Lap partial nephrectomy results improve with experience

Amsterdam, Netherlands-Researchers performing removal of challenging renal tumors using laparoscopic partial nephrectomy (LPN) in 300 consecutive cases have found that, compared with the first 100 cases, blood loss and overall complications decreased despite increased complexity of treating surgically difficult small renal tumors.

The surgeon performed LPN for hilar tumor or tumor in a solitary kidney in increasing increments: in 10% of patients in group I, 9% in group II, and 15% in group III. Comparing group I and group III patients, researchers noted a progressive increase in use of the transperitoneal approach (p=.001), incidence of heminephrectomy (p<.001), and pelvicaliceal repair (p<.001), which resulted in longer warm ischemia time (p<.001), operative time (p<.001), and hospital stay (p<.001).

Learning curve apparent

"LPN is an advanced procedure in which considerable expertise is necessary. Our experience now includes 450 patients," Massimiliano Spaliviero, MD, a fellow in advanced laparoscopic urology under the direction of Dr. Gill at the Cleveland Clinic's Glickman Urological Institute, reported at the World Congress on Endourology here. "Our LPN technique at this point duplicates open surgical principles. Biologic hemostatic agents have become an essential adjunct to our technique."

Session moderator Mahesh Desai, MD, MS, chairman, department of urology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India, noted that the study results highlighted the late complications from group II instead of those from the earliest group of patients (group I), as one would expect form the learning curve.

"We began expanding our indications in group II to include deeper tumors and those closer to the hilum," Dr. Spaliviero explained. "In group III, although we included even more complicated tumor cases, with the adjunctive use of Floseal [Baxter US, Deerfield, IL], a biologic hemostatic agent, and mastering of the technique, we were able to minimize complications."

Some urologic surgeons attending Dr. Spaliviero's presentation showed concern about potential recurrences after using this technique and expressed hope for tangible evidence linking particular cases with tumor recurrence.

"At this point, we have seen only one recurrence in 450 cases. The patient, with initial negative margins and uncomplicated recovery, presented at 1 year with a hilar mass, which was definitely a recurrence," Dr. Spaliviero said. "Overall, we noted a definite association between the warm ischemia time and the complexity of the tumor."

He maintained that laparoscopic partial nephrectomy, although a technically challenging procedure with a steep learning curve and potential for complications, was achieving increasing clinical relevance in the management of select renal tumors. With increasing experience, more challenging tumors can be approached with this procedure, he said.