Laparoscopic vs open donor nephrectomy:Lessons learnt from single academic center experience

AIM To compare laparoscopic and open living donor neph-rectomy, based on the results from a single center during a decade.METHODS This is a retrospective review of all living donor neph-rectomies performed at the Massachusetts General Hospital, Harvard Medical School, Boston, between 1/1998 - 12/2009. Overall there were 490 living donors, with 279 undergoing laparoscopic living donor nephrectomy （LLDN） and 211 undergoing open donor nephrectomy （OLDN）. Demographic data, operating room time, the effect of the learning curve, the number of conversions from laparoscopic to open surgery, donor preoperative glomerular fltration rate and creatinine （Cr）, donor and recipient postoperative Cr, delayed graft function and donor complications were analyzed. Statistical analysis was performed.RESULTSOverall there was no statistically significant differencebetween the LLDN and the OLDN groups regardingoperating time, donor preoperative renal function, donorand recipient postoperative kidney function, delayed graftfunction or the incidence of major complications. Whenthe last 100 laparoscopic cases were analyzed, there wasa statistically significant difference regarding operatingtime in favor of the LLDN, pointing out the importanceof the learning curve. Furthermore, another significantdifference between the two groups was the decreasedlength of stay for the LLDN （2.87 d for LLDN vs 3.6 d for OLDN）.CONCLUSION Recognizing the importance of the learning curve, this paper provides evidence that LLDN has a safety profle comparable to OLDN and decreased length of stay for the donor.

Place of Open Radical Nephrectomy, in the Era of Laparoscopy in Subsaharian Africa

Introduction: Kidney cancer is discovered in Africa often at advanced or locally advanced stages. These patients could be treated by radical nephrectomy or cytoreductive nephrectomy. Open surgery still retains its place due to the technical difficulties which are linked to the stage of the tumors in this era where laparoscopy is becoming the gold standard. Through this study, we wanted to highlight the advanced stages of patients operated by open surgery in our institution rather than laparoscopy, however, with good results. Patients and Method: It was a retrospective study over a period of 5 years. Were included all patients in whom radical nephrectomy had been performed during this period. Results: Thirty-five (35) open radical nephrectomies for kidney cancer were performed. The average tumor size was 11.6 cm (±3.4 cm). The mean operating time was 169 min ± 63.4 min with extremes of 115 min (1 h 55 min) and 360 min (6 h). This duration was longer for large tumors (p = 0.002). Intraoperative incidents occurred in 4 patients (11.4%);it was a vena cava injury (02) and a spleen injury (02). Blood loss was estimated on average at 535 ml. The mean follow-up time was 19 ± 11 months. The overall survival rate was 90% at 3 months, 53% at 12 months and 35.4% at 24 months. Conclusion: The large size of kidney tumor found in Africa may constitute an obstacle to performing nephrectomies by laparoscopy. However, mastering the laparoscopic technique with appropriate equipment can help reduce operative morbidity.

Open Partial Nephrectomy: One Night Length of Stay Is Safe and Cost Effective

Objective: To review our open partial nephrectomy (OPN) experience and compare to known robotic partial nephrectomy (RPN) data to determine whether length of stay (LOS) and morbidity are significant drivers in the surgical approach employed for partial nephrectomy. Methods: We reviewed our OPN experience during the last 3 years examining age, tumor size, LOS, pathology, blood loss, complications, recurences, and deaths. Results: Seventy-five patients underwent OPN during this period. Mean age was 59 years, tumor size 2.8 cm, percent malignant 75%, estimated blood loss 350 cc. With a median follow-up of 18 months, there was one urinoma managed by drain-age, one pseudo aneurysm that required embolization and one pulmonary embolism that required anticoagulation. There were no readmissions, no tumor recurences, and no deaths. Our major complication rate was 4% as compared to other trials that re-ported major complication rates between 1% - 9% for RPN and between 3% - 24% for OPN. In the first half of the experience (n = 37), median LOS was 57 hours. Using a pathway encouraging early ambulation and smaller incisions in the second half of the experience (n = 38), median LOS was 35 hours. This is much shorter than reported RPN LOS of 62 - 67 hours and OPN LOS of 108 - 142 hours. Conclusion: OPN can be performed safely and effectively with one night hospital stay. This provides a more cost-effective approach to partial nephrectomy with similar or better complication rates and calls into question the main value drivers of RPN.

Long-term oncologic outcomes of laparoscopic versus open partial nephrectomy

Background Most of the literatures on laparoscopic partial nephrectomy （LPN） versus open partial nephrectomy （OPN） focus on technical details and early or mid-term oncologic outcomes, reflecting that the approach is safe and provides mid- term benefits compared with traditional open surgery. However, the difference of long-term oncologic outcome between LPN and OPN remains unclear. The aim of this meta-analysis was to evaluate the long-term oncologic outcome of LPN in the treatment of localized renal tumors compared with that of OPN. Methods A systematic search of electronic databases including Medline, Embase, and Cochrane library was conducted. Comparative studies reporting on long-term oncologic outcome of LPN versus OPN were regarded eligible. The odds ratio （OR） and its corresponding 95% confidence intervals （CO were calculated for the oncologic outcomes. The methodologic quality of the included studies was evaluated using the strict criteria of the Newcastle-Ottawa scale. Results Six comparative studies （1495 participants including 555 LPN and 940 OPN） were included in the present study. There was no significant difference between LPN and OPN in 5-year overall survival （OS） rates （OR=1.83, 95% Cl （0.80, 4.19））, 5-year cancer specific survival （CSS） rates （OR=1.09, 95% CI （0.62, 1.92））, and 5-year recurrence free survival （RFS） rates （OR=0.68, 95% CI （0.37, 1.26））. Conclusion The results of this meta-analysis revealed that there was no significant difference in long-term oncologic outcome between LPN and OPN for treatment of localized renal tumors.

The Effect of Different Surgical Methods on the Number of Circulating Tumor Cells in the Peripheral Blood of Patients with Renal Cell Carcinoma

Objective: The objective is to explore the effects of different surgical methods-retroperitoneal laparoscopic radical nephrectomy (RLRN) and open radical nephrectomy (ORN) on the number of circulating tumor cells (CTC) in the peripheral blood of patients with renal cancer. Methods: The clinical data of 63 patients in the Department of Urology, Affiliated Hospital of Chengde Medical College who underwent radical surgery for renal cancer were divided into CTC positive group (18 cases of open surgery and 16 cases of minimally invasive surgery) and CTC negative group (14 cases of open surgery), 15 cases of minimally invasive surgery), overall group (32 cases of open surgery, 31 cases of minimally invasive surgery). Observe the changes in the number of CTC 1 week before operation and 1 week after operation. Results: In the positive group, whether it was open surgery or minimally invasive surgery, the postoperative CTC level of patients was significantly reduced (P < 0.05). In the negative group, the CTC decreased significantly after open surgery (P > 0.05), and the CTC level decreased significantly after minimally invasive surgery (P < 0.01). In the overall group, both open and minimally invasive surgery CTC decreased significantly, and the difference was statistically significant (P < 0.05). Conclusion: The two different surgical methods can reduce the level of CTC, but compared with ORN, RLRN can significantly reduce the number of postoperative CTC. Patients in the CTC-negative group may be less suitable for open surgery. CTC levels have certain potential in the selection and guidance of treatment modes for patients with renal cell carcinoma (RCC).