Purpose: Nephron sparing surgery provides effective therapy in patients with a solitary sporadic renal tumor 4 cm. or less and a normal contralateral kidney. Laparoscopic radical nephrectomy has been applied as a newer alternative therapy in these patients. These 2 contemporary approaches represent divergent treatment alternatives at centers where laparoscopic nephron sparing surgery is not offered. We compared the short-term and long-term impact of these 2 treatment modalities in patients with a sporadic localized solitary renal tumor 4 cm. or less and a normal opposite kidney.
Materials and methods: A retrospective review of a contemporary series of patients (1996 to 2001) who underwent open nephron sparing surgery and met study inclusion criteria was performed and compared with a similar cohort (1997 to 2001) that underwent laparoscopic radical nephrectomy. Only patients with a single renal tumor of 4 cm. or less, normal serum creatinine less than 1.5 mg./dl. and a normal contralateral kidney were included in analysis. The 2 groups were compared in regard to demographic, clinical and pathological variables using parametric and nonparametric tests. Linear regression analysis was done to compare the percent change in serum creatinine, while adjusting for demographic and clinical variables, and followup.
Results: A total of 35 patients who underwent laparoscopic radical nephrectomy and 82 who underwent open nephron sparing surgery met study inclusion criteria. Mean patient age in the laparoscopic group was significantly greater (67.3 versus 56.2 years, p <0.001), mean American Society of Anesthesiologists class score was higher (p = 0.04) and mean tumor size was greater (3.1 versus 2.6 cm., p = 0.003) than in the nephron sparing group. The laparoscopic group had significantly decreased mean blood loss (100 versus 200 ml., p <0.001), hospital stay (1 versus 5 days, p <0.001), narcotic use (16.5 versus 224 mg., p <0.001) and operative time (184.4 versus 216.2 minutes, p <0.007) compared with the nephron sparing group. Patients who underwent nephron sparing surgery experienced less postoperative deterioration in renal function, as measured by the percent increase in serum creatinine postoperatively (0% versus 25%, p <0.001). The results of regression analyses at 4 and 6 months of followup indicated that open nephron sparing surgery is associated with significantly lower serum creatinine than laparoscopic radical nephrectomy after adjusting for demographic and clinical variables, and followup.
Conclusions: Open nephron sparing surgery and laparoscopic radical nephrectomy are relatively recent and significant developments for treating patients with renal cell carcinoma and they represent accepted standards of care in those with a small renal mass and normal contralateral kidney. In patients presenting with a sporadic solitary renal tumor of 4 cm. or less and a normal contralateral kidney the significant short-term and intermediate term benefits of the laparoscopic approach must be weighed against the long-term advantage of better renal function associated with open nephron sparing surgery. The distinct advantages of these 2 approaches may ultimately be realized with the standardization of laparoscopic partial nephrectomy.