ENDOUROLOGY & LAPAROSCOPY

Laparoscopy for Renal Cell Carcinoma: Diffusion Versus Regionalization?
Miller DC, Taub DA, Dunn RL, Wei JT, Hollenbeck BK
Michigan Urology Center, University of Michigan Health System, Ann Arbor, MI, USA
J Urol. 2006;176:1102-6

• Purpose: Recognizing the emergence of laparoscopy as a standard of care for surgical treatment in many patients with organ confined renal cell carcinoma, we explored the diffusion of this technology by examining temporal trends in the nationwide use of laparoscopic total and partial nephrectomy in patients with renal cell carcinoma.
• Materials and Methods: Data from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample were abstracted for 1991 through 2003. International Classification of Diseases-Ninth Revision, Clinical Modification 9 codes were used to identify patients undergoing open and laparoscopic total and partial nephrectomy for renal cell carcinoma. Using hospital sampling weights we calculated annual incidence rates for open and laparoscopic nephrectomy, thereby estimating the diffusion of laparoscopy. Bivariate and multivariate analyses were used to identify patient and hospital characteristics associated with the more frequent use of laparoscopic techniques.
• Results: Data on 63,812 patients were abstracted from the Nationwide Inpatient Sample, yielding a weighted national estimate of 323,979 who underwent laparoscopic (4.9%) or open (95.1%) nephrectomy (total or partial) for renal cell carcinoma between 1991 and 2003. Although it is still infrequent, the use of laparoscopy has increased steadily since 1998 with a utilization peak in 2003 of 1.7 laparoscopic nephrectomies per 100,000 American population, representing 16% of all total and partial nephrectomies for renal cell carcinoma in 2003. Treatment year, overall hospital nephrectomy volume and teaching hospital status were the most robust determinants of increased laparoscopic use (each p <0.001).
• Conclusions: Although its use has increased progressively in the last decade, the dissemination of laparoscopy for renal cell carcinoma has been generally slow and limited in scope. The next step in this body of work is to identify specific technical, educational and policy interventions that will influence the diffusion of this alternative standard of care.
  
  
• Editorial Comment
  The surgical approach for the treatment of renal cell carcinoma has evolved since Clayman and colleagues performed the first Laparoscopic Radical Nephrectomy in 1990. Moreover, the innovative and scientific nephron-sparing concept pioneered and popularized by Novick culminated with the development of the minimally invasive laparoscopic partial nephrectomy first performed by Winfield et al. This manuscript reveals a surprising reality of our practice trends in the USA, when surgical management is the option. Although the laparoscopic approach maybe considered the gold standard for the surgical treatment of Renal cell carcinoma, majority of cases are performed using the open technique. Finally, the authors concluded that the current trend is a progressive increase in the dissemination of the laparoscopic technique but it has been slow and limited in scope and studies are necessary to optimally identify the limiting factors and better propagate this surgical technique.

Dr. Fernando J. Kim
Chief of Urology, Denver Health Med Ctr
Assistant Professor, Univ Colorado Health Sci Ctr
Denver, Colorado, USA