Data show similar outcomes for lap, open nephrectomy

August 15, 2006

Studies of laparoscopic nephrectomy presented at the AUA annual meeting suggest that the minimally invasive procedure has come of age and produces outcomes that rival open surgery under a variety of circumstances.

New findings about laparoscopic radical prostatectomy and renal cryotherapy also were among the five most important AUA take-home messages on laparoscopy chosen by Stephen Y. Nakada, MD, professor and chairman of the department of urology, University of Wisconsin, Madison.

Long-term survival and recurrence rates in patients undergoing laparoscopic radical nephrectomy are similar to those of patients undergoing open nephrectomy.

The authors found that the cancer-specific survival at 5 years' follow-up was 91% in both groups. Metastasis-free survival rates were 91% and 80% in the laparoscopic and open groups, respectively; and recurrence-free survival rates were 97% and 100%, respectively.

"This critical long-term study demonstrates equivalence between the two approaches in terms of cancer control," Dr. Nakada told Urology Times. "There are volumes of data showing the improved convalescence and benefits derived from the minimally invasive procedure. This study validates that laparoscopic approaches treat T1 and T2 tumors equally well as open procedures, long term."

Positive margins following laparoscopic partial nephrectomy do not necessarily portend recurrence, nor can they be interpreted as indicating the presence of residual tumor.

Investigators at Johns Hopkins, Baltimore, and the Cleveland Clinic looked at 511 patients undergoing laparoscopic partial nephrectomy for renal cell carcinoma and identified nine (1.8%) with positive margins on final pathology. Two of these underwent radical nephrectomy within 4 months of the finding.

Overall, 88% of the patients remained disease free at median follow-up of 32 months. This rate is similar to that seen in patients with negative margins.

"The study essentially shows that positive margin status may not indicate residual tumor," Dr. Nakada said.

He advised urologists to devise strategies for addressing positive margins, including careful observation, and to discuss them thoroughly with patients before any procedure is undertaken.

A significant decrease in surgical margin rates among surgeons performing laparoscopic radical prostatectomy can be attributed to continuous quality improvement and constant surgeon self-evaluation.

A team at Memorial Sloan-Kettering Cancer Center in New York initiated weekly case review conferences involving surgeons, radiologists, and uropathologists.

Between January 2003 and June 2005, the conferees reviewed 485 laparoscopic radical prostatectomies and looked for ways to improve the procedure. During the 29 months of weekly meetings, the team saw improvements in positive margin rates and in the incidence of organ-confined and non-organ-confined disease.

In short, the study suggests that no surgical team is so good that it cannot get better with extra effort.

"The best aspect of this study is that the pathologists and radiologists examined all available clinical data associated with the procedure with the urologists," said Dr. Nakada. "It is very easy to get caught up in performing the same technique over and over.

"This study emphasizes the value of reassessing clinical patterns and the value of multidisciplinary collaboration. This is what every center should do when striving to improve complex procedures."

Laparoscopic nephrectomy in the obese is not only practical, but, perhaps, preferable to open surgery.

The ability of laparoscopy to minimize trauma is never more apparent than in the obese patient.

Cleveland Clinic researchers compared intraoperative and postoperative findings in 140 patients with a body mass index of 30 or higher who underwent laparoscopic partial nephrectomy and in 238 non-obese patients who underwent the same procedure. No significant differences in intraoperative and postoperative complications were reported.

"These findings are no surprise," Dr. Nakada said. "The open procedure in obese patients can take a significant amount of OR time just to open and close the incision, and the risk of wound infection can be substantial. Obese patients do poorly postoperatively from a pulmonary standpoint with the long incision.