Urologic Experience

A careful search of the urologic literature demonstrates a relatively low incidence of laparoscopic port site seeding from adrenal, renal, urothelial, testicular, or prostate carcinomas (Table 1).

Dunn et al. demonstrated no port site recurrence or peritoneal seeding in their initial nine-year experience of 61 laparoscopic radical nephrectomies removed through both intact delivery and morcellation (38). As in other series (39), it is noteworthy that Clayman's group morcellated all specimens within a specially designed, impermeable sac, with the port site redraped in an effort to prevent wound contamination. Their institution's efforts are also successful in obviating port site recurrence following laparo-scopic nephroureterectomy (40).

Rassweiler et al. reported a decade's experience of 1098 laparoscopic procedures for urologic malignancies (36). Local recurrence was observed in eight patients following nephroureterectomy for ureteral transitional cell carcinoma, one radical nephrec-tomy for renal cell carcinoma, one patient with teratoma following retroperitoneal lymph node dissection, three instances of prostate cancer, and one case following adrenalectomy for metastatic melanoma. port site recurrences, however, were observed following metastatic laparoscopic adrenalectomy for small cell carcinoma of the lung (Fig. 1) and following one postchemotherapy retroperitoneal lymph node dissection. Unfortunately descriptions of tissue manipulation, entrapment techniques, and specimen delivery are not discussed with these reports (36).

The inherent aggressive biologic behavior of metastatic disease to the adrenal gland is a likely mechanism for port site recurrence following laparoscopic adrenalec-tomy. To date, there are no identified primary adrenal malignancy port site recurrence reports. Conversely, there are two reports of port site recurrence following laparoscopic adrenalectomy for metastatic small cell carcinoma (36,37). Chen et al. describe wide en bloc dissection in an attempt to avoid manipulation of the adrenal gland and entrapment in an impermeable extraction device was noted in their report. However, at five months, the patient presented with a palpable port site mass (Fig. 2) and bowel obstruction. Palliative external beam radiotherapy management was attempted, but the patient expired as a result of metastatic disease 10 months postadrenalectomy (37).

To date, there have been four reports of port site seeding following laparoscopic radical nephrectomy for renal cell carcinoma. In a series of 57 laparoscopic radical nephrectomies, with specimen morcellation, one patient with T3N0M0 (Fuhrman IV/IV) disease suffered a solitary recurrence at one trocar site, 25 months after radical nephrectomy (24). Castilho et al. report multiple-site port site recurrences in a 72-year-old-male with a T1N0M0 renal cell carcinoma after laparoscopic radical nephrectomy. In this patient, ascites, relative immunosuppression from cirrhosis, or morcellation within a "plastic" nonimpermeable sac may have each contributed to this port site recurrence (25). Finally, one hand-assisted laparoscopic radical nephrectomy port site recurrence has also been reported (26). A patient with a 10 cm T2N0M0, Fuhrman grade III, renal cell carcinoma was without initial tumor violation, and negative surgical margins, but had the specimen delivered intact through the hand port without entrapment. Specific delivery through the hand port orifice or wound (without port) was not discriminated in this report. At nine months postnephrectomy, however, a 6 X 5 cm hand port site mass was seen (Fig. 3).The patient was treated with wide

TABLE 1 m Reported PSR Following Minimally Invasive Management of Urologie Malignancy

TABLE 1 m Reported PSR Following Minimally Invasive Management of Urologie Malignancy

References

Pathology (primary TNM stage, grade)

Primary laparoscopic approach

Recurrence identification

Management

Renal cell carcinoma

24

Renal cell carcinoma (T3N0M0,

Transperitoneal

Port site discomfort with solid mass.

Surgical excision, every 3-mo clinical and radiographic

Fuhrman IV/IV)

CT confirmation at 25 mo

(chest X ray, CT) follow-up. No evidence of disease

at 35 mo postnephrectomy

25

Renal cell carcinoma (morcellated

Transperitoneal

Abdominal masses Identified on CT

Alpha-interferon Immunotherapy. Patient

specimen, stage not reported,

died 8 mo postnephrectomy

Fuhrman IV/IV)

26

Renal cell carcinoma (T2N0M0,

Hand-assisted, transperitoneal

Clinically palpable with CT confirmation

Operative excision, biopsy, and Immunotherapy

Fuhrman lll/IV)

at 9 mo

referral

27

Renal cell carcinoma PT3a, ll/IV

Retroperitoneal

Left lumbar pain 39 wk postnephrectomy

External beam radiation with no further

TCC

with CT confirmation

follow-up reported

1 uu 28

Ureteral TCC (TINxMx, "high-grade")

Extraperitoneal

Clinically palpable with CT confirmation

Operative excision with negative pathologic

at 12 mo

margins and 18-mo follow-up

29

TCC (TNM not reported, "high grade"

Extraperitoneal

Painful mass at trocar site, with CT

Ultrasound biopsy for confirmation.

TCCa Invasive Into renal parenchyma

confirmation at 3 mo

No other management reported

with one positive hilar lymph node)

30

TCCT4bNxM0, grade II

Transperitoneal laparoscopic

Palpable nodule "shortly after" biopsy

Open exploration with positive biopsy.Tumor

staging and biopsy

Involvement of urachus, anterior abdominal

wall, and preaortic lymph nodes

31

TCC (stage not reported, "high-grade"

"Laparoscopic" nephrectomy

Painful umbilical port site 8 mo

Open positive biopsy with CT follow-up demonstrating

TCCa Invasion with small vascular

postnephrectomy

residual local recurrence at renal fossa, along

focus of invasion)

psoas muscle, and hepatic metastases. Patient

referred for chemotherapy. No follow-up reported

Pelvic lymph node dissection

32

LPLND for CaP (T3N1M0, grade II)

Transperitoneal

Clinically palpable at 6 mo

Aspiration cytologic confirmation with no other

diagnostic or therapeutic maneuvers. Patient

died 8 mo postlymphadenectomy

33

LPLND for TCC (T3N1M0, grade II)

Transperitoneal

Clinically palpable subcutaneous masses

Observation secondary to previous post-LPLND failure

at multiple port sites, with CT confirmation

of M-VAC, chemotherapy and external beam

radiotherapy. Hepatic mass Identified on CT.

Patient died one mo after PSR recognition

34

TCC (T2NxM0, grade II (at time of LPLND)

Transperitoneal

Right lower extremity edema 3 mo

Open biopsy positive for TCCa. Patient refused

(T3N0M0, grade III) after open

post cystectomy, with positive CT for right

chemotherapy and died three mo later

cystectomy and ureteroslgmoidoscopy

pelvic lymphadenopathy and 3 cm right

superior port site mass

Miscellaneous

35

Squamous cell carcinoma of the

Retroperltoneoscopic

Clinically palpable with CT confirmation

Surgical excision with mesh repair of aponeurotic

renal pelvis (T3N0M0)

nephroureterectomy

at 6 mo

defect. Disease free at 6-mo follow-up from excision

36

1. Metastatic small cell carcinoma

Not reported

CT (adrenal lesion). Month not reported

Not reported. Each patient died within 6 mo

to adrenal (TNM not reported)

after Identification of PSR

2. Nonseminomatous germ cell tumor

to the retroperltoneum.

(TNM not reported)

37

Metastatic small cell carcinoma to

Transperitoneal

Clinically palpable with CT confirmation

Palliative external beam radiotherapy. Patient died

adrenal (stage lib small cell

at 5 mo

10 mo postadrenalectomy

carcinoma of lung)

Abbreviations: PSR, port site recurrence; TCC, transitional cell carcinoma; CT, computed tomography; LPLND, laparoscopic lymph node dissection; CaR carcinoma of the prostate; TNM, tumor nodal metastatic; M-VAC, methotroxln vinblastin adrlomycin clsplatln.

FIGURE 1 ■ Port site recurrence (white arrow) following retroperitoneal adrenalectomy for metastatic small cell carcinoma of the lung. Source: From Ref. 36.

FIGURE2 ■ Computed tomography image of port site recurrence (white arrow) following transperitoneal adrenalectomy for metastatic small cell carcinoma of the lung. Source: From Ref. 37.

FIGURE 1 ■ Port site recurrence (white arrow) following retroperitoneal adrenalectomy for metastatic small cell carcinoma of the lung. Source: From Ref. 36.

FIGURE2 ■ Computed tomography image of port site recurrence (white arrow) following transperitoneal adrenalectomy for metastatic small cell carcinoma of the lung. Source: From Ref. 37.

FIGURE3 ■ Computed tomography image of port site recurrence at hand-port site following hand-assisted laparoscopic nephrectomy for renal cell carcinoma. Source: From Ref. 26.

FIGURE 4 ■ Subcutaneous port site masses following extraperitoneal nephroureterectomy for ureteral transitional cell carcinoma. Source: From Ref. 28.

Long-term open versus laparoscopic nephrectomy comparison by Portis et al. demonstrates no significant differences in local or distant metastatic recurrence rates, with no wound or port site recurrence.

local excision and immunotherapy therapy (26). Finally, at 39 weeks post left retroperitoneoscopic radical nephrectomy, Iwamura et al. report the most recent abdominal wall recurrence in a patient with a primary T3a, Fuhrman grade II clear cell renal cell carcinoma. Importantly, tissue entrapment was not used in this case (27).

The exact incidence of laparoscopic port site recurrence following laparoscopic radical nephrectomy is not known. However, wound metastases following open radical nephrectomy for renal cell carcinoma are reported in approximately 0.4% (2 of 518) of cases (41). In open colon surgery for known cancer there is a 1.5% wound recurrence rate reported in the literature (42). In a retrospective multicenter study, with a mean follow-up of 19.2 months (range, 1-72; 51 with greater than two years follow-up), Cadeddu et al. reported no port site recurrence from laparoscopic nephrectomy for renal cell carcinoma in 157 cases (43).

Long-term open versus laparoscopic nephrectomy comparison by Portis et al. demonstrates no significant differences in local or distant metastatic recurrence rates, with no wound or port site recurrence (44).

Transitional cell carcinoma appears to be more biologically susceptible to soft tissue metastatic implantation (45) and port site recurrence (46). In the laparoscopic staging and treatment of transitional cell carcinoma there have been several reports of port site seeding (28-31,33,47). In three instances, port site recurrence developed after laparoscopic staging with a biopsy or laparoscopic pelvic lymph node dissection of a primary bladder tumor. In one of three cases related to nephrectomy, seeding developed in a patient with a tuberculous atrophic kidney containing unsuspected transitional cell carcinoma (29). Loss of entrapment sac integrity was cited as a possible predisposing confounding factor in this case. Another case of port site recurrence was reported after laparoscopic extraperitoneal nephroureterectomy was performed one week following ureteroscopy and ureteral stent placement (Fig. 4). At the time of laparoscopic nephroureterectomy, the ureteral stent was seen protruding outside of the collecting system, possibly seeding the perirenal tissues (28). The uncommon squamous cell carcinoma from urothelial origin has also demonstrated abdominal wall recurrence following retroperitoneoscopic nephroureterectomy (35).

Bangma et al. reported on the first patient with port site seeding after laparoscopic pelvic lymph node dissection for prostate cancer (32). Since their initial report, several additional cases have been reported, each after nonentrapped, piecemeal extraction of lymphatic tissues (31,33,34,48). In contrast, Cadeddu et al. found no cases of port site seeding after 372 cases of laparoscopic pelvic lymph node dissection. A review of a subset of 40 patients with positive pelvic lymph nodes for prostate cancer (at the time of laparoscopic pelvic lymph node dissection) revealed no port site seeding up to three years after surgery. Furthermore, there was no acceleration in the natural history of the disease after laparoscopic pelvic lymph node procedures (49,50). Although pelvic lymph node extractions for urothelial and prostatic carcinomas demonstrate port site recurrence, no laparoscopic prostatectomy procedures have demonstrated port site recurrence.

Indeed, contemporary data reflect that direct contamination and seeding are the likely mechanisms, as hematogenous and other models (including one renal cell carcinoma model) fail to reflect port site recurrences from pneumoperitoneum creation.

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