Surgical innovations for the management of renal cell carcinoma (RCC) have resulted from the ingenuity of numerous urologists. In addition, tremendous technologic advancements have facilitated the successful application of minimally invasive options to an increasing number of patients with suspected RCC. Today, most kidney surgeons consider laparoscopic radical nephrectomy (LRN) the standard of care for many patients with renal tumors who are neither candidates for nephron preservation nor for observation. However, in the contemporary era, is a LRN an acceptable surgical approach for patients with larger or more advanced renal masses? The authors report a multi-institutional, retrospective series of 222 patients who underwent LRN for pathologic stage T2 or T3 RCC. In the absence of a control population or a randomized, prospective trial of surgical approaches for radical nephrectomy, we can only make assumptions regarding the oncologic efficacy of the laparoscopic approach. In this study, patients with suspected adjacent organ involvement, vena cava tumor thrombus, or bulky lymphadenopathy were referred for open surgery. Yet, we do not know if there were other medical or surgical selection biases that might have resulted in the exclusion of patients from undergoing LRN. Do these study limitations suggest that a urologist should refrain from using a laparoscopic approach for more complex renal tumors until more definitive conclusions regarding oncologic efficacy are determined? Not necessarily. Given the increasing acceptance and the successful experience with LRN, it is doubtful that a prospective trial comparing surgical approaches for more advanced renal tumors and any impact of the surgical approaches on oncologic efficacy would yield meaningful differences favoring open techniques. Certainly, the authors demonstrated the feasibility of LRN in patients with larger renal tumors and they provided data regarding surrogate indicators of oncologic efficacy, including surgical margins and lymph node yield. Surgical margins were negative in all patients undergoing LRN, and in the 30% of patients who underwent lymph node dissection (LND), the median lymph node yield was 6 nodes (range, 2-18 nodes). In regards to the role of a LND, there is controversy about when a lymphadenectomy is indicated and to what extent the dissection should be performed.1 Although a routine LND for patients with clinical T1 or T2 RCC does not appear to impact survival, there are advocates for an extended LND in patients with features of locally advanced RCC, even in the context of clinical N0 disease.2 and 3 The results of this retrospective analysis suggest that when indicated, a laparoscopic LND can be accomplished successfully. Recognizing the possible selection biases and limitations of the current study, the authors' results confirm the safety of the laparoscopic approach for this patient population, evidenced by the low 5.4% rate of elective and emergency conversion to open surgery and the overall low 2.7% rate of intraoperative and postoperative grade III or IV complications. Although the laparoscopic approach might not be suitable for some patients with clinical T2-T3, N0, RCC, the authors' results support continued efforts toward optimizing minimally invasive surgical strategies and outcomes for patients with more advanced renal tumors.
Operative Safety and Oncologic Outcome of Laparoscopic Radical Nephrectomy for Renal Cell Carcinoma > 7 cm: A Multicenter Study of 222 Patients REPLY
PORPIGLIA, Francesco
2013-01-01
Abstract
Surgical innovations for the management of renal cell carcinoma (RCC) have resulted from the ingenuity of numerous urologists. In addition, tremendous technologic advancements have facilitated the successful application of minimally invasive options to an increasing number of patients with suspected RCC. Today, most kidney surgeons consider laparoscopic radical nephrectomy (LRN) the standard of care for many patients with renal tumors who are neither candidates for nephron preservation nor for observation. However, in the contemporary era, is a LRN an acceptable surgical approach for patients with larger or more advanced renal masses? The authors report a multi-institutional, retrospective series of 222 patients who underwent LRN for pathologic stage T2 or T3 RCC. In the absence of a control population or a randomized, prospective trial of surgical approaches for radical nephrectomy, we can only make assumptions regarding the oncologic efficacy of the laparoscopic approach. In this study, patients with suspected adjacent organ involvement, vena cava tumor thrombus, or bulky lymphadenopathy were referred for open surgery. Yet, we do not know if there were other medical or surgical selection biases that might have resulted in the exclusion of patients from undergoing LRN. Do these study limitations suggest that a urologist should refrain from using a laparoscopic approach for more complex renal tumors until more definitive conclusions regarding oncologic efficacy are determined? Not necessarily. Given the increasing acceptance and the successful experience with LRN, it is doubtful that a prospective trial comparing surgical approaches for more advanced renal tumors and any impact of the surgical approaches on oncologic efficacy would yield meaningful differences favoring open techniques. Certainly, the authors demonstrated the feasibility of LRN in patients with larger renal tumors and they provided data regarding surrogate indicators of oncologic efficacy, including surgical margins and lymph node yield. Surgical margins were negative in all patients undergoing LRN, and in the 30% of patients who underwent lymph node dissection (LND), the median lymph node yield was 6 nodes (range, 2-18 nodes). In regards to the role of a LND, there is controversy about when a lymphadenectomy is indicated and to what extent the dissection should be performed.1 Although a routine LND for patients with clinical T1 or T2 RCC does not appear to impact survival, there are advocates for an extended LND in patients with features of locally advanced RCC, even in the context of clinical N0 disease.2 and 3 The results of this retrospective analysis suggest that when indicated, a laparoscopic LND can be accomplished successfully. Recognizing the possible selection biases and limitations of the current study, the authors' results confirm the safety of the laparoscopic approach for this patient population, evidenced by the low 5.4% rate of elective and emergency conversion to open surgery and the overall low 2.7% rate of intraoperative and postoperative grade III or IV complications. Although the laparoscopic approach might not be suitable for some patients with clinical T2-T3, N0, RCC, the authors' results support continued efforts toward optimizing minimally invasive surgical strategies and outcomes for patients with more advanced renal tumors.
I documenti in IRIS sono protetti da copyright e tutti i diritti sono riservati, salvo diversa indicazione.
