|MINI SYMPOSIUM: GENITO URINARY
|Year : 2012 | Volume
| Issue : 1 | Page : 102-106
Port site metastasis after laparoscopic radical nephrectomy: A single-center experience
V Kumar, A Mandhani, A Srivastava, MS Ansari, UP Singh, R Kapoor
Department of Urology and Renal Transplantation, SGPGIMS, Lucknow, Uttar Pradesh, India
|Date of Web Publication||25-Jul-2012|
Department of Urology and Renal Transplantation, SGPGIMS, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Objective: To assess the incidence and review the probable etiologies of port site recurrence in patients undergoing laparoscopic radical nephrectomy. Materials and Methods: One hundred thirty-six patients undergoing laparoscopic surgeries for renal malignancy, including 133 radical nephrectomies and 3 partial nephrectomies, from December 1999 to December 2008 at our institution were followed up for a median period of 59 months (12-120 months). Of the procedures, 121 were performed by transperitoneal, 5 by retroperitoneal and 10 by combined approach (retroperitoneal renal artery clipping followed by transperitoneal nephrectomy). Formal lymphadenectomy was not performed. Postoperative surveillance after radical nephrectomy included history and physical examination with blood tests 3-6 monthly, chest X-ray yearly and abdominal contrast-enhanced computed tomography (CECT) 1-2 yearly. The development of port site recurrence was diagnosed by physical examination, CECT and pathological findings. Results: Conversion to open surgery was done in 33 patients. Two (1.47% overall) port site recurrences were observed, both after radical nephrectomies done for renal masses with clinical stages T2N0M0 and TIN0M0. The pathological staging in the two were T2N1M0 Fuhrman's Grade III and T3aN1M0 Grade III, respectively. Conclusion: Our results report that laparoscopic approach does not necessarily increase the risk of port site recurrence, provided the cases are carefully chosen, principles of oncologic surgery are followed, and conditions that increase the risk of port site metastasis are avoided.
Keywords: Laparoscopic, metastasis, port
|How to cite this article:|
Kumar V, Mandhani A, Srivastava A, Ansari M S, Singh U P, Kapoor R. Port site metastasis after laparoscopic radical nephrectomy: A single-center experience. Indian J Cancer 2012;49:102-6
|How to cite this URL:|
Kumar V, Mandhani A, Srivastava A, Ansari M S, Singh U P, Kapoor R. Port site metastasis after laparoscopic radical nephrectomy: A single-center experience. Indian J Cancer [serial online] 2012 [cited 2020 Jul 11];49:102-6. Available from: http://www.indianjcancer.com/text.asp?2012/49/1/102/98932
| » Introduction|| |
Techniques in laparoscopic surgery have evolved over the past decade, bringing in a progressive shift from traditional open surgery toward minimally invasive access to treat genitourinary oncologic conditions. Its proven benefits are now recognized in terms of decreased postoperative pain, blood loss, recovery time and equivalent short and intermediate efficacy. But question about the oncological adequacy crops up time and again since the first report of port site metastasis after laparoscopic surgery for urological malignancy was published in 1994. 
Port site metastases are recurrent tumorous lesions developing locally in the abdominal wall within the scar tissue of one or more trocar sites.  Metastasis at port site is quite rare, though some cases have been reported in literature. , The purpose of our study was to evaluate the incidence of port site recurrence after laparoscopic procedures for renal malignancies and to review the various risk factors and strategies to prevent them.
| » Materials and Methods|| |
Between December 1999 and December 2008, 136 patients (median age 55 years, range 15-76 years) underwent laparoscopic procedures for renal malignancies, including 133 radical nephrectomies and 3 partial nephrectomies. All patients were assessed by computed tomography (CT) of the abdomen, chest X-ray, renal and liver function tests, and those who were found to have T1-2N0M0 disease on preoperative staging and good performance status were considered for laparoscopic surgery. Laparoscopic nephrectomies were performed through the transperitoneal approach in 121 patients, retroperitoneal approach in 5 and combined approach (retroperitoneal renal artery clipping followed by transperitoneal nephrectomy) in 10 patients.
Laparoscopic technique for radical nephrectomy
Primary trocar insertion was done by open Hasson's technique and pneumoperitoneum created. Once pneumoperitoneum was established, a 12-mm camera port was placed periumbilically or lateral to the rectus muscle at the level of the umbilicus. Remaining trocars were inserted under direct vision. Usually, three ports were used for the left-sided and four for the right-sided tumors.
Dissection of the kidney
Following mobilization of the colon, the renal vessels were dissected and transected using the hem-o-lock clips (weck). The kidney was mobilized outside Gerota's fascia. The ureter was dissected about 5-7 cm below the level of the lower pole of the kidney and was clipped and cut.
An extraction bag (made from urobag) was used for specimen retrieval without morcellation through a 5-7 cm incision extending from one of the major port sites. No formal lymphadenectomy was performed. All 10-12 mm port sites were sutured meticulously with vicryl.
Postoperative surveillance after radical/partial nephrectomy included history and physical exam with blood tests 3-6 monthly, chest X-ray yearly and abdominal CT 1-2 yearly. Port site recurrence was diagnosed by physical examination, contrast-enhanced computed tomography (CECT) and pathological findings.
| » Results|| |
The median age of the patients was 55 years (range 15-76 years) with male to female ratio of 3.1:1. Right kidney was involved in 76 patients (55.8%). Out of 133 patients who underwent radical nephrectomies, laparoscopic procedures could be accomplished successfully in 100 (5 by retroperitoneal approach), while in 33 patients, laparoscopy was converted to open procedure due to various technical reasons. Out of three partial nephrectomies, one had to be converted to open.
Histopathologic examination confirmed clear cell renal carcinoma (CA) in 103 patients, papillary in 15, chromophobe renal cell CA (RCC) in 8, oncocytoma in 6, and other subtypes (multilocular cystic RCC, metanephric adenoma, tubulocystic RCC, and leiomyosarcoma) in 4. The stage distribution of various pathological types is shown in [Table 1].
During the median follow-up of 59 months (range 12-120 months), it was found that two patients (1.47% overall) developed port site metastasis between 7 and 12 months of surgery. These patients had undergone right transperitoneal laparoscopic radical nephrectomy for clinical stage T1N0M0 and T2N0M0 RCC.
One patient, a 74-year-old female, developed port site metastasis at scar of working 10 mm port site [Figure 1] along with local recurrence in renal fossa 1 year after surgery for clinical stage T2N0M0 RCC (pathological stage was T2N1M0 RCC Fuhrman Grade III). The presentation was vague abdominal complaints and palpable masses in right lumbar region and at one of the scars of port sites. Exploratory laparotomy was done for cytoreductive surgery, which showed nodules at the working port site [Figure 2]. Histopathologic examination of the tissue revealed RCC.
|Figure 2: Photograph showing port site nodule during exploratory laparotomy for cytoreduction|
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The other patient, a 16-year-old male, presented 7 months after surgery with abdominal distention and umbilical swelling of 15 days duration [Figure 3]. CECT revealed recurrence at the umbilical (camera) port site, renal fossa and in the bony pelvis. Fine needle aspiration cytology from the port site and the pelvic mass revealed malignant cells consistent with metastatic RCC. He was a known case of juvenile rheumatoid arthritis (JRA), had undergone transperitoneal laparoscopic radical nephrectomy for a 5 5 cm central, solid mass in the right kidney with no lymph nodes and renal vein thrombosis (T1N0M0), but pathological stage came out to be T3aN1M0 Fuhrman Grade III.
|Figure 3: Photograph of port site metastasis after laparoscopic converted to open nephrectomy|
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There was no apparent breach of Gerota's fascia in any of the cases. In the second case, intraoperative uncontrolled bleeding due to avulsion of an accessory artery led to decision to convert to open surgery, but there was no recurrence at the site of surgical incision of conversion.
| » Discussion|| |
Laparoscopic nephrectomy for benign renal disease has evolved tremendously since the initial success by Clayman et al. in 1990.  But laparoscopic cancer management has been delayed for several reasons, such as tumor spread or trocar placement seeding and also because the technique is very complex and carries a longer operating time on high morbidity population. The true incidence of port site metastasis in all cancers is difficult to accurately ascertain because of the limited number of large studies with long-term follow-up but is estimated as 0-21%.  The majority of reported cases have involved gastrointestinal and gynecological cancer,  and the first case of port site metastasis was reported in 1978 after diagnostic laparoscopy for ovarian carcinoma.  Though Muntener et al. reported the incidence of port site metastasis to be 0.9% in a series of 115 patients with upper tract transitional cell carcinoma after laparoscopic radical nephroureterectomy, the incidence in urologic laparoscopic oncology reports of large contemporary series has been estimated as 0.09%  to 0.35%. 
Some authors had not found any case of trocar site metastasis in their studies and had supported the utility of laparoscopy as management for bladder cancer, provided the principles of oncologic surgeries are strictly followed. , Micali et al. reported port site incidence of 0.09% in a 19-institution survey of laparoscopic uro-oncology procedures, but they found no case of port site recurrence from renal cell cancer despite more than 3000 procedures reported and use of morcellation in 40% of the radical nephrectomies.  In our study, the incidence of port site metastasis was 1.47%.
The etiology of port site metastases is not clearly understood, but is probably multifactorial. The causes of port site metastasis may be divided into four major groups, including natural tumor behavior, local wound factors, immune and stress response, and laparoscopy related factors like tumor cell spillage, direct inoculation, aerosolization of the tumor cells and systemic vectors.  Tumor cell spillage can take place through inadvertent sectioning into the tumor in situations of high-grade or high-stage disease, direct wound implantation, infringement of tumor margins, or tumor presence in ascites or peritoneum. It is believed that disruption of the peritoneal barrier may lead to direct contamination of the incisional layers by the tumor. The port site provides a localized peritoneal breach and an area of high cellular proliferation associated with wound healing where malignant cells can grow more easily. Intra-abdominal recurrences after laparoscopy develop preferentially in serosal lesions, underscoring the importance of an intact peritoneal barrier for preventing the implantation of free cancer cells into the peritoneal cavity. Furthermore, incisional scar metastasis is a well-recognized problem in open oncologic surgery, with a reported incidence of 0.4% in RCC and 1.5% in colon CA.  A number of studies have compared open and laparoscopic resection and have demonstrated no difference in wound implantation rate for RCC.  In the current era of nonbladed trocars, in which the peritoneum is not closed in certain institutions, closure of the peritoneal cavity and fascial layers may prove beneficial to prevent seeding. Microleakage around ports, often known as the "chimney effect", might cause intra-abdominal turbulence that leads to tumor cell dissemination into immunoincompetent spaces, such as the space between the fascia and muscle. This creates an ideal situation for the formation of local metastases because local tissue is traumatized by trocar movement.  It has been shown that the carbon dioxide pneumoperitoneum does not affect tumor cell dissemination or seeding.  In fact, no difference in the incidence of port site metastasis with gasless laparoscopy or using different insufflation gases has been found. ,
In the present series, we used an impermeable bag (made from urobag) for extraction of the intact specimen over lap sac due to its cost-effectiveness. Although by comparing specimen morcellation with intact removal, Walther et al. described decreased analgesic requirements and a shorter hospital stay, the conflicting results of the benefits of specimen morcellation in combination with prolonged operative times and expenses associated with morcellation made intact specimen removal our technique of choice. The removal of an intact specimen results in only minimal trauma to the patient and minimizes the risk of tumor spillage or metastatic implantation, with complete tissue availability for histopathologic evaluation.
In the present series, both the patients manifesting port site metastases had a clear indication for laparoscopic radical nephrectomy, but they turned out to be pathologically T2N1M0 and T3aN1M0, highlighting the limitations of current imaging modalities for staging RCC. Further, in the second patient, uncontrolled bleeding due to avulsion of an accessory artery led to decision to convert to open surgery. The extra blood loss, increased duration of the surgical procedure, and steroid use for JRA might have resulted in a more suppressed immune status. He developed port site recurrence within 7 months and this may be attributed to the aggressive behavior of the tumor and compromised immune status.
Although port site metastases most probably reflect biology of the malignant disease, specific measures suggested to prevent port site metastasis include minimal tumor handling with strict avoidance of tumor boundary violation, avoidance of morcellation, avoidance of leakage of gas in between the abdominal wall and trocars and through trocars, and rinsing instruments with cytotoxic substances such as povidone iodine, at least in high-grade, high-stage disease in view of their irritative tissue effect. ,, Peritoneal incisions should be suture closed and the pneumoperitoneum should be released using trocar valve. The surgical specimen should be entrapped as soon as possible and retrieved by using an impermeable plastic bag, thus avoiding the contact between malignant tissue and peritoneum or subcutaneous tissue, that too through an adequate incision to avoid tissue trauma which could be responsible for wound implantation.  Morcellation, if at all performed, should be done within a nonpenetrable, nonpermeable sac within the peritoneal cavity. Furthermore, laparoscopic surgery should be avoided in the presence of ascitis. , Addition of heparin to irrigation fluid has been found to prevent tumor implantation after accidental intraoperative tumor spillage.  Schneider et al. demonstrated a 50% decrease in the incidence of port site metastases when preventive measures were used and the risk of developing a port site recurrence was decreased by 7.7-fold. 
| » Conclusions|| |
Metastasis at port site is not a common complication and probably the incidence can be further minimized by adopting the well-known oncological rules of open surgery to laparoscopy. Also, the conditions that accelerate the formation of port site metastasis should be avoided, such as laparoscopic surgery when there is ascites, trocar dislodgement and gas leakage along and around the trocars. Meticulous suturing of larger trocar wounds and use of impermeable bag for specimen retrieval are further advised. Urologists should be aware of this rare, but serious, complication of oncological laparoscopic surgery, especially in case of highly aggressive tumors.
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[Figure 1], [Figure 2], [Figure 3]