The presence of inflammation and fibrosis in benign renal conditions can make laparoscopic simple nephrectomy a technically challenging procedure. The operative times and the conversion rates to open surgery in these cases have been reported to be higher compared to those with noninflammatory renal conditions.6
Duarte et al7
retrospectively compared 50 laparoscopic simple nephrectomies for inflammatory causes (based on pathology) with 29 simple nephrectomies in noninflammatory kidneys. They found a significantly higher conversion rate to open surgery in the inflammatory kidneys (28% vs 3%) as well as a higher transfusion rate (12% vs 0%). The length of hospital stay for patients undergoing simple laparoscopic nephrectomy in patients with inflammatory conditions was longer than that with noninflammatory conditions (8.3 vs 3.2 days).
Wolf et al8
were the first to compare patients undergoing hand-assisted versus standard laparoscopic nephrectomy. In patients with inflammatory renal conditions, they found that the mean operative times for hand-assisted laparoscopic nephrectomy were significantly shorter than with standard laparoscopic nephrectomy (229 vs 348 minutes).
They also found no significant difference in the time to resumption of oral intake, length of hospital stay, analgesic requirements, and pain score between the standard and hand-assisted laparoscopic nephrectomy groups.
Tan et al9
present the only other HALSN series in the literature. Their series compared 22 cases of HALSN of inflammatory renal causes to 24 patients who underwent HALRN for renal tumor. Patients undergoing HALSN for inflammatory renal conditions had a 45% complication rate (15% major complications, 30% minor complications). The major complications consisted of conversion to open surgery for bleeding, an intraoperative diaphragm injury that was recognized and fixed laparoscopically, and a death due to postoperative gastrointestinal bleeding in a patient with gastroduodenal ulcers in a setting of Zollinger-Ellison syndrome. The minor complications included ileus, pneumonia, mild pancreatitis, temporary renal impairment, and venous thrombosis of an upper extremity. In comparison, patients undergoing HALRN had a 21% complication rate (13% major, 8% minor). The mean length of hospital stay was 7.2 days vs 4.7 days for the inflammatory versus renal tumor group.
Our study showed that HALSN for inflammatory renal conditions has comparable outcomes to those with hand-assisted laparoscopic nephrectomy for renal tumors. Both the HALSN and HALRN had similar complication rates (both major and minor complications), only one patient undergoing HALSN underwent conversion to open surgery compared to no conversions to open in the HALRN group, and no patients in either group required a transfusion. The analgesic requirements for both groups were similar. The combination of a higher number of patients in the HALSN group with previous abdominal surgery (12 vs 5 patients) and the inflammatory renal cause may account for the larger number of patients with postoperative ileus in the HALSN group (4 vs 2 patients) and the longer length of hospital stay in these patients. The rate of conversion to open in our study is slightly better and our complication rates are comparable to those of other contemporary laparoscopic simple nephrectomy series. ()
Despite our comparable complication rates to rates of other series, it is important to recognize that our HALSN series was performed by 3 experienced laparoscopic surgeons. We urge caution in proceeding with more challenging cases in those with less laparoscopic experience.
Comparison of Different Techniques for Laparoscopic Simple Nephrectomy
Other studies have shown significantly higher operative times in patients undergoing simple nephrectomy for inflammatory renal conditions compared to standard nephrectomy. The overall operative times for patients in our study undergoing HALSN was longer than that for HALRN, though the difference was not statistically significant (301 vs 286 min; P=.54). The operative time for both groups in our series may be due to a number of different factors. The measurement of overall operative time in the medical records included both anesthesia and operative times. The operating room setting for the cases performed were in a training institution, so both the anesthesia time and operative times may be increased due to teaching residents throughout these cases. There was variability between the overall operative times in this study. The average overall operative time for one surgeon in the study was 384 minutes (15 cases), while the average overall operating room time for the remaining 2 surgeons (18 cases) was 232 minutes. The overall estimated blood loss was relatively low, and this may be due to more meticulous dissection in some cases. Finally, it should be noted that though there was no difference in the BMI between groups, both patient populations were obese (BMI>30kg/m2), which may increase anesthesia time (difficult intubation), time for positioning, as well as operative time (increased time for dissection) in both groups.