Complications and failure to rescue after laparoscopic versus open radical nephrectomy

Abstract

Purpose: Since to our knowledge the population level impact of laparoscopy on post-radical nephrectomy morbidity and mortality remains unknown, we compared the rates of postoperative complications and failure to rescue (the fatality rate in patients with a complication) in patients treated with laparoscopic vs open radical nephrectomy.

Materials and methods: Using linked SEER (Surveillance, Epidemiology and End Results)-Medicare data we identified patients with kidney cancer who were treated with laparoscopic or open radical nephrectomy from 2000 through 2005. After measuring the frequency of postoperative complications and failure to rescue we fit multivariate logistic regression models to estimate the association of these outcomes with surgical approach, adjusting for patient characteristics, cancer severity and surgery year. We also assessed the relationship between case volume, complications and failure to rescue.

Results: We identified 2,108 (26%) and 5,895 patients (74%) treated with laparoscopic and open radical nephrectomy, respectively. The overall rates of complications and failure to rescue were 36.9% and 5.3%, respectively. The predicted probability of any, major, medical and surgical complications was 15%, 12%, 13% and 23% lower, respectively, after laparoscopic than after open radical nephrectomy (each p <0.05). Despite less frequent complications patients treated with laparoscopic radical nephrectomy had a greater probability of failure to rescue (7.6% vs 4.6%, p = 0.010). Higher volume surgeons and hospitals had a lower rate of failure to rescue in patients treated with radical nephrectomy (each p <0.05) but not with open radical nephrectomy.

Conclusions: Supporting the decreased morbidity of laparoscopy, patients treated with radical nephrectomy had fewer complications than those who underwent open radical nephrectomy. However, failure to rescue was more common in patients with a complication after radical nephrectomy, suggesting that these events may be more difficult to recognize and manage successfully, especially among less experienced surgeons and hospitals.