Research ArticleClinical Studies

Radical Nephrectomy with Transperitoneal Subcostal Incision for Large and Locally Advanced Tumors of the Right Kidney

JOHN ANASTASIOU, THEODORE KARATZAS, EVANGELOS FELEKOURAS, THEODORE TOKAS, GEORGE KOUTALELLIS, DIONISIOS MITROPOULOS and CONSTANTINOS CONSTANTINIDES
Anticancer Research November 2012, 32 (11) 5023-5029;

Abstract

Background: Several surgical approaches have been used for radical nephrectomy for large and locally advanced tumors of the right kidney. Aim: To present our experience with radical nephrectomy using a right subcostal incision with a transperitoneal approach in patients with very large tumors of the right kidney. Patients and Methods: Between 2003 and 2010, 34 patients with very large tumors of the right kidney were submitted to surgery. Eighteen patients underwent a transperitoneal approach with a right subcostal incision (intervention group) and 16 patients were operated on with retroperitoneal flank incision (control group). Results: No significant complications during surgery were observed in the intervention group; two patients needed blood transfusions of 300 cc during the first postoperative day. In the control group, injury of the renal vein or inferior vena cava (IVC) was a relatively common complication; five patients needed blood transfusions of 300 cc during the first postoperative day. Conclusion: A transperitoneal right subcostal incision for radical nephrectomy in patients with large and locally advanced tumors of the right kidney seems to offer better access to the renal pedicle, and to the great vessels of the area as well as better exposure of the organs of the abdominal cavity. This approach could be more useful in cases in which liver involvement is possible.

Renal tumors account for 2 to 3% of all adult carcinomas (1). They are most commonly present in patients in developed countries. Renal cell carcinoma (RCC) is the commonest among all renal carcinomas, with relative prevalence in males versus females (1.5:1) and in patients ages between 60 and 70 years (1). Out of all patients with RCCs, 30 to 40% present with distant disease and might not be curable. Another 4 to 10% of patients present with tumor thrombi extending into the inferior vena cava (IVC) and even more extensively into the right atrium (1, 2). Radical nephrectomy is the standard treatment of choice for most patients with clinically-localized and locally advanced renal cell carcinomas (2-4). Primary renal tumors with IVC extension without evidence of metastatic disease are potentially curable with radical resection (3, 4).

Several surgical approaches and techniques have been described for the surgical management of renal tumors depending on their size and location and on whether they have extended into the vena cava. Radical nephrectomy is usually performed through a retroperitoneal flank incision, although a transperitoneal approach, with a midline or paramedian incision, may be also employed. Adrenalectomy is not usually performed, except for cases in which tumor infiltration extends to the adrenal gland. In large tumors of the right kidney, an anterior subcostal incision (Kocher) can be performed, especially in cases in which a tumor thrombus exists in the renal vein with infrahepatic involvement of the IVC or for locally advanced tumors extending to adjacent structures or infiltrating the liver. A left subcostal incision can also be an option for large tumors of the left kidney.

The choice of the most appropriate approach for radical nephrectomy depends on individual preference and is a matter of opinion. Little data exist in recent literature concerning morbidity and mortality after radical nephrectomy comparing different incisions. In this study, we present the experience of our departments with radical nephrectomy in patients with large and locally advanced right renal tumors using a transperitoneal anterior approach with a right subcostal incision compared with patients having the same size tumors but operated on with a flank retroperitoneal incision. The complications rates and patients outcomes with the two different approaches were evaluated.

Figure 1.
Figure 1.

Magnetic resonance angiography (MRA): tumor thrombus in the renal vein extended into the vena cava producing caval blockage. Arrows show tumor thrombus in the vena cava from MR cavography.

Patients and Methods

Between May 2003 and July 2010, 34 patients underwent radical nephrectomy for large and locally advanced right renal tumors at our institution. Sixteen patients (the control group) were operated on with a flank incision using a retroperitoneal approach, and 18 patients (the intervention group), 11 men and seven women, were operated on with a right subcostal (Kocher) incision using a transperitoneal approach. Typical symptoms in both groups included hematuria, fever, flank pain and fatigue. Palpable masses in the right flanks of the patients were commonly identified, except for two patients in whom the tumors were diagnosed incidentally (Table I). In the intervention group of patients, the mean tumor diameter was 8.5 cm (range=6.5-15 cm). In six patients, the ipsilateral adrenal gland had been infiltrated by the tumor, including one female patient in whom the tumor was located in the upper pole of the kidney and infiltrated the adrenal gland and who also had a metastatic mass in the contralateral adrenal gland. The tumor occupied the upper pole in 11 patients and the whole kidney in seven patients. Ten patients had a tumor thrombus in the renal vein that involved the infrahepatic vena cava (Figure 1). Seven out of 18 patients had positive lymph nodes diagnosed by computerized-tomography (CT) or magnetic resonance imaging (MRI), or that were identified intraoperatively and confirmed by histopathological examination. The diagnostic imaging tests used were renal ultrasound, CT scan with i.v. contrast and MRI. In selected cases, magnetic angiography was employed (Figure 1).

The control group consisted of 16 patients with large and locally advanced tumors of the right kidney that had a mean diameter of 8.2 cm (range=7.2-13.0 cm). These patients were operated on with a retroperitoneal approach through a flank incision. The tumors were located in the upper pole of the right kidney in 12 patients and in the middle of the kidney in four patients. In five patients, the tumor infiltrated the right adrenal gland. Two patients had a tumor thrombus in the renal vein with IVC involvement and four patients had lymph node metastasis. The same imaging methods were employed in the control group.

View this table:
Table I.

Clinical symptoms and demographics of patients operated for radical nephrectomy

Figure 2.
Figure 2.

Introduction of Foley catheter into the vena cava (IVC): a Foley catheter is introduced into the IVC distally to the thrombus to produce proximal occlusion of the IVC.

Figure 3.
Figure 3.

Thrombus extraction from the vena cava: the arrow shows the thrombus.

Preoperatively, all patients received chemoprophylaxis, usually with a beta-generation cephalosporin, except for the patients who were allergic to β-lactam antibiotics or in cases of positive preoperative microbiuria with β-lactam resistance. In these cases, an aminoglycoside or piperacillin with tazobactam was used. All patients received low molecular weight heparin postoperatively.

The surgical procedure in the intervention group was performed through a right subcostal incision (Kocher) extended to or across the midline according to the size of the tumor. The abdominal cavity was explored for metastatic disease. A rib grip retractor (iron intern A. Stieber) was used to secure a better operative exposure. Mobilization of the ascending colon, right hepatic flexure and duodenum was achieved and reflected medially to reveal the vena cava and aorta thoroughly. The right kidney was exposed and mobilized outside the Gerota fascia. Before addressing the renal vessels, ligation and division of the gonadal vein, at the point where it enters the IVC, were preferable. The renal artery and vein were then dissected outside of the retroperitoneal perirenal fascia and were separately ligated. The ureter was also dissected and divided. The kidney was then dissected free and removed. In cases of adrenal infiltration by the tumor, the resection involved radical nephrectomy en bloc with the adrenal gland. In those patients in whom a tumor thrombus existed in the renal vein and which extended to the IVC producing caval blockage, vascular occlusion of the IVC distally to the thrombus was performed. With a small longitudinal caval venotomy, a Foley catheter was introduced for proximal occlusion of the IVC (Figure 2) and removal of the tumor thrombus was performed (Figure 3). If the tumor was adherent to any portion of the caval wall, the area was segmentally excised. The cava was carefully inspected for any residual tumor and was back-flushed to remove any residual thrombus or debris. The caval venotomy was then closed, primarily with running monofilament sutures and the vascular clamps were released. In those cases in which the tumor extended to the right hepatic lobe (Figure 4), complete mobilization of the liver was required to perform suprahepatic clamping of the IVC. The liver was isolated by first performing a Pringle maneuver to minimize hepatic vein blood flow. Some patients required partial liver resection, assisted by the radiofrequency ablation (RFA) technique, because the tumor infiltrated the right hepatic lobe (5) (Figure 5). In this group of patients, an intraoperative ultrasound was also performed to detect any other intrahepatic metastatic sites. Lymphadenectomy of the area around the renal vessels and of the paracaval, para-aortic and retroperitoneal areas followed. Two drainage tubes were used, one in the place of the excised kidney and the other in the Douglas pouch.

Figure 4.
Figure 4.

Hepatectomy en bloc with nephrectomy: right posterior hepatectomy en bloc with nephrectomy for a large and locally extended tumor of the right kidney.

Figure 5.
Figure 5.

Magnetic resonance imaging of a large tumor of the right kidney invading the liver.

In the control group, two patients with a tumor thrombus in the renal vein underwent thrombectomy. Patients with ipsilateral adrenal infiltration by the renal tumor underwent a radical nephrectomy en bloc with adrenalectomy and patients with metastatic lymphadenopathy underwent regional lymphadenectomy.

Histopathology of the kidneys in the intervention group revealed a clear renal cell carcinoma in 10 patients, papillary (type 2) renal cell carcinoma in two patients, poor-differentiation transitional cell carcinoma in five patients who had a secondary ureterectomy, and adrenal adenocarcinoma in one patient. In the control group, 15 patients had a clear renal cell carcinoma and one patient had a papillary (type 2) renal cell carcinoma.

Results

All patients were mobilized on the first postoperative day and had a free diet on the second day. Postoperative analgesia with paracetamol and opioids was administered on demand.

In the intervention group, the mean operative time was 95 min (range=85 to 115 min). Twelve patients had a cancer thrombus in the renal vein and/or in the IVC and required thrombectomy. In seven patients, the tumor extended to the right hepatic lobe and complete mobilization of the liver was required to perform sub-diaphragmatic clamping of the IVC. In five of these patients, an RFA-assisted partial hepatectomy was performed because the tumor infiltrated the right lobe of the liver. In the remaining two patients, the tumor was tightly attached to the liver capsule without infiltration and liver resection was not required. All of the patients with a tumor extending into the right hepatic lobe were subjected to intraoperative ultrasound to detect for intrahepatic metastatic sites. Six patients required right adrenalectomy and four patients required cholecystectomy because of tumor infiltration in these organs. In a female patient with a primary tumor on the right upper pole of the kidney, ipsilateral adrenal infiltration and contralateral adrenal metastasis, a right nephrectomy and bilateral adrenalectomy were performed, using a bilateral subcostal incision (Chevron). Additionally, seven patients required regional lymphadenectomy because metastatic lymphadenopathy was identified.

View this table:
Table II.

Intraoperative characteristics.

An average of one unit (300 cc) of blood was transfused in the intervention group of patients. In eight patients, blood transfusion was not required, and seven patients were transfused only once. One patient who underwent a simultaneous adrenalectomy was transfused intraoperatively with 600 cc of blood because of laborious access and control of the adrenal vessels. Another patient who underwent partial hepatectomy received 1200 cc of blood and the patient who underwent bilateral adrenalectomy received 900 cc of blood (Table II).

In the intervention group of patients, no serious intraoperative complications were observed. The mean postoperative time of catheter removal was four days. Three patients had a decapsulation of a small area of the liver, which was treated with the use of an argon laser. One patient who underwent a bilateral adrenalectomy needed to stay in the intensive care unit for five days because of acute adrenal failure. Seven patients presented with fever during the first or second postoperative day, which was easily treated. Other postoperative complications were angina pectoris in three patients and cardiopulmonary failure episode during the second postoperative day in one patient, which was treated conservatively.

In the control group of patients, the mean operative time was 104 min (range=78 to 123 min). Two patients with a tumor thrombus in the renal vein underwent thrombectomy. Five patients with ipsilateral adrenal infiltration underwent radical nephrectomy en bloc with adrenalectomy and four patients with metastatic lymphadenopathy underwent a regional lymphadenectomy. Seven patients did not require transfusions, while the mean transfusion rate was 600 cc/patient (Table II). In this group of patients, the main intraoperative complication was an injury to the IVC, performed during the renal pedicle dissection. One patient had a duodenal injury that was repaired with sutures and the patient had no further complications. Six patients presented a high postoperative temperature most likely attributable to the synthetic hemostatic agents used to control bleeding from the retroperitoneal area and the repair of the great vessels, which were difficult to control because of the diminished exposure of the field. Finally, one patient presented a pulmonary embolism on the first postoperative day, which was treated with the appropriate anti-coagulants. The intraoperative and postoperative complications in both groups are reported in Table III.

View this table:
Table III.

Postoperative characteristics and patients complications.

Discussion

During the evolution of radical nephrectomy for renal tumors, there have been different approaches for surgical treatment. The selection of a surgical approach is guided more by individual preference than by necessity and is based mainly on the extension of surgical resection and the need for a secure exploratory laparotomy. The method of choice is definitely the retroperitoneal approach with a flank incision. The transperitoneal approach, with a subcostal, midline, paramedian, or thoracoabdominal incision, especially for large and locally advanced tumors, seems to offer some advantages. The principal advantage of the transperitoneal approach is that the exposure of the area of the renal pedicle is excellent and the incision can be easily extended. A vertical midline incision is easier and quicker to create. It also allows better access for inspection of the abdominal organs. A transverse incision provides better access to the lateral and superior portion of the kidney and a unilateral subcostal incision can be extended across the midline as a chevron incision to provide excellent exposure of the kidneys, aorta and vena cava. However, greater blood loss, postoperative ileus and intra-abdominal adhesions and splenic injury are possible complications in patients with left renal tumors (6, 7). The retroperitoneal approach is relatively contraindicated for large tumors because the operative field is limited and resection of the lower two ribs is usually indicated to secure access to the great vessels and to the rest of adjacent organs (7).

There are very limited data in the literature comparing these two different approaches. The first retrospective study published by Proca et al. in 1978, presented results from transperitoneal nephrectomy using primarily a bilateral subcostal incision extended into the pararectal region in a group of 51 patients with tumors of the right or left kidney (9). In their series, the authors carried-out eight explorations of the IVC and in one case, total resection of the IVC was performed. In 1999, Mejean et al., in a retrospective study of 656 patients, suggested that transperitoneal nephrectomy with a subcostal incision offered a better approach without significant complications in postoperative intestinal function (10). In this study, the main complication was splenic injury among the cases of left renal tumors. Three years later, the first published study comparing the two approaches did not demonstrate significant differences in postoperative complications, while the transperitoneal approach was preferred in patients with large and high-stage renal tumors (8). In 2005, Parekh et al., in a retrospective study of renal cell carcinomas with renal vein and IVC involvement, described the transperitoneal approach with a subcostal incision and simultaneous resection of renal vein or vena cava tumor thrombi, which was performed in 30 out of 44 patients (11). They underlined the importance of MRI in assessing the presence and extent of tumor thrombi. They also questioned the significance of the tumor thrombus level and the intramural invasion of the renal vein, in comparison with the presence of lymph node metastases, to overall patient survival. Despite their results supporting the aggressive surgical treatment adopted, they did not analyze the advantages and disadvantages of this approach and their study was not comparative (11).

A history of previous abdominal operations plays an important role in the selection of the surgical approach. In patients with a history of major abdominal operations, a retroperitoneal approach with a flank incision is usually preferred. In contrast, a transperitoneal approach is preferable in patients with larger tumors infiltrating major regional vessels or adjacent organs. A transperitoneal subcostal incision has been used, in recent years, to resect most renal tumors because the exposure of the great vessels is excellent. In cases of locally extended right upper pole renal tumor, this surgery is best approached with a thoracoabdominal route.

Large renal tumors have an abundant blood supply, with frequently observed encroachment of the infrarenal veins. The rate of tumorous invasion into the renal vein is 30% and the incidence of involvement of the IVC ranges from 4 to 10% (12). According to Bastian et al., tumorous invasion into the renal vein and the IVC does not reduce 5-year survival (13); therefore, complete removal of the tumor embolus is necessary to dissociate the renal vein and the vena cava thoroughly and to treat the patient radically. In our study, all 12 tumor thrombectomies performed were complete, leaving the vessels free of thrombi. Furthermore, in patients subjected to partial hepatectomy because of tumor infiltration, no liver metastasis was detected on intraoperative ultrasound.

The need for concomitant adrenalectomy should be defined, as its benefits have not yet been fully-proven (14, 15). It seems advantageous in patients with large upper pole renal tumors because the adrenal gland is enclosed within the Gerota fascia and large tumors may compress or even infiltrate the ipsilateral adrenal gland (16). Ipsilateral adrenal metastasis occurs in 2 to 10% of most reported series and the risk of adrenal metastasis is related to the malignant potential of the primary tumor and its size and position (6). A study of 247 patients with renal cell carcinoma showed that only 3% of patients had adrenal involvement (7). Each case was diagnosed preoperatively with CT scan. However, patients with large tumors or with tumors sited high in the upper pole are most likely best-served with standard radical nephrectomy that includes adrenalectomy. Radical resection, also with bilateral subcostal incision, should be performed in patients that have large upper pole renal tumor infiltrating the ipsilateral adrenal glands along with contralateral adrenal metastasis. In the case of our female patient, a chevron incision was used to perform right nephrectomy and bilateral adrenalectomy.

The role of regional lymphadenectomy in prognosis is also under discussion. In patients with disease-positive lymph nodes, resection does not seem to offer better patient survival; however, many surgeons perform it because it does not increase mortality rates (17). Recently, however, there was a large, prospective clinical trial that supported the opposite point of view (18). Among our cases, lymph node metastasis occurred in seven patients and required regional lymphadenectomy.

This study presents the experience of our departments, particularly in treating large kidney tumors of the right side, because of their close proximity to the liver and the great vessels. The limitations of this study are the relatively small sample size and its retrospective nature. The operations were performed by four different surgeons, for whom technique and level of experience were comparable. The results of this study agree with the current literature although the existing data are scarce.

Conclusion

The transperitoneal approach offers better oncological results for extremely large kidney tumors and in cases of obvious infiltration of the great vessels and extention to the liver. Although the retroperitoneal approach is the standard for small kidney tumors, the transperitoneal anterior subcostal incision is effective, especially for larger and locally extended tumors. It provides excellent exposure of the area of the renal pedicle and the great vessels, as well as for tumors that compress or infiltrate the liver. It also allows better access for inspection of the peritoneal cavity, and it can be extended across the midline to provide bilateral renal access, or to optimize exposure of the great vessels. This direct access to the peritoneal cavity also facilitates exploration for metastatic disease. As with any transperitoneal approach, an anterior subcostal incision has a slightly higher risk of bowel disturbance, leading to ileus, bowel obstruction and visceral injury. The surgeon's experience and the patient's performance are very important factors in selecting the appropriate approach.

Footnotes

  • Conflicts of Interest

    The Authors declare that they have no conflicts of interest, economic or otherwise.

  • Received August 31, 2012.
  • Revision received October 10, 2012.
  • Accepted October 12, 2012.

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Radical Nephrectomy with Transperitoneal Subcostal Incision for Large and Locally Advanced Tumors of the Right Kidney
JOHN ANASTASIOU, THEODORE KARATZAS, EVANGELOS FELEKOURAS, THEODORE TOKAS, GEORGE KOUTALELLIS, DIONISIOS MITROPOULOS, CONSTANTINOS CONSTANTINIDES
Anticancer Research Nov 2012, 32 (11) 5023-5029;
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