Elsevier

Urology

Volume 73, Issue 5, May 2009, Pages 1077-1082
Urology

Oncology
Laparoscopic Radical Versus Partial Nephrectomy for Tumors >4 cm: Intermediate-term Oncologic and Functional Outcomes

https://doi.org/10.1016/j.urology.2008.11.059Get rights and content

Objectives

To compare the oncologic and functional outcomes of laparoscopic radical nephrectomy (LRN) and laparoscopic partial nephrectomy (LPN) for clinical Stage T1b-T3 renal cell carcinoma >4 cm in size.

Methods

This retrospective analysis compared patients undergoing LRN (n = 75) or LPN (n = 35) at a tertiary referral center from April 2001 to December 2005 for Stage T1b-T3N0M0 renal cell carcinoma. The endpoints included radiologically verified systemic and local recurrence, cancer-specific mortality, overall mortality, and chronic kidney disease as determined from the calculated glomerular filtration rate and Kidney Foundation Dialysis Outcomes Quality Initiative diagnostic criteria.

Results

The LRN group had larger tumors (5.3 vs 4.9 cm; P = .03), more T3a tumors (33% vs 9%; P = .006), and more clear cell pathologic features (85% vs 66%; P = .03). No surgical margins in either group were positive. The median follow-up was 57 months (range 27-79) for the LRN group and 44 months (range 27-85) for the LPN group (P = .1). The overall mortality (11% vs 11%), cancer-specific mortality (3% vs 3%), and recurrence (3% vs 6%) rates (P = .4) were equivalent. The postoperative decrease in the estimated glomerular filtration rate was less in the LPN group than in the LRN group at 13 and 24 mL/min, respectively (P = .03). Postoperatively, 2-stage increases in the chronic kidney disease stage occurred in 12% vs 0% of patients in the LRN and LPN groups, respectively (P < .001).

Conclusions

Our intermediate-term data have indicated that in appropriate patients with Stage T1b-T3 tumors >4 cm, LPN provides equivalent oncologic efficacy and superior renal functional outcomes compared with LRN. Future studies are required to confirm these trends.

Section snippets

Material and Methods

The data were obtained from an institutional review board-approved prospectively maintained database. From March 2001 to December 2005, 465 patients underwent LRN and 510 patients underwent LPN at our institution. The American Society of Anesthesiologists perioperative risk scores were assigned by staff anesthesiologists for all patients before surgery. The inclusion criteria included patients with organ-confined pathologically confirmed renal cell cancer (RCC) >4 cm in size who underwent

Results

The demographic, operative, and pathologic data are listed in Table 1. Of the 110 patients, 75 (68%) underwent LRN and 35 (32%) underwent LPN. An annual trend was seen in the decreased use of LRN and increased use of LPN throughout the study period. Both groups were equivalent in age, body mass index, American Society of Anesthesiologists performance status score, and tumor laterality. The mean operative estimated blood loss was 80 mL greater in the LPN group than in the LRN group (262 vs 179

Comment

The present study compared the intermediate-term oncologic and renal functional outcomes in patients with Stage pT1b-T3 RCC tumors treated with either LRN or LPN. These data have demonstrated that the RFS and CSS rates are equivalent and that LPN confers greater renal functional preservation. The indications for LPN can be extended to larger anatomically amenable tumors in this higher risk patient population in select patients.

The primary goal of LPN in any setting is oncologic control.

Conclusions

The results of our study have shown that LPN is equivalent to LRN in intermediate-term oncologic control for kidney tumors ≥4 cm in this cohort. LPN for these large tumors provided the benefit of renal functional preservation and decreased the incidence of postoperative Stage III or greater CKD by 34% compared with LRN. The indications for LPN can be extended to patients with anatomically amenable Stage pT1b-pT3 tumors. Careful patient selection and adequate laparoscopic expertise are

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