ENDOUROLOGY & LAPAROSCOPY

Laparoscopic versus open partial nephrectomy
Beasley KA, Al Omar M, Shaikh A, Bochinski D, Khakhar A, Izawa JI, Welch RO, Chin JL, Kapoor A, Luke PP
From the Division of Urology, University of Western Ontario, London, Ontario, Canada; Department of Decision Support, London Health Sciences Centre, London, Ontario, Canada; Division of Urology, McMaster University, Hamilton, Ontario, Canada
Urology. 2004; 64: 458-61

• Objectives: To compare, retrospectively, the results of laparoscopic partial nephrectomy (LPN) to open partial nephrectomy (OPN) using a tumor size-matched cohort of patients. Limited data are available comparing LPN to OPN in the treatment of small renal tumors.
• Methods: Between September 2000 and September 2003, 27 LPNs and 22 OPNs were performed to treat renal masses less than 4 cm. Patient demographics and tumor location and size (2.4 ± 1.0 cm versus 2.9 ± 0.9 cm, respectively; P = not statistically significant) were similar between the LPN and OPN groups.
• Results: Although the mean operative time was longer in the LPN than in the OPN group (210 ± 76 minutes versus 144 ± 24 minutes; P <0.001), the blood loss was comparable between the two groups (250 ± 250 mL versus 334 ± 343 mL; P = not statistically significant). No blood transfusions were performed in either group. The hospital stay was significantly reduced after LPN compared with after OPN (2.9 ± 1.5 days versus 6.4 ± 1.8 days; P <0.0002), and the postoperative parenteral narcotic requirements were lower in the LPN group (mean morphine equivalent 43 ± 62 mg versus 187 ± 71 mg; P <0.02). Three complications occurred in each group. With LPN, no patient had positive margins or tumor recurrence. Also, direct financial analysis demonstrated lower total hospital costs after LPN ($4839 ± $1551 versus $6297 ± $2972; P <0.05).
• Conclusions: LPN confers several benefits over OPN concerning patient convalescence and costs, despite prolonged resection times at our current phase of the learning curve. Long-term results on cancer control in patients treated with LPN continue to be assessed.
  
  
• Editorial Comment
  Laparoscopic nephron sparing surgery is here to stay! Although other comparative studies have been published, this study it notable for the remarkable similarity between the open and laparoscopic groups. The data suggest that the safety and efficacy of the laparoscopic procedure is equivalent to that of open surgery, with improved convalescence and reduced cost. In addition, the authors are not part of the original group that started performing this procedure in the mid-to-late 1990’s. They are part of the second wave of skilled laparoscopic surgeons who have better training, have learned from the efforts of the pioneers, and have successfully incorporate laparoscopy into routine oncologic practice. At large centers with advanced laparoscopy, laparascopic partial nephrectomy is now the standard approach to all but the most central of small renal masses. The enthusiasm for the procedure must not overcome good surgical practice, however. The difficulty of laparascopic partial nephrectomy increases dramatically as tumors are deeper and more central. Each surgeon must establish individual “comfort zones” with the lesion that he or she can tackle laparoscopically. In the early experience at our own institution, we overestimated our technique after a series of challenging but successful cases - only to have some major hemorrhagic complications (the complication that typically rewards the overconfident surgeon in this procedure). We backed off, altered our technique, slowly advanced again, and are now routinely performing laparascopic partial nephrectomies that would have failed with our technique of only a year ago. Renal hilar clamping and laparoscopic suturing are, despite great efforts to simplify the technique, still required for deep resections with the current technology. There is great hope that future advances will reduce the technical requirements, and risk, of laparascopic partial nephrectomy.

Dr. J. Stuart Wolf Jr.
Associate Professor of Urology
University of Michigan
Ann Arbor, Michigan, USA