The best method for doing the procedure appears to be laparoscopic if one considers blood loss and length of hospital stay as documented in earlier albeit smaller series from Walther and colleagues at the NCI1 and Gill and colleagues at the Cleveland Clinic2. In this large series, a laparoscopic cytoreductive nephrectomy was performed in only 22% of patients, although the authors noted that their inclusion criteria would have allowed up to 40% of their patients to have their procedure performed laparoscopically. The inclusion criteria included: mass < 14 cm, no renal vein or caval involvement, and absence of bulky lymphadenopathy. Of note, all specimens were removed intact and half of the procedures were done hand-assist while the other half were done with standard laparoscopy and an incision with intact removal at the end of the procedure; a comparison of these two approaches was not provided in the manuscript. Of note, the blood loss (224 cc) and hospital stay (3.8 days) were less for the laparoscopic patients compared to a cohort of patients who met the inclusion criteria but were done open (625 cc. and 6 days); however, both groups received therapy at the same time (44 days). Overall 97% of patients went on to receive therapy. There were no cases of port site or incision site seeding.

In my mind, if any case would be worthy of morcellation rather than intact removal, it would be among these patients with documented metastatic disease and a lifespan commonly less than a year. In the original report by Walther, morcellation was compared to intact removal; despite the small number of patients, the results with regard to pain medications and hospital stay were statistically significantly less for those patients who underwent morcellation. Indeed, in a recent report from UCSF, among 17 laparoscopic cytoreductive surgeries in which both either intact removal or specimen morcellation was done, the morcellation procedures were associated with a shorter hospital stay (reduced by 2.3 days), fewer blood transfusions, and a shorter time to receiving systemic therapy. 3 In my opinion, it is worth the extra effort, on the part of the surgeon, to improve the quality of life of these individuals in particular, whose lifespan is sure to be all too brief.

Urology 68(3):528-532 September 2006

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