Laparoscopic Versus Open Radical Nephrectomy for Renal Cell Carcinoma: a Systematic Review and Meta-Analysis

Open versus minimally invasive nephroureterectomy in octogenarians: An analysis of surgical approach trends, outcomes, and survival analysis with propensity matching

INTRODUCTION

Upper tract urothelial carcinoma (UTUC) is a rare disease accounting only for 5%-10% of urothelial carcinoma (UC). For localized high-risk disease, radical nephroureterectomy (RNU) is the standard of care. While minimally invasive (MIS) RNU has not been shown to decisively improve overall survival (OS) compared to open surgery, MIS RNU has been associated with reduced hospital length of stay (LOS), blood transfusion requirements and improved recovery, which are important considerations when treating older patients. The purpose of this study is to examine trends in surgical approach selection and outcomes of open vs. MIS RNU in patients aged ≥80 years.

METHODS

Using the National Cancer Database (NCDB), patients aged ≥80 years who underwent open or MIS (either robotic or laparoscopic) RNU were identified from 2010 to 2019. Demographic, patient-related, and disease-specific factors associated with either open or MIS RNU were assessed using multivariate logistic regression models. Survival analysis was conducted using Kaplan-Meier plots and Cox-proportional hazard regression. Inverse probability of treatment weighting (IPTW) was utilized to adjust for confounding variables. Survival analysis was also conducted on the IPTW adjusted cohort using Kaplan-Meier plots and Cox-proportional hazard regression.

RESULTS

5,687 patients were identified, with 1,431 (25.2%) and 4,256 (74.8%) patients undergoing open and MIS RNU respectively. The proportion of RNU performed robotically has increased from 12.5% in 2010 to 50.4% in 2019. MIS was associated with a shorter hospital LOS (4.7 days versus 5.9 days, SMD 23.7%). Multivariate analysis revealed that MIS was associated with a significant reduction in 90-day mortality (OR: 0.571; 95%CI: 0.34-0.96, P = 0.033) and improved median OS (53.8 months [95%CI: 50.9-56.9] vs 42.35 months [95%CI: 38.6-46.8], P < 0.001) compared to open surgery. IPTW-adjusted survival analysis revealed improved median OS with MIS when compared to open surgery, with a survival benefit of 46.1 months (95%CI: 40.2-52.4 months) versus 37.7 months (95%CI: 32.6-46.5 months, P = 0.0034) respectively. IPTW-adjusted cox proportional hazard analysis demonstrated that MIS was significantly associated with reduced mortality (HR 0.76, 95%CI: 0.66-0.87, P < 0.001).

CONCLUSION

In octogenarians undergoing RNU, MIS is associated with improved median OS and 90-day mortality.

Renal cell carcinoma outcomes in end-stage renal disease: A 40-year study from two Japanese institutions

OBJECTIVES

The objective of the study was to analyze the outcomes of patients with renal cell carcinoma (RCC) arising in end-stage renal disease (ESRD) over a 40-year span.

METHODS

We retrospectively evaluated data of patients with ESRD-RCC diagnosed between 1979 and 2020 at two institutions. We assessed changes in stage, surgical approaches, and cancer-specific survival (CSS) following nephrectomy according to era between ESRD-RCC and sporadic RCC. Furthermore, perioperative outcomes in patients with ESRD-RCC were compared between laparoscopic and open surgery.

RESULTS

Patients with ESRD-RCC (n = 549) were diagnosed at an earlier stage (p = 0.0276), and the ratio of laparoscopic nephrectomy was increased (p < 0.0001) according to eras. Since 2000 (i.e., after implementation of laparoscopic nephrectomy), patients with ESRD-RCC (n = 305) had significantly shorter CSS (p = 0.0063) after nephrectomy than sporadic RCC (n = 2732). After adjustment by multivariate analysis and propensity score matching, ESRD status was independently associated with shorter CSS (p = 0.0055 and p = 0.0473, respectively). Improved CSS in sporadic RCC (p < 0.0001), but not ESRD-RCC (p = 0.904), according to era contributed to this difference. Laparoscopic nephrectomy showed favorable outcomes, including shorter surgery time, lower estimated bleeding volumes, transfusion rates, and readmission rates, and shorter postoperative hospitalization than open nephrectomy (p < 0.05).

CONCLUSIONS

Advances in diagnostic and treatment modalities potentially enable early diagnosis and minimally invasive surgery for patients with ESRD-RCC. As ESRD-RCC may not present indolently, careful post-operative monitoring is needed.

Impact of Assistant Experience on Perioperative Outcomes of Simple and Radical Laparoscopic Nephrectomy: Does It Really Matter?

Background and Objectives: While systematic reviews highlight the advantages of laparoscopic nephrectomy over traditional open surgery, the impact of an assistant's experience on surgical outcomes remains unclear. This study aims to evaluate whether the level of assistant expertise influences laparoscopic nephrectomy outcomes. Materials and Methods: Retrospective data from our institutional database were analyzed for patients who underwent laparoscopic nephrectomy between January 2018 and December 2022. Procedures were performed by a highly experienced surgeon, including postgraduate year (PGY)-3 to PGY-5 residents as assistants. Senior-level assistants had completed at least 10 procedures. Patient characteristics, surgical outcomes, and postoperative details were collected. Multivariable linear and logistic regression models were performed to test the effect of assistant experience (low vs. high) on estimated blood loss (EBL), length of stay (LOS), operative time (OT), and postoperative complications. Results: 105 patients were included, where 53% had highly experienced assistants and 47% had less experienced ones. Low assistant experience and higher BMI predicted longer operative time (OT), confirmed by multivariable regression (β = 40.5, confidence interval [CI] 18.7-62.3, p < 0.001). Assistant experience did not significantly affect EBL or LOS after adjusting for covariates (β = -14.2, CI -91.8-63.3, p = 0.7 and β = -0.83, CI -2.7-1.02, p = 0.4, respectively). There was no correlation between assistant experience and postoperative complications. Conclusions: Assistant experience does not significantly impact complications, EBL, and LOS in laparoscopic nephrectomy. Surgeries with less experienced assistants had longer OT, but the overall clinical impact seems limited. Trainee involvement remains safe, guided by experienced surgeons.

Quadratus lumborum block and transversus abdominis plane block in laparoscopic nephrectomy: a meta-analysis

Aim: To study the efficacy of quadratus lumborum block (QLB) and transversus abdominis plane (TAP) in laparoscopic nephrectomy patients. Materials & methods: We conducted a meta-analysis of randomized controlled trials for QLB and/or TAP technique compared with each other or a control. Results: Direct analysis of 24 h post-op pain score at rest for each compared with control showed significant reduction, QLB (mean differences [MD] [95% CI]: -1.12 [-1.87,-0.36]; p = 0.004) and TAP (MD [95% CI]: -0.36 [-0.59, -0.12]; p = 0.003). With movement both were respectively lower than control QLB (MD [95% CI]: -1.12 [-1.51, -0.72]; p = <0.0001) and TAP (MD [95% CI]: -0.50 [-0.95, -0.05]; p = 0.03). Moreover, QLB demonstrated less risk 24 h of post-op nausea vomiting (PONV) versus control (PONV; risk ratios [RR] [95% CI]: 0.64 [0.45,0.90]; p = 0.01). Conclusion: TAP and QLB reduce pain scores compared with control, whereas only QLB reduces PONV compared with control.

Surgical Complications Requiring Reoperation in Open Versus Minimally Invasive Radical Nephrectomy: A Contemporary Analysis of the National Surgical Quality Improvement Program

BACKGROUND

To explore reoperation rates for different radical nephrectomy (RN) approaches that are experiencing a shift from open radical nephrectomy (ORN) toward minimally invasive surgery (MIS), we aimed to compare reoperation rates along with their culprit etiologies between the different types of surgical approaches for RN.

METHODS

The national surgical quality improvement program dataset was used to select patients who underwent RN between the years 2012-2019. A 1:1 propensity score matched analysis was used. Reoperation rates and causes were then compared between open and MIS approach.

RESULTS

The propensity matched cohort included 15,294 patients. Reoperation rates due to large bowel injury (0.01 vs. 0.14%), vascular injury (0.07 vs. 0.22%), and other abdominal (0.5 vs. 0.77%) were more common in ORN as compared to MIS (MIS vs. ORN, respectively, p < 0.034). Reoperation due to hernia (0.14 vs. 0.03%) was more common in MIS as compared to ORN (p = 0.027). No difference was seen for small bowel injury and incision/wound debridement. General reoperation (1.61 vs. 2.22%) and mortality (0.57 vs. 1.47%) were also more common in ORN as compared to MIS (p < 0.008).

CONCLUSION

Reoperation due to large bowel injury, vascular injury, and other abdominal was more likely to occur in ORN. Whereas reoperation due to hernia was more likely to occur in MIS. Surgical approach was an independent risk factor for immediate and early reoperation rates in RN patients. These results could be used to counsel patients pre-operatively on possible surgical approaches and complications.

Survival after minimally invasive vs. open radical nephrectomy for stage I and II renal cell carcinoma

BACKGROUND

A recently reported phase III randomized trial comparing open and minimally invasive hysterectomy showed significantly higher rates of local recurrence after minimally invasive surgery (MIS) for cervical cancer. This raised concerns regarding patterns of recurrences and survival after MIS in general. This study aims to determine the effect of MIS on all-cause mortality among patients undergoing radical nephrectomy for Stage I and II renal cell carcinoma (RCC).

METHODS

We utilized the National Cancer Database to identify patients diagnosed with clinical stage I-II RCCs between 2010 and 2013. Patients for whom a laparoscopic or robotic radical nephrectomy was attempted were compared to patients who underwent open radical nephrectomy (ORN). Adjusted regression models with inverse probability propensity score weighting (IPW) were utilized to identify independent predictors of receiving MIS. All-cause mortality rates were compared using IPW survival functions and log-rank tests. Adjusted Cox proportional hazard models were fitted to determine independent predictors of OS.

RESULTS

27,642 patients were identified; 11,524 (41.7%) had MIS, while 16,118 (58.3%) had ORN. Kaplan-Meier survival curves in the IPW cohort showed significant OS advantage for patients who underwent MIS (p < 0.001). Furthermore, length of hospital stays (3 vs. 4 days), 30 day readmission rates (2.4 vs. 2.87%), 30 day (0.53 vs. 0.96%) and 90 day mortality rates (1.04 vs. 1.77%) were significantly higher in the ORN group (p < 0.001).

CONCLUSIONS

MIS was associated with better OS outcomes compared to ORN for stage I and II RCC. In addition, MIS had lower post-operative readmission, 30- and 90 day mortality rates.

Impact of type of minimally invasive approach on open conversions across ten common procedures in different specialties

BACKGROUND

Conversion rates during minimally invasive surgery are generally examined in the limited scope of a particular procedure. However, for a hospital or payor, the cumulative impact of conversions during commonly performed procedures could have a much larger negative effect than what is appreciated by individual surgeons. The aim of this study is to assess open conversion rates during minimally invasive surgery (MIS) across common procedures using laparoscopic/thoracoscopic (LAP/VATS) and robotic-assisted (RAS) approaches.

STUDY DESIGN

Retrospective cohort study using the Premier Database on patients who underwent common operations (hysterectomy, lobectomy, right colectomy, benign sigmoidectomy, low anterior resection, inguinal and ventral hernia repair, and partial nephrectomy) between January 2013 and September 2015. ICD-9 and CPT codes were used to define procedures, modality, and conversion. Propensity scores were calculated using patient, hospital, and surgeon characteristics. Propensity-score matched analysis was used to compare conversions between LAP/VATS and RAS for each procedure.

RESULTS

A total of 278,520 patients had MIS approaches of the ten operations. Conversion occurred in 5% of patients and was associated with a 1.77 day incremental increase in length of stay and $3441 incremental increase in cost. RAS was associated with a 58.5% lower rate of conversion to open surgery compared to LAP/VATS.

CONCLUSION

At a health system or payer level, conversion to open is detrimental not just for the patient and surgeon but also puts a significant strain on hospital resources. Use of RAS was associated with less than half of the conversion rate observed for LAP/VATS.

Risk of Postoperative Renal Failure in Radical Nephrectomy and Nephroureterectomy: A Validated Risk Prediction Model

INTRODUCTION

The study aimed to construct and validate a risk prediction model for incidence of postoperative renal failure (PORF) following radical nephrectomy and nephroureterectomy.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database years 2005-2014 were used for the derivation cohort. A stepwise multivariate logistic regression analysis was conducted, and the final model was validated with an independent cohort from the ACS-NSQIP database years 2015-2017.

RESULTS

In cohort of 14,519 patients, 296 (2.0%) developed PORF. The final 9-factor model included age, gender, diabetes, hypertension, BMI, preoperative creatinine, hematocrit, platelet count, and surgical approach. Model receiver-operator curve analysis provided a C-statistic of 0.79 (0.77, 0.82; p < 0.001), and overall calibration testing R2 was 0.99. Model performance in the validation cohort provided a C-statistic of 0.79 (0.76, 0.81; p < 0.001).

CONCLUSION

PORF is a known risk factor for chronic kidney disease and cardiovascular morbidity, and is a common occurrence after unilateral kidney removal. The authors propose a robust and validated risk prediction model to aid in identification of high-risk patients and optimization of perioperative care.

Outcomes after transperitoneal laparoscopic ureteronephrectomy for the treatment of primary renal neoplasia in seven dogs

OBJECTIVE

To describe the perioperative characteristics and outcomes in dogs that underwent transperitoneal laparoscopic ureteronephrectomy (TLU) for primary renal neoplasia.

STUDY DESIGN

Short case series.

ANIMALS

Seven client-owned dogs.

METHODS

Medical records were reviewed and data extracted regarding perioperative characteristics and animal outcomes. TLU was performed using a single-port + 1 or multiple port techniques. Hemostatic clips or a vessel-sealing device were used for occlusion of renal hilar vessels. The ureter was occluded and transected close to the ureterovesicular junction and the tumor was placed in a specimen retrieval bag for extraction from the abdomen.

RESULTS

Preoperative contrast enhanced computed tomography (CECT) was performed in 6/7 dogs. Median estimated tumor volume measured from abdominal CECT removed by TLU was 32.42 cm³ (interquartile range [IQR] 14.76-94.85). Median surgery time for TLU was 90 minutes (IQR 85-105). In one dog, elective conversion to open laparotomy was performed due to large tumor size. Median time to discharge was 31 hours (IQR 24-48). No major perioperative complications occurred and all dogs survived to discharge. Progression free survival in four dogs was 422 days (IQR 119-784).

CONCLUSION

TLU was performed for the extirpation of modest sized primary renal tumors with acceptable perioperative outcomes and a low complication rate.

CLINICAL RELEVANCE

TLU may be considered for the treatment of selected cases of primary renal neoplasia in dogs.

Simplifying Laparoscopic Nephrectomy for Beginners: Double Window Technique With En Bloc Hilar Stapling

Laparoscopic nephrectomy is a commonly performed procedure. As with any surgical procedure, this too has a significant learning curve. The management of renal hilum is the most critical part of this surgery. It requires a meticulous intra-hilar dissection to identify the renal artery and vein. The kidneys are extremely vascular structures and any injury to these vessels during dissection can result in life-threatening bleeding. Hence, it is obvious that beginners most often face difficulty and apprehension at this step of the laparoscopic nephrectomy. We describe a simple technique of laparoscopic nephrectomy which includes the creation of two windows, one at the lower pole and the second at the upper pole, isolation of the hilum, and en bloc stapling of the renal hilar vessels. This method safeguards against collateral damage to the surrounding structures. It also avoids the need for intra-hilar dissection, hence decreasing the chances of vascular injuries.

Comparison of Perioperative Outcomes for Radical Nephrectomy Based on Surgical Approach for Masses Greater than 10cm

Introduction and Objective Robotic-assisted radical nephrectomy (RRN) is increasingly utilized as an alternative to laparoscopic radical nephrectomy (LRN) but there are concerns over costs and objective benefit. In the setting of very large renal masses (>10 cm), comparison between techniques is limited and it is unclear whether a robotic approach confers any perioperative benefit over LRN or open radical nephrectomy (ORN). In this study, perioperative outcomes of RRN, LRN, and ORN for very large renal masses are compared. Methods Using the National Cancer Database, patients were identified who underwent radical nephrectomy for kidney tumors >10 cm diagnosed from 2010-2015. Patients were analyzed according to surgical approach. Perioperative outcomes, including conversion to open, length of stay, readmission rates, positive surgical margins, and 30 and 90-day mortality were compared among cohorts. Results A total of 9288 patients met inclusion criteria (RRN = 842, LRN = 2326, ORN = 6120). Compared to ORN, recipients of RRN or LRN had similar rates of 30-day readmission and 30- and 90-day mortality. Length of hospital stay was significantly shorter in RRN (-1.73 days ±0.19; p<0.0001) and LRN (-1.40 days ±0.12; p<0.0001) compared to ORN. LRN had a higher rate of conversion to open compared to RRN (OR 1.48; 95% CI 1.10-1.98; p=0.0087). Conversion to open from RRN or LRN added 1.3 additional days of inpatient stay. Over the study period, RRN use increased from 4.1% to 14.8%, LRN from 20.9% to 25.6%, while ORN use decreased from 75% to 59.6%. Conclusions Minimally invasive approaches are increasingly utilized in very large renal masses. RRN has lower rates of conversion to open but produces comparable perioperative outcomes to LRN. Minimally invasive approaches have a shorter length of inpatient stay but otherwise report similar surgical margin status, readmission rates, and mortality rates compared to open radical nephrectomy.

Factors affecting long-term renal functions after partial vs radical nephrectomy for clinical T1 renal masses: A Multicentre Study of the Urooncology Association, Turkey

PURPOSE

To compare the functional outcomes of patients who underwent partial (PN) or radical nephrectomy (RN) for clinical T1 (cT1) renal tumours using the Kidney Cancer Database of the Urooncology Association, Turkey.

METHODS

We retrospectively reviewed 1004 patients who underwent PN and RN for cT1 renal tumours at multiple academic tertiary centres between 2000 and 2018. Patients with preoperative end-stage chronic kidney disease and/or metastatic disease were excluded.

RESULTS

There were 452 patients in the PN group and 552 patients in the RN group. The median follow-ups were 74.9 and 83.7 months in RN and PN cohort. The eGFR was significantly reduced in both groups on postoperative day 1 (PN = 13.7 vs RN = 19.1 mL/min/1.73 m² : P < .001). In the PN group, eGFR showed a tendency to recover according to a quadratic pattern and reached preoperative levels in the first and third years (95.6 ± 28.8 mL/min/1.73 m² and 96.9 ± 28.9 mL/min/1.73 m² , respectively), with no significant difference between the eGFRs in the 1st and 3rd years (P = .710). To define groups at risk, different cut-off values for the GFR were considered. Among patients with a baseline GFR < 90, the RN cohort had significantly lower eGFRs in the first and third years than the PN cohort (P = .02). Logistic regression showed that comorbidities, coronary artery disease, diabetes and hypertension had no adverse impacts on the changes in the eGFR (P = .60, P = .13, and P = .13, respectively).

CONCLUSION

For the treatment of stage T1 kidney tumours, open or laparoscopic partial nephrectomy has the benefit to preserve renal function.

Risk Factors and Patterns of Locoregional Recurrence After Radical Nephrectomy for Locally Advanced Renal Cell Carcinoma

Purpose

We aimed to investigate the risk factors and patterns of locoregional recurrence (LRR) after radical nephrectomy (RN) in patients with locally advanced renal cell carcinoma (RCC).

Materials and Methods

We retrospectively analyzed 245 patients who underwent RN for non-metastatic pathologic T3-4 RCC from January 2006 to January 2016. We analyzed the risk factors associated with poor locoregional control using Cox regression. Anatomical mapping was performed on reference computed tomography scans showing intact kidneys.

Results

The median follow-up duration was 56 months (1-128 months). Tumor extension to renal vessels or the inferior vena cava (IVC) and Fuhrman's nuclear grade IV were identified as independent risk factors of LRR. The 5-year actuarial LRR rates in groups with no risk factor, one risk factor, and two risk factors were 2.3%, 19.8%, and 30.8%, respectively (p<0.0001). The locations of LRR were distributed as follows: aortocaval area (n=2), retrocaval area (n=5), and tumor bed (n=11). No LRR was observed above the celiac axis (CA) or under the inferior mesenteric artery (IMA).

Conclusions

Tumor extension to renal vessels or the IVC and Fuhrman's nuclear grade IV are the independent risk factors associated with LRR after RN for pT3-4 RCC. The locations of LRR after RN for RCC were distributed in the tumor bed and regional lymphatic area from the bifurcation of the CA to that of the IMA.

Impact of margin status on survival after radical nephrectomy for renal cell carcinoma

BACKGROUND

Data about the impact of surgical margin positivity on patient outcomes following radical nephrectomy (RN) for renal cell carcinoma (RCC) is limited. We evaluate the effect of positive surgical margins (PSMs) on relapse-free survival (RFS) and overall survival (OS.) METHODS: Clinicopathologic data of patients who underwent RN for RCC was analyzed based on margin status. χ² and Student t test were used to compare groups. Cox regression analysis was used for the analysis. Kaplan-Meier method was used for survival curves.

RESULTS

A total of 485 patients who underwent RN for RCC were analyzed. Most patients with T1/T2 stage had NSM. Most patients with T4 had PSM. T3 patients were split between the two groups. Analysis of the T3 group showed shorter RFS in the PSM group at 3 years (hazard ratio [HR]: 4.3, p = .01), and 5 years (HR: 4.3, p = .01.) OS analysis showed worse OS in PSM but not statistically significant. There was a significant association between PSM and laterality (p = .023) and histologic type (p = .025.) CONCLUSIONS: PSM was associated with shorter RFS after RN in T3 RCC patients. There was a trend towards worse OS in the PSM group, but it did not reach statistical significance. Laterality and histologic type were associated with surgical margin status.

Minimally invasive radical nephrectomy: a contemporary review

Minimally invasive renal surgery has revolutionized the surgical management of renal cancer since the initial report of laparoscopic nephrectomy in 1991. Laparoscopic nephrectomy became the mainstay of management in surgically resectable renal masses since the 1990s. The growing body of literature supporting nephron-sparing surgery over the last two decades has meant that minimally invasive radical nephrectomy (MI-RN) is now the preferred treatment for renal tumors not amenable to partial nephrectomy. While there is a well-described experience with complex radical nephrectomy using standard laparoscopy, robot-assisted surgery has shortened the learning curve and facilitated greater uptake of minimally invasive surgery in difficult surgical scenarios traditionally performed open surgically. Increased experience and expertise with robot-assisted renal surgery has led to expansion of the indications for MI-RN to include larger masses, locally advanced renal masses invading adjacent tissues or regional hilar/retroperitoneal lymph nodes, cytoreductive nephrectomy (CN) in metastatic disease, and concurrent venous tumor thrombectomy for renal vein or inferior vena cava (IVC) involvement. In this article, we review the various surgical techniques and adjunctive procedures associated with MI-RN.

Laparoscopic versus open nephrectomy in resource-constrained developing world hospitals: a retrospective analysis

Background

Laparoscopic nephrectomy is the standard of care for nephrectomy in most developed countries. Its adoption in our setting has been limited due to lack of equipment and expertise. This paper sets out to show that laparoscopic nephrectomy is technically feasible in the state sector in South Africa.

Methods

A retrospective chart review was performed of all patients having undergone nephrectomy over a five-year period at two state hospitals in KwaZulu-Natal Province, South Africa. Demographic information, pre-operative imaging findings, operative information and post-operative outcomes were analysed.

Results

Nephrectomy was performed in 196 patients. Open nephrectomy (ON) was the intended surgical approach in 73% (n = 143) and laparoscopic nephrectomy (LN) in 27% (n = 53). The conversion rate from LN to ON was 11% (n = 6). For malignancies, there was no difference in surgical resection margin status across the ON, LN and conversion groups; however, tumour size was larger in the conversion group compared to the LN group. Estimated blood loss and transfusion rates were lower in the LN group. The average length of hospital stay was shorter in the LN group (5 vs 10 days). High dependency unit (HDU) admission rate was lower in the LN group (12.1%) compared to the ON group (50%) and the conversion group (40%). No difference in high-grade complications was noted between the ON and LN groups, and more patients in the LN group (82.5%) had no complications compared to the open group (9.9%).

Conclusion

LN is non-inferior to ON in terms of operative time, oncology outcomes and high-grade complications. LN is superior in terms of blood loss, transfusion rate, length of hospital stay and overall complication rate. LN appears to show technical feasibility in the state sector and highlights the need for laparoscopic training.

Minimally Invasive Surgery for Patients with Locally Advanced and/or Metastatic Renal Cell Carcinoma

Despite advances in systemic therapy and immunotherapy, surgery continues to have a role in management of advanced renal cell carcinoma (aRCC). Minimally invasive surgery (MIS) is considered standard of care for smaller, localized tumors due to faster recovery without compromising oncologic outcomes. There are concerns about MIS for aRCC due to a potential risk of inferior oncologic outcomes and unusual patterns of disease recurrence. Recent studies, however, suggest that in properly selected patients with aRCC, MIS can provide improved peri-operative outcomes without compromising oncologic control.

Comparison of Cancer Specific Outcomes following Minimally Invasive and Open Surgical Resection of Early Stage Kidney Cancer from a National Cancer Registry

PURPOSE

With anecdotal observations of atypical recurrences following minimally invasive surgery and alongside new concerns following cervical cancer surgery, there is a need to evaluate cancer specific outcomes for minimally invasive kidney cancer surgery using national data. We evaluated cancer specific outcomes following minimally invasive surgery vs open surgery for early stage kidney cancer.

MATERIALS AND METHODS

We performed a retrospective population based cohort study using data from the SEER (Surveillance, Epidemiology, and End Results) program linked with Medicare claims that included beneficiaries at least 66 years old diagnosed between 2004 and 2013 with early stage, nonurothelial kidney cancer who underwent surgical resection within a year of diagnosis. We compared overall survival, disease specific survival, rate of second kidney cancer surgery and rate of postoperative systemic cancer therapy based on whether surgery was minimally invasive surgery or an open resection. Multivariable regression was used to account for confounders.

RESULTS

A total of 5,150 patients were included in analysis and 3,062 (59.5%) underwent minimally invasive surgery. On multivariable analysis minimally invasive surgery was not associated with differences in overall survival (HR 0.94, 95% CI 0.84-1.06) or disease specific survival (HR 0.96, 95% CI 0.83-1.11). Patients treated with minimally invasive surgery were more likely to receive systemic cancer therapy (HR 1.31, 95% CI 1.09-1.59). No difference in the rate of second surgery associated with surgical approach was observed.

CONCLUSIONS

Use of minimally invasive surgery for early stage kidney cancer was not associated with differences in overall or disease specific survival, or the rate of second kidney cancer surgery. Patients treated with minimally invasive surgery received more postoperative systemic therapy, which could represent a disparate cancer specific outcome associated with minimally invasive surgery.

Comparison of Minimally Invasive Versus Open Pancreatoduodenectomy for Pancreatic Ductal Adenocarcinoma: A Propensity Score Matching Analysis

Background: Few studies have compared perioperative and oncological outcomes between minimally invasive pancreatoduodenectomy (MIPD) and open pancreatoduodenectomy (OPD) for pancreatic ductal adenocarcinoma (PDAC). Methods: A retrospective review of patients undergoing MIPD and OPD for PDAC from January 2011 to December 2017 was performed. Perioperative, oncological, and survival outcomes were analyzed before and after propensity score matching (PSM). Results: Data from 1048 patients were evaluated (76 MIPD, 972 OPD). After PSM, 73 patients undergoing MIPD were matched with 219 patients undergoing OPD. Operation times were longer for MIPD than OPD (392 vs. 327 min, p < 0.001). Postoperative hospital stays were shorter for MIPD patients than OPD patients (12.4 vs. 14.2 days, p = 0.040). The rate of overall complications and postoperative pancreatic fistula did not differ between the two groups. Adjuvant treatment rates were higher following MIPD (80.8% vs. 59.8%, p = 0.002). With the exception of perineural invasion, no differences were seen between the two groups in pathological outcomes. The median overall survival and disease-free survival rates did not differ between the groups. Conclusions: MIPD showed shorter postoperative hospital stays and comparable perioperative and oncological outcomes to OPD for selected PDAC patients. Future randomized studies will be required to validate these findings.

Robotic-assisted laparoscopic resection of a primary renal neuroendocrine carcinoma

Primary renal neuroendocrine carcinomas (RNC) are extremely rare urological neoplasms, with fewer than 100 cases reported in the literature. There are no established protocols concerning diagnosis and treatment, and there is no definitive data on prognosis. Here, we report the findings of a 54-year-old woman who presented with intermittent back pain due to a large mass, which was initially suspected to be a renal cell or upper tract urothelial carcinoma. The patient underwent robotic-assisted laparoscopic nephrectomy and lymph node dissection without complications. Pathology revealed an RNC with local metastases to para-aortic lymph nodes without evidence of another primary origin. Subsequent surveillance showed no evidence of disease until 48-month follow-up imaging revealed a liver lesion suspicious for possible metastatic cancer. This report represents the second documented usage of robot-assisted laparoscopic nephrectomy for RNC and the longest follow-up in the literature. We review the diagnosis, treatment and follow-up of patients with RNC.

Evaluating the impact of resident involvement during the laparoscopic nephrectomy

Introduction

Laparoscopic nephrectomy (LN) is the most performed laparoscopic procedure by urologic residents (Res). A large amount of data exists on laparoscopic nephrectomies in terms of safety and surgical outcomes, but only a little is known about the influence of residents. The purpose of this study was to evaluate this influence on the clinical outcome of a laparoscopic nephrectomy.

Material and methods

Retrospectively, patients who had undergone a LN between 2010 and 2018 were assessed. Data included patient demographics, date of surgery, pre- and postoperative results and complications. The patients who had undergone a LN were divided into two groups: one where residents were involved and another group where only a staff surgeon (Sur) performed the operation. All training residents had a questionnaire sent to them to evaluate their role during the LN.

Results

A total of 229 patients met the study criteria, of which 78 patients were operated together with a resident and 151 by a staff surgeon alone. Both groups were homogeneous in terms of age, comorbidities, left/right sided LN and tumor-stage. Between these two groups, no significant differences were observed in median estimated blood loss (Res 87 ml vs. Sur 100 ml), intraoperative adverse events (Res 10.3% vs. Sur 6% p = 0.24), conversion to open surgery (Res 6.4% vs. Sur 6%) and high-grade postoperative complications (Res 3.9% vs. Sur 4.6%). However, when a resident participated, the LN lasted on average 20 minutes longer (Res mean 130 min vs. Sur 110 min p ≤0.001).

Conclusions

Our data shows that involvement of a resident in laparoscopic nephrectomy has no effect on the clinical outcome. Therefore, it is safe to perform a laparoscopic nephrectomy together with a resident, but it is important to take the additional surgical time into account.

Comparison of selective and main renal artery clamping in partial nephrectomy of renal cell cancer: A PRISMA-compliant systematic review and meta-analysis

BACKGROUND

The aim of the present study was to perform a systematic review and meta-analysis of the studies comparing the efficiency and safety of selective renal artery clamping (SAC) and main renal artery clamping (MAC) in partial nephrectomy (PN) for renal cell cancer (RCC).

METHODS

According to the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement, a literature search on PubMed, EMBASE, Web of Science, and Chinese National Knowledge Infrastructure were conducted to identify relevant studies published through December 2017. Outcomes of interest included baseline characteristics and perioperative surgical variables.

RESULTS

In all, 14 studies involving 2824 RCC patients comparing SAC and MAC were included in this meta-analysis. No differences were detected in mean patient body mass index (P = .08), tumor size (P = .22), baseline estimated glomerular filtration rate (eGFR) (P = .60), American Society of Anesthesiologists score (P = .97), or RENAL score (P = .70). The mean age was significantly younger in the SAC group compared with the MAC group (P = .002). There was no difference between SAC and MAC groups in terms of warm ischemia time (P = .31), transfusion rate (P = .18), length of hospital stay (P = .47), or postoperative complication rate (P = .23). Although SAC had longer operating time (OT) (P = .04) and more estimated blood loss (EBL) (P = .0002), a lower percentage decrease in eGFR in the SAC group was found compared to the MAC group (P = .002).

CONCLUSIONS

Patients undergoing PN with SAC had longer OT and higher EBL. SAC was more frequently used in younger patient. SAC offered better renal function preservation when compared with MAC for RCC. Given the inherent limitations of the included studies, further well-designed randomized controlled trials are required to verify these findings.

Kidney cancer in Saudi Arabia. A 25-year analysis of epidemiology and risk factors in a tertiary center

OBJECTIVES

To evaluate available epidemiological data and risk factors for kidney cancer in a tertiary care center in Riyadh, Saudi Arabia, over a period of 25 years.

METHODS

This retrospective study conducted in a tertiary care center included all adult patients with primary kidney cancer who presented and were managed between 1990 and 2015. Based on this information, we forecast the incidence of the disease in our center over the next 5 years (2016 to 2020).

RESULTS

In total, 371 patients were included in the study. The mean age of the patients was 56.3 years and the majority were male (61%). Among the patients, 55.8% were diagnosed incidentally. At the time of diagnosis, 53.2% were hypertensive, 46.2% were diabetic, 39.1% had dyslipidemia, and 25% were smokers. In addition, most patients were obese (42.3%) or overweight (30%). The most frequent histopathological variants were clear cell and chromophobe. Most patients presented with Stage 1. Minimally invasive surgery (laparoscopic, robotic) was performed in 55% of cases. Based on these data, we predicted that 172 new cases will present at our tertiary care center in 5 years from 2016 to 2020.

CONCLUSION

The incidence in kidney cancer is increasing and is associated with an alarming increase in the prevalence of associated risk factors.