Trends and Morbidity for Minimally Invasive versus Open Cytoreductive Nephrectomy in the Management of Metastatic Renal Cell Carcinoma
Dimitar Zlatev, MD1; Daniel Pucheril, MD, MBA1; Manuel Ozambela, MD1; Ye Wang, PhD1; Benjamin Chung, MD, MS2; Steven L. Chang, MD MS1
1Brigham and Women's Hospital, Boston, MA; 2Stanford University Medical Center, Stanford, CA
BACKGROUND: Cytoreductive nephrectomy (CN) prior to systemic therapy for metastatic renal cell carcinoma (RCC) is recommended in patients with a surgically resectable primary tumor. Traditionally performed as open surgery, the advent of laparoscopic and robotic surgery provides a minimally invasive alternative to CN with a potential for accelerated recovery and earlier initiation of systemic therapy. We sought to compare the trends and morbidity of laparoscopic, robotic, and open CN for patients with metastatic RCC.
METHODS: Using the Premier Hospital Database (Premier, Inc., Charlotte, NC), we identified 24,145 patients who underwent elective radical nephrectomy for metastatic RCC in the United States between 2003 and 2015. Comparative analysis between laparoscopic, robotic, and open CN was performed with propensity weighting on rates of 90-day complications, blood transfusion, intensive care unit (ICU) admission, prolonged length of stay (LOS), discharge destination, 90-day readmission, operative time, and direct hospital costs.
RESULTS: Over the course of the study period, the rates of open CN decreased from 76.7% to 66.4%, laparoscopic CN decreased from 22.3% to 11.4%, and robotic CN increased from 0.6% to 22.1%. Compared to open CN, the laparoscopic approach was associated with a 30% decreased odds of 90-day major complications (OR 0.70, 95% CI 0.50 - 0.97, p<0.05). Compared to open CN, both laparoscopic and robotic approaches were associated with significantly decreased odds of blood transfusion (OR 0.46 and 0.38, respectively), ICU admission (OR 0.57 and 0.48, respectively), and LOS (OR 0.50 and 0.35, respectively). Direct costs were lowest for laparoscopic CN.
CONCLUSIONS: Compared to open CN, minimally invasive CN is associated with decreased rates of blood transfusion, ICU admission, and LOS. Laparoscopic CN is additionally associated with decreased major complications and direct costs compared to open CN. When technically feasible, the utilization of minimally invasive CN, especially laparoscopic, may be associated with improved
outcomes, decreased costs, and accelerated recovery prior to systemic therapy in patients with metastatic RCC.
Back to 2018 Program