Laparoskopik nefrektomide başlangıç deneyimlerimiz

Ali Rıza KURAL,Oktay DEMİRKESEN,Haluk AKPINAR,İlter TÜFEK,Veli YALÇIN,BURAK ÖZKAN

Özet

Günümüzde laparoskopik basit veya radikal nefrektomi, nefroüreterektomi, parsiyel nefrektomi uygun endikasyonlarla yaygın olarak uygulanmaktadır. Bu çalışmada da non-fonksiyone böbrek, böbrek tümörü ve üst üriner sistemde değişici epitel hücreli kanser nedeniyle kliniğimizde gerçekleştirilen laparoskopik böbrek cerrahisi ile ilgili başlangıç deneyimleri bildirilmektedir. Temmuz 2002-Haziran 2004 tarihleri arasında 42 laparoskopik nefrektomi gerçekleştirildi. Ortalama hasta yaşı 56.9 (27-88) olarak belirlendi. Non-fonksiyone böbrek nedeniyle 10 laparoskopik basit nefrektomi (LN), böbrek hücreli karsinom nedeniyle 21 laparoskopik radikal nefrektomi (LRN), 4 el-yardımlı laparoskopik radikal nefrektomi (EY-LRN), 3 el-yardımlı laparoskopik parsiyel nefrektomi (EY-LPN) ve değişici epitel hücreli karsinom nedeniyle 4 laparoskopik nefroüreterektomi (LNÜ) (1 el-yardımlı) gerçekleştirildi. Laparoskopik nefrektomiyle birlikte bir hastada semptomatik benin prostat hiperplazisine nedeniyle transüretral prostat rezeksiyonu, 1 hastada üretral darlık nedeniyle üretrotomi intern ve 2 hastada laparoskopik kolesistektomi eş zamanlı olarak gerçekleştirildi. Laparoskopik basit nefrektomi, el-yardımlı laparoskopik radikal nefrektomi, laparoskopik radikal nefrektomi, el-yardımlı parsiyel nefrektomi ve laparoskopik nefroüreterektomi için ortanca kan kaybı miktarları sırasıyla 150, 210, 200, 150, 150 ml olarak ölçüldü. Ortanca operasyon süreleri sırasıyla; 150, 210, 180, 180 ve 160 dk olarak hesaplandı. Ortanca hastanede kalış süreleri ise; 4, 3, 4, 4, ve 4 olarak belirlendi. Toplam 6 (%14) komplikasyon görüldü. İki hastada standart laparoskopiden el-yardımlı tekniğe geçiş, 1 hastada açık cerrahiye dönüşüm (el-yardımlı parsiyel nefrektomi uygulanan), eş zamanlı laparoskopik kolesistektomi yapılan bir hastada safra fistülü, 1 hastada ameliyat sırası kanama ve 1 hastada da mesane yaralanması saptandı. Hastalarımızın ortanca takip süresi 6 aydır (1-23). Tanı anında akciğer metastazı olan bir hasta dışında tüm hastalar lokal yada sistemik metastaz bulgusu olmadan takiplerine devam etmektedirler. Akciğer metastazı olan hasta ise operasyondan yaklaşık 9 ay sonra kaybedilmiştir. Laparoskopik nefrektomi (basit, radikal veya parsiyel) ülkemiz koşullarında da güvenli olarak uygulanabilen bir yöntemdir. İyi hazırlık ve hasta seçimi, ekip olarak çalışma gerekliliği ve farklı yöntemlerin (standart ve el yardımlı) uygulanabilir olması özellikle başlangıç döneminde dikkate alınması gereken unsurlardır.

Abstract

Introduction: Since the first laparoscopic nephrectomy was performed, laparoscopic nephrectomy for symptomatic benign renal pathology has been performed at multiple institutions. Based on the excellent results of laparoscopic simple nephrectomy for benign pathology, laparoscopic radical nephrectomy and nephroureterectomy for renal cell and transitional cell carcinoma are being studied as standard therapy at selected centers throughout the world. Due to this favorable experience with laparoscopic radical nephrectomy, laparoscopic partial nephrectomy is being performed for small renal cell carcinoma as an alternative to the open surgery. Current experiences suggest that, in comparison with open surgery, laparoscopic renal procedures for renal tumors allows a technically adequate operation with decreased patient morbidity while affording equivalent cancer control. Herein, we are reporting our initial experiences with laparoscopic nephrectomy in 42 cases. Materials and Methods: We have performed 42 laparoscopic nephrectomies between July 2002 and June 2004 at our institution. Mean patient age was 56.9 (27-88). 10 laparoscopic simple nephrectomy for non-functioning kidney, 21 laparoscopic radical nephrectomy and 4 hand-assisted laparoscopic radical nephrectomy for renal tumors, 3 hand-assisted laparoscopic partial nephrectomy for renal parenchymal tumors smaller than 4 cm and 4 laparoscopic nephroureterectomy (3 standard and 1 hand-assisted) for upper urinary tract transitional cell carcinoma were performed. Transurethral resection of prostate for symptomatic benign prostate hyperplasia in one, internal urethrotomy for urethral stricture in one and laparoscopic cholecystectomy in 2 patients were performed at the same time as additional procedures. Results: Median estimated blood losses were 150, 210, 200, 150 and 150 ml for laparoscopic simple nephrectomy, hand-assisted laparoscopic radical nephrectomy, laparoscopic radical nephrectomy, hand-assisted partial nephrectomy and laparoscopic nephroureterectomy respectively. Median operative times were 150, 210, 180, 180 and 160 minutes. Median hospital stays were 4, 3, 4, 4 and 4 days respectively. There were 5 complications, including intraoperative bleeding, one conversion to open surgery, two conversions to hand-assisted laparoscopy and one bile fistula at the patient whom laparoscopic cholecystectomy was performed at the same time. Because of intraoperatif bleeding one patient had gone to critical care unit for cardiovascular stabilization. Our median follow-up time for the patients was 6 months (range 1 to 23). All the patients except one who had pulmoner metastases at the time of diagnosis were alive and there were no evidence of local or systemic recurrence and also port site recurrence. The patient with the pulmoner metastases died 9 months after the surgery. Conclusion: The benefits of laparoscopy compared with open surgery include better intraoperative and postoperative outcome. In addition this technique maintains the same oncological principles used in open surgery and allows the specimen to be removed en bloc. However, the ultimate goal of minimally invasive surgery is to provide benefits equivalent to those of open surgery but that are associated with less morbidity. Using the hand-assisted laparoscopic technique surgeons can maintain traditional skills associated with tactile sensation. Urologist with laparoscopic experience can perform hand-assisted and standard laparoscopic nephrectomy safely and efficiently with minimal complication. Laparoscopic nephrectomy (simple, radical or partial) is a safe and an effective method that can be applied in our country. Preparation, patient selection, team-work and availability of different techniques (standard or hand-assisted) are the basic criteria that should be considered in the initial period of this method.