Introduction
Exposure of the kidney during surgery must be adequate to perform operation and to deal with any possible complications. This is particularly important in renal surgery because kidney is located deeply in the upper retroperitoneum with access limited by the lower ribs, liver, and spleen. Injuries to large renal vessels may be difficult to control or repair through small incisions, particularly in the presence of a large tumor. Poor exposure renders the operation unnecessarily difficult and also leads to excessive retraction, with bruising of the muscles and possible injury to the intercostal nerves, which can increase postoperative pain. The thoracoabdominal incision is performed by urologists primarily for certain renal, adrenal and retroperitoneal tumors, and provides excellent exposure and allows for early vascular control and en bloc resection [
1]. The need for early vascular control is very important, especially for oncologic procedures [
2]. Therefore, many urologists consider a thoracoabdominal incision to be the incision of choice for radical nephrectomy, especially for large renal tumors, but complication is a major concern. Therefore, some urologists have applied other approaches, such as the transabdominal and flank incision [
3-
5]. The flank incision is mainly used for simple nephrolithotomy or nephrectomy, and in some cases for radical or partial nephrectomy, especially for small renal tumors [
2-
5].
Intuitively, it is perceived by some urologists that the complication of a thoracoabdominal incision far exceeds that of a flank incision. But to date, the efficacy and complication of thoracoabdominal incision in comparison to flank incision for radical nephrectomy in the patients with large renal tumors are unknown. We compared the two approaches to verify whether the thoracoabdominal incision has more advantages than the flank incision in terms of operation time, hemorrhage volume in operation, time length of presence of drainage tube, postoperative analgesia usage, time length of stay and time from surgery to return to activities and work.
Materials and methods
A questionnaire assessing postoperative pain, administration of pain medications and return to activities and work was sent to the patients who undergoing radical nephrectomy through the 11th or 12th rib (group 1: underwent flank incision, including 96 patients) or the 9th to 10th rib (group 2: undergoing thoracoabdominal incision, including 98 patients) from 2003 to 2007 in our hospital. A case retrospective analysis assessing operation time, perioperative hemorrhage volume, size of tumors, success rate of treating tumor thrombus in renal vein or vena cava, time length of presence of drainage tube, time of off-bed, postoperative analgesia usage and time length of hospital stay, postoperative pain, use of pain medications and time from surgery to return to activities and work was done to patients whose questionnaires were returned. Pain was assessed by using a visual analogue scale [
6]. A relatively arbitrary criteria were used to define intensity of pain as severe — 55 mm or more on the scale, moderate — 31 to 54 or mild — 30 or less [
7,
8].
A total of 56 patients in group 1 and 60 in group 2 returned the questionnaire. Group 1 was comprised of 36 men and 20 women with a mean age of 55.3 years. Group 2 included 38 men and 22 women, respectively, with a mean age of 57.1 years. Mean follow-up plus or minus standard deviation was 22.4 ± 6.5 (range 8 to 30, median 23.5) months in group 1 and 22.6 ± 6.4 (range 8 to 30, median 24) months in group 2. Data on operation time, rate perioperative hemorrhage volume, size of tumors, success in the treatment of tumor thrombus in renal vein or vena cava, time length of presence of drainage tube, postoperative analgesia usage and length of stay, postoperative pain, use of pain medications and time length from surgery to return to activities and work were extracted from the case retrospective analysis and questionnaire. The Student t test and Chi-square test were applied to compare the data between the 2 groups. For all comparisons, differences were considered statistically significant at P <0.05. Data analysis was performed by using statistical software SPSS11.5.
Results
Of the patients, 96 underwent radical nephrectomy through the 11th or 12th rib (group 1: flank incision) and 98 through the 9th to 10th rib (group 2: thoracoabdominal incision). A total of 56 patients in group 1 and 60 in group 2 responded to the questionnaire (58% and 61% response rates in groups 1 and 2, respectively). Postoperative complications in responders and non-responders in both groups were similar. All the operations in both groups were successfully conducted without any severe complications. There was no significant difference in age, sex and course of disease between two groups. There were no major complications in group 1. In group 2, two patients had major complications unrelated to the incision. The incidence of minor complications, such as ileus and wound infection was similar in both groups.
The time lengths of operation and presence of abdominal drainage tube in group 1 were significantly shorter than those in group 2 (P < 0.005, Table 1). The size of tumors in group 1 was significantly smaller than that in group 2 (P < 0.0005, Table 1). The success rate of treating thrombus in renal vein or vena cava in group 2 was significantly higher than that in group 1 (P < 0.05, Table 1). The lengths of off-bed time and hospital stay in group 1,were less than those in group 2 (P > 0.5, Table 1). Perioperative hemorrhage volume in group 1 was significantly more than that in group 2 (P < 0.0005, Table 1). No chest tube was placed in anyone in group 1 and all patients in group 2 had a chest tube. No differences were noted in terms of intensity of pain on postoperative day 1, on day of discharge and 1 month postoperatively (Tables 2-4). There was no difference between the two groups in terms of pain control (Table 1). The necessity and duration of analgesic requirements were compared in Table 4. Again, no differences were found in terms of lasting days of postoperative pain and days of postoperative analgesia use. With regard to the return to normal activities, although the patients of group 1 returned to daily activities earlier, this difference was not statistically significant between the two groups (P = 0.052). The time length from surgery to return to work was similar in both groups (Table 4).
Discussion
Before selecting an appropriate incision for renal surgery, the following factors are considered: operation to be performed, underlying renal pathology, previous operations, concurrent extrarenal pathology that requires another operation to be done simultaneously, need for bilateral renal operations, and body habitus. Although thoracoabdominal and flank incisions have different indications, either incision can be applied in many circumstances, such as for renal tumors and adrenal tumors. Hence, as both approaches were widely used for renal surgery [
2], it was appropriate to compare them. Some urologists trend to use the flank incision as they believe that it has less morbidity than a thoracoabdominal incision. Nevertheless, there is a risk of visceral damage in the flank incision, such as damages to liver and spleen during retraction to overcome limited access, especially when removing large tumors or the thrombus in renal vein even in vein cava through the flank approach.
The thoracoabdominal incision provides excellent exposure and allows for early vascular control and en bloc resection, so the operation time is significantly shortened and perioperative hemorrhage volume is obviously reduced. In our study, both incisions did not have difference in terms of off-bed time, hospital stay, early postoperative pain, need for pain medications after discharge home, and time length from surgery to return to daily activities and work. In the flank incision group, there was a trend that patients returned to daily activities earlier, although the time from surgery to return to work was not significantly different between the two groups. However, we recognize that returning to work is a suboptimal measure of morbidity, since most patients take sick leave whether or not they are able to work. Thus, the use of an additional measure of morbidity, which is returning to daily activities, is justified and may be a better measure of morbidity than returning to regular work. Age may also have an impact on patient ability to return to daily activities and work. The patients in flank incision group were younger than those in the thoracoabdominal incision group.
The patients in thoracoabdominal incision group were older, and they tended to have slower postoperative recovery than young healthy subjects. Besides, the mean size of tumors in thoracoabdominal incision group was larger than that in the flank incision group. Despite these differences, the patients in group 1 tended to return to daily activities earlier than those in group 2. We were unable to demonstrate a significant difference, perhaps due to a small sample size. We assumed that a chest tube would increase pain in the perioperative period. However, there was no difference in terms of pain intensity or control in both groups (the tube was always removed on day 1 to 3).
Renal cell carcinoma extension into the renal vein and/or inferior vena cava (IVC) is present in about 4% to 15% of cases of renal cell cancer [
9]. Surgical removal of the kidney with the attached tumor thrombus remains the primary modality of management in these cases [
10]. During the last 3 decades, there have been steady improvements in surgical techniques and perioperative care, which have dramatically improved the ability to remove these tumors safely. Thoracoabdominal approaches have been traditionally advocated to facilitate surgical exposure [
11-
14]. In our study, 38 out of 40 patients were treated successfully in the treatment of tumor thrombus through the thoracoabdominal approach and 2 failed for the tumor thrombus extension into right atrium. But in the flank approach, only 18 out of 26 were treated successfully, among the 8 failures, 6 had tumor thrombus involving the retro-hepatic IVC with close proximity to the main hepatic veins and 2 involving the supradiaphragmatic IVC. Tumor thrombus associated with renal cell carcinoma is no longer considered to exert a detrimental impact on survival. Patients who are acceptable surgical candidates have survival rates as high as 68% in 5 years [
15,
16].
The thoracoabdominal approach requires entering the chest cavity and splitting the diaphragm, which has inherent complications. So some urologists believe that it is more morbid to apply a thoracoabdominal incision. Karakousis [
17] reported that pulmonary atelectasis was the most common complication in the thoracoabdominal incision (7/34). We think if the patients are treated by closed thoracic drainage appropriately and given good mental care and catheter nursing, the complication can be avoided. There was no complication in all these operations.
The flank approach provides good access to the renal parenchyma and collecting system. It is an extraperitoneal approach and induces minimal disturbance to other viscera. Contamination to the peritoneal cavity is avoided and drainage of the perirenal space is readily established. This approach is particularly useful in obese patients because most of the panniculus falls forward, making this incision relatively straightforward even in very large person. The principal disadvantage of the flank incision is that exposure area of renal pedicle is not as good as that by using anterior transperitoneal approaches. In addition, the flank incision may be proven to be unsuitable for the patient with scoliosis or cardiorespiratory problems.
The thoracoabdominal approach is desirable for performing radical nephrectomy in patients with large tumors involving the upper portion of the kidney [
17], particularly for the renal cell carcinoma invading the vena cava [
11-
13]. For renal, adrenal, and retroperitoneal tumors, the thoracoabdominal incision may be an ideal approach that provides optimal exposure, allows for early vascular control, and permits en bloc resection for large or difficult tumors in retroperitoneum or abdomen. It is particularly advantageous in treating tumors on the right side, as the liver and its venous drainage into the upper vena cava can limit exposure of the tumor and impair vascular control when the tumor mass is being removed [
2]. There is less need for a thoracoabdominal incision on the left side because the spleen and pancreas can be easily elevated away from the tumor mass. The thoracoabdominal incision optimizes exposure of the suprarenal area. Nevertheless, because it involves additional operative time and greater potential pulmonary morbidity, the approach is reserved for patients in whom additional exposure over that provided by an anterior subcostal incision is considered important to achieve complete and safe tumor removal. A perception exists that the morbidity of the thoracoabdominal incision far exceeds that of a flank incision. In fact, our research has demonstrated that the complication associated with the thoracoabdominal incision is comparable to that of a flank incision. Although we have advocated a thoracoabdominal approach for retroperitoneal tumors, the appropriate surgical incision should be based on surgeon comfort and familiarity, with the consideration of the individual patient and the particular disease.
We recognize that there may have been some bias in our study. Patients who responded to the questionnaire may be different from non-responders in terms of postoperative pain or time length from surgery to return to daily activities and/or work, although they are similar in terms of early postoperative complications. Although the response rates are acceptable, higher response rates would be more reliable. The health status of patients in both groups may have had some impact on the results of the survey. Patients in both groups were approximately two years out from surgery and, for this reason, were more likely to report a positive experience regarding immediate postoperative pain following successful surgery for renal tumors. Despite all of the factors that may have affected our study, we consider the comparison to be valid, and we have found comparable morbidity in both groups.
Conclusions
The efficacy and complication were comparable for thoracoabdominal and flank incisions in terms of operation time, perioperative hemorrhage volume, time lengths of presence of abdominal drainage tube, off-bed, hospital stay, postoperative pain, discontinuation of pain medication, and time from surgery to return to daily activities and work. While we were unable to demonstrate any significantly greater morbidity in the thoracoabdominal incision compared to the flank incision, future prospective randomized studies using a validated questionnaire is necessary to confirm these results. Urologists should not avoid the thoracoabdominal approach when indicated. Such indications may include radical nephrectomy for complex and large renal tumors, partial nephrectomy for upper pole lesions or even adrenal and upper retroperitoneal surgery. The thoracoabdominal incision provides better exposure, may be easier and faster in certain situations, and allows the surgeon to perform a better cancer operation without violating the principles of oncologic surgery. Furthermore, if future studies validate ours, urologists may be more comfortable using the thoracoabdominal approach when indicated.
Higher Education Press and Springer-Verlag Berlin Heidelberg
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