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Laparoscopic Radical Nephrectomy for T3 and Metastatic Renal Cell Carcinoma
Ignacio F. San Francisco, M.D. 1, Mehrdad Alemozaffar, M.D.2, Oseas Neves, M.D. 2, Jodi Mechaber, NP2, Andrew A. Wagner, M.D. 2
1Pontificia Universidad Católica de Chile and Beth Israel Deaconess Medical Center, Santiago, Chile, 2Beth Israel Deaconess Medical Center, Boston, MA

BACKGROUND: Laparoscopic radical nephrectomy (LRN) has become the standard surgical option for patients with T1 or T2 stage renal cell carcinoma (RCC) not amendable to nephron-sparing surgery. Evidence of renal vein thrombus or metastatic disease have traditionally been contraindications for a laparoscopic approach. We hypothesized that, in experienced hands, LRN can be performed safely for advanced cases of RCC.
METHODS: Between August 2006 and April 2010 a total of 89 consecutive LRN were performed at a tertiary center by one surgeon (A.W.). Of these, 83 had a preoperative diagnosis of RCC or suspicious for RCC based on imaging studies and/or renal biopsies. Complete clinical and pathological data were obtained from our prospectively maintained kidney surgery database. We compared two contemporary groups. Group 1 (N= 35) corresponded to patients with T3a disease, involving the renal vein (T3b), and/or metastatic RCC who underwent cytoredutive laparoscopic radical nephrectomy, and Group 2 (N= 48) corresponded to patients with T1-T2 tumors or final pathology of benign tumor. The assessed variables included: operative time, ASA score, estimated blood loss, intraoperative and postoperative complications, conversion rate to open surgery, length of hospital stay and surgery related mortality.
RESULTS: Of the 83 patients with a clinical diagnosis of RCC, the final pathology showed 75 RCCs, 4 oncocytomas, one AML, 2 benign tumors and one inflammatory tumor. The median age of the 83 patients was 62 years, their tumor size was 6.0 cm, their surgical time was 180 minutes, their estimated blood loss was 50cc, and their hospital stay was 2 days. The rates of intraoperative and postoperative complications were 5% and 14%, respectively, and the conversion rate to open surgery was 1.2%. Eleven patients had renal vein thrombus (T3b), eighteen patients were T3a and 22 patients had cytoreductive laparoscopic nephrectomy for metastatic RCC. Group 1 had a significant longer OT (196 min. vs. 167 min., p=0.0006) and higher ASA score (p=0.0004) than group 2. However, intraoperative complications, postoperative complications, LOS, EBL, transfusion, and conversion rates were the same for groups 1 and 2. There were no perioperative deaths.
CONCLUSIONS: LRN is a safe option for larger kidney tumors, those with renal vein involvement and those requiring debulking for M1 disease, at a tertiary center. Surgical time is longer for these advanced cases suggesting higher technical difficulty; however, there was no increase in complication rate.


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