Comparison of oncological outcomes of transperitoneal and retroperitoneal laparoscopic radical nephrectomy for the management of clear-cell renal cell carcinoma: a multi-institutional study.

Department of Urology, The Catholic University of Korea College of Medicine, Seoul, Korea.
BJU International (Impact Factor: 3.13). 05/2011; 107(9):1467-72. DOI: 10.1111/j.1464-410X.2010.09636.x
Source: PubMed

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.

  • [Show abstract] [Hide abstract]
    ABSTRACT: Growing evidence suggests that obesity, an established cause of renal cell cancer (RCC), may also be associated with a better prognosis. To evaluate the association between RCC survival and obesity, we analyzed a large cohort of patients with RCC and undertook a meta-analysis of the published evidence. We collected clinical and pathologic data from 1,543 patients who underwent nephrectomy for RCC between 1994 and 2008 with complete follow-up through 2008. Patients were grouped according to BMI (kg/m(2) ): underweight <18.5, normal weight 18.5 to <23, overweight 23 to <25 and obese ≥25. We estimated survival using the Kaplan-Meier method and Cox proportional hazard models to examine the impact of BMI on overall survival (OS) and cancer-specific survival (CSS) with adjustment for covariates. We performed a meta-analysis of BMI and OS, CSS and recurrence-free survival (RFS) from all relevant studies using a random-effects model. The 5-year CSS increased from 76.1% in the lowest to 92.7% in the highest BMI category. A multivariate analysis showed higher OS [hazard ratio (HR) = 0.45; 95% CI: 0.29-0.68) and CSS (HR = 0.47; 95% CI: 0.29-0.77] in obese patients than in normal weight patients. The meta-analysis further corroborated that high BMI significantly improved OS (HR = 0.57; 95% CI: 0.43-0.76), CSS (HR = 0.59; 95% CI: 0.48-0.74) and RFS (HR = 0.49; 95% CI: 0.30-0.81). Our study shows that preoperative BMI is an independent prognostic indicator for survival among patients with RCC.
    International Journal of Cancer 05/2012; · 6.20 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: What's known on the subject? and What does the study add? Laparoscopic nephrectomy is now considered to be the reference procedure for kidney cancer. It can be performed via a transperitoneal or retroperitoneal approach. Each approach has its advantages and disadvantages. No definitive conclusions regarding objective difference between the two approaches have been reached to date. This meta-analysis indicates that in appropriately selected patients, especially patients with posteriorly located renal tumors, the retroperitoneal approach may be faster and equally safe compared with the transperitoneal approach. 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; · 3.13 Impact Factor
  • [Show abstract] [Hide abstract]
    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. · 10.48 Impact Factor