UroToday - The incidence of isolated renal fossa metastasis after radical nephrectomy is very low (1-2%). Patients who undergo surgical excision of these isolated renal fossa metastasis with or without adjuvant therapy have been shown to have better 5-year disease specific survival than medical therapy (radiation, chemotherapy, or immunotherapy) or observation alone. We report the first series of patients who underwent hand assisted laparoscopic excision of renal fossa metastasis following radical nephrectomy. Although the utilization of laparoscopic technique in this setting provided advantages of decreased blood loss, short hospital stay, and rapid convalescence, it is important to realize that the final goal of the procedure is to attain a favorable oncological outcome. In our series of 5 patients with a long mean follow-up of 46 months, the cancer-specific and disease-free survival rates were 60% and 20%, respectively; which is comparable to that seen in open series. However, this report is a limited retrospective case series with significant selection bias in that patients who underwent laparoscopic exploration had small volume disease not involving surrounding structures. None of our patients underwent partial or complete excision of adjacent organs or structures which again signifies more advanced disease and thus more involved surgeries as described in some open approach studies. It is expected that outcomes for patients with tumor invasion into adjacent organs and structures would be worse than those without invasion. This makes comparison of this series to open series difficult.

We would also like to emphasize the fact that that reoperation for a renal fossa recurrence can be very difficult and should be performed only by experienced laparoscopic surgeons. Abdominal wall adhesions from previous operations, presence of bowel adhered to the recurrence in the renal fossa and the proximity of the recurrences to vital structures are the main technical challenges and should be addressed with caution. Appropriate patient selection is the key for avoiding complications and achieving a successful outcome. Surgical success is believed to be complete resection of the recurrent mass with negative surgical margins. Patients with very large tumors and those encasing or invading the great vessels or surrounding organs are probably best managed in an open fashion. Threshold for conversion to hand-assist or open approach should be low. Intraoperative consultation with surgeons of other specialties (e.g. vascular, gastrointestinal and transplant surgeons) should be utilized whenever necessary as enbloc resection of surrounding organs and extended lymphadenectomy may need to be performed occasionally. Frozen sections should be done whenever margins are of concern. Again, the goal of the operation should be complete surgical removal of the recurrent disease in the least morbid and the safest manner.

Gaurav Bandi, MD , as part of Beyond the Abstract on UroToday. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations, etc., of their research by referencing the published abstract.

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