8 Morcellation or Intact Extraction in Laparoscopic Radical Nephrectomy

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Contents

Introduction 213 Histological Aspect 213

Operative Procedures: Intact Removal, Fractionation and Morcellation 214

Entrapment of Dissected Specimen 214 Intact Removal 216

Morcellation 216 Fractionation 216

Benefits and Risks of Each Method 216 Future Aspects 218

References 218

Introduction

Laparoscopy provides for the dissection of diseased tissue or organs with the same beneficial results for both benign and malignant disease as in open surgery while not deteriorating the patient's quality oflife.

The laparoscopic procedure has a minimally invasive nature; it does not require a long incision, offers less postoperative pain, and earlier convalescence and recovery to normal activity. Extraction ofthe dissected organ was initially a troublesome issue since intact removal required an additional incision that could compromise the nature oflaparoscopy. This was resolved by morcellation and removal ofthe dissected organ without an additional incision, as developed by Clay- man et al. [1]. However, in oncological surgery the dissected organ must be removed from the body for a complete cure as well as for an accurate pathological diagnosis. So, while intact removal requires an additional incision but provides an accurate diagnosis, morcellation removal provides minimal invasiveness but precludes an accurate diagnosis.

Extraction ofthe dissected specimen is one ofthe controversies in urologic laparoscopy for malignant diseases, especially for renal cell carcinomas. In laparoscopic nephroureterectomy for transitional cell car-

cinoma ofthe kidney and ureter, the intact removal of the specimen has been the general procedure since morcellation or fractionation of the dissected specimen provides the histology ofthe tumor but obfus- cates the pathological staging which significantly in- fluences any decision for further treatment. Intact extraction has also been used generally in laparoscopic radical prostatectomy for prostate cancer. Since the dissected specimen is small in size, an additional incision is not required for its removal. In prostate cancer, pathological findings play a significant role in the decision for further treatment for transitional cell carcinoma ofthe upper urinary tract. In laparoscopic radical nephrectomy for renal cell carcinomas, the dissected specimen is large, 12´8´6 cm in size, and requires at least a 6- to 7-cm-long additional incision for intact removal, which could compromise the nature oflaparoscopy. Morcellation removal, however, does not provide an accurate pathological staging.

Histological Aspect

In the early period oflaparoscopic radical nephrectomy for renal cell carcinomas, we extracted the specimen intact through an additional 5-cm-long incision between two ports. This provided a complete pathological examination indicating both the histology of the tumor and an accurate pathological stage ofdis- ease and possibly prevented tumor spillage into the working space and port sites [2]. Clayman and colleagues also used intact removal for laparoscopic radical nephrectomy [3]. In the late 1990s, Clayman and colleagues, and Barrett et al. adopted morcellation ofthe dissected specimen for extraction without an additional incision [4, 5]. This did not deteriorate the minimally invasive nature oflaparoscopy, but, however, had the risk ofdissemination ofthe tumor cells into the working space and their seeding to the port

8 Morcellation or Intact Extraction in Laparoscopic Radical

Nephrectomy

Yoshinari Ono, Yohei Hattori

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sites. Some authors reported tumor recurrence in the working space and port sites [6, 7]. Rassweiler et al.

applied fractionation removal of the dissected kidney from the working space without an additional incision [8]. We also adopted fractionation removal for the kidneys with a less than 5-cm-diameter disease, but intact removal for the kidneys with disease that is 5 cm or more in diameter [9]. Fractionation ofthe kidney into 10±15 pieces also has the risk ofdissemination oftumor cells into the working space and of seeding to the port site, but provides a pathological staging without an additional incision in small disease. On the other hand, Abbou et al., Janetschek et al. and Gill et al. used intact removal in laparoscopic radical nephrectomy for renal cell carcinomas [10±12].

Operative Procedures: Intact Removal, Fractionation and Morcellation

Entrapment of Dissected Specimen

The first step for removal is entrapping the dissected specimen. For intact removal, LapSac (Cook Urologi- cal Inc. Spencer, IN, USA) and Endocatch II (US Sur- gical, Norwalk, CT, USA) are used as devices for entrapment. LapSac is a reinforced nylon pouch with an integral polyurethane inner coating, impermeable, very strong, and comes in four different sizes, from 2´5 to 8´10 in. [13]. An 8´10 inch sack is usually used. For both fractionation and morcellation re-

moval, double LapSac sacks, in which one sack is placed inside the other, are used to contain any damage caused by the morcellator or scissors. The mouth ofthe LapSac sack is equipped with a hydrophilic guidewire (Terumo Co., Tokyo, Japan) and can open wide in the working space because ofits inherent elas- ticity. The dissected specimen is then easily manipu- lated into the sacks, the mouth pulled out through the

Fig. 1. Double LapSac equipped with hydrophilic guidewire at the mouth

Fig. 2. The mouth is pulledout through the original incision for the first port

Fig. 3. The dissected specimen was moved on the liver in right nephrectomy

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original first port incision and the guidewire removed [9, 14] (Figs. 1±6). Endocatch II is used for intact removal ofthe dissected specimen and is placed into the working space through a 15-mm-diameter port.

By pushing the handle, the mouth ofthe sack is opened wide and the dissected specimen is easily ma- nipulated into the sack. After entrapping the specimen, the mouth is closed by pulling the handle. The sack with the intact specimen is then removed through the additional incision (Figs. 7, 8).

Fig. 4. The dissected kidney is maneuvered into a double LapSac equipped with a hydrophilic guidewire that opens the mouth of the sacks in the working space

Fig. 5. Entrapment of the dissected specimen

Fig. 6. The mouth is closedby pulling the hydrophilic guidewire after entrapment of the specimen

Fig. 7. Endocatch II

Fig. 8. The mouth of Endocatch II is opened and the specimen is entrappedinto the bag

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Intact Removal

The sack with the intact dissected specimen is taken out through an additional 5- to 7-cm-long incision between the two ports or by extending the original trocar incision [12, 15]. The incision length depends on the size ofthe dissected specimen. A muscle-slitting incision is recommended for an earlier recovery (Fig. 9).

Morcellation

The mouth ofthe double LapSac sacks is pulled out through the original trocar incision after the trocar and sutures are removed. An electric tissue morcellator in combination with a vacuum (Cook Urological Inc. Spencer, IN, USA) is introduced through the mouth ofthe specimen-containing sacks and the specimen is morcellated and aspirated from within the sacks [1, 13] (Figs. 10, 11). The empty sacks are then removed. This is completed without an additional incision and takes less than 15 min.

Fractionation

The mouth ofthe sacks is also pulled out through the original trocar incision after the trocar and sutures are removed. The original incision and skin are cov- ered by a drape. The specimen is cut into 10±15 pieces within the sacks using a Kelly clamp through the mouth ofthe sacks under direct vision. The small pieces are taken out ofthe sacks, and the sacks are re-

moved through the original incision [9]. This takes 15±20 min (Fig. 12).

Benefits and Risks of Each Method

Intact removal provides for a complete pathological examination indicating important information such as the histology, staging, positive/negative margin and positive/negative vascular and lymphoid invasion. In- tact removal is time-saving, with less risk oftumor dissemination into the working space and tumor im- Fig. 9. The specimen removedby intact removal

Fig. 10. Morcellator

Fig. 11. Use of morcellator

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plantation at the port sites, but requires an additional incision, which might compromise the nature oflaparoscopy. However, we reported a comparison ofpost- operative incisional morbidity between intact removal and fractionation removal in 60 patients treated with laparoscopic radical nephrectomy [9, 15]. Intact removal was performed on 26 patients undergoing a transperitoneal approach (Group I; n=11) and a retroperitoneal approach (Group II; n=15), and fractionation removal was done in the remaining 34 patients undergoing fractionation specimen removal after transperitoneal laparoscopic radical nephrectomy (Group III). Postoperative dosage ofanalgesics for the initial 4 days was 41 mg, 29 mg, and 29 mg, and con-

valescence was 22.4 days, 22.7 days, and 23.3 days, respectively. There was no significant difference between the intact removal group and fractionation removal group. Gill et al. referred to our data and described no apparent significant difference in patient morbidity between intact extraction and morcellation or fractionation [12]. On the basis ofthese findings, they now use intact extraction in laparoscopic radical nephrectomy. To minimize cosmetic morbidity, they cur- rently remove the specimen through a muscle-splitting low Pfannenstiel incision located at or below the pubic hair line in male patients and through the vagina in female patients (Table 1).

Morcellation removal provides extraction ofthe dissected specimen without the additional incision that might compromise the less invasive nature oflaparoscopy, but offers only limited pathological findings in terms ofthe histology and grade ofthe tumor cells, and no information indicating stage, margin, and vascular and lymphoid invasion. Other risks are tumor dissemination into the working space and tumor im- plantation at the port sites. Clayman and his colleagues and Barrett et al. adopted a tissue morcellator for removal ofthe specimen with no incision [4±7, 16, 17]. Dunn and Clayman analyzed data of61 patients undergoing laparoscopic radical nephrectomy and demonstrated that there was a definite trend toward higher analgesics use in the intact removal group and a slightly longer hospital stay [4]. Walther and Clay- man analyzed the data of11 patients undergoing laparoscopic cytoreductive nephrectomy and demonstrated reduced postoperative analgesics and shorter hospital stay for morcellated-kidney patients com- pared with those who had undergone intact removal Fig. 12. The specimen removedby fractionation removal.

The tumor mass is intact andavailable for pathological examination

Table 1. Operative outcome of laparoscopic radical nephrectomy No.patients Removal of

specimen Operation

time Blood loss Conversion Complication Return to Normal Activity

Barrett et al. [5] 72 Morcellation 2.9 h (±) 6 (8%) 2 (3%) (±)

Dunn et al. [4] 61 Intact/

morcellation 5.5 h 172 ml 2 (3%) 21 (34%) 25 days

Abbou et al. [10] 50 Intact 2.3 h 150 ml 3 (6%) 4 (8%) 19 days

Janetschek et al. [11] 73 Intact 2.4 h 168 ml 0 (0%) 9 (12%) (±)

Gill et al. [12] 100 Intact 2.8 h 212 ml 2 (2%) 14 (14%) 29 days

Chan et al. [17] 67 Intact/

morcellation 4.3 h 289 ml 1 (2%) 10 (15%) (±)

Our series 252 Intact/

fractionation 4.5 h 300 ml 10 (4%) 36 (14%) 23 days

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[16]. Clayman and his colleagues described that for these patients, intact removal and pathological stage would only be ofvalue ifadjuvant therapy were planned, which is not the case for renal cell carcinomas at present. They offer a purer laparoscopic approach and morcellate the specimens. Chan and Ka- voussi also reported the outcome oftheir 61 renal cell carcinoma patients who underwent laparoscopic radical nephrectomy, and described that 40 patients underwent morcellation removal and the remaining 27 patients underwent intact removal [17]. They described that two ofthe 40 morcellated specimens in- volved stage pT3 disease, while one tumor each with perinephric fat and intrarenal renal vein invasion in- volved stage pT3a and pT3b disease, respectively, and morcellation may be performed under direct vision.

When accurate pathological staging is desired, specimens can be removed intact through an additional incision.

Another risk ofmorcellation is tumor spillage. Fen- ti and Barrett, however, reported that of85 patients no dissemination occurred in the working space in the one patient who had seeding oftumor cells at the port site [5, 6]. Fugita et al. also observed one patient who had port site seeding after morcellation removal in laparoscopic radical nephrectomy for renal cell carcinoma [7]. However, Dunn et al. described no dissemination in the working space or seeding to the port sites in the 39 morcellation patients, and Chan et al. also described no dissemination or seeding in 40 morcellation patients [5, 17].

Fractionation removal also provides extraction with no additional incision, and the possibility ofa pathological examination indicating stage, margin, and vascular and lymphoid invasion as described later. How- ever, there is the risk ofthe dissemination oftumor cells into the working space and their seeding to the port sites. We have used fractionation of specimens for 93 patients with less than a 5-cm-diameter tumor since January 1997 [9, 18±20]. Neither seeding ofthe tumor cells at the port sites nor dissemination in the working space was found. In addition, no damage to the sacks was caused by the Kelly clamp. As to the pathological examination ofthe specimen removed by fractionation, a histopathological examination was possible ofall 93 specimens in our series. Six patients were indicated as having pathological 3a disease and diagnosed as having clinical T1N0M0 disease [19].

Fractionation removal often provided intact tumor mass in patients with less than 5-cm-diameter tumors.

Future Aspects

Since the first success of laparoscopic radical nephrectomy for renal cell carcinoma in 1992, the procedure has been performed worldwide in over 2,000 patients with renal cell carcinomas. It is still unclear whether intact removal or morcellation/fractionation removal is better for patients undergoing laparoscopic radical nephrectomy. The controversy will continue until a new ideal extraction method is developed. At the present time, extraction ofthe dissected specimen is the surgeon's preference.

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