ENDOUROLOGY & LAPAROSCOPY

Trends toward laparoscopic nephrectomy at a community hospital
Huynh PN, Hollander JB
Department of Urology, William Beaumont Hospital, Royal Oak, Michigan, USA
J Urol. 2005; 173: 547-51

• Purpose: For proper indications at university hospitals laparoscopic nephrectomy is often considered the standard of care. At community hospitals past surveys have not demonstrated this change. We describe the changing practice patterns of performing laparoscopic nephrectomies in indicated patients at our community hospital. We reviewed our data on monitoring our training program.
• Materials and Methods: A retrospective chart review was performed of 381 consecutive complete nephrectomies performed at our institution from February 2000 to December 2003, including 62 live donor nephrectomies. Patient age, pathological size, operative time, estimated blood loss, duration to solid food intake and duration of hospitalization were compared between open nephrectomy and laparoscopic nephrectomy groups using the Wilcoxon 2-sample test. Surgical practice and surgeon characteristics were also described.
• Results: Patients who underwent laparoscopic nephrectomy demonstrated superior postoperative recovery with earlier return to solid diet and shorter hospitalization. The 2 groups were similar in regard to major complication rates. The number of laparoscopic nephrectomies increased annually, while the number of open nephrectomies decreased. The number of laparoscopic urologists increased annually. More importantly laparoscopic urologists performed an increasing number of nephrectomies, while nonlaparoscopic urologists faced a decrease in the number of nephrectomies performed. There appeared to be little evidence of hand assisted laparoscopic nephrectomy as a bridge to learning standard laparoscopic nephrectomy.
• Conclusions: Our training paradigm has safely and effectively trained community urologists to perform laparoscopic nephrectomies. Laparoscopic nephrectomy is now considered a standard treatment option along with conventional open surgery and it should be offered to the patient in the medical setting. Although fellowship trained urologists can certainly add expertise to any program, community based hospitals do not have to depend on them.
  
  
• Editorial Comment
  Since Claymann and colleagues described the first laparoscopic radical nephrectomy (LRN) in 1991, the technology and techniques have evolved. Currently, LRN is considered the standard treatment option for renal cancer patients. Although academic investigators have documented the advantages of this minimally invasive procedure and its variations in surgical technique, interestingly, there is little data from the community surgeons’ side. This manuscript demonstrates the feasibility, safety and learning curve of this surgical approach in the community setting.
  The increase of laparoscopic cases from 8 in 2000 to 52 in 2003 that the authors described revealed a significant annual increase of nephrectomies (open, laparoscopic donor and radical) with less time of hospitalization and resumption of solid food intake without increasing the rate of complications.
  The practice includes general, oncological and laparoscopy fellowship trained urologists. Even the urologists that did not receive formal fellowship training were able to take the minimally invasive approach utilizing the hand assist device.
  Clearly this data shows that laparoscopic nephrectomies will be widely accepted as treatment of renal cancer and transplantation for potential donors in the community setting.

Dr. Fernando J. Kim
Assistant Professor of Urology
University of Colorado Health Sciences Center
Denver, Colorado, USA