ENDOUROLOGY & LAPAROSCOPY

Laparoscopic nephrectomy: assessment of morcellation versus intact specimen extraction on postoperative status
Hernandez F, Rha KH, Pinto PA, Kim FJ, Klicos N, Chan TY, Kavoussi LR, Jarrett TW
From the Departments of Urology and Pathology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
J Urol. 2003; 170: 412-5

• Purpose: We compared pathological evaluation and postoperative recovery in patients undergoing transperitoneal laparoscopic nephrectomy at our institution with morcellated vs intact specimen extraction.
• Materials and Methods: A prospective evaluation of 57 consecutive patients undergoing radical and simple transperitoneal laparoscopic nephrectomy was reviewed. One patient was excluded from study due to transitional cell carcinoma, which was detected intraoperatively. The 33 morcellated specimens were extracted at the umbilical port and the 23 intact specimens were extracted through a midline infraumbilical incision. Data were obtained on narcotic requirements, hospital stay, complications, estimated blood loss, mass size based on preoperative imaging, specimen weight and extraction incision length.
• Results: Mean incision length in the morcellated and intact specimen removal groups was 1.2 and 7.1 cm, respectively (p < 0.001). No significant differences in pain or recovery were noted between the 2 groups. Two cases of microscopic invasion of the perinephric adipose tissue in the intact specimen group were up staged from clinical T1 to pT3a disease. No change in patient treatment was made based on this information.
• Conclusions: We did not find a significant difference in surgical time, pain or hospital stay. Only incision length was statistically significant. Postoperative recovery appeared to be similar in these 2 groups. With modern imaging modalities information on pathological stage did not alter patient treatment.
  
• Editorial Comment
  Although prospective, this study was non-randomized. The authors report that “the decision to morcellate or perform intact extraction was based solely on patient preference”. There were some differences between the groups, including patients that were older (mean age of 54.6 vs. 61.5 years, p = 0.03) and larger (BMI of 31.7 vs. 27.9) in the morcellated group. The mean operative time was only 11 minutes longer in the morcellated group. Unfortunately, the authors did not report the operative time for extraction separately. It would have been informative to compare the operative time after complete dissection of the kidney, to determine if the longer extraction time in the morcellated group was outweighed by the longer time to close the incision in the intact extraction group. Entrapping a specimen in the Cook LapSac is a challenging task, which the authors appropriately bemoan in their discussion section, and I would think that in most surgeon’s hands it would take longer to entrap and morcellate a specimen than to close the 7.1 cm average incision for intact extraction. That the authors of this study managed to perform morecellation in only 11 minutes longer than they took to perform intact extraction, especially given the greater BMI in the morcellated group, is a testament to their skill. The major finding of this study is the lack of benefit in terms of patient convalescence in the morcellation group, despite the smaller incision. This leaves cosmetics as being the only advantage of morcellation. There are a number of potential advantages to intact extraction. With intact extraction, pathological staging is possible. There is a growing body of evidence, however, that there is little prognostic difference between clinical T1 renal cancers that are confirmed as pT1 and those that are upstaged to pT3a. In addition, there is concern that morcellation might increase the risk of port implantation. Fortunately, there have been only 3 reported cases of port site implantation of renal cell carcinoma, and 2 of them occurred after inappropriate blind morcellation in a plastic bag. My conclusion is that port site implantation is not a significant concern with renal cell carcinoma and that there is minimal benefit to the pathological staging provided by intact extraction. Given this, and the findings of this study, the only difference between intact extraction and morcellation is improved cosmetics in the last. As such, I prefer morcellation unless the specimen is very large (> 750 grams), in which cases I use hand-assistance (and therefore intact extraction) to simplify dissection and entrapment.

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