What is the risk of local recurrence after laparoscopic transperitoneal radical nephrectomy in children with Wilm's tumors? Analysis of a local series and review of the literature.
Aurore Bouty, MD, Michael Nightingale, MD, Annie Roberts, MD, Katherine Burnand, MD, Marty Campbell, MD, Yves Heloury, MD.
Royal Children's Hospital, Parkville, Australia.
Introduction: Laparoscopic radical nephrectomy is an alternative to open surgery in Wilms' tumours. However, concerns have been raised on the risk of local recurrence with this relatively new approach. The aim of the study was to determine the incidence of local recurrence after laparoscopic transperitoneal radical nephrectomy (LTRN).
Patients and methods: In addition to 19 local cases, we conducted a review of the literature (Pubmed, Embase) with the key words Wilms; Laparoscopy; Minimally invasive surgery; Nephrectomy; Recurrence. Patients with retroperitoneoscopic resection and/or nephron-sparing surgery were excluded.
Results: 104 LTRN have been performed for Wilms' tumours. Among these, 94 patients received pre-operative chemotherapy. Three patients had a pre-operative rupture of the tumour (two retroperitoneal, one intra) and one had a renal vein thrombosis. There was no per-operative rupture. Median volume of the tumour, when reported, was 300ml (3.8-776).
Local stage was specified in 86 cases: 49 stage I, 28 stage II and 9 stage III. Seven studies reported the median number of lymph nodes sampled during surgery. In these cases, there was a median of 2.5 (0-14) lymph nodes sampled in 49 patients. All lymph nodes were negative for tumour cells.
Post-operative histology was reported in 67 cases. For patients treated according to the COG approach, 26 had favourable and two had unfavourable histology. For those treated by the SIOP approach, there was 6 low, 31 intermediate and two high risk tumours.
With a median follow-up of 19 months (0.1-114), there were four local recurrences with a median of 8.5 months after surgery. Among these four patients, three were initial local stage I (one low risk, one intermediate, one high risk - blastematous predominant) and one stage III.
Conclusion: The incidence of local recurrence after laparoscopic nephrectomy (3.9%) is not superior to the one after open surgery (7.9%). However, these tumours amenable to minimally invasive surgery are smaller, with a higher number of stage I and II, and more standard histology. Therefore, inclusion of patients in international protocols with a prolonged and systematic follow-up is of utmost importance to carefully evaluate the risk of recurrence in this population.
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