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

Background and Purpose: Standard laparoscopic nephrectomy (LN) has been shown to be as effective oncologically as open surgery for both stage T-1 and stage T-2 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 T-2 renal tumors. To our knowledge, this study is the first to directly compare the results in pathologic stage T-1 and stage T-2 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). Patients and Methods: 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 T-1 and 10 stage T-2. 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 T-2 tumors was as advantageous as for T-1 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. Results: The mean size was 4.68 and 9.22 cm for stage T-1 and T-2 tumors, respectively. Intraoperatively, stage T-2 tumors were associated with less blood loss than were T-1 tumors (105 mL v 190 mL). Operative times were equivalent, at 190 and 185 minutes for stage T-1 and T-2, respectively. No open conversions were required in the T-2 group v four (8.7%) in the T-1 group. Three of these open conversions were seen in the first 25 HAL cases. No complications or conversions were seen in the stage T-2 patients. Of note, the majority of the operations for stage T-2 disease were performed after the learning curve had been surpassed. Conclusion: The HAL nephrectomy maintains the benefits associated with standard LN. Stage T-1 and T-2 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 T-2) can be removed safely and expeditiously with little blood loss and a low complication rate. In the short term, patients with stage T-2 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.