Dr. Canda started by highlighting that these patients are older with many comorbidities and are often obese. These challenges make it difficult to perform a partial nephrectomy, whether the approach is open, laparoscopic or robotic. Furthermore, these patients may have difficult, large masses that are either close to the collecting system or close to the main renal vessels. Surgeons performing these procedures need a great deal of experience with partial nephrectomy, and often warm ischemia time is expected to be long if a partial nephrectomy is performed. Particularly if a partial nephrectomy is performed laparoscopically or robotically, this may be difficult to create cold ischemia with ice application. In Dr. Canda’s opinion, the risk of complications is high if partial nephrectomy is performed and he favors minimally invasive nephrectomy, particularly for cT2 tumors.
Dr. Canda notes that there are severally minimally invasive nephrectomy options available, including laparoscopic, hand-assisted laparoscopic, and robotic. Many studies have reported that similar oncologic outcomes can be achieved whether the approach is laparoscopic versus open, including those with higher stage and locally advanced tumors. Laparoscopy has the advantage of having (i) less morbidity, (ii) shorter duration of hospital stay, (iii) shorter convalescence time, (iv) lower analgesic requirement, and (v) less perioperative blood loss.
Generally, laparoscopy (compared to open) for T2 or higher stage tumors has similar (i) blood transfusion rates, (ii) complication rates, and (iii) similar quality of life scores. This becomes particularly important for T2 or higher stage tumors where laparoscopy (compared to open surgery) has (i) lower estimated blood loss, (ii) less postoperative pain, (iii) shorter duration of hospital stay, and (iv) faster convalescence. These patients also have similar intraoperative and postoperative complication rates, as well as similar cancer-specific survival, progression-free survival, and overall survival.
Whether the minimally invasive nephrectomy is performed transperitoneal or retroperitoneal is also inconsequential as both techniques result in similar oncologic and quality of life outcomes. Similarly, there is no difference in 5-year overall survival, cancer specific survival or recurrence free survival when comparing hand-assisted versus laparoscopic nephrectomy. Surgery is quicker with hand-assisted laparoscopy versus conventional laparoscopic, however length of stay and time to normal activity is longer for hand-assisted laparoscopy. Finally, robotic and conventional laparoscopic nephrectomy also have comparable oncologic outcomes, including cancer specific mortality.
Presented by: Abdullah E. Canda, MD, Professor, Ankara Ataturk Training and Research Hospital, Istanbul, Turkey
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