ENDOUROLOGY & LAPAROSCOPY

Complications of abdominal urologic laparoscopy: longitudinal five-year analysis
Parsons JK, Varkarakis I, Rha KH, Jarrett TW, Pinto PA, Kavoussi LR
From the James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
Urology. 2004; 63: 27-32

• Objectives: To analyze complications of abdominal laparoscopic surgery of the urinary tract at a single institution during a 5-year period.
• Methods: From 1996 to 2000, we identified 894 abdominal laparoscopic procedures performed at a single institution: 600 nephrectomies (live donor, simple, radical, nephroureterectomy, and partial), 112 pyeloplasties, 61 renal biopsies, 35 retroperitoneal lymph node dissections, 31 renal cyst ablations, 18 adrenalectomies, and 37 other abdominal procedures. The charts were retrospectively reviewed for complications, which were classified as operative, postoperative, or medical. Complications were correlated with patient age and American Society of Anesthesiologists score. Statistical analysis was performed with Fisher’s exact test and chi-square tests.
• Results: A total of 118 complications (13.2%) occurred. Two patients (0.2%) died. As a result of operative complications, the procedure of 13 patients (1.5%) was converted to an open one. As a result of postoperative complications, 13 (1.5%) underwent operative and 6 (0.7%) nonoperative intervention. The most common intraoperative complications were vascular (n = 23), adjacent organ (n = 10), and bowel (n = 9) injuries. The most common postoperative complications were neuromuscular pain (n = 12), hematoma (n = 11), urine leak (n = 7), and wound infection (n = 7). The differences in the annual complication rates for all procedures did not attain statistical significance (P = 0.5). Among all procedures, excluding live donor nephrectomy, complications of any kind correlated with a greater patient American Society of Anesthesiologists score (P = 0.01).
• Conclusions: Rather than decreasing, the overall incidence of laparoscopic complications did not change significantly during a 5-year period at our institution. The factors contributing to this observation likely included the progression of inexperienced individual surgeons through the learning curve, the introduction of new, more sophisticated laparoscopic procedures, and stable rates of patient comorbidity. This experience may represent the average complication rate for urologic laparoscopy at a large-volume, academic training center.
  
  
• Editorial Comment
  For years I have been counseling patients pre-operatively that, overall, there is a about a 5% risk of major complication and about a 10% risk of a minor complication associated with laparoscopic nephrectomy. The data from this very large and long series supports those approximations. The context of these figures is important to consider. On one hand, a lower rate of complications might have been expected given the expertise of the senior surgeons at this institution. On the other hand, as pointed out in this article, the performance of many inexperienced trainees is included in this series. In addition, the typical referral patterns that lead the sicker patients to the large medical centers also might tend to increase complication rates. Overall the rates have been stable over time, suggesting that this is about what anyone might expect given a certain level of experience and capability with laparoscopy.

Dr. J. Stuart Wolf Jr.
Associate Professor of Urology
University of Michigan
Ann Arbor, Michigan, USA