Comparison of oncological outcomes of transperitoneal and retroperitoneal laparoscopic radical nephrectomy for the management of clear-cell renal cell carcinoma: a multi-institutional study
ABSTRACT • To investigate the oncological efficacy of retroperitoneal laparoscopic radical nephrectomy (RLRN) compared with transperitoneal laparoscopic radical nephrectomy (TLRN) for the management of clear-cell renal cell carcinoma (RCC).
• With emphasis on survival and disease recurrence, a retrospective analysis was made of 580 patients who underwent TLRN (472 patients) or RLRN (108 patients) at 23 institutions between January 1997 and December 2007. • Inclusion criteria were clear-cell RCC, stage pT1 to pT2 without any nodal involvement, and metastasis. • Overall survival and recurrence-free survival curves were estimated using the Kaplan-Meier method. • To assess the association between the surgical approach and survival outcomes, Cox proportional hazard models were constructed.
• The median follow-up was 30 months in the TLRN group and 35.6 months in the RLRN group. Both groups were comparable regarding age, gender, body mass index (BMI), Fuhrman's grade, size of tumours and stage. • Kaplan-Meier curves and the log-rank test showed no significant difference between the TLRN and RLRN groups in 5-year overall (92.6% vs 94.5%; P = 0.669) and recurrence-free survival (92.0% vs 96.2%; P = 0.244). • In a Cox regression model with age, gender, Eastern Cooperative Oncology Group performance status, BMI, nuclear grade and T-stage adjusted variables, no significant difference was found between the two surgical approaches.
• The present study is the largest oncological analysis for laparoscopic radical nephrectomy (LRN) comparing transperitoneal and retroperitoneal approaches. The data from it provide the objective evidence to suggest similar oncological outcomes for both approaches to LRN.
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ABSTRACT: The increasing incidence of localised renal cell carcinoma (RCC) over the last 3 decades and controversy over mortality rates have prompted reassessment of current treatment. To critically review the recent data on the management of localised RCC to arrive at a general consensus. A Medline search was performed from January 1, 2004, to May 3, 2011, using renal cell carcinoma, nephrectomy (Medical Subject Heading [MeSH] major topic), surgical procedures, minimally invasive (MeSH major topic), nephron-sparing surgery, cryoablation, radiofrequency ablation, surveillance, and watchful waiting. Initial active surveillance (AS) should be a first treatment option for small renal masses (SRMs) <4 cm in unfit patients or those with limited life expectancy. SRMs that show fast growth or reach 4 cm in diameter while on AS should be considered for treatment. Partial nephrectomy (PN) is the established treatment for T1a tumours (<4 cm) and an emerging standard treatment for T1b tumours (4-7 cm) provided that the operation is technically feasible and the tumour can be completely removed. Radical nephrectomy (RN) should be limited to those cases where the tumour is not amenable to nephron-sparing surgery (NSS). Laparoscopic radical nephrectomy (LRN) has benefits over open RN in terms of morbidity and should be the standard of care for T1 and T2 tumours, provided that it is performed in an advanced laparoscopic centre and NSS is not applicable. Open PN, not LRN, should be performed if minimally invasive expertise is not available. At this time, there is insufficient long-term data available to adequately compare ablative techniques with surgical options. Therefore ablative therapies should be reserved for carefully selected high surgical risk patients with SRMs <4 cm. The choice of treatment for the patient with localised RCC needs to be individualised. Preservation of renal function without compromising the oncologic outcome should be the most important goal in the decision-making process.European Urology 06/2011; 60(4):662-72. DOI:10.1016/j.eururo.2011.06.040 · 12.48 Impact Factor
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ABSTRACT: Purpose: Due to the limited working space available during retroperitoneal laparoscopic radical nephrectomy (LRN), the body habitus of the patient is likely to affect the risk of operative difficulties. This study sought to determine whether anthropometric measurements based on computerized tomography (CT) and abdominal X-ray could be used to predict operative difficulties during retroperitoneal LRN. Patients and methods: Between August 2004 and January 2012, 96 consecutive patients with preoperative CT and abdominal X-ray examinations underwent retroperitoneal LRN for a T1 or T2 stage renal tumor at our institution. The association between anthropometric measurements and demographics of patients and operative duration, estimated blood loss (EBL), and perioperative complications were retrospectively analyzed. Multivariate analysis was performed, and p<0.05 was considered significant. Results: Anterior perirenal fat distance (p=0.016) and distance from the 12th rib to the iliac crest (p=0.038) were independently associated with operative duration. Only anterior perirenal fat distance (p=0.001) was independently associated with EBL. No intraoperative complications and re-operations occurred. The occurrence or severity of postoperative complications was not significantly associated with anthropometric measurements. Body mass index ≥ 25.0 kg/m2 was not significantly associated with operative difficulties. Conclusion: The anterior perirenal fat distance and the distance from the 12th rib to the iliac crest can be used to predict operative difficulties during retroperitoneal LRN.Journal of endourology / Endourological Society 10/2012; 27(2). DOI:10.1089/end.2012.0383 · 2.10 Impact Factor
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ABSTRACT: Objective To evaluate the efficiency and safety of the retroperitoneal and transperitoneal approaches in laparoscopic radical/partial nephrectomy (RN/PN) for renal cell carcinoma. Methods A systematic search of PUBMED, EMBASE, and the Cochrane Library was performed to identify prospective randomized controlled trials and retrospective observational studies that compared the outcomes of the two approaches. Outcomes of interest included perioperative and postoperative variables, surgical complications and oncological variables. Results Twelve studies assessing transperitoneal laparoscopic RN (TLRN) vs retroperitoneal laparoscopic RN (RLRN) and six studies assessing transperitoneal laparoscopic PN (TLPN) vs retroperitoneal laparoscopic PN (RLPN) were included. The RLRN approach had a shorter time to renal artery control (weighted mean difference [WMD] 68.65 min; 95% confidence interval [CI] 40.80-96.50; P < 0.001) and a lower overall complication rate (odds ratio 2.12; 95% CI 1.30-3.47; P = 0.003) than TLRN. RLPN had a shorter operating time (WMD 48.85 min; 95% CI 29.33-68.37; P < 0.001) and a shorter length of hospital stay (WMD 1.01 days; 95% CI 0.39-1.63; P = 0.001) than TLPN. There were no significant differences between the retroperitoneal and transperitoneal approaches in other outcomes of interest. Conclusions This meta-analysis indicates that, in appropriately selected patients, especially patients with posteriorly located renal tumours, the retroperitoneal approach may be faster and equally safe compared with the transperitoneal approach. Despite our rigorous methodology, conclusions drawn from our pooled results should be interpreted with caution because of the inherent limitations of the included studies.BJU International 10/2012; 111(4). DOI:10.1111/j.1464-410X.2012.11598.x · 3.13 Impact Factor