British Journal of Urology (1998), 82, 615–618

A review of our first 100 cases of laparoscopic nephrectomy:defining risk factors for complicationsF.X. KEELEY and D.A. TOLLEYScottish Lithotriptor Centre, Western General Hospital, Edinburgh, UK

Objective To present the complications from our first staghorn calculi, polycystic kidney disease, and xan-thogranulomatous pyelonephritis. While there was no100 cases of laparoscopic nephrectomy, a technically

demanding procedure requiring lengthy experience, discernible decline in the decrease in complicationswith experience, operative duration decreased from aand to define the risk factors.

Patients and methods Indications for laparoscopic neph- mean of 204 min for the first 20 cases to 108 min forthe last 20. Complications and conversions were morerectomy included patients requiring nephrectomy for

benign pathology and those requiring nephroureterec- closely associated with diagnosis than with the sur-geon’s experience.tomy for upper tract transitional cell carcinoma con-

fined to the upper ureter and/or renal pelvis. All Conclusion Laparoscopic nephrectomy and nephrouret-erectomy can be undertaken for a variety of indicationspatients were operated on by one surgeon (D.A.T.) via

a transperitoneal route and data on diagnosis, out- with reasonable complication and conversion rates.Although inflammatory conditions increase the diB-come and complications collected prospectively.

Results The overall complication rate was 18%, of which culty of these procedures, we feel that patients requir-ing nephrectomy for benign disease should be oCered3% were major and 15% minor complications. Five

cases were converted to open surgery electively. a trial of laparoscopic surgery.Keywords Laparoscopy, nephrectomy, complicationsComplications and conversions were associated with

a history of pyonephrosis, previous renal surgery,

Several risk factors have been associated with compli-Introduction

cations and conversions. In a large multicentre study,laparoscopic tumour nephrectomy had a higher compli-Laparoscopic nephrectomy is a demanding procedure

requiring extensive experience. Several investigators cation rate than laparoscopic simple nephrectomy [4].In addition, complications were most likely to occur inhave noted the advantages to the patient inherent in

the laparoscopic approach, including less need for post- the first 20 cases, suggesting that this reflected suBcientexperience and training to minimize the rate. We presentoperative narcotics and a faster return to normal activi-

ties [1,2]. We previously reported that laparoscopic the complications from the first 100 cases at our insti-tution, all performed by one surgeon, and attempt tonephrectomy and nephroureterectomy compare well

with the open procedures in terms of overall morbidity, identify risk factors for complications and for conversionto open surgery.length of stay and operative duration [3]. Laparoscopic

nephrectomy also compares well with open nephrectomyin terms of cost, as measured in the UK National Health

Patients and methodsService [2].

The complications reported for laparoscopic nephrec- Between September 1992 and March 1997, 100 patients(38 male, 62 female; mean age 50.5 years, range 15–91)tomy are generally similar to those of open nephrectomy,

but a few are unique to the laparoscopic approach, underwent laparoscopic nephrectomy (n=79) ornephroureterectomy (n=21) at our institution. The indi-including injuries related to trocar placement, and

carbon dioxide retention or embolization. In addition, cations for nephrectomy are listed in Table 1. Our policyhas been to oCer a trial of laparoscopy to all patientsthe technical diBculty of laparoscopic nephrectomy has

led to musculoskeletal injuries related to prolonged oper- with benign pathology, including those with inflamma-tory conditions and previous surgery. We have alsoation [4].oCered laparoscopic nephroureterectomy to patients withTCC in the upper ureter and/or renal pelvis. All theAccepted for publication 7 June 1998

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616 F.X. KE ELEY and D.A. TOL LEY

Table 2 Minor complicationsTable 1 Indications for nephrectomy; some patients had more thanone indication

Complication n Treatment Risk factorsIndication n

Fever 4 Antibiotics Polycystic kidneydisease (1); staghorn (2)Pyelonephritis 26

Pelvi-ureteric junction obstruction, poor function 21 Wound 3 Drainage, Open and percutaneousinfection antibiotics stone surgery (1);Transitional cell carcinoma 21

Stones pyonephrosis (1);XGP(1)Not staghorn 12

Staghorn 7 Pulmonary 1 Diuresis History of congestiveoedema heart failureReflux 9

Pyonephrosis 6 Pneumonitis 2 Antibiotics 91 years old (1);staghorn (1)Hypertension 6

Renal cell carcinoma 3 Duodenal 1 Conservative NonehaematomaPolycystic kidney disease 2

Xanthogranulomatous pyelonephritis 2 Urinary 2 Catheterization Noneretention

Ileus 2 Conservative NoneTotal 15present patients were operated on by one surgeon

(D.A.T.).The steps of the technique used for laparoscopic neph-

rectomy were: the patient is placed in the flank position, caval injury, that was treated by open repair. The thirdpatient, aged 77 years, had a history of obesity, coronarythe first trocar placed at the edge of the rectus level with

the umbilicus, and the second and third trocars placed artery disease and transient ischaemic attacks. He under-went nephroureterectomy lasting 180 min for renalin an anterior axillary line. The colon is reflected

medially, Gerota’s fascia entered and when required, a pelvic TCC, which had previously been resected percu-taneously. Postoperatively, he developed a haematomafourth trocar is placed in the mid-axillary line. The hilum

is dissected while the kidney is retracted laterally. in the renal bed, a bleeding diathesis and a fatal myocar-dial infarction 3 days after surgery.Endoclips are used for the artery and EndoGIA staples

(Autosuture Inc, USA) for the vein. Peri-renal dissection Ten patients required transfusions; the number ofunits transfused per procedure was 0.38. There was oneis used to free the kidney and the ureter divided last.

The specimen is then removed in an organ-retrieval bag. complication with a delayed presentation, in a patientwho presented with a superficial wound infectionInitial access to achieve pneumoperitoneum was per-

formed under direct vision, using the Hasson technique, 12 days after surgery. There were no intra-operativeport-related complications and no injuries to bowel.to minimize the risk of injury from the Veress needle.

For nephroureterectomy, the initial step was to resect Compared with a contemporary series of open nephrec-tomies performed for benign indications at our insti-the ureteric orifice transurethrally. After repositioning

the patient, the ureter was clipped before laparoscopic tution, the complication (18% vs 28%) and transfusionrates (0.38 vs 0.89 units per procedure) were lower fordissection of the kidney and ureter, which were removed

intact by extension of the inferior port site. laparoscopy [3].Patients with minor complications had a similar meanData were collected prospectively; the clinical records

of all patients were reviewed, noting either complications operative duration (141 vs 143 min) but a longer hospi-tal stay (6.2 vs 4.8 days) than patients with no compli-or conversion to open surgery, to identify any potential

risk factors. cations. In contrast, patients who required conversionto open surgery or who had a major complication hada longer mean operative duration (315 min) and length

Resultsof stay (11.8 days).

The complication rate was similar for both laparo-The overall complication rate was 18% (Table 2), ofwhich 3% were major and 15% minor. Three patients scopic nephrectomy (17.5%) and nephroureterectomy

(18%). However, when patients with inflammatory con-had major complications; the first, aged 59 years, hadbilateral TCC and a previous history of percutaneous ditions such as pyonephrosis, staghorn calculi, xanthog-

ranulomatous pyelonephritis (XGP) and those withresection, underwent nephroureterectomy, and sus-tained an aortic injury, treated by open repair. The previous renal surgery were excluded, there was a higher

incidence of minor complications and conversions tosecond, aged 52 years, had hypertension and no renalfunction, underwent nephrectomy, sustained a vena open surgery (Table 3). All but one of the local infectious

© 1998 British Journal of Urology 82, 615–618

LAPAROSCOPIC NEPHRE CTOMY 617

Table 3 Conversions and complications in patients with transitional The eCect of experience was more evident in the decreas-cell carcinoma and inflammatory conditions, compared with ing operative duration (Table 4).those without

Indication Discussion

There were 18 complications and five elective conver-BenignVariable TCC no inflammation +inflammation sions in this series of 100 patients undergoing laparo-

scopic nephrectomy and nephroureterectomy. Our policyn 21 37 42 has been to oCer a trial of laparoscopy to all patientsMean age (years) 66 36 52 with benign conditions and selected patients with TCC.Operative 171 128 164 The series included 42 patients with a variety of inflam-duration (min)

matory conditions, e.g. XGP, pyonephrosis and previousLength of stay (days) 7.95 4.37 5.12surgery, all of which proved to be significant risk factorsConversion, n (%) 0 0 5 (12)for complications and conversion to open surgery.Complications, n (%)

Major 2 (10) 1 (3) 0 Nevertheless, we believe that the overall benefits of aMinor 2 (10) 4 (10) 9 (21) laparoscopic approach usually outweigh the risks, even

in this diBcult group of patients. We do not presentlyoCer laparoscopic nephrectomy to patients with sus-pected RCC or XGP.

complications occurred in this group of patients. Overall,Several technical points should be detailed for the

29 of 42 patients with inflammatory conditions (69%)avoidance of complications: strict attention to basic

underwent laparoscopic nephrectomies without compli-surgical principles; trocars should be placed under direct

cation or conversion to open surgery, compared withvision; extra care should be taken to avoid even minor

87% in those patients without these risk factors. Thehaemorrhage, as blood in the field obscures vision dra-

mean operative duration was longer in the inflammationmatically; the renal hilum should be approached before

group, but the mean length of stay was only marginallyperirenal or ureteric dissection if at all possible; adequate

longer (Table 3).exposure and retraction are essential; early conversion

In addition to the two cases of vascular injury notedto open surgery for failure to progress; appropriate

earlier, five cases were electively converted to openselection of patients, including preoperative CT in

surgery; four for failure to progress (two with staghornpatients with suspected XGP or known upper tract TCC,

calculi/pyonephrosis, one with locally advanced TCCto exclude tumour extension; and finally, a regular team

and one with XGP), and one to remove a large polycysticof surgeons and nurses, to reduce unnecessary delays

kidney, where entrapment of the kidney failed. All casesand frustration.

requiring elective conversion were in patients withThe present complication and conversion rates are

underlying inflammatory conditions or previous surgery.broadly similar to those published previously.

Even with accumulating experience, there was noComplication rates in the largest reported series were

discernible trend over time in complications and conver-2.8–37% [1,5] and conversion rates 2.8–10.3% [6,7].

sions (Table 4), with the exception of the last 20 cases,Gill et al. [4] reported a 6% rate of conversion to open

which we attribute to the relative paucity of inflamma-surgery and a 16% rate of complications in a multi-

tory conditions in this group of patients (three of 20).institutional study. Complications in that series tendedto occur in the first 20 cases and were more common

Table 4 The number of conversions and complications, and the in patients undergoing laparoscopic radical nephrec-mean operative duration in successive groups of 20 patients tomy. Rassweiler et al. [7] recently reported a 5.8%

complication rate and a 10.3% rate of conversion toGroup of 20

open surgery. However, a more detailed analysis of theseseries is limited by their multi-institutional nature, givenVariable 1 2 3 4 5the wide range of operative techniques used.

The nature of complications encountered in the pre-Complication (n)sent series was similar to that of other series [1,4,7–9],Major 1 0 1 1 0

Minor 3 3 4 3 1 with a few minor exceptions. We encountered no bowelConversion (n) 1 1 2 1 0 injuries or intra-operative complications related to trocar

access, which we attribute to our use of the open-accessOperative 204 153 158 130 108duration (min) (Hasson) technique and strict adherence to basic surgical

principles. In addition, there were no postoperative

© 1998 British Journal of Urology 82, 615–618

618 F.X. KE ELEY and D.A. TOL LEY

musculoskeletal complications, possibly because of the Referencesshorter operative duration. There were several minor 1 Kerbl K, Clayman RV, McDougall EM et al. Transperitoneal

nephrectomy for benign disease of the kidney: a comparisoninfectious complications in patients with a history ofof laparoscopic and open surgical techniques. Urologystaghorn calculi, XGP and pyonephrosis, despite the1994; 43: 607–13prophylactic use of broad-spectrum antibiotics. Perhaps

2 Wilson BG, Deans GT, Kelly J, McCrory D. Laparoscopicthis can be attributed to the limited irrigation of thenephrectomy: initial experience and cost implications. Broperative field through the laparoscopic approach.J Urol 1995; 75: 276–80The relatively long operative duration reported by

3 Sharma NK, Stephenson R, Tolley DA. Should laparoscopicmost investigators [1,6,10] for laparoscopic nephrectomy

nephrectomy/nephroureterectomy be the preferred treat-and nephroureterectomy has been used by critics to ment option for most renal pathology? A comparativeargue against the widespread adoption of these tech- study. J Urol 1996; 155: 491A, abstract 722niques. The present mean duration was 153 min, which 4 Gill IS, Kavoussi LR, Clayman RV et al. Complications ofcompares well with a contemporary open surgical series laparoscopic nephrectomy in 185 patients: a multi-

institutional review. J Urol 1995; 154: 479–85[3]. The current mean is 111 min in our last 40 cases.5 Fahlenkamp D, Turk I, Degar S, Loening SA. ComplicationsBy maintaining the operative duration in line with that

of laparoscopy, observations after 903 cases. J Urol 1997;for open surgery, we support those reports rating laparo-157: 140A abstract 547scopic nephrectomy as less expensive than open nephrec-

6 Ono Y, Katoh N, Kinukawa T, Matsuura O, Ohshima S.tomy [2].Laparoscopic radical nephrectomy: Nagoya experience.As shown in Table 4, increased experience shortensJ Urol 1997; 158: 719–24

operative duration but does not necessarily reduce com-7 Rassweiler JJ, Fornara P, Fahlenkamp D et al. Laparoscopic

plication and conversion rates, which appear to be more nephrectomy — the Austro-German experience. J Urolclosely related to the patient’s underlying disease process. 1997; 157: 403A abstract 1582Most of these complications were minor and had little 8 Cadeddu JA, Regan F, Kavoussi LR, Moore RG. The role ofor no eCect on the patients’ recovery. Peters [11], in a computerized tomography in the evaluation of compli-

cations after laparoscopic urological surgery. J Urol 1997;survey of the laparoscopic experience of paediatric col-158: 1349–52leagues, reported that complication rates diminished

9 Eraky I, El-Kappany HA, Ghoneim MA. Laparoscopicsignificantly only after 100 cases. Given the greaternephrectomy: Mansoura experience with 106 cases. BrdiBculty involved in performing laparoscopic nephrec-J Urol 1995; 75: 271–5tomy compared with diagnostic laparoscopy, a longer

10 McDougal EM, Clayman RV, Elashry OM. Laparoscopicperiod of training and experience should perhaps beradical nephrectomy for renal tumor: the Washington

expected. This requirement for extensive experience ofUniversity experience. J Urol 1996; 155: 1180–5

laparoscopic nephrectomy may have contributed to earl- 11 Peters CA. Complications in pediatric urological laparos-ier reports which tended to overestimate its cost [12] copy: results of a survey. J Urol 1996; 155: 1070–3and may mask some of its inherent advantages [13]. 12 Winfield HN, Rashid TM, Lund GO, Troxel SA, Donovan

Laparoscopic nephrectomy can be performed safely JI. Comparative financial analysis of laparoscopic versusopen nephrectomy. J Urol 1994; 151: 342A abstract 460and eBciently, but thus far has been limited to few

13 Gill IS, Clayman RV, McDougall EM. Advances in urologicalreferral centres. The way forward is to simplify thelaparoscopy. J Urol 1995; 154: 1275–94techniques and improve training, thereby making it

14 Keeley FX Jr, Sharma NK, Tolley DA. Hand-assistedmore accessible to the general urologist. To this end,laparoscopic nephroureterectomy. J Urol 1997; 157: 399Ahand-assisted laparoscopy may bridge the gap betweenabstract 1565the experts and the novice by reducing the necessary

experience required [14].

Authors

F.X. Keeley Jr, MD, Endourology Fellow.AcknowledgementsD.A. Tolley, MBBS, FRCS, Consultant Urologist and Director.

The authors acknowledge the contributions of Mr Correspondence: Mr D.A. Tolley, Scottish Lithotriptor Centre,Richard Stephenson, Mr Neerja Sharma and Dr Michael Western General Hospital, Crewe Road, Edinburgh EH4 2XU,

UK.Chrisofos.

© 1998 British Journal of Urology 82, 615–618