New England Section of the American Urological Association

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Institutional Review Of Open Versus Laparoscopic Partial Nephrectomy For Surgical Treatment Of Renal Cell Carcinoma
Edouard Nicaise, BS, Adam S. Feldman, MD, Alice Yu, MD, Yichuan G. Hsieh, PhD, Naren Nimmagadda, MD, Francis J. McGovern, MD, Matthew Wszolek, MD, Michael L. Blute, MD, Douglas M. Dahl, MD
Massachusetts General Hospital, Boston, MA

Background:
Laparoscopic partial nephrectomy (PN) is a widely performed, minimally-invasive alternative to open PN. We compared pre-, peri- and post-operative factors in patients undergoing either open or laparoscopic PN for treatment of renal cell carcinoma (RCC).
Methods:
Under IRB approved protocol we interrogated our institutional RCC database for all patients who underwent either open or laparoscopic PN for RCC from 1997-2018. Patients with benign pathology on surgical pathology were excluded from this analysis. Open versus laparoscopic technique decision was at the discretion of the treating urologic surgeon. Laparoscopic cases include both pure laparoscopic and robotic assisted laparoscopic techniques. Outcomes analyzed included intra-operative parameters, pathologic outcomes, post-operative complications and disease local recurrence rates.
Results:
The study cohort consisted of 732 patients with a median age of 59 at the time of surgery for RCC (IQR, 50-67) and a total of 760 unique PN cases (187 open and 573 laparoscopic). 48 (8.4%) of the laparoscopic cases were performed with robotic assistance and were not analyzed separately. The median size of the tumor on imaging was 2.6cm (IQR, 2-3.9cm) for open procedures and 2.45cm (IQR, 1.8-3.4cm) for laparoscopic. Surgical pathology for open PN revealed 150 (75.4%) pT1a, 32 (16.4%) pT1b, 3 (1.5%) pT2, 13 (6.7%) pT3a. For laparoscopic PN, surgical pathology revealed 458 (78.2%) pT1a, 90 (15.4%) pT1b, 4 (0.7%) pT2, 34 (5.8%) pT3a. The mean surgery time was 213.6 minutes (SD 65.0) for open procedures and 208.8 minutes (SD 74.1) for laparoscopic procedures (p=0.433). When vascular clamping was used, the mean ischemic time was 20.6 minutes (SD 9.0) for open procedures compared to 22.0 (SD 7.4) minutes for laparoscopic procedures (p=0.025). Mean estimated blood loss was 400cc (SD 401) and 248cc (SD 267) for open and laparoscopic procedures respectively (p=0.001). Positive margins occurred in 10/187 (5.3%) of open PN vs. 19/573 (3.2%) of laparoscopic PN. Risk of any post-operative complication for open PN was 29.9%, with a 5.3% risk of Clavien grade 3a-4a complications. For laparoscopic PN, the risk of any complication was 15.4% and 3.5% for Clavien grade 3a-4a complications. Local recurrence rates were 2.1% for open procedures and 2.8% for laparoscopic procedures.
Conclusions:
Laparoscopic partial nephrectomy is an effective, minimally-invasive surgical option for curative treatment of RCC with comparable surgical oncologic outcomes and an apparent lower complication risk. The statistically significant difference in ischemic time of 1.4 minutes is of unlikely clinical significance and we are currently investigating functional outcomes.


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