The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 56:M287-M291 (2001)
© 2001 The Gerontological Society of America
Laparoscopic Nephrectomy in Young-Old, Old-Old, and Oldest-Old Adults
Paolo Fornaraa,b,
Christian Doehna,
Robert Fresea and
Dieter Jochama
a Department of Urology, Medical University of Lübeck, Germany
b Department of Urology, Martin Luther King University, Halle, Germany
Christian Doehn, Department of Urology, Medical University of Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany E-mail: doehn{at}medinf.mu-luebeck.de.
Decision Editor: John E. Morley, MB, BCh
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Abstract
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Background. This study reports findings for laparoscopic nephrectomy in comparison with open nephrectomy in geriatric patients.
Methods. Since 1993, a total of 249 patients have undergone nephrectomy for benign disease at the Medical University of Lübeck, Germany. In 11 patients older than 65 years, a laparoscopic nephrectomy was performed (in the majority via a transperitoneal approach), and 42 patients older than 65 years underwent an open-flank nephrectomy. Clinical parameters were evaluated in comparison with both groups and stratified according to age groups.
Results. With respect to operative results (operative duration and pre- and postoperative hemoglobin levels), no relevant differences were observed between the laparoscopy group and the open-nephrectomy group, even when stratified according to patient age. However, patients in the laparoscopy group demonstrated a significant advantage concerning blood loss and the number of required blood transfusions, regardless of age. In addition, patients after laparoscopy showed advantages in the postoperative course. Benefits were proven for the analgesic consumption, hospital stay, and convalescence parameters. Although complication rates were comparable in both groups, an increase was observed in both groups for patients aged between 75 and 84 years.
Conclusions. Laparoscopic nephrectomy offers comparable operative results (with reduced blood loss and less need for blood transfusions) when compared with open surgery. Significant advantages can be demonstrated in the postoperative course, and especially geriatric patients benefit from these aspects of the minimally invasive approach. Laparoscopy should be regarded as the primary therapeutic option for nephrectomy for benign disease in these patients.
OVER the last decades, progress in the development of new minimally invasive operative techniques, modern anesthesia, and peri- and postoperative management has led to a reduction of operative risks, even for geriatric patients. The current trend demands an evaluation of this problem against the background of more differential parameters, such as biological age, life expectancy and quality of life, invasivity of diagnostic and therapeutic procedures, and other important criteria, such as morbidity and mortality rates
(1)
(2). Difficulties exist in the definition of geriatric patients, especially in terms of comparability of diagnostic and therapeutic efforts. In English-language geriatric terminology, the designations young old (65–74 years), old old (75–84 years), and oldest old (
85 years) are commonly in use
(1)
(3).
Endoscopic and laparoscopic techniques have recently gained acceptance in the field of new operative modalities due to the proven reduced invasivity, compared with the open approach. The first laparoscopic nephrectomy, which was performed by Clayman and colleagues
(4) in 1990, was a milestone. Since 1992, laparoscopy has been widely used in the treatment of a variety of urological diseases. Results of laparoscopic procedures in children and geriatric patients have been published
(5)
(6). In addition, these procedures have been used in patients with chronic renal failure, and after kidney transplantation
(7)
(8). Thus, the indication for laparoscopy has been extended for patient groups with a certain risk profile. Laparoscopic procedures, in general, offer certain advantages, as has been shown by several authors in their comparisons of open and laparoscopic nephrectomy
(9)
(10)
(11)
(12). Patients benefit especially in the postoperative course in terms of less morbidity, less pain and analgesic consumption, and earlier mobilization and start of oral intake
(9)
(10)
(11)
(12). The brief postoperative course leads to a shorter hospital stay and convalescence. These objective parameters are of special importance in geriatric patients.
This article evaluates the significance of laparoscopic nephrectomy in comparison with open surgical nephrectomy in the young old (65–74 years), the old old (75–84 years), and the oldest old (85 years).
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Methods
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Patients and Operative Indications
Since 1993, a total of 249 nephrectomies for benign renal conditions have been performed in the Department of Urology at the Medical University of Lübeck. There were 131 laparoscopic nephrectomies and 118 open-flank nephrectomies. The indications for nephrectomy were given in case of shrunken kidneys with a reduction or loss of function due to recurrent pyelonephritis, reflux nephropathy, hydronephrosis, or hypertension. The age distribution of the whole study population is given in Table 1 . Patients were stratified by age, and the results presented are focused on the following three age groups: 65 to 74 years (the young old); 75 to 84 years (the old old); 85 years and older (the oldest old).
Technique of Laparoscopic Nephrectomy
Each patient was placed in a supine position under general anesthesia. A Verres needle was placed supraumbilically, and a pneumoperitoneum of 10 to 16 mm Hg of pressure was established. The first trocar was inserted in the periumbilical region, and the abdominal cavity was inspected by endocamera. For a right-sided nephrectomy, two trocars were inserted along the right anterior axillary line, 4 cm above and below the umbilicus. An additional trocar was placed in the abdominal midline, 5 cm below the xiphoid process. The operating table was tilted 30° to the left and a Toldt's line incision was made using endoscissors and an endodissector. The bowel was mobilized and retracted medially. After incision of the Gerota's fascia, the ureter was identified and used as a guiding structure to the renal hilum. The renal hilum was dissected bluntly, and the renal vein and the artery were separated. The renal artery was secured with three clips on the proximal side; alternatively, a vascular stapler was used. The renal vein was commonly ligated using a vascular stapler. The next step was the complete removal of the kidney from the surrounding fat and connective tissue; again, predominantly a blunt dissecting technique was used. As a final step, the ureter was dismembered and secured with two clips on the distal side. The organ specimen was manipulated into an entrapment sac and removed from the abdominal cavity using an extended trocar incision. Visible bleeding from small vessels was stopped by electrocoagulation, and, in case of diffuse minor bleeding, 1 to 2 ml of fibrin glue was applied to the renal bed. A morcellator was not used to provide adequate histopathological examination. Finally, the abdominal pressure was reduced to 5 mm Hg, and possible venous bleeding stopped. The trocars were removed under visual control, and the peritoneum and fascia were closed with nonabsorbable sutures, without placement of a drainage tube.
Postoperative Management
The nasogastric tube and bladder catheter were removed within 12 hours after the operation. Circulation parameters were closely monitored, and blood count, clotting parameters, and electrolytes in serum were updated 4 to 6 hours after the procedure and on the first postoperative day. Postoperative analgesia and intravenous hydration were adjusted according to the individual demands of the patient. Indications for blood transfusions and antibiotic medication were likewise given individually.
Technique of Open Nephrectomy
Open nephrectomy was performed via a subcostal or intercostal incision in a standard fashion. The patient was placed in a flank position on the operating table. After access to the retroperitoneal space, the renal hilum was identified and the renal vessels were ligated separately. After complete mobilization of the kidney and ligation of the ureter, the organ was removed. One or two drainage tubes were placed, and the incision was closed. The postoperative management was handled in a similar fashion to that of patients after laparoscopic nephrectomy, or adjusted according to the individual situation.
Statistical Analysis
The results were calculated as medians and minimal or maximal values. For comparison of unpaired results, the Mann-Whitney U test was used. Results within each group were assessed using the Friedman test and the Wilcoxon-Wilcox test. A p value <.05 was regarded as statistically significant.
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Results
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Operative Results
No major difference was observed for the median operative duration in the age groups of 65 to 74 years and 75 to 84 years in the laparoscopy group, compared with the overall operative durations in this group. Results were comparable in the open nephrectomy group. With respect to pre- and postoperative hemoglobin levels, both groups showed comparable results, regardless of patient age. The perioperative blood loss was, again independent of patient age, lower in the laparoscopy group than in the open nephrectomy group. This difference was statistically significant (p < .001). Although blood transfusions were not necessary in the laparoscopy group, up to 75% of patients in the open nephrectomy group required blood transfusions (p < .001). A summary of the results and comparative operative data of the whole study population are given in Table 2 .
Postoperative Results
Complication rates in geriatric patients were again comparable in the laparoscopy and open nephrectomy groups (p > .05). An increase in complication rates was observed in the group of patients aged between 75 to 84 years. The laparoscopy group showed a statistically significant advantage in analgesic consumption (measured as mg of morphine equivalent), duration of hospitalization, and convalescence, regardless of age, with the exception of the patient group aged between 65 and 74 years. In the open nephrectomy group, 2 patients (4.8%) died of cardiopulmonary accidents within 30 days after the operation. A summary of the results and comparative postoperative data of the whole study population are given in Table 3 .
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Discussion
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New operation techniques, such as endoscopic and laparoscopic procedures, have gained acceptance in recent years due to their proven reduced invasivity in comparison to the open surgical approach. These, in general, minimally invasive procedures offer a variety of clinical advantages. For a laparoscopic nephrectomy, these advantages were repeatedly demonstrated by different authors
(9)
(10)
(11)
(12). Generally, the following benefits were observed: (a) reduction of the operative trauma; (b) shorter hospital stay; (c) briefer postoperative course; (d) faster return to work; (e) potential conversion to care on an outpatient basis.
For certain indications, such as adrenalectomy, nephrectomy, and nephroureterectomy, the reduced invasiveness has been demonstrated in experimental studies
(13). For this study, mediators of the acute phase reaction were measured (e.g., C-reactive protein and interleukins). It was observed that patients who underwent a laparoscopic procedure showed a markedly lower elevation of these para-meters in the postoperative phase than patients after open surgery. This difference was independent of patient age and statistically significant
(13). For procedures without major systemic reactions (e.g., varix ligation), laparoscopy may not reduce invasiveness, but offers clear technical advantages
(13).
Especially geriatric patients, as a potential risk group, may benefit from these advantages of laparoscopic techniques. Apart from the patient's age, the number of existing comorbidities is of crucial importance for an uneventful course after surgery
(14)
(15). In addition, the mental and nutritional status of the patient, as well as the patient's hydration are of special concern. Factors like hyperglycemia, hyponatremia, and anemia have been identified as potential hazards for the postoperative course. Tschantz and Tuchschmid
(16) reported on 250 patients aged older than 65 years who underwent various surgical procedures (traumatological, vascular, thoracic, and abdominal surgery). The authors emphasized the importance of the preoperative correction of metabolic factors (hyperglycemia, hypoalbuminemia, and dehydration), as well as the importance of a swift and an atraumatic operative technique.
Other factors that have been frequently identified as prognostic factors for operative success are patient age (increased age is believed to be associated with physiologically impaired organ functions), comorbidity, estimated operative risk according to the American Society of Anesthesiologists' classification, and the necessity of operating under the conditions of a case of emergency (in contrast to elective surgery)
(17)
(18)
(19)
(20)
(21)
(22)
(23). Gonzalez-Serva and colleagues
(17) were able to demonstrate in a group of 814 patients that the presence of uremia and/or sepsis and/or underlying malignant disease have a relevant influence on the mortality rate after renal surgery. The presence of these factors led to an increase in mortality from 1.35% to 30%. Certainly most of these authors conclude that patient age is an important factor for operative success and postoperative course. But, according to the results, many authors concluded that patient age alone might not be regarded as the single argument for or against an operative procedure
(18).
In our study, the results of laparoscopic nephrectomy are compared with the results of open surgical nephrectomy in geriatric patients with benign kidney disease. In accordance with the data from current literature, we noted significant advantages in the laparoscopy group with respect to the operative parameters, blood loss and number of blood transfusions
(9)
(10)
(11)
(12). This is of special interest in geriatric patients who often present preoperatively with a low hemoglobin, compared with younger patients. Stable hemoglobin levels might account for a smaller number of patients with myocardial ischemia in the peri- or postoperative course. In the postoperative course, we noted significant benefits for the patients in the laparoscopy group with respect to analgesic consumption, start of oral intake, and mobilization (data not shown), as well as hospital stay and convalescence, regardless of patient age. This favorable postoperative course is of considerable importance for geriatric patients, as these patients generally have lower power reserves at their disposal. Only with respect to complication rates were differences noted related to patient age, whereas no differences were found between the laparoscopic and open nephrectomy group. A significant increase in complication rates was observed in the group of patients aged 75 to 84 years.
Current literature reports long-term results of laparoscopic unilateral nephrectomy in a considerable number of patients not stratified by age
(12)
(24)
(25)
(26). For procedure-related complications, two studies from 1995 reported complication rates of 16% and 30.2%, respectively
(24)
(25). In contrast, a more recent study
(26), and our data, showed complication rates of 6% and 20.6%, respectively. Although our study compares complication rates for both the laparoscopic and the open approaches, a trend toward a reduction of complication rates due to increased experience with laparoscopic nephrectomy can be assumed. This would not be unexpected since other operative parameters, such as initially prolonged operative durations and higher conversion rates, have been distinctly reduced
(12)
(24)
(25)
(26). Data acquired by the Laparoscopy Working Group of the German Urological Association in a multicenter study gives an overview of 482 laparoscopic nephrectomies performed at 14 laparoscopic centers in Germany
(26). The mean operative duration was 188 minutes, the conversion rate was 9.4%, and the complication rate was 6%. The mean hospital stay was 5.5 days. In comparison with historical data from a nationwide survey of the Laparoscopy Working Group of the German Urological Association, in 1993, all parameters have profoundly improved. The complication rate was reduced from over 10% to 6%
(26). All authors unanimously confirmed the advantages of laparoscopy for reduced analgesic consumption and shorter hospital stay and convalescence
(12)
(24)
(25)
(26). Our data confirm all these clinical benefits for the patient. Interestingly, all parameters were independent from patient age.
In conclusion, laparoscopic nephrectomy offers comparable results to open surgical nephrectomy, with reduced blood loss and fewer required blood transfusions. With respect to the parameters of the postoperative course, laparoscopy provides considerable advantages. Geriatric patients benefit most from these advantages. The laparoscopic procedure should be regarded as the primary approach for nephrectomy in these patients.
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Acknowledgments
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We thank Karyl Kaylene Höptner for assistance in preparing the manuscript.
Received April 3, 2000
Accepted May 1, 2000
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Abstract
Methods
