ENDOUROLOGY & LAPAROSCOPY

The impact of minimally invasive techniques on open partial nephrectomy: a 10-year single institutional experience
Weight CJ, Fergany AF, Gunn PW, Lane BR, Novick AC
Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
J Urol. 2008; 180: 84-8

• Purpose: With the advent of minimally invasive, nephron sparing surgical options we hypothesized that the indications, perioperative parameters and complication rates of open partial nephrectomy may have changed significantly during a 10-year period.
• Materials and Methods:periods. From 1994 to 1996 (before laparoscopic partial nephrectomy, cryoablation and radio frequency ablation) 208 cases were compared vs. 347 open partial nephrectomies performed from 2004 to 2006 with regard to indications, perioperative parameters and complication rates.
• Results: There were no significant differences between the groups with regard to age (59 vs. 58 years), gender (65.5% vs. 65.0% male) and tumor size (3.9 vs. 3.6 cm). Tumors removed in the recent era were more often in a solitary kidney (40.0% vs. 15.6%) and centrally located (55.6% vs. 37.3%), and pathological evaluation more often revealed higher grade (Fuhrman 3 or 4) (43.1% vs. 27.8%, each p < 0.0001). Despite increased technical difficulty ischemia time in the more recent era was shorter (19.1 vs. 40.6 minutes, p = 0.0000), and the urological and overall complication rates were statistically similar (7.5% vs. 8.9%, p = 0.6071 and 19.1% vs. 14.4%, p = 0.1723, respectively).
• Conclusions: At a tertiary referral center the introduction of minimally invasive, nephron sparing surgical techniques has drawn away less complicated, less aggressive tumors, reserving the bulk of more complicated central tumors for open partial nephrectomy without decreasing the total number of open cases. With experience these more difficult central tumors are being successfully treated with decreased warm ischemia time and complication rates that are comparable to those in historical series.
  
  
• Editorial Comment
  This retrospective study demonstrated that the outcomes of the management of small renal masses in a high volume tertiary care institution were consistent when oncological principles were followed despite the different minimally invasive techniques were applied to treat these masses.
  The open partial nephrectomies were reserved to manage more complicated central masses, while the laparoscopic approach allowed small masses to be managed with nephron-sparing techniques, including ablative technology.
  The overall number of open procedures remained the same, as well as the level and number of complications for both open and minimally invasive approaches.
  Once again, the authors demonstrated that when the basic oncological principles are followed and a systemic protocol evaluates patients for complex minimally invasive surgery, experienced surgeons could attain comparable results as historically established open surgery in a high volume tertiary care institution.

Dr. Fernando J. Kim
Chief of Urology, Denver Health Med Ctr
Assistant Professor, Univ Colorado Health Sci Ctr
Denver, Colorado, USA
E-mail: fernando.kim@uchsc.edu