AUA 2018: Mini-Subcostal Incision for Open Radical Nephrectomy in the Minimally Invasive Era

San Francisco, CA ( As robotic partial nephrectomy continues to gain traction, there is increasing utilization of minimally invasive approaches to radical nephrectomy. While most institutions are comfortable with pure laparoscopic radical nephrectomy, some institutions have even begun to move to robotic radical nephrectomy. However, health care costs become a major obstacle to these novel techniques – is it cost effective to do a robotic nephrectomy when a laparoscopic nephrectomy has similar outcomes?

More recently, there has been renewed interest towards a mini-incision subcostal radical nephrectomy. In particular, with increasing MIS approaches in Urology, there is concern than open surgical skills are lacking. Open surgical skills are essential for the urologist in-training and in practice. In this abstract, the authors report their peri- and post-operative outcomes after a standardized mini-subcostal incision technique for open radical nephrectomy (RN) – in the hopes that with similar outcomes, it may be a bridge for surgical training in the future!

It should be noted that the senior author of the abstract, Dr. Russo, is a strong advocate against robotic surgery, and has made this well known.

This was a retrospective analysis of a prospectively maintained database of patients undergoing transperitoneal open RN utilizing a mini-subcostal incision (8-12cm) and standardized post-operative recovery pathway between January 2013 - May 2016. The standardized post-operative recovery pathway was listed on the poster and encompassed 2 post-operative days – expected discharge was POD #2.

A total of 196 patients with a median follow-up of 11 months (range 1-40) were available for analysis – as the focus was immediate peri-operative outcomes, this was sufficient follow-up. 

The median age of patients was 59.4 years. Median tumor size was 7.7 cm (IQR=5-9.6) and 132 (67%) of patients were pT3 or greater. Hence, these are not small renal masses; in general, they were more advanced malignancies.

In terms of intra-operative measures, median EBL was 300 ml (IQR=100-575) and median duration of surgery was 129 min (IQR=102-151). Intraoperatively, 28 patients (14%) had at least one blood transfusion and 1 patient had an enterotomy. In terms of post-operative measures, median LOS was 1.5 days (range 1-18 days). 

Postoperative complications were assessed - the early (<-= 30 days) complication rate for minor (Clavien I-II) and major (Clavien III-V) complications was 19.5% and 3%, respectively. The minor late (>30 days) complication rate was 2%. No patients experienced late major complications or surgically-related deaths in our cohort.

  • They provided a chart of the main complications.
  • Clavien III complications (early) were wound infection, pancreatic fistula, bowel perforation, renal failure, and intra-abdominal infection
  • Clavien III late complication was pleural effusion
While no direct comparison was made to MIS approaches, even though the institution does have other surgeons who utilize an MIS approach, the authors state that mini-incision nephrectomy fares favorably. They conclude that this approach is a cost effective (though with slightly longer hospital stays, that may not be the case?) and safe alternative to minimally invasive approaches and allows surgeons and trainees to retain and expand their essential open surgical skills.

I would argue that laparoscopic radical nephrectomy, if feasible, is probably the most cost and time-effective management of these tumors – if technically feasible. However, head-to-hear comparisons are needed to flesh this out.

Presented by: Kyle A. Blum, New York City, NY
Co-Authors: Maria F. Becerra, Alejandro Sanchez, Mazyar Ghanaat, Renzo G. DiNatale, Mahyar Kashan, Shawn Mendonca, Brandon J. Manley, Nicole Benfante, A. Ari Hakimi, Paul Russo

Written by: Thenappan Chandrasekar, MD, Clinical Fellow, University of Toronto, @tchandra_uromd at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA