This article focuses on the laparoscopic approaches to radical and partial nephrectomy for the managment of renal cell carcinoma and on the laparoscopic and endoscopic approaches for treating upper tract urothelial carcimoma. An in-depth discussion of treatment for transitional cell carcinoma is also presented.
Renal cell carcinoma
The incidence of renal tumors continues to increase with the more widespread use of abdominal imaging. With this increasing incidence, more tumors are detected that are potentially amenable to less invasive treatment. At the same time, technologic advances have created new minimally invasive options for the treatment of smaller lesions . Since the performance of the first laparoscopic nephrectomy in 1990 , there has been an ever-growing incorporation of laparoscopic techniques into clinical practice; in fact, laparoscopic nephrectomy has become a standard treatment of renal tumors that are not candidates for nephron-sparing surgery. Currently, tumors that are amenable to a nephron-sparing approach may be treated with one of several options. Laparoscopic partial nephrectomy (LPN) has established its intermediate oncologic equivalency to the open method , although this technique has not experienced the same incorporation into clinical practice as laparoscopic radical nephrectomy (LRN), likely, in large part, because of the technical complexity of the procedure and the potentially higher complication rates. When treating the small renal mass, other alternatives have become available, specifically needle ablative techniques. The clinical evidence is building in favor of cryoablation and radiofrequency ablation for the treatment of small renal tumors. Other experimental techniques that could further reduce the invasiveness of treatment, such as noninvasive high-intensity focused ultrasound (HIFU) and the gamma knife, have also been explored; however, to date, clinical results have been few and disappointing .
This article focuses primarily on the laparoscopic approaches to radical and partial nephrectomy for management of renal cell carcinoma (RCC). An in-depth discussion of treatment options for transitional cell carcinoma (TCC) is also covered.
Small renal tumors
Most solid renal tumors with a diameter of 4 cm or less are amenable to treatment with nephron-sparing surgery; the oncologic outcomes are excellent and equivalent to radical nephrectomy . Tumors 3 cm or less are thought to be best suited for needle ablative treatment. The natural history and cancer potential of these small masses is an important consideration, given the fact they are often found in elderly patients who have significant comorbidities. One study looked at tumors 4 cm or less and reviewed the histopathologic results of 287 tumor excisions, attempting to characterize the aggressiveness of smaller renal masses . In this series, 19.5% of the masses were found to be benign. Among the patients who had RCC, high grade and high stage seemed to be correlated with tumor size; to wit, Fuhrman grade 3/4 or pT3a lesions were found in 4.2% and 4.2% (≤2 cm), 5% and 14.9% (2.1–3 cm), and 25.5% and 35.7% (3.1–4.0 cm), respectively. Distant metastases were seen in 2.4% of tumors 3 cm or less and in 8.4% of tumors 3.1 to 4.0 cm. This underscores the fact that tumor aggressiveness seems to increase dramatically in tumors larger than 3 cm, calling into question the reliability of the current T1a system, which includes tumors up to 4 cm in size. Indeed, not only aggressiveness but the likelihood of cancer seems to be related to the size of the mass. Regarding the latter, when looking at tumor sizes from less than 1 cm to greater than 7 cm, with each 1-cm increase in tumor size, the odds of cancer increase by 17% .
An ongoing concern with the treatment of the small renal mass is that upward of 20% to 25% of lesions 4 cm or less are benign . This high incidence of benign lesions makes the natural history of untreated renal masses an area of interest. In a meta-analysis of untreated renal lesions, the mean growth rate was 2.8 mm/y and only 1% of the patients developed metastasis during the surveillance period . Important questions, such as cancer-specific death in untreated lesions and how to differentiate benign from malignant growth patterns, remain unanswered. Indeed, surveillance rather than immediate ablative therapy has been proposed as one treatment strategy. To this end, the work of Kouba and colleagues is most enlightening. In this study of 43 patients who had 46 solid or cystic (Bosniak IV) masses with a mean size of 2.9 cm who were followed for an average of 3 years, there was a median growth rate of 6 mm/y. Only 28% came to surgery (ie, growth rate of 9 mm/y), among whom 87% had cancerous lesions. During the same period, 10% of the patients died from unrelated causes, having had no renal surgery. Over the 3-year period, no patient developed metastatic disease, and among those coming to surgery, all still had a nephron-sparing procedure.
Small renal tumors
Most solid renal tumors with a diameter of 4 cm or less are amenable to treatment with nephron-sparing surgery; the oncologic outcomes are excellent and equivalent to radical nephrectomy . Tumors 3 cm or less are thought to be best suited for needle ablative treatment. The natural history and cancer potential of these small masses is an important consideration, given the fact they are often found in elderly patients who have significant comorbidities. One study looked at tumors 4 cm or less and reviewed the histopathologic results of 287 tumor excisions, attempting to characterize the aggressiveness of smaller renal masses . In this series, 19.5% of the masses were found to be benign. Among the patients who had RCC, high grade and high stage seemed to be correlated with tumor size; to wit, Fuhrman grade 3/4 or pT3a lesions were found in 4.2% and 4.2% (≤2 cm), 5% and 14.9% (2.1–3 cm), and 25.5% and 35.7% (3.1–4.0 cm), respectively. Distant metastases were seen in 2.4% of tumors 3 cm or less and in 8.4% of tumors 3.1 to 4.0 cm. This underscores the fact that tumor aggressiveness seems to increase dramatically in tumors larger than 3 cm, calling into question the reliability of the current T1a system, which includes tumors up to 4 cm in size. Indeed, not only aggressiveness but the likelihood of cancer seems to be related to the size of the mass. Regarding the latter, when looking at tumor sizes from less than 1 cm to greater than 7 cm, with each 1-cm increase in tumor size, the odds of cancer increase by 17% .
An ongoing concern with the treatment of the small renal mass is that upward of 20% to 25% of lesions 4 cm or less are benign . This high incidence of benign lesions makes the natural history of untreated renal masses an area of interest. In a meta-analysis of untreated renal lesions, the mean growth rate was 2.8 mm/y and only 1% of the patients developed metastasis during the surveillance period . Important questions, such as cancer-specific death in untreated lesions and how to differentiate benign from malignant growth patterns, remain unanswered. Indeed, surveillance rather than immediate ablative therapy has been proposed as one treatment strategy. To this end, the work of Kouba and colleagues is most enlightening. In this study of 43 patients who had 46 solid or cystic (Bosniak IV) masses with a mean size of 2.9 cm who were followed for an average of 3 years, there was a median growth rate of 6 mm/y. Only 28% came to surgery (ie, growth rate of 9 mm/y), among whom 87% had cancerous lesions. During the same period, 10% of the patients died from unrelated causes, having had no renal surgery. Over the 3-year period, no patient developed metastatic disease, and among those coming to surgery, all still had a nephron-sparing procedure.
Laparoscopic partial nephrectomy
Winfield and colleagues performed the first LPN in 1991 for benign disease, with McDougall and colleagues subsequently extending the application to renal tumors in 1993. The traditional open approach to nephron-sparing surgery has established oncologic and functional outcomes with 10-year follow-up . Several groups have published their results with the laparoscopic technique ( Table 1 ) . Lane and Gill recently published the results on 58 patients who had undergone an LPN with at least 5 years of follow-up (median of 5.7 years; range: 5–6.9 years). The mean tumor size was 2.9 cm, and the 5-year overall and cancer-specific survival (CSS) rates were 86% and 100%, respectively, which is comparable to the published open series. There was one positive surgical margin (1.7%) and an overall complication rate of 21%. On average, the creatinine increased from 0.9 mg/dL before surgery to 1.0 mg/dL after surgery. No patient with a normal preoperative creatinine level developed postoperative chronic renal insufficiency, as defined by a serum creatinine level greater than 2 mg/dL. Thirty-seven patients (66%) had RCC on the final histopathologic analysis, and in this group of patients, there were no distant recurrences and a single local recurrence (1.7%). Allaf and colleagues reported the oncologic outcomes of 48 patients who had pathologically proved RCC with a mean follow-up of 38 months. The mean tumor size was 2.4 cm, with 42 patients having pT1 tumors and 6 patients having pT3a tumors. All patients had a negative intraoperative frozen margin; however, one of these was determined to be positive on the final pathologic examination (2.1%). This patient remained disease-free with greater than 3 years of follow-up. Two patients (4.2%) developed a local recurrence at 18 and 46 months after surgery. Jeschke and colleagues reported on their series of 51 patients undergoing LPN with a mean follow-up of 34 months (range: 3–78 months). The mean tumor size was 2 cm (range: 1–5 cm), with 35 patients having pT1 tumors and 3 having pT3a tumors; 38 patients (76%) were confirmed to have pathologic RCC. Surgical margins were negative in all cases. One patient (2.6%) developed a local recurrence 12 months after the initial surgery, and no distant recurrences were seen. The overall complication rate was 10%.
| Authors | Institution | No. patients [tumors) (N) | Mean tumor size [cm] (range) | Mean warm ischemia time (minutes) | Mean EBL (mL) | Malignancy rate (%) | Positive surgical margin (%) | Length of follow-up/months (range) | Recurrence | Complications | Survival | |||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Local | Distant | Intraoperative | Postoperative | Overall | Recurrence-free (%) | Cancer-specific (%) | Overall (%) | |||||||||
| Lane et al | Cleveland Clinic | 56 | 2.9 (1.3–7.0) | — | — | 66% | 1 (1.7%) | 68 (60–83) | 1 | 0 | 6% | 13% | 18% | 97% | 100% | 86% |
| Moinzadeh et al | Cleveland Clinic | 100 | 2.9 | 27 | 219 | 68% | 2 (2%) | 43 (24–62) | 0 | — | — | — | — | 100% | 100% | 86% |
| Weld et al | Washington University | 60 | 2.5 (0.7–5.1) | 26.9 (10–44) | 226 | 60% | 0 (0%) | 25 | 0 | 0 | — | — | 30% | 100% | — | — |
| Wille et al | Humboldt University | 44 | 2.8 (1–5) | 21 (7–41) | — | 82% | 0 | 15 (6–37) | 0 | 0 | 0% | — | — | 100% | — | — |
| Link et al | Johns Hopkins | 217 | 2.6 (1–10) | 27.6 (5–60) | 385 | 66% | 7 (3.5%) | 24 (7–54) | 2 | 0 | — | 10.6% | — | — | — | — |
| Ramani et al | Cleveland Clinic | 200 | 2.9 (1–10) | 28.7 (15–58) | 247 | — | — | — | — | — | 5.5% | 27.5% (15.5% delayed) | 33% | — | — | — |
| Abukora et al | Elisabethinen Austria | 78 | 2.4 (0.5–3.5) | 33.8 (17–56) | 212 | 83% | 1 (1.2%) | 16 (3–38) | 0 | 0 | 9% | 19% | 28% | 100% | — | — |
| Allaf et al | Johns Hopkins | 48 | 2.4 (1.0–4.0) | — | — | 100% | 1 (2.1%) | 38 (22–84) | 2 | 0 | — | — | — | 96% | 100% | — |
| Seifman et al | University of Michigan | 40 | 2.3 | — | 300 | 73% | 1 (2.5%) | 24 | 0 | 0 | — | — | 38% | 100% | — | — |
| Jeschke et al | University of Innsbruck | 51 | 2.0 | — | 282 | 76% | 0 (0%) | 34 (3–78) | 0 | 0 | 2% | 8% | 10% | 100% | 100% | — |
Three large series comparing laparoscopic with open partial nephrectomy (OPN) are summarized in Table 2 . A direct comparative analysis of 100 consecutive LPNs to a contemporary cohort of 100 consecutive OPNs was reported by Gill and colleagues . The LPN group had smaller tumors (2.8 versus 3.3 cm), a shorter operative time (3 versus 3.9 hours), less blood loss (125 versus 250 mL), and a longer warm ischemia time (28 versus 18 minutes) when compared with the OPN group. The overall complication rate was similar, with 19% of patients in the LPN group and 13% in the OPN group experiencing complications. Five percent of the LPN group had intraoperative complications versus none in the OPN group, however. Additionally, the LPN group had more renal or urologic complications (11% versus 2%). This study confirmed that laparoscopic nephron-sparing surgery is an effective therapeutic approach, albeit a technically demanding and more morbid procedure than OPN even in highly experienced hands. Advantages of LPN included decreased narcotic use (20- versus 252-mg morphine equivalents), shorter hospital stay (2 versus 5 days), and a more rapid convalescence (4 versus 6 weeks). Permpongkosol and colleagues reported the outcomes of 85 LPNs compared with 58 OPNs with pathologically proven RCC and mean follow-ups of 40 and 49 months, respectively. The 5-year recurrence-free and overall survival rates were 91% versus 97% and 94% versus 96% for LPN and OPN, respectively, demonstrating equivalent intermediate oncologic outcomes. The largest comparative study reported the outcomes of 771 LPNs compared with 1028 OPNs from three tertiary care centers . The OPN group had larger tumors (3.5 versus 2.7 cm) and represented a higher risk group based on performance status, impaired renal function, and solitary tumor status. LPN was associated with a shorter operative time (201 versus 266 minutes) decreased blood loss (300 versus 376 mL), and a shorter hospital stay (3.3 versus 5.7 days) but had a longer warm ischemia time (30 versus 20 minutes) and more postoperative complications (25% versus 19%). Renal functional outcomes (98% versus 99%) and 3-year CSS (99% versus 99%) were similar with both approaches.
| Authors | Institution | Surgery | Patients [tumors] (N) | Mean tumor size [cm] (range) | Mean warm ischemia time (minutes) | Mean EBL (mL) | OR time (minutes) | LOS (days) | Malignancy rate (%) | Positive surgical margin (%) | Length of follow-up [months] (range) | Recurrence | Intra operative complications | Postoperative complications | Survival | ||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Local | Distant | Bleeding/Urine leak | All post operative | Recurrence-free (%) | Cancer-specific (%) | Overall (%) | |||||||||||||
| Gill et al | 3 centers a | LPN | 771 | 2.7 (0.5–7.0) | 30 (4–68) | 300 | 201 | 3.3 | 72% | 22 (2.9%) | 14 (0–84) | 1.4% b | 0.9% b | 1.8% | 4.2% | 25% | — | 99% b | — |
| 3.1% | |||||||||||||||||||
| OPN | 1028 | 3.5 (0.6–7.0) | 20 (4–52) | 376 | 266 | 5.8 | 83% | 13 (1.3%) | 34 (0–91) | 1.5% b | 2.1% b | 1.0% | 1.6% | 19% | — | 99% b | — | ||
| 2.3% | |||||||||||||||||||
| Permpongkosol et al | Johns Hopkins | LPN | 85 | 2.4 (0.5–5.3) | 29.5 | 437 | 225 | 3.3 | 100% | 2 (2.4%) | 40 (18–96) | 2 (2.3%) | 1 (1.2%) | 3.5% | — | 7% | 91% c | — | 94% c |
| OPN | 58 | 2.9 (1–5) | 48 | 428 | 276 | 5.4 | 100% | 1 (1.7%) | 49 (18–106) | 1 (1.7%) | 1 (1.7%) | 3.5% | — | 22% | 97% c | — | 96% c | ||
| Gill et al | Cleveland Clinic | LPN | 100 | 2.8 | 28 | 125 | 180 | 2.0 | 70% | 3 | — | — | — | 5% | 3% | 16% | — | — | — |
| 3% | |||||||||||||||||||
| OPN | 100 | 3.3 | 18 | 250 | 231 | 5.0 | 85% | 0 | — | — | — | 0% | 0% | 13% | — | — | — | ||
| 1% | |||||||||||||||||||
a Cleveland Clinic, Johns Hopkins, and Mayo Clinic.
b Three-year Kaplan-Meier estimates.
With regard to the morbidity of LPN, Ramani and colleagues looked at the complications seen in 200 consecutive LPNs. A total of 66 patients (33%) experienced at least one complication. Hemorrhage was the most common complication and was seen in 19 patients (9.5%), occurring during surgery in 7 (3.5%), after surgery in 4 (2%), and delayed (after discharge) in 8 (4%) at a mean of 16 postoperative days. A urine leak was seen in 9 patients (4.5%) and was typically managed with a double-J stent. Again, this series came from the Cleveland Clinic, which has the largest experience with LPN, stressing that even in the most experienced hands, the morbidity of LPN is a significant consideration.
Technique
Approach
LPNs have been successfully performed by means of transperitoneal and retroperitoneal approaches. The choice is typically based on surgeon preference, tumor location, and patient factors, although the transperitoneal approach provides a larger working space with more familiar anatomy, which may facilitate tumor excision and renorrhaphy. In general, for lesions that are directed posteriorly, a retroperitoneal approach is chosen, especially if no entry into the collecting system is anticipated because of the mass being largely exophytic (ie, less than 10 mm extension into the kidney).
Intraoperative ultrasound
The use of intraoperative laparoscopic ultrasound has become common to define the borders of the tumor and to assist in planning the plane of incision for removal. Additionally, the entire kidney may be surveyed to rule out other lesions.
Vascular control
Vascular clamping provides a bloodless field for more precise tumor excision. Vascular occlusion can be achieved with internalized bulldog vascular clamps or with an exteriorized handheld Satinsky clamp. When using bulldog clamps, one is typically placed on the artery and another on the vein, although clamping of the artery alone is also an option, because the renal venous blood flow is decreased by upward of 90% with a pneumoperitoneum pressure of 15 mm Hg .
The bulldog clamps seem to provide the most reliable occlusive force when placed entirely across the vessel to the end of the clamp . Additionally, over time, some bulldogs fatigue and no longer provide supraphysiologic occlusion forces, which could explain some of the variability noted among bulldog clamps and recommendations of some surgeons to check for cessation of arterial inflow to the kidney with a laparoscopic ultrasound Doppler probe or to place at least two bulldog clamps on the artery (J. Landman, personal communication).
The Satinsky clamps are typically placed across the entire hilum without isolating the artery and vein individually. In the authors’ experience, vascular control is not required for all tumors, and it is their policy to use vascular control only for tumors that are 10 mm or deeper from the kidney surface and are likely to entail closure of the collecting system; with this approach, warm ischemia time is avoided during the excision of most exophytic masses .
Warm ischemia
The acceptable duration of warm ischemia that can be tolerated without causing reversible nephron loss has not been firmly established, although minimizing warm ischemia time is generally agreed to be important. Typically, warm ischemia times 30 minutes or less are desirable, but some have shown that warm ischemia time up to 40 to 45 minutes may be well tolerated . Of note, in the porcine model, warm ischemia times of 90 minutes are tolerated with complete return of function in 2 weeks . All this depends more on the patient than on the absolute warm ischemia time, because the elderly patient, the hypertensive patient who has arteriosclerosis, patients with preexisting renal insufficiency, or the diabetic patient seems to be more prone to damage from warm ischemia even of short duration. This has led some surgeons to release the vascular clamps before completing the renorrhaphy, thereby producing warm ischemia times of 15 minutes or less .
Adjuncts
Bleeding is the most common complication after LPN, and several hemostatic agents exist to help achieve hemostasis. These include thrombin-impregnated gelatin matrix, fibrin sealants, and oxidized cellulose. Looking at risk factors for complications after LPN, thrombin-impregnated gelatin matrix has been shown to decrease the risk for postoperative bleeding complications .
Current technique: with warm ischemia
Using a transperitoneal approach, the kidney is mobilized and the renal hilum is isolated en bloc. The capsule of the kidney is exposed within Gerota’s fascia to the edge of the tumor, leaving the peritumoral fat in place. Intraoperative ultrasound is used to confirm the size and depth of the tumor, and the argon beam monopolar cautery is then used to score the renal capsule around the tumor along the planned site of excision. All sutures (6-inch length of 2-0 Vicryl on SH needle and 10-inch length of 0 Vicryl on CT-1 needle) and bolsters needed for repair are placed into the abdominal cavity before applying the vascular clamp to minimize warm ischemia time. The handheld Satinsky clamp is applied across the renal hilum, the tumor is excised, and reconstruction is performed using a specific series of techniques in an attempt to minimize bleeding . In this regard, at the authors’ institution, tumor excision is performed using an energy-based device; either a bipolar or ultrasonic based sealing device. The argon beam monopolar cautery is then applied to the tumor base, followed by suture repair of the collecting system and exposed vessels. A absorbable polydioxanone suture anchor is used to secure the suture at either end, as previously described . A layer of thrombin-impregnated gelatin matrix is applied, followed by oxidized cellulose bolsters; then, a series of simple sutures is used to close the parenchymal defect, again utilizing absorbable polydioxanone suture anchors. Finally, fibrin glue or thrombin-impregnated gelatin matrix is applied on the surface of the repair. Using this technique, no early or delayed postoperative bleeding complications have occurred over a 2-year period .
Current technique: without warm ischemia
In patients who have a 3-cm or smaller tumor that is nonhilar and does not extend into the renal parenchyma by more than 10 mm, the lesion can be excised without any warm ischemia. A spiral CT angiogram is performed with three-dimensional reconstruction to measure the depth of the tumor accurately and assess its proximity to the collecting system. This approach requires the use of a bipolar or ultrasonic sealing device to excise the lesion. Although questions have been raised concerning the integrity of the margin, in fact, neither the bipolar nor the ultrasonic modality precludes an accurate assessment of the margin status according to an extensive study recently completed at the authors’ institution . The approach to the tumor is based on its location, with retroperitoneoscopy being performed for posteriorly directed tumors and transperitoneal laparoscopy being performed for anteriorly directed tumors. The hilum can be dissected at the surgeon’s discretion; however, this is not routinely done in the authors’ operating room. Once the peritumoral fat is removed and the lesion is clearly seen for a complete 360° circumference, the planned site of incision is marked with monopolar electrocautery and the argon beam cautery. The renal capsule is then incised completely around the tumor. The pneumoperitoneum pressure is then elevated to 20 to 25 mm Hg, the anesthesiologist is notified, and a timer is set for 10 minutes. Using the bipolar or ultrasonic sealing device, the activated blade is passed to its full depth at the inferior point of the tumor; this is done so that one is always working away from any bleeding that may occur. Once the jaws of the device are closed and activated (ie, bipolar based sealing device) or activated and closed (ie, ultrasonic based sealing device), the dissection continues to the right and left side and upward. Throughout the process, the assistant can use the argon beam to stop any bleeding that occurs; the surgeon uses the suction unit in the nondominant hand continually to expose the next adjacent area to be incised. As the tumor is rolled upward and out of its parenchymal bed, the argon beam is used to continue to aid hemostasis on the parenchymal surface. In this manner, the tumor is mobilized and excised. As soon as the tumor is free, the parenchymal bed is treated with argon beam cautery, followed by fibrin glue, a layer of oxidized cellulose, and another layer of fibrin glue; a couple of minutes are allowed to pass to enable the fibrin glue to set up. Usually, this entire process should take less than 10 minutes. The pneumoperitoneum is then lowered to 5 mm Hg to check for any bleeding. In none of our cases have we found it necessary to place a bolster or to suture the edges of the capsule or parenchyma. A 5-mm round drain is placed at the end of the procedure.
Laparoscopic radical nephrectomy
Since Clayman and colleagues performed the first laparoscopic nephrectomy (LRN) in June of 1990 at Washington University, this technique has become internationally accepted. In fact, many urologists consider this the standard of care for those patients who have T1, T2, or T3a tumors amenable to treatment by means of the laparoscopic approach but are not candidates for nephron-sparing surgery. The decreased morbidity of LRN has been well documented with reductions in postoperative pain, hospital stay, and convalescence. Several studies with maturing follow-up data have been published, establishing the oncologic equivalency to the open procedure ( Table 3 ) . Portis and colleagues reported a multicenter series of 64 patients treated with LRN compared with a group of 69 patients treated with open radical nephrectomy (ORN). With a median follow-up of 54 months (range: 0–94 months), no difference was seen between the two approaches, with a 5-year recurrence-free survival, 5-year CSS, and overall survival rates of 92%, 98%, and 81%, respectively, in the laparoscopic group. Permpongkosol and colleagues reported on a series of 67 patients who had an LRN with a median follow-up of 73 months (range: 12–164 months) that was compared with 54 patients who had renal cancer and had an ORN. The 10-year disease-free, cancer-specific, and actuarial survival rates for the laparoscopic group were 94%, 97%, and 76% compared with 87%, 86%, and 58% in the open group, respectively. Hemal and colleagues reported on their series of 132 patients having a laparoscopic nephrectomy for pT1 to pT2 RCC with a median follow-up of 56 months (range: 3–80 months). The survival analysis was grouped by T stage, with 5-year CSS rates and 5-year recurrence-free survival rates of 97.2% and 97.2%, 86.3% and 84.3%, and 82.2% and 82.2%, respectively, for pT1a, pT1b, and pT2 tumors. With a decade of follow-up in some series, LRN has now demonstrated oncologic equivalency to open surgery.
| Authors | Institution | Type of surgery | Patients (N) | Tumor size (range) | Mean EBL (mL) | Length of follow-up [months] (range) | Complications | 5-year survival | 10-year survival | ||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Recurrence-free (%) | Cancer-specific (%) | Overall (%) | Recurrence-free (%) | Cancer-specific (%) | Overall (%) | ||||||||
| Colombo et al | Cleveland Clinic | LRN | 63 | 5.4 | 179 | 65 (19–92) | 7% | 91% | 91% | 78% | — | — | — |
| ORN | 53 | 6.4 | 501 | 76 (8–105) | — | 93% | 93% | 84% | — | — | — | ||
| Hemal et al | All India Institute | LRN | 132 | 6.9 (3.6–14) | 193 | 56 (3–80) | 17% | 87% | 88% | 86% | — | — | — |
| Kawauchi et al | 22 centers | HALRN | 123 | 4.4 | 173 | 41 | 9% | 92% | 92% | — | — | — | — |
| ORN | 70 | 4.4 | 448 | 74 | 10% | 91% | 94% | — | — | — | — | ||
| Permpongkosol et al | Johns Hopkins | LRN | 67 | T1–46 (69%) | — | 73 (12–164) | — | 94% | 97% | 85% | 94% | 97% | 76% |
| T2–21 (31%) | |||||||||||||
| ORN | 54 | T1–40 (74%) | — | 80 (8–157) | — | 87% | 89% | 72% | 87% | 86% | 58% | ||
| T2–14 (26%) | |||||||||||||
| Saika et al | Nagoya University | LRN | 195 | 3.7 | 248 | 40 (2–121) | 15% | 91% | — | 94% | — | — | — |
| ORN | 68 | 4.4 | 482 | 65 (11–126) | 7% | 87% | — | 94% | — | — | — | ||
| Portis et al | 3 centers a | LRN | 64 | 4.3 (2–10) | 219 | 54 (0–94) | — | 92% | 98% | 81% | — | — | — |
| ORN | 69 | 6.2 (2.5–15) | 354 | 69 (8–114) | — | 91% | 92% | 89% | — | — | — | ||
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