Complications

Numerous studies regarding open nephron-sparing surgery present data on technical and renal-related complications secondary to partial nephrectomy (Table 5) (76,77). Urinary fistula is the most frequent complication following nephron-sparing surgery. Other complications include hemorrhage, ureteral obstruction, and acute or chronic renal insufficiency. Corman et al. (78) compared complications after open radical (n = 1373) and open partial (n = 512) nephrectomy. Analyzing surrogate-to-complication morbidities (progressive renal insufficiency, acute renal failure, UTI, prolonged ileus, postoperative transfusion requirement, and deep wound infection), no significant differences were detected (p = 0.58) between radical nephrectomy and nephron-sparing surgery in specific complication rates (Table 6).

The most common complications of laparoscopic partial nephrectomy include intraoperative or delayed hemorrhage, urine leak, and open conversion (Table 7). In the first 200 consecutive patients undergoing laparoscopic partial nephrectomy from August 1999 to January 2003 at the authors' institute (80), perioperative complications occurred in 66 patients (33%). Open conversion was required in two patients (1%) due to dense postsurgical adhesions (one), and persistent bleeding secondary to inadequate renal hilum clamping (one). Reoperative laparotomy was necessary in four patients (2%) for delayed hemorrhage after discharge (two), ischemia of the colon (one), and leakage from the ileoileal anastomosis in one patient undergoing laparoscopic ileal ureter for inadvertent ureteral injury during laparoscopic partial nephrectomy. Overall, hemorrhagic complications (Table 8) occurred in 19 patients (9.5%), of whom 18 required blood transfusion. Intraoperative hemorrhages (n = 7; 3.5%) were due to bulldog malfunction (three), Satinsky clamp malfunction (one), systemic coagulopathy (one), or inadequate control of multiple renal arteries (two). Intraoperative hemorrhage was managed with laparoscopic parenchymal suturing in five patients, laparoscopic radical nephrectomy in one patient with normal contralateral kidney, and emergent open conversion in one patient. Four patients (2%) developed postoperative bleeding from the partial nephrectomy bed at a mean interval of two days; all responded to conservative management. Delayed hemorrhagic complications after hospital discharge occurred in eight patients (4%) at a mean interval of 16 days (range, 6-30). Etiology of the delayed hemorrhage included vigorous exercise (one), accidental fall (one), coagu-lopathy (one), systemic heparinization (one), intraoperatively unrecognized splenic tear (one), or unknown (three). Patients with delayed hemorrhage were treated conservatively (four), or with percutaneous selective angioembolization (two); two patients underwent explorative laparotomy. Urinary leak occurred in nine patients (4.5%), eight (89%) of whom had intraoperative suture repair of pelvicalyceal entry during laparo-scopic partial nephrectomy. Management included J-stenting in six patients, J-stent-ing and CT-guided drainage in two patients, or conservatively in one patient. Other urological complications occurred in 4.5% of patients and included transient renal

TABLE 5 ■ Open Partial Nephrectomy: Complications

Total no. of

Urinary

Bleeding

Acute

Perioperative

Reoperation

Author

patients

fistula (%)

(%)

hemodialysis (%)

deaths (%)

(%)

Marberger et al. (19)

72

6.5

4.3

4.3

2.2

2.2

Petritsch et al (73)

120

-

-

0.8

1.7

-

Morgan and Zincke (21)

104

3.3

1.1

1.1

2.2

-

Steinbach et al. (22)

140

2.1

1.4

-

1.4

1.4

Moll et al. (23)

152

6.7

3.7

-

-

0.6

Campbell et al. (74)

259

17.4

2.3

4.9

1.5

3.1

Polascik et al. (75)

67

9

0

0

1.5

0

Lerner et al. (10)

169

1.8

-

0

0.6

1.8

Belldegrun et al. (14)

146

1.4

2.1

-

2.1

2.1

Ghavamian et al. (28)

76

2.6

1.3

1.3

-

9.2

Source: From Ref. 41.

Source: From Ref. 41.

TABLE 6 ■ Comparison of Complications Between Open RN and Open NSS

Author

Total no. of pts

Open NSS: no. of compl. (%)

Open RN: no. of compl. (%)

p Value

Uzzo et al. (76)

80

4 (8%)

2 (7%)

>0.05

Lee et al. (15)

262

9 (11%)

25 (14%)

0.62

Lau et al. (16)

328

11 (6.7%)

10 (6%)

NS

Corman et al. (78)

1885

146 (10.5%)

68 (13.3%)

NS

Shekarriz et al. (77)

120

6 (10%)

2 (3.3%)

0.2

Abbreviation: NS, not significant; NSS, nephron-sparing surgery; RN, radical nephrectomy. Source: From Ref. 77.

insufficiency (four), inferior epigastric artery injury (one), epididymitis (one), transient hematuria (one), and ureteral injury (one). Non-urological complication occurred in 15% of patients including pulmonary (ten), cardiovascular (nine), musculoskeletal (five), gastrointestinal (four), or septic (two).

Complications occurring after laparoscopic partial nephrectomy and laparo-scopic radical nephrectomy for renal tumors <4.5 cm were recently assessed by Kim et al. (64). In the laparoscopic partial nephrectomy group (n = 79), mean operative time was 3 hours, mean warm ischemia time 26.4 minutes (range, 13-37), and mean blood loss 391.2 mL. Four patients (5.1%) had hemorrhages requiring blood transfusion, with one open conversion. Specific intraoperative complications during laparoscopic partial nephrectomy included one ureteral injury, one lumbar vein injury, and one splenic capsule injury treated laparoscopically. Two cases of postoperative urinary leak were treated conservatively with suction drains. However, comparing laparoscopic partial nephrectomy with the laparoscopic radical nephrectomy group, no significant differences were noted as regards specific complications. Positive surgical margin were detected in two laparoscopic partial nephrectomy patients (2.5%), of whom one underwent laparoscopic radical nephrectomy, while a 26-month disease-free follow-up was observed in the other patient.

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