Comparison of oncological outcomes of transperitoneal and retroperitoneal laparoscopic radical nephrectomy for the management of clear-cell renal cell carcinoma: a multi-institutional study

Transperitoneal vs retroperitoneal laparoscopic radical nephrectomy: a double-arm, parallel-group randomized clinical trial

OBJECTIVE

To compare the outcomes of patients undergoing Retroperitoneal laparoscopic Radical nephrectomy (RLRN) and Transperitoneal laparoscopic Radical nephrectomy (TLRN).

METHODS

A total of 120 patients with localized renal cell carcinoma were randomized into either RLRN or TLRN group. Mainly by comparing the patient perioperative related data, surgical specimen integrity, pathological results and tumor results.

RESULTS

Each group comprised 60 patients. The two group were equivalent in terms of perioperative and pathological outcomes. The mean integrity score was significantly lower in the RLRN group than TLRN group. With a median follow-up of 36.4 months after the operation, Kaplan-Meier survival analysis showed no significant difference between RLRN and TLRN in overall survival (89.8% vs. 88.5%; P = 0.898), recurrence-free survival (77.9% vs. 87.7%; P = 0.180), and cancer-specific survival (91.4% vs. 98.3%; P = 0.153). In clinical T2 subgroup, the recurrence rate and recurrence-free survival in the RLRN group was significantly worse than that in the TLRN group (43.2% vs. 76.7%, P = 0.046). Univariate and multivariate COX regression analysis showed that RLRN (HR: 3.35; 95%CI: 1.12-10.03; P = 0.030), male (HR: 4.01; 95%CI: 1.07-14.99; P = 0.039) and tumor size (HR: 1.23; 95%CI: 1.01-1.51; P = 0.042) were independent risk factor for recurrence-free survival.

CONCLUSIONS

Our study showed that although RLRN versus TLRN had roughly similar efficacy, TLRN outperformed RLRN in terms of surgical specimen integrity. TLRN was also significantly better than RLRN in controlling tumor recurrence for clinical T2 and above cases.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ( https://www.chictr.org.cn/showproj.html?proj=24400 ), identifier: ChiCTR1800014431, date: 13/01/2018.

Biological sex disparity in survival outcomes following treatment for renal cell carcinoma: A systematic review and meta-analysis

INTRODUCTION

Renal cell carcinoma (RCC), a type of kidney cancer has biological sex-based differences that play a role in cancer incidence. Specifically, the incidence of urinary system cancers in men is two times greater than in women, while the incidence of genital cancers is three times greater. There is conflicting epidemiologic and limited evidence in the literature to suggest apparent biological sex discrepancy. The primary objective of this review and meta-analysis is to synthesize evidence to understand biological sex disparity in the survival outcomes of RCC following any treatment intervention.

METHODS

A three-step search strategy was utilized in this review. We searched MEDLINE, EMBASE and PsycINFO databases for manuscript on biological sex differences in treatment outcomes. Study screening, critical appraisal, and data extraction were executed independently by pairs of reviewers among co-authors. Studies that had any form of treatment modality in the management of RCC were included. Study designs included observational studies in the form of prospective and retrospective studies that utilized cox proportional hazard assumption to conduct survival analysis. The data synthesis was carried out using the R metafor software package (Software version of 1.2.8) and Microsoft Office Excel 2019 package (Microsoft Corporation, USA). The random effects model was estimated using restricted maximum likelihood estimation (REML). Data synthesis included narrative review and meta-analysis.

RESULTS

We had 23 eligible studies for this review. On review of the full text, 35 studies were excluded due to irrelevances to measure estimates utilized. Finally, 12 studies were selected for the meta-analysis with a total of n = 21,2453 individuals. Females had a better survival outcome following a treatment intervention for RCC than their male counterpart [Mean effect size = -0.1737 (95 % CI: -0.2524, -0.0949)].

CONCLUSION

Females were more likely to be cancer free than their male counterpart following treatment for RCC. This finding will inform appropriate decision making for stakeholders.

Retroperitoneal laparoscopic radical nephrectomy (RLRN) is associated with poor integrity of Gerota's fascia and perirenal fat: A prospective comparative study

Purpose

To figure out the difference of integrity of Gerota's fascia and perirenal fat between Retroperitoneal Laparoscopic Radical Nephrectomy (RLRN) and Transperitoneal Laparoscopic Radical Nephrectomy (TLRN).

Methods

This is a prospective comparative study of patients with Renal Cell Carcinoma (RCC) from a designated tertiary center in Lanzhou, China. We have developed and propose a scoring tool to quantify the integrity of nephrectomy specimens from both approaches. The integrity score is based on 6 common conditions of nephrectomy specimens. Specimens are scored on a 1 to 6-point scale according to the integrity of Gerota's fascia and perirenal fat. We applied the integrity score to 142 consecutive patients. Integrity scores were compared between RLRN and TLRN groups. Factors associated with low integrity score were assessed by logistic regression.

Results

Among 142 patients, 79 (55.6%) patients and 63 (44.4%) patients, respectively, underwent RLRN and TLRN. There was a significant difference in the distribution of integrity score between the two groups (P < 0.001). RLRN (odds ratio 10.65, 95%CI 4.29-26.45, P < 0.001), tumor size (odds ratio 1.22, 95%CI 1.04-1.42, P = 0.015) and Body Mass Index (BMI) (odds ratio 0.83, 95%CI 0.72-0.96, P = 0.010) were significantly associated with low integrity score. The logistic regression equation showed good power to predict low integrity score.

Conclusion

RLRN has poor integrity of Gerota's fascia and the perirenal fat. The integrity score can be used to evaluate the extent of resection and specimen completeness in LRN. Postoperative evaluation of the integrity score is of great value for urologists to evaluate the risk of tumor residue.

A comparison of surgical practice and operative outcomes between retroperitoneal and transperitoneal laparoscopic nephrectomies – 6 years of data from the BAUS Nephrectomy database

Objectives:

While the choice of surgical approach for laparoscopic nephrectomy is broadly split between transperitoneal and retroperitoneal options, the evidence for the impact of this decision on perioperative outcomes is built on relatively small volume data, with often inconsistent findings and conclusions. We aimed to assess the impact of operative approach on perioperative outcomes for laparoscopic radical, partial and simple nephrectomy and nephroureterectomy through analysis of the British Association of Urological Surgeons (BAUS) Nephrectomy database.

Patients and methods:

All patients added to the BAUS Nephrectomy database with laparoscopic surgery between 2012 and 2017 inclusively were included and subdivided by operation and surgical approach. Preoperative patient and tumour characteristics, as well as intraoperative and post-operative short-term outcomes, were assessed.

Results:

Overall, 26,682 operations were documented over the review window (81.6% transperitoneal). Small increases in blood loss ( p = 0.001), transfusion rate ( p = 0.02) and operative length ( p = 0.01) were seen for transperitoneal radical nephrectomies and longer hospital stays seen for retroperitoneal procedures (radical nephrectomy p = 0.00l; partial nephrectomy p = 0.04). Retroperitoneal procedures were associated with increased rates of conversion for simple nephrectomy ( p = 0.02), nephroureterectomy ( p = 0.03) and most notably partial nephrectomy (10.5% versus 4.4%; p = 0.001). No further variation in intraoperative complications, post-operative complications, tumour margin positivity rates, unintended ITU admission, or likelihood of death was identified related to surgical approach.

Conclusion:

Observed variations in perioperative outcomes were generally modest in nature, and little ground is seen to support a change in operative technique for those committed to one approach. A caveat to this exists with open conversion for retroperitoneal partial nephrectomies and requires careful consideration of patient selection by the individual surgeon.

Level of evidence:

4

Retroperitoneoscopic nephrectomy: current status

The classic retroperitoneal open surgical access to the kidney has been duplicated while performing laparoscopy but is less common than transperitoneal laparoscopy. We reviewed minimally invasive retroperitoneoscopic nephrectomy as a part of the international consultation on urological diseases and European Association of Urology international consultation on minimally invasive surgery in urology. A Pubmed/Medline search was performed to identify studies assessing the feasibility, safety and efficacy of laparoscopic and robotic retroperitoneoscopic nephrectomy. The articles were reviewed to assess outcomes after simple, radical and donor nephrectomy and comparative trials between retroperitoneoscopic versus the open and transperitoneal route were evaluated. Retroperitoneoscopic nephrectomy is feasible for most cases of benign non-functioning kidneys. Retroperitoneoscopic radical nephrectomy is also feasible for most tumours and may be better suited for posteriorly located tumours. Both retroperitoneoscopic and transperitoneal nephrectomy have similar outcomes but the operative time may be shorter for the former. The data are insufficient for robotic retroperitoneoscopic nephrectomy probably because of limited space and lack of benefit of a robot in ablative surgeries.

Level of evidence: 3a

Use of endoscopic tissue morcellator in removing retroperitoneal fat in retroperitoneoscopic radical nephrectomy

Background

Evaluate the safety and effectiveness of using an endoscopic tissue morcellator (ETM) to remove the retroperitoneal fat during retroperitoneoscopic radical nephrectomy (RRN).

Methods

The use of ETM in the removal of retroperitoneal fat was retrospectively analyzed in patients who underwent RRN for localized renal cancer in our hospital from January 2010 to January 2018. We accrued the appropriate patients and divided them into two groups. The first group included patients of RRN where ETM was used to remove the retroperitoneal fat, while the second group was comprised of patients of RRN where ETM was not performed, which served as the control group. Each group was further divided into two subgroups, including obese patients (BMI ≥ 28) and patients suffering from high-volume renal cancer (Stage T2a). The differences between the two groups as well as their subgroups were analyzed and statistically compared.

Results

All 222 nephrectomies were completed under retroperitoneoscopy, ETM was used in 105 of these 222 patients. Among them, 31 cases were of obese patients, and 26 cases were of high-volume renal cancer patients. The other 117 patients had undergone RRN without the use of ETM. Among them, 36 cases were of obese patients, and 28 cases were of high-volume renal cancer patients. The differences in age, BMI, tumor position, and tumor size between the two groups were not statistically significant, P > 0.05. Both the surgical time and the blood loss for the ETM group were significantly lower than the control group, p < 0.05. In the subgroup analysis, the obese patients and patients with high tumor volume also showed a significantly lower surgical time and less blood loss, p < 0.05. The postoperative hospitalization time, the total survival rate, and the disease-free survival rate were not statistically significant, p > 0.05.

Conclusions

The use of ETM in removing the retroperitoneal fat during the RRN can potentially reduce the surgical time and lessen the blood loss. This technique is especially advantageous for obese and large-volume tumor patients.

Risk Factors Related with Retroperitoneal Laparoscopic Converted to Open Nephrectomy for Nonfunctioning Renal Tuberculosis

PURPOSE

The present study was designed to investigate the risk factors affecting the conversion to open surgery in retroperitoneal laparoscopic nephrectomy of nonfunctioning renal tuberculosis (TB).

PATIENTS AND METHODS

The records of 144 patients who underwent a retroperitoneal laparoscopic nephrectomy procedure by a single surgeon were retrospectively reviewed. The following factors, including age, sex, body mass index (BMI), diabetes status, hypertension status, side of kidney, size of kidney, degree of calcification, mild perirenal extravasation, contralateral hydronephrosis, the time of anti-TB, and surgeon experience were analyzed. Univariate and multivariate logistic regression analyses were used for statistical assessment.

RESULTS

Twenty-three patients were converted to open surgery and the conversion rate was 15.97%. In univariate analysis, BMI ≥35 kg/m² (p = 0.023), hypertension (p = 0.011), diabetes (p = 0.003), and kidney size (p = 0.032) were the main factors of conversion to open surgery. Sex, age, side, anti-TB time, calcification, mild extravasation, and surgeon experience were not significantly related. In multivariate regression analysis, BMI ≥35 kg/m², hypertension, diabetes, and enlargement of kidney were the most important factors for conversion to open surgery.

CONCLUSIONS

Depending on the results achieved by a single surgeon, BMI ≥30 kg/m², diabetes, hypertension, and enlargement of kidney significantly increased the conversion risk in retroperitoneal laparoscopic nephrectomy for nonfunctioning renal TB.

Comparison of transperitoneal and retroperitoneal laparoscopic nephrectomy for renal cell carcinoma: a systematic review and meta-analysis

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Laparoscopic nephrectomy is now considered to be the reference procedure for kidney cancer. It can be performed via a transperitoneal or retroperitoneal approach. Each approach has its advantages and disadvantages. No definitive conclusions regarding objective difference between the two approaches have been reached to date. This meta-analysis indicates that in appropriately selected patients, especially patients with posteriorly located renal tumors, the retroperitoneal approach may be faster and equally safe compared with the transperitoneal approach.

OBJECTIVE

To evaluate the efficiency and safety of the retroperitoneal and transperitoneal approaches in laparoscopic radical/partial nephrectomy (RN/PN) for renal cell carcinoma.

METHODS

A systematic search of PUBMED, EMBASE, and the Cochrane Library was performed to identify prospective randomized controlled trials and retrospective observational studies that compared the outcomes of the two approaches. Outcomes of interest included perioperative and postoperative variables, surgical complications and oncological variables.

RESULTS

Twelve studies assessing transperitoneal laparoscopic RN (TLRN) vs retroperitoneal laparoscopic RN (RLRN) and six studies assessing transperitoneal laparoscopic PN (TLPN) vs retroperitoneal laparoscopic PN (RLPN) were included. The RLRN approach had a shorter time to renal artery control (weighted mean difference [WMD] 68.65 min; 95% confidence interval [CI] 40.80-96.50; P < 0.001) and a lower overall complication rate (odds ratio 2.12; 95% CI 1.30-3.47; P = 0.003) than TLRN. RLPN had a shorter operating time (WMD 48.85 min; 95% CI 29.33-68.37; P < 0.001) and a shorter length of hospital stay (WMD 1.01 days; 95% CI 0.39-1.63; P = 0.001) than TLPN. There were no significant differences between the retroperitoneal and transperitoneal approaches in other outcomes of interest.

CONCLUSIONS

This meta-analysis indicates that, in appropriately selected patients, especially patients with posteriorly located renal tumours, the retroperitoneal approach may be faster and equally safe compared with the transperitoneal approach. Despite our rigorous methodology, conclusions drawn from our pooled results should be interpreted with caution because of the inherent limitations of the included studies.

Body mass index and survival in patients with renal cell carcinoma: a clinical-based cohort and meta-analysis

Growing evidence suggests that obesity, an established cause of renal cell cancer (RCC), may also be associated with a better prognosis. To evaluate the association between RCC survival and obesity, we analyzed a large cohort of patients with RCC and undertook a meta-analysis of the published evidence. We collected clinical and pathologic data from 1,543 patients who underwent nephrectomy for RCC between 1994 and 2008 with complete follow-up through 2008. Patients were grouped according to BMI (kg/m(2) ): underweight <18.5, normal weight 18.5 to <23, overweight 23 to <25 and obese ≥25. We estimated survival using the Kaplan-Meier method and Cox proportional hazard models to examine the impact of BMI on overall survival (OS) and cancer-specific survival (CSS) with adjustment for covariates. We performed a meta-analysis of BMI and OS, CSS and recurrence-free survival (RFS) from all relevant studies using a random-effects model. The 5-year CSS increased from 76.1% in the lowest to 92.7% in the highest BMI category. A multivariate analysis showed higher OS [hazard ratio (HR) = 0.45; 95% CI: 0.29-0.68) and CSS (HR = 0.47; 95% CI: 0.29-0.77] in obese patients than in normal weight patients. The meta-analysis further corroborated that high BMI significantly improved OS (HR = 0.57; 95% CI: 0.43-0.76), CSS (HR = 0.59; 95% CI: 0.48-0.74) and RFS (HR = 0.49; 95% CI: 0.30-0.81). Our study shows that preoperative BMI is an independent prognostic indicator for survival among patients with RCC.

Treatment of localised renal cell carcinoma

CONTEXT

The increasing incidence of localised renal cell carcinoma (RCC) over the last 3 decades and controversy over mortality rates have prompted reassessment of current treatment.

OBJECTIVE

To critically review the recent data on the management of localised RCC to arrive at a general consensus.

EVIDENCE ACQUISITION

A Medline search was performed from January 1, 2004, to May 3, 2011, using renal cell carcinoma, nephrectomy (Medical Subject Heading [MeSH] major topic), surgical procedures, minimally invasive (MeSH major topic), nephron-sparing surgery, cryoablation, radiofrequency ablation, surveillance, and watchful waiting.

EVIDENCE SYNTHESIS

Initial active surveillance (AS) should be a first treatment option for small renal masses (SRMs) <4 cm in unfit patients or those with limited life expectancy. SRMs that show fast growth or reach 4 cm in diameter while on AS should be considered for treatment. Partial nephrectomy (PN) is the established treatment for T1a tumours (<4 cm) and an emerging standard treatment for T1b tumours (4-7 cm) provided that the operation is technically feasible and the tumour can be completely removed. Radical nephrectomy (RN) should be limited to those cases where the tumour is not amenable to nephron-sparing surgery (NSS). Laparoscopic radical nephrectomy (LRN) has benefits over open RN in terms of morbidity and should be the standard of care for T1 and T2 tumours, provided that it is performed in an advanced laparoscopic centre and NSS is not applicable. Open PN, not LRN, should be performed if minimally invasive expertise is not available. At this time, there is insufficient long-term data available to adequately compare ablative techniques with surgical options. Therefore ablative therapies should be reserved for carefully selected high surgical risk patients with SRMs <4 cm.

CONCLUSIONS

The choice of treatment for the patient with localised RCC needs to be individualised. Preservation of renal function without compromising the oncologic outcome should be the most important goal in the decision-making process.