ENDOUROLOGY & LAPAROSCOPY

Comparison of different extraction sites used during laparoscopic radical nephrectomy
Bird VG, Au JK, Sandman Y, De Los Santos R, Ayyathurai R, Shields JM
Department of Urology, Miller School of Medicine, University of Miami, Miami, Florida, USA
J Urol. 2009; 181: 1565-70

• Purpose: Laparoscopic radical nephrectomy is commonly performed for renal tumors that are not amenable to nephron sparing treatment. A number of techniques for intact specimen extraction are used. The development of incisional hernias from the extraction site is a known but infrequent delayed complication. We analyzed different extraction sites and risk factors for such hernias.
• Materials and Methods: We retrospectively analyzed a cohort of patients undergoing laparoscopic radical nephrectomy with intact specimen extraction through 3 sites. Patients and operation specific parameters were included with particular attention to factors predisposing patients to incisional hernia, including chronic obstructive pulmonary disease, diabetes mellitus, chronic steroid use and a high body mass index.
• Results: A total of 181 nephrectomies were performed in 175 patients and 175 kidneys (96.7%) had malignancy. Mean tumor size was 4.9 cm. Mean followup was 28.8 months. Extraction was done from a lower quadrant site in 55 patients (31.4%), from the umbilical site in 58 (33.2%) and from a paramedian site in 62 (35.4%). Patients with paramedian and lower quadrant extraction sites were older (p = 0.016), and had a higher body mass index (p = 0.001) and greater specimen weight (p = 0.003). In 4 patients an incisional hernia developed. An incisional hernia was significantly associated with the paramedian extraction site (p = 0.015).
• Conclusions: Incisional hernias may occur as a delayed complication of laparoscopic radical nephrectomy. This complication most commonly develops at the extraction site. In patients with a high body mass index using a paramedian extraction site is a significant risk factor for incisional hernia formation.
  
  
• Editorial Comment
  Laparoscopic radical nephrectomy has evolved and questions such as intact organ extraction versus morcellation were answered by different investigators recommending intact extraction for different reasons. Unfortunately, larger extraction sites may cause incisional hernia. The authors have demonstrated that when patients are obese the optimal site for extraction is the paramedian site since it may decrease the chance for incisional hernia after extraction.

Dr. Fernando J. Kim
Chief of Urology, Denver Health Med. Ctr.
Assistant Professor, Univ. Colorado Health Sci. Ctr.
Denver, Colorado, USA
E-mail: fernando.kim@uchsc.edu