OVID interrogation software. The study included 77 men from the Dundee cohort referred for clinically localized renal cell carcinoma who underwent open or laparoscopic radical nephrectomy between January 1998 and 2004, with at least 5 years of follow-up evaluation for each. These men were included in a metaanalysis of observational studies reporting on 438 patients with a mean or median follow-up period of 5 years. The data was analyzed using Minitab statistical software and Cochrane RevMan 5.4 using the random model. RESULTS: The five studies (including the Dundee cohort) investigating the effects of the laparoscopic approach on renal cancer management showed no significant differences in 5 years survival between laparoscopic and open surgical approaches for the resection of kidney cancer. The resulting pooled odds ratio (OR) did not differ markedly between the two groups (pooled OR, 0.82; 95% confidence interval [CI], 0.48-1.39). Similar to overall survival, the laparoscopic and open surgical approaches for renal cancer surgery did not differ significantly (Figs. 4, 5). The pooled ORs for the two outcomes were 0.76 (955 CI, 0.36-1.56) for laparoscopic surgery and 0.73 (95% CI, 0.32-1.69) for open surgery. The quality of the studies was poor. The reported designs of the studies were prone to selection, confounding, and reporting biases. CONCLUSIONS: The current retrospective data (observational studies) comparing long-term oncologic outcomes between laparoscopic and open radical nephrectomy did not demonstrate any significant differences during a follow-up period of 5 years.