Correspondence Department of Surgery, Urology Service, Memorial Sloan–Kettering Cancer Center, Weill Cornell College of Medicine, 1275 York Avenue, New York, NY 10021, USA

Email russop@mskcc.org

Original article

Gill IS et al. (2007) Comparison of 1,800 laparoscopic and open partial nephrectomies for single renal tumors. J Urol 178: 41–46   PubMed

Synopsis

Background

Open partial nephrectomy (OPN) is an established treatment option for selected patients with renal cell carcinoma (RCC); a minimally invasive laparoscopic partial nephrectomy (LPN) can also be performed in these patients.

Objective

To evaluate the perioperative and postoperative experience and renal function outcomes in patients with RCC treated with LPN, compared with patients treated with OPN.

Design and intervention

Between 1 January 1998 and 31 August 2005, all patients who received LPN at the Cleveland Clinic, Cleveland, OH, or the Johns Hopkins Hospital, Baltimore, MD, and all patients who received OPN at the Cleveland Clinic or the Mayo Clinic, Rochester, MN, were reviewed; data were obtained from prospective and retrospective kidney cancer registries. Patients were included in the study if they were suspected of having a single clinical renal tumor <7 cm (T1), and were excluded if they had multifocal tumors, familial syndromes or radiological evidence of metastases or locally advanced disease. Physical examination, medical history, routine laboratory studies, abdominopelvic CT, chest X-ray and MRI were performed preoperatively. Tumor size, clinical staging, pathological staging and intraoperative and postoperative complications were recorded postoperatively.

Outcome measures

Perioperative outcome measures included length of surgery, amount of blood loss during surgery, and perioperative complications such as substantial injury to an adjacent organ, vessel or ureter. Postoperative outcome measures included length of hospitalization after surgery, postoperative complications, metastasis, and cancer-specific survival. The renal function outcome measure was the lowest serum creatinine level within 90 days of surgery.

Results

In total, 771 patients underwent LPN and 1,028 patients underwent OPN. Patients in the OPN group had a lower performance status, more tumors in a solitary functioning kidney, more tumors >4 cm, more centrally located tumors, and more malignancy than the LPN group at baseline (P <0.0001). The mean operative time for LPN and OPN was 3.3 and 4.3 hours, respectively (P <0.0001), the perioperative blood loss was 300 and 376 ml, respectively, the mean warm ischemia time was 30.7 and 20.1 min, respectively, and the total percentage of patients with intraoperative complications was 1.8% and 1.0%, respectively. After surgery, the duration of hospital stay was 3.3 and 5.8 days in patients who underwent LPN and OPN, respectively, and the percentage of patients who had a postoperative complication was 18.6% and 13.7%, respectively. The preoperative and lowest serum creatinine levels during the 90 days after surgery were 1.01 and 1.18 mg/dl, respectively, for LPN patients, and 1.25 and 1.42 mg/dl, respectively, for OPN patients. Kaplan–Meier estimates for cancer-specific 3-year survival were 99.3% for the LPN group and 99.2% for the OPN group.

Conclusions

LPN is a viable alternative treatment to OPN for specific patients with RCC. Selection for LPN or OPN should depend on surgical expertise at the treatment center and patient and tumor characteristics.

Commentary

The outcomes of patients with T1 renal tumors treated with partial nephrectomy are equivalent to those of patients treated with radical nephrectomy,¹ and the survival rates of patients with renal cancer who undergo partial nephrectomy are anticipated to be >90% across histological subtypes.² Resecting a benign tumor or an indolent carcinoma, such as papillary carcinoma or chromophobe RCC with limited metastatic potential, enhances the value of partial nephrectomy. Among apparently healthy patients with renal tumors of <4 cm, 26% have an estimated glomerular filtration rate (eGFR) of less than 60 ml/min/1.73m², which is diagnostic for stage 3 chronic kidney disease (CKD).³ CKD is an independent risk factor for hospitalization, the development of cardiovascular disease and death, the likelihood of which are increased as the eGFR decreases.⁴ Radical nephrectomy is an independent risk factor for the development of new CKD, or the worsening of pre-existing CKD,³ the sequelae of which can lead to comorbidities that are more life-threatening than a small renal cortical tumor. Despite the strong evidence that partial nephrectomy is the best treatment for small renal tumors, data indicate that in the USA, 90% of patients with tumors <4 cm still undergo radical nephrectomy.⁵

In this study, OPN patients were at a higher perioperative risk than LPN patients, which might have contributed to the longer hospital stays in OPN patients compared with LPN patients. Patients in the LPN group were more likely than the OPN group to have elective indications rather than imperative or absolute indications for partial nephrectomy, yet LPN was associated with longer warm ischemic time, more postoperative complications—particularly urologic—and an increased number of subsequent procedures to treat complications, compared with OPN. The authors used serum creatinine level, which is a crude indicator of renal function, rather than eGFR as their means of assessing the effect of warm ischemia on renal function. As determined by the Modification of Diet in Renal Disease equation, which takes race, sex, and age into account, eGFR is more accurate for the assessment of renal function than serum creatinine levels.^{3, 6}

During both LPN and OPN, attention to operative details might lessen the likelihood of postoperative complications such as urinary fistula, arteriovenous malformation and hemorrhage. A careful assessment of tumor size, location, multi-focality, bilaterality and renal functional reserve, coupled with an honest appraisal of the skills of the surgical team, will lead to a rational decision between OPN and LPN.

If LPN can not be completed, the default operation should be conversion to OPN, not to radical nephrectomy, which is usually performed. Enhanced training in both OPN and LPN is essential to avoid unnecessary radical nephrectomy for small renal tumors. The long-term renal functional preservation, and the induction of CKD or worsening of pre-existing CKD, must be considered on a par to local renal tumor control when deciding on therapy. The calculation of eGFR, a patient's age, tumor size and the presence of substantial comorbidity, particularly in elderly patients, can make a strong case for active surveillance. More important than whether OPN or LPN is utilized is the use of partial nephrectomy in patients with RCC, as it is fundamental to patients' future health. Radical nephrectomy must be reserved for patients with massive renal tumors that are not amenable to kidney-sparing operations.

Acknowledgments

The synopsis was written by Rachel Murphy, Associate Editor, Nature Clinical Practice.

References

1. Dash A et al. (2006) Comparison of outcomes in elective partial vs radical nephrectomy for clear cell renal cell carcinoma of 4–7 cm. BJU Int 97: 939–945 | Article | PubMed | ISI |
2. Lee CT et al. (2000) Surgical management of renal tumors 4 cm or less in a contemporary cohort. J Urol 163: 730–736 | Article | PubMed | ISI | ChemPort |
3. Huang WC et al. (2006) Chronic kidney disease after nephrectomy in patients with renal cortical tumours: a retrospective cohort study. Lancet Oncol 7: 735–740 | Article | PubMed | ISI |
4. Go AS et al. (2004) Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med 351: 1296–1305 | Article | PubMed | ISI | ChemPort |
5. Miller DC et al. (2006) Partial nephrectomy for small renal masses: an emerging quality of care concern? J Urol 175: 853–857 | Article | PubMed | ISI |
6. Yossepowitch O et al. (2006) Temporary renal ischemia during nephron sparing surgery is associated with short-term but not long-term impairment in renal function. J Urol 176: 1339–1343 | Article | PubMed | ISI |

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Subject areas under which this article appears: Urologic oncology (nonprostatic)