Nefrectomia laparoscópica: análise de 34 pacientes

acb Acta Cirúrgica Brasileira Acta Cir. Bras. 0102-8650 1678-2674 Sociedade Brasileira para o Desenvolvimento da Pesquisa em Cirurgia São Paulo, SP, Brazil OBJETIVO: Relatar a experiência da instituição na realização de nefrectomia laparoscópica para doenças benignas e malignas dos rins. MÉTODOS: Desde fevereiro de 2000 a março de 2003, 34 pacientes (14 homens e 20 mulheres) foram submetidos à nefrectomia transperitoneal laparoscópica no Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo: 28 pacientes (82,3%) por doença benigna, e 06 (17,6%) por doença maligna. Os pacientes operados por doença benigna apresentaram exclusão renal pelas seguintes etiologias: litíase (N=9, 32,1%), pielonefrite crônica (N=8, 28,6%), refluxo vesicoureteral (N=4, 14,3%), estenose de JUP (N=3, 10,7%), rim multicístico (N=2, 7,1%) e pionefrose (N=2, 7,1%). A idade variou entre 2 e 79 anos (média de 35,16 anos). RESULTADOS: dos 34 procedimentos, 31 (91,1%) foram completados com sucesso pelo método laparoscópico, sendo necessárias apenas 02 (5,8%) conversões para nefrectomia aberta (pionefrose) e 02 (5,8%) reintervenções cirúrgicas. O tempo operatório médio foi de 240 minutos (180 à 400 minutos). Dois pacientes (5,8%) apresentaram complicações intraoperatórias, sendo 01 lesão de serosa duodenal e 01 lesão de pedículo renal, ambas controladas por laparoscopia. Reintervenção cirúrgica foi necessária em 2 pacientes (5,8%). O tempo médio de internação hospitalar foi de 58h (variando de 18 a 240h). CONCLUSÃO: a nefrectomia laparoscópica apresentou baixo índice de complicações, curto período de internação e ausência de mortalidade, mesmo quando realizada no início da curva de aprendizado. ARTIGO RETROSPECTIVO Laparoscopic nephrectomy: analysis of 34 patients1 Nefrectomia laparoscópica: análise de 34 pacientes André Luís Alonso DomingosI; Ricardo Brianezi TiraboschiI; Rodolfo Borges ReisII; Antonio Carlos Pereira MartinsIII; Cassio Bottene SchneiderII; Sylvio Tucci JrII; Haylton Jorge SuaidII; Edson Luis PaschoalinIV IMedical Residents / Hospital das Clinicas – FMRP-USP IIAssistant Professor of Urology / Hospital das Clinicas – FMRP-USP IIIProfessor of Urology / Hospital das Clinicas – FMRP-USP IVPost graduation alumni / FMRP-USP Correspondence ABSTRACT OBJECTIVE: To analyze the clinical experience of laparoscopic nephrectomy for benign and malignant diseases at a university hospital. METHODS: From February 2000 to March 2003, 34 patients (14 men and 20 women) underwent transperitoneal laparoscopic total nephrectomy at the Hospital das Clinicas – FMRP-USP: 28 (82.3%) patients had benign diseases and 6 (17.7%) malignant neoplasias. Benign diseases were represented by: urinary stones (N-9, 32.1%), chronic pyelonephritis (N-8, 28.6%), vesicoureteral reflux (N-4, 14.3%), ureteropelvic obstruction (N-3, 10.7%), multicystic kidney (N-2, 7.1%) and pyonephrosis (N-2, 7.1%). Patients age range was 2-79 years (mean – 35,1 years). RESULTS: In 32/34 patients the procedures were accomplished successfully. In 2 (5.8%) cases of pyonephrosis, open conversion was necessary due to perinephric abscess and difficulties in dissection of renal hilum. Two patients had intraoperative complications (1 duodenum serous laceration an 1 vascular lesion of renal hilum), but both were managed laparoscopically. Two (5.8%) post operative complications (1 delayed bleeding and 1 pancreatic fistula) required open surgical exploration. The mean time of hospital stay was 58h (18 to 240h). CONCLUSION: Laparoscopic nephrectomy proved to be a method safe and associated with a low rate of morbidity, shorter hospital stay and no casualties. Key words: Nephrectomy. Laparoscopy. RESUMO OBJETIVO: Relatar a experiência da instituição na realização de nefrectomia laparoscópica para doenças benignas e malignas dos rins. MÉTODOS: Desde fevereiro de 2000 a março de 2003, 34 pacientes (14 homens e 20 mulheres) foram submetidos à nefrectomia transperitoneal laparoscópica no Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo: 28 pacientes (82,3%) por doença benigna, e 06 (17,6%) por doença maligna. Os pacientes operados por doença benigna apresentaram exclusão renal pelas seguintes etiologias: litíase (N=9, 32,1%), pielonefrite crônica (N=8, 28,6%), refluxo vesicoureteral (N=4, 14,3%), estenose de JUP (N=3, 10,7%), rim multicístico (N=2, 7,1%) e pionefrose (N=2, 7,1%). A idade variou entre 2 e 79 anos (média de 35,16 anos). RESULTADOS: dos 34 procedimentos, 31 (91,1%) foram completados com sucesso pelo método laparoscópico, sendo necessárias apenas 02 (5,8%) conversões para nefrectomia aberta (pionefrose) e 02 (5,8%) reintervenções cirúrgicas. O tempo operatório médio foi de 240 minutos (180 à 400 minutos). Dois pacientes (5,8%) apresentaram complicações intraoperatórias, sendo 01 lesão de serosa duodenal e 01 lesão de pedículo renal, ambas controladas por laparoscopia. Reintervenção cirúrgica foi necessária em 2 pacientes (5,8%). O tempo médio de internação hospitalar foi de 58h (variando de 18 a 240h). CONCLUSÃO: a nefrectomia laparoscópica apresentou baixo índice de complicações, curto período de internação e ausência de mortalidade, mesmo quando realizada no início da curva de aprendizado. Descritores: Nefrectomia. Laparoscopia. INTRODUCTION Since the report of the first laparoscopic nephrectomy by Clayman in 19901, the method deserved widespread investigation and use. The advances in technology of instrumentation as well as the establishment of surgical training programs led to execution of more complex procedures in a shorter surgical time. Despite the fact of the difficulties to perform nephrectomy in cases of pyonephrosis and severe pyelonephritis the technique is considered safe for the treatment of benign and malignant diseases of the kidney2,3,4,5. Laparoscopic nephrectomy allows better esthetic results, lower morbidity, lesser postoperative pain, shorter hospital stay and faster return to normal activities than open surgery6,7. A longer learning curve and a higher cost of equipment that represent an apparent disadvantage of laparoscopic surgery is counterbalanced by the aforementioned advantages which compares favorably to open surgery8. The aim of this study is to analyze the results of the first 34 laparoscopic consecutive nephrectomies carried out at our institution. METHODS We revised the records of 34 patients (age range: 2 to 79 years; mean: 35.1 + 18.7 years) submitted to transperitoneal laparoscopic total nephrectomy, at the Hospital das Clínicas – FMRP-USP, from February of 2000 till March of 2003. Fourteen were men and 20 women. The diagnosis was benign disease in 28 (82.3%) and malignant tumor in 6 (17.7%). The benign diseases responsible for kidney functional exclusion were: urinary stone in 9 cases (32.1%), chronic pyelonephritis in 8 (28.5%), vesicoureteral reflux in 4 (14.3%), ureteropelvic junction obstruction in 3 (10.7%), multicystic kidney in 2 (7.1%) and pyonephrosis in 2 (7.1%). All 6 patients with malignant disease had hypernephroma stage T1N0M09 (tumor size <5cm in 5 and 6cm in 1). Patients were operated on under general anesthesia and received 1g of intravenous cefazoline 1h before the beginning of surgery followed by 2 additional doses with intervals of 8h. Patients were placed on operating table in supine position tilted 45º toward the opposite side of the elected for surgery. A Foley catheter was placed in the bladder for 12-24h. In 32 patients the pneumoperitoneum with CO2 gas was established with a Veress' needle while in 2 the first port was created through a small open incision (Hasson). During the procedure the pressure of pneumoperitoneum was kept in 12 mmHg by an automatic CO2 gas insufflator (AstusTM). A four-port technique was preferred in the following locations: mid-clavicular line (level of umbilicus – 10mm), anterior axillary's line (2 ports of 10mm each) and posterior axillary's line (1 port – 10mm). RESULTS Surgeries lasted for 180 to 400 minutes (mean 240 minutes – Table 1). Curiously no difference in operating time was observed between procedures for benign or malignant diseases. Hospital stay varied from 18 to 240h with a mean of 58h. Two patients had a prolonged hospitalization due to complications of concomitant diseases (atrial fibrillation and Diabetes Mellitus, respectively 144h and 240h). We had two intraoperative complications: 1 injury of duodenal serous (right nephrectomy) and 1 lesion of vascular renal hilum (left nephrectomy). Both were managed properly without necessity of conversion to open surgery (Table 2). Two (5.8%) of 34 patients required conversion to open access in consequence of the presence of perinephric abscesses which did not allow a safe dissection of renal artery and vein. Postoperative complications occurred in 2 cases: 1 pancreatic fistula and 1 delayed bleeding. These 2 patients required open surgical intervention and recovered completely. Only the patient that showed delayed postoperative hemorrhage required blood transfusion. DISCUSSION The length time of laparoscopic nephrectomy depends on the surgeon specific skill dictated by the learning curve2. Our data showed a mean operating time of 240 minutes which is similar to that seen in some reports2,3 but longer than others that refer lower means as 90 minutes6. It is worth while to mention that most procedures of our series were performed by medical residents. Injury of abdominal viscera and bleeding are the most common complications of laparoscopic nephrectomy2. The rate of 5.8% of such intercurrences observed in our data is comparable to those published elsewhere2,4,10. Conversion to open surgery was necessary in 5.8% of our patients which is in the upper limit of the rate range reported previously2,3,10. New surgical interventions in the postoperative period to manage complications in 5.8% of cases is similar to data reported previously2,10. The mean hospital stay of 58h reflects the low morbidity of the method and is in accordance with the literature2,3,6,7. CONCLUSION Laparoscopic nephrectomy proved to be a method safe and associated with a low rate of morbidity, shorter hospital stay and no casualties. Correspondence to Antonio Carlos Pereira Martins Departamento de Cirurgia – HCFMRP-USP Av. Bandeirantes, 3.900, 9º Andar Ribeirão Preto, SP CEP: 14048-900 1 . This research was carried out at the Hospital das Clinicas – FMRP-USP 1. Clayman RV, Kavoussi LR, Soper NJ. Laparoscopic nephrectomy: initial case report. J Urol 1991; 146:278-82. Laparoscopic nephrectomy: initial case report J Urol 1991 278 82 146 Clayman RV Kavoussi LR Soper NJ 2. Rassweiler J, Fornara P, Weber M, Janestek G, Fahlenkamp D, Henkel T, Beer M, Stackl W, Boeckmann W, Recker T, Lampel A, Fischer C, Humke U, Muller K. Laparoscopic nephrectomy: the experience of the laparoscop working group of the German Urologic Association. J Urol 1998; 160:18-21. 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