CUA 2018: Comparing Laparoscopic Cytoreductive Nephrectomy to Open Surgery: A Large, Multicentre, Retrospective Analysis

Halifax, Nova Scotia ( Laparoscopic surgery is known to minimize perioperative morbidity and decrease the length of hospital admission, however, its benefit in cytoreductive nephrectomy continues to be a topic of debate. A previously published multi-center experience of laparoscopic cytoreductive nephrectomy found that among 120 patients, median operative time was 210 min, and median estimated blood loss was 150 cc1. Four (3.3 %) patients were converted to open surgery due to locally advanced disease and/or bleeding, and postoperative complications occurred in 23.3% of patients, of which 71.4 % were classified as minor (Clavien-Dindo I-II). To further assess the safety and feasibility of laparoscopic cytoreductive nephrectomy, Samir Ksara, MD and colleagues performed a large, multicenter, retrospective analysis comparing laparoscopic radical cytoreductive nephrectomy to open cytoreductive radical nephrectomy. The objective of this study was to assess whether laparoscopic cytoreductive nephrectomy minimizes the delay to systemic therapy and offers an overall survival benefit when compared to open cytoreductive nephrectomy.

For this study, data was collected from The Canadian Kidney Cancer Information System, a prospectively maintained database from 14 Canadian centers. Patients who underwent cytoreductive nephrectomy from January 1, 2011 to June 1, 2016 were included (n=224). Cox proportional hazard modeling was used to adjust for age, gender, pathological stage, size of the largest tumor, grade, and whether the patient received neoadjuvant systemic therapy.

Among the 224 patients meeting inclusion criteria, 93 patients underwent laparoscopic surgery (41.5%), and 131 patients underwent open surgery. The 1-year survival estimate was 85.5% for the open group and 83.3% for the laparoscopic group, with no statistically significant difference in survival, noted for those who underwent laparoscopic or open cytoreductive nephrectomy (HR 0.69; p=0.13). Furthermore, there was no significant difference noted in time to delivery of systemic therapy between the two groups (p=0.20), however, there was a splitting of the Kaplan-Meier curves at six months after surgery, favoring the laparoscopic group. 

The strength of this study is that it represents a real-world utilization of laparoscopic and open cytoreductive nephrectomy experience in Canada. However, the study is limited by lack of information regarding baseline characteristics, although the authors adjusted for several variables in their model. Furthermore, with the recent results of the phase III CARMENA clinical trial suggesting that not all patients may benefit from a cytoreductive nephrectomy2, the clinical utility of these results remains to be completely elucidated. Ksara concluded that in the context of this analysis, laparoscopic cytoreductive nephrectomy does not lead to earlier delivery of systemic therapy and shows no benefit in overall survival when compared to open cytoreductive nephrectomy.

1. Bragayrac L, Hoffmeyer J, Abbotoy D, et al. Minimally invasive cytoreductive nephrectomy: A multi-institutional experience. World J Urol 2016;34(12):1651-1656.
2. Mejean A, Ravaud A, Thezenas S, et al. Sunitinib alone or after nephrectomy in metastatic renal cell carcinoma. N Engl J Med 2018 Jun 3 [Epub ahead of print].

Presented by: Samir Ksara, MD, University of Manitoba, Winnipeg, Manitoba, Canada
Co-Authors: Premal Patel1, Darrel Drachenberg1, Antonio Finelli2, Ricardo Rendon3, Simon Tanguay4, Anil Kapoor5, Jun Kawakami6, Ronald Moore7, Alan So8, Luke Lavallee9, Jean-Baptiste Lattouf10, Frédéric Pouliot11, Amy Liu12, Olli Saarela12.
Author Information:
1. Department of Urology, University of Manitoba, Winnipeg, MB, Canada
2. Division of Urology, Department of Surgical Oncology, University of Toronto, Toronto, ON, Canada
3. Department of Urology, Dalhousie University, Halifax, NS, Canada
4. Division of Urologic Oncology, Department of Surgery, McGill University , Montreal, QC, Canada
5. Department of Urology, McMaster University, Hamilton, ON, Canada; 6Division of Urology, University of Calgary , Calgary, AB, Canada
7. Division of Urology, University of Alberta, Edmonton, AB, Canada; 8Department of Urology, University of British Columbia, Vancouver, BC, Canada
9, Division of Urology, University of Ottawa, Ottawa, ON, Canada; 10Department of Urology, University of Montreal Health Centre, Montreal, QC, Canada; 11Division of Urology, Université Laval, Quebec, QC, Canada; 12Cancer Care Ontario, University of Toronto, Toronto, ON, Canada

Written By: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre Twitter: @zklaassen_md at the 73rd Canadian Urological Association Annual Meeting - June 23 - 26, 2018 - Halifax, Nova Scotia