Locally advanced RCC with renal vein thrombus has historically presented a more challenging surgical case that is most often performed via an open technique. Advances in laparoscopy have led investigators to examine the feasibility of LRN for locally advanced tumors. Recent reports demonstrate that hand-assisted and pure laparoscopic nephrectomy can be safe and effective for tumors with renal vein thrombus [9
]. Guzzo et al reported 37 patients who underwent LRN for T3b RCC with operative outcomes comparable to LRN for lower stage tumors [median operative time 190 minutes, median EBL 200 ml, and median length of stay (LOS) 3 days, median pathologic size 7.5 cm [9
]. Henderson, et al. documented oncologic outcomes comparable to open radical nephrectomy for 13 patients with T3b disease that underwent hand-assisted laparoscopic nephrectomy (HALN) [10
]. With median follow-up of 2.7 years, 3 of 12 patients developed metastatic disease without local recurrence. Perioperative outcomes were similar to Guzzo et al., with median operative time 176 min, EBL 250 ml, and LOS 3 days. Martin et al. reported 14 patients with mean follow-up of 32 months who underwent LRN for T3b disease with one conversion to open due to positive frozen section in the renal vein, and all without local recurrence 4 years later. Two patients with high-grade RCC and extracapsular extension developed metastatic disease. Mean operative time was 140 minutes, EBL 155 ml, LOS 2.9 days [11
]. Our pilot experience, with OR times ranging 132-171 minutes, EBL of 100 ml, and LOS 2-3 days is comparable with these reports. The issue of cosmesis is not addressed in depth in series of LRN for T3b tumors and we are unable to compare our incision sizes with these series.
We chose to proceed with a periumbilical approach. Indeed, while a Pfannenstiel incision has been reported upon for radical nephrectomy [12
], nephroureterectomy [12
], and donor nephrectomy [13
], we felt more comfortable with closer access to the renal hilum, adrenal and upper pole. Indeed, while a Pfannenstiel approach may offer some further advantages, we felt that upper pole retraction (for adrenal and bulky tumor dissection) may be more easily facilitated and the vascular dissection may more be readily approached peri-umbilically.
Safe, complete thrombectomy is facilitated by optimized exposure with meticulous dissection and identification of a transition point at the distal thrombus margin. Martin et al. described adding a hand-port for manual assistance when laparoscopic milking or determination of tumor thrombus margin was difficult [11
]. In our experience, addition of a fourth trocar and insertion of a laparoscopic paddle assists with bowel retraction for optimal vascular exposure. A long atraumatic bowel grasper may aid in milking the tumor thrombus away from the IVC and determining margin for venous ligation. On the right side, the stapler is placed flush against the IVC and on the left side, the stapler is placed distal to the transition point of the thrombus.
LESS-RN is a relatively new technique, and although initial results have been comparable to multi-site LRN [7
], a larger number of cases must be performed to establish whether LESS-RN is equivalent to multi-site LRN or open radical nephrectomy for RCC with renal vein thrombectomy. A small number of patients and relatively short length of follow-up limit our experience. At this time we would not recommend LESS-RN-RVT for tumors crossing midline or those associated with bulky lymphadenopathy. Furthermore, as this pilot series utilized carefully selected patients, and while we believe that application of the LESS platform to nephrectomy/thrombectomy is potentially more limited by the type of tumor as opposed to the BMI of the patient, patients who are profoundly obese would likely require a lateral shift in port placement. The technique of LRN with concurrent inferior vena cava (IVC) tumor thrombectomy has been demonstrated [14
]. This technique requires an additional 8 to 12 cm incision. Application of LESS technique may be adaptable to select LRN with IVC thrombectomy by extending the peri-umbilical midline incision made during LESS-RN cephalad, allowing adequate exposure for IVC thrombectomy. Lymph node dissection at the time of nephrectomy is a controversial topic and an area of renewed investigation. While a clear indication exists for excision of radiologically-identified lymphadenopathy, emerging data demonstrate that incidence of unsuspected lymph-node metastases is low (4.0%) and that no established survival advantage of a complete lymph-node dissection in conjunction with nephrectomy exists [15
]. As none of our cases demonstrated lymphadenopathy, lymphadenectomy at the time of nephrectomy was not performed. However, LESS-lymphadenectomy at the time of colectomy [16
] and retroperitoneal lymphadenectomy has been reported in the gynecological literature [17
], and we see no limitation to the accomplishing of this in the setting of nephrectomy, depending on lymph node location and bulk.
The main goal of cancer surgery is cure when possible. LESS parallels many advancements made by multi-site laparoscopy with quivalent operative outcomes to multi-site laparoscopy having been demonstrated in select patients. While cosmetic benefits have been demonstrated with the LESS platform, emerging data on other quality of life variables such as shortened length of stay and minimal analgesic requirement have also been reported [7
]. Our preliminary experience is consistent with these findings. One patient did not require opiates postoperatively, the other who was on baseline hydrocodone returned to preoperative analgesics within 23 hours; both resumed regular oral intake by 36 hours, and patient-1 and -2 were discharged home 57 hours and 81 hours after admission, respectively. No perioperative complications were encountered. Indeed, further reductions in recovery time and analgesic requirements may very well help improve quality of life in patients with advanced cancer, and in Case 2, the patient was able to start systemic targeted therapy 2 weeks postoperatively. However, further experience, and prospective comparison to multi-port laparoscopy is necessary to delineate the optimal utilization of LESS in the minimally invasive armamentarium.