Open versus lap nephrectomy: Similar long-term outcomes

Cleveland-Which approach to radical nephrectomy produces the most durable outcomes in survival and restored renal function: laparoscopy or open surgery?

Actually, neither approach holds a clear advantage, according to a long-term retrospective review of patient records presented here at the 2006 World Congress of Endourology by urologists at the Cleveland Clinic. They suggest that the choice of procedure is better predicated on what is most appropriate to the patient and the tumor stage, rather than the superiority of either surgical approach.

Researchers led by senior author Inderbir S. Gill, MD, examined the medical records of 116 patients diagnosed with localized renal cell carcinoma and who underwent radical nephrectomy from January 1997 through January 1999. In addition, they gleaned data on long-term results from patient charts, radiographic images, and telephone contact with patients and their families.

Long-term survival parameters included 5-year overall survival, cancer-specific survival, and recurrence-free survival. Renal function outcomes also were scrutinized for the two groups.

Survival data were evaluated according to clinical stage. No difference was seen between the two groups in patients with clinical T1 and T2 tumors. At median follow-up of 65 months for the LRN group (range, 19-92 months) and 76 months for the ORN cohort (range, 8-105 months), no significant differences in outcomes were observed between the two cohorts. With respect to the long-term benchmarks, 5-year survival rates were 78% and 84% for the laparoscopic and open groups, respectively (p=.24); and the rates of both cancer-specific survival and recurrence-free survival were identical between the two groups: 91% and 93%, respectively (p=.75).

Little had changed in outcomes for either cohort at 7 years.

"Cancer-specific survival for clinical T1 tumors in both the LRN and the ORN groups was similar, at 96%," said study co-author J. Roberto Colombo, MD, a research fellow at the Cleveland Clinic's Glickman Urological Institute. "There were no significant differences in overall or cancer-specific survival in patients with clinical T1 and T2 tumors. While cancer-specific survival for patients with clinical T2 tumors after 7 years was 85% in ORN and 61% in LRN, the difference was not statistically significant."

At 7 years follow-up, survival in the LRN group decreased slightly to 72%, but all other outcomes for both groups were identical to those at the 5-year mark. One patient in the LRN group had a local recurrence and four experienced systemic metastases; no ORN patients had local recurrence, but three patients experienced systemic metastases.

Mean time to development of metastatic disease in the LRN group was 19 months compared with 14.5 months in the ORN group (p=.52). Four patients in the LRN group (8%) and three patients in the ORN group (7%) died from kidney cancer; eight patients in the LRN cohort and four in the ORN cohort died from other causes.

Renal function outcomes measured from baseline echoed the trend of the survival outcomes: Serum creatinine levels rose by 33% and 25%, and estimated creatinine clearance fell by 31% and 23% for the LRN and ORN patients, respectively. Four patients in each group developed chronic renal insufficiency, but none died as a result of it.

Although laparoscopic techniques have been refined significantly since 1999, study co-author Brian R. Lane, MD, PhD, said he did not believe a similar study conducted today would yield different outcomes, with one exception.