Laparoscopic nephrectomy: Moroccan experience of 68 cases

The aim of this study was to analyze the feasibility and the safety of laparoscopic nephrectomy in the treatment of pathologies of the upper urinary tract through the experience of the Urology B department. We have retrospectively and monocentrally selected patients who underwent laparoscopic nephrectomy from January 2017 to December 2019. The collection was carried out on archived files, based on demographic, clinical and perioperative data. The primary endpoint was the occurrence of complications and secondarily the length of the operation and the length of hospital stay. The statistical analysis was carried out using the SPSS software. A total of 68 patients were included in our series. The average age of our patients was 57.8 years. There was a slight female predominance: 39 female patients (57.4%) for 29 male patients (42.6%). Indications for nephrectomy were dominated by renal tumor (33.82%) followed by lithiasis (16.17%) and non-functioning kidney (16.17%) at the same rank. During the study period, 31 (45.6%) simple nephrectomy, 26 (38.2%) total nephrectomy, 1 (1.5%) partial nephrectomy and 10 (14.7%) nephroureterectomy were performed in our department. In our series, the average operating time was 180 min. Estimated blood loss averaged 321.8 ml with extremes of a few milliliter to 1100 ml. Intraoperative complications were reported in 10 (14.7%) patients; conversion was necessary in 6 cases (8.82%). The postoperative follow-up was straightforward in 53 (77.94%) patients with an average hospital stay of 3.6 days. The rate of postoperative complications according to Clavien–Dindo was 22.1%. Histological examination of the nephrectomies carried out in our department revealed mainly chronic non-specific pyelonephritis in 24 (35.3%) patients, followed by renal cell carcinoma in 23 (33.82%) patients and urothelial carcinoma in 9 (13.2%) patients. Laparoscopic nephrectomy appears to be an efficient and reliable technique. This technique has led to a significant improvement in operative morbidity, mainly represented by the length of hospital stay, operating time and blood loss.


Background
Since the advent of laparoscopic surgery, many procedures have been described and performed with varying success. When it comes to urology, it all started when Ralph Clayman performed the first laparoscopic nephrectomy in 1991 [1]. He had chosen the transperitoneal (TP) route to perform a right nephrectomy, and during the same year, Ferry performed a left nephrectomy by the same route [2,3]. In 1993, Gaur proposed the retro-peritoneal (RP) approach to perform laparoscopic nephrectomy [4]. Since then, laparoscopic nephrectomy has undergone significant development, whether performed trans or retroperitoneally, with or without robot assistance. The operative consequences of this technique remain simple, less painful, and the recovery time is shorter than open surgery.
The aim of this study is to evaluate the feasibility of laparoscopic nephrectomy, its advantages and especially its complications through the experience of the urology B department of the Ibn Sina hospital.

Methods
We retrospectively analyzed, at the urology department, a cohort of patients who had undergone laparoscopic nephrectomy; all surgical indications taken together, over 3 years from January 2017 to December 2019, were excluded from our study patients with incomplete records.
We were particularly interested in the length of hospitalization, the duration of the operation and the postoperative complications. All patients gave their informed and free consent. Data collection was carried out on an operating sheet summarizing the clinical, biological and radiological parameters of the different patients. Statistical analysis was performed by IBM SPSS Statistics 20 software.

Results
We included in our study 68 patients including 39 women and 29 men whose median age was 57.8 ± 14 years ( Table 1). The indications for hospitalization were based on ultrasound and abdominal-pelvic CT data. The CT scan done systematically for all patients found: • Kidney tumor in 23 patients (33, 82%); • Upper urinary tract urothelial carcinoma (UUTUC) in 9 patients (13.2%); • Severe hydronephrosis with destroyed renal parenchyma in 27 patients (39, 7%). • A normal kidney in pre-transplantation in 8 cases (11.7%). • A compressive renal cyst in a patient.
The pre-anesthetic consultation assigned an ASA I score to nearly half of the patients (31 patients) an ASA II score to 31 other patients and an ASA III score to 6 patients.
Ten patients presented intraoperative complications, 6 of which required conversion to open surgery. The postoperative consequences were simple in 53 (77.94%) patients with an average hospital stay of 3.6 ± 1.7 days. Postoperative complications involved 15 patients including 7 wall infections (Clavien-Dindo 1), 4 subcutaneous emphysemas (Clavien-Dindo 1), 3 cases of anemia resulting in transfusion (Clavien-Dindo II) and 1 death. However, no respiratory complications or thromboembolic complications were observed. And the patients had a return to normal physical activities after 3 weeks (Table 2).
Anatomopathological analysis of the surgical specimens found:

Discussion
Since the first LN performed by Ralph Clayman in 1991, the laparoscopic approach of the kidney has become the technique of choice in the surgical management of renal pathologies. It has experienced considerable growth in both material resources and the skills of practitioners, with the advent of the robot and the popularization of laparoscopic surgical technique. LN currently occupies a large place among the surgical options available at the urology B department, evidenced by the rate of 30 LN per year since 2019.
The indications for LN were based on data from the morphological assessment, including obligatorily an uroscan. The surgical option is always discussed at a service meeting, taking into account the scan results, the prognosis of the pathology in question, the patient's renal function and its comorbidities. The predominant aetiologies in our series were neoplasms (32 patients with renal tumor or UUTUC) and dumb kidneys (27 patients with a kidney destroyed either on calculus, on junction syndrome or on ureteral stenosis). The functional value of the kidney was judged both on the contrast uptake at nephronic time on the uroscanner, and on the renal scintigraphy.
Laparoscopic surgery is characterized by lengthening the operative time, but in contemporary series and that of Rozenberg et al. the mean operating time is identical to that of conventional surgery (116 min) [5]. The average duration of surgery reported in the literature ranges from 101 to 336 min. In our series, it was in the order of 180 ± 58.8 min.
Blood loss in published series ranged from 0 to 828 ml. The lowest losses recorded by Oscar Schatloff et al. [6] in a retrospective study including 129 patients admitted for laparoscopic nephrectomy, and the highest by Hee Youn Kim et al. [7] in a comparative study of the retroperitoneal (34 patients) and transperitoneal (30 patients) pathways of laparoscopic radical nephrectomy for large solid renal tumors (> 7 cm).
The conversion to open surgery is not in itself a complication; on the contrary, it is a reasoned and reasonable change of strategy which allows the patient's best interests to be kept in mind at all times. According to Keeley et al. [8], the need for conversion is more often related to the underlying disease than to the experience or ability of the operator. We totaled 6 cases of conversion due to bleeding, hepatic laceration, adhesions or colonic breach.  The postoperative results have quite variable results, but it is difficult to make a comparison because there is no consistency in the definitions of postoperative complications. Abdominal pain and shoulder pain are frequent postoperative complications, apparently due to irritation of the peritoneum and diaphragm by carbon dioxide. They are often suppressed by minor analgesics as in our series.
Most of the authors, in their comparative series, identify minor complications, designating those requiring medical treatment and/or simple monitoring, and major complications, which were defined as those requiring hospitalization in intensive care units, reoperation or potentially fatal [9]. In our series, we noted 11 Clavien-Dindo I complications, 3 Clavien-Dindo II complications and 1 death. Histological examination of the operative specimen confirmed tumors R0 excision during these different LN.
In terms of downsides, the RP approach has reduced workspace, limited landmarks, and in the case of a dorsal renal tumor, the renal vessels are spotted. In contrast, the TP approach presents a risk of damage to adjacent abdominal organs, requires bowel mobilization, difficulty with renal artery procedures and a history of abdominal surgery [10].

Conclusion
Laparoscopic nephrectomy is a surgical technique with very satisfactory results for both practitioners and patients, with respect for carcinological rules. It remains preferred in our center, compared to open nephrectomy when the indication is suitable. It allowed a significant improvement in operative morbidity, mainly represented by the length of hospital stay, the operative time and blood loss.