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postoperative hemorrhage or urine leak rate. Possibly due to these decreased hemorrhage and urine leak rates our overall incidence of postoperative complications also significantly decreased from the earlier 22.1% to 8.5% in the most recent era (p ⬍0.0001). Our current cancer positive margin rate is low at 0.6%. Finally, despite increasing tumor complexity conversion to LRN occurred in only 1.7% of cases. Our study has shortcomings. This single surgeon experience reflects a tertiary referral practice and, thus, our trend toward more complex LPN cases may not necessarily reflect the LPN field at large. Technically easier cases may be managed by local urologists closer to the patient’s home or by other laparoscopic surgeons at this institution. Also, our study exclusively focuses on evolving LPN trends and outcomes. We did not evaluate trends of open partial nephrectomy or other minimally invasive, nephron sparing alternatives. Patients were divided into 3 eras retrospectively with the intent to group patients who underwent early unclamping LPN in era 3. A limitation of the presented renal function outcomes is the lack of differential data on the operated and the nonoperated kidney. Indeed, such differential data would more accurately reflect the functional status of the operated kidney but this is
also a limitation of prior publications.1,5,13 Our followup duration in the entire cohort is short at a median of 3.4 years (range 0.1 to 9) but the intermediate term overall and cancer specific survival data reported appear to be in line with those in the open partial nephrectomy literature. Finally, although all data were collected prospectively, analysis was retrospective.
CONCLUSIONS Our 9-year single surgeon experience with 800 consecutive patients who underwent LPN for tumor indicates that we are increasingly performing LPN for more complex tumors that may be central, hilar, pT1b or located in a solitary kidney. Despite this our LPN outcomes improved, resulting in significantly decreased ischemia time, lower complication rates, superior renal function outcomes and excellent negative margin rates. Nevertheless, LPN remains an advanced procedure requiring complete comfort in the minimally invasive environment.
ACKNOWLEDGMENTS Respectfully dedicated to the memory of Dr. Andrew C. Novick (1958 to 2008).
REFERENCES 1. Huang WC, Levey AS, Serio AM et al: Chronic kidney disease after nephrectomy in patients with renal cortical tumours: a retrospective cohort study. Lancet Oncol 2006; 7: 735. 2. Pahernik S, Roos F, Rohrig B et al: Elective nephron sparing surgery for renal cell carcinoma larger than 4 cm. J Urol 2008; 179: 71. 3. Leibovich BC, Blute ML, Cheville JC et al: Nephron sparing surgery for appropriately selected renal cell carcinoma between 4 and 7 cm results in outcome similar to radical nephrectomy. J Urol 2004; 171: 1066. 4. Permpongkosol S, Bagga HS, Romero FR et al: Laparoscopic versus open partial nephrectomy for the treatment of pathological T1N0M0 renal cell carcinoma: a 5-year survival rate. J Urol 2006; 176: 1984. 5. Gill IS, Kavoussi LR, Lane BR et al: Comparison of 1,800 laparoscopic and open partial nephrectomies for single renal tumors. J Urol 2007; 178: 41.
6. Haber G and Gill IS: Laparoscopic partial nephrectomy: contemporary technique and outcomes. Eur Urol 2006; 49: 660. 7. Baumert H, Ballaro A, Shah N et al: Reducing warm ischemia time during laparoscopic partial nephrectomy: a prospective comparison of 2 renal closure techniques. Eur Urol 2007; 52: 1164. 8. Bollens R, Rosenblatt A, Espinoza BP et al: Laparoscopic partial nephrectomy with “on-demand” clamping reduces warm ischemia time. Eur Urol 2007; 52: 804. 9. Nguyen MM and Gill IS: Halving ischemia time during laparoscopic partial nephrectomy. J Urol 2008; 179: 627. 10. Common terminology criteria for adverse events v3.0 (CTCAE). In: Cancer Therapy Evaluation Program. Bethesda: National Cancer Institute 2006. 11. Levey AS, Coresh J, Balk E et al: National Kidney Foundation practice guidelines for chronic kidney
disease: evaluation, classification, and stratification. Ann Intern Med 2003; 139: 137. 12. Kamoi K, Aron M, Haber GP et al: Contemporary outcomes of open versus laparoscopic partial nephrectomy: impact of ‘early unclamping’ technique. Unpublished data. 13. Thompson RH, Frank I, Lohse CM et al: The impact of ischemia time during open nephron sparing surgery on solitary kidneys: a multiinstitutional study. J Urol 2007; 177: 471. 14. Uzzo RG and Novick AC: Nephron-sparing surgery for renal tumors: indications, techniques, and outcomes. J Urol 2001; 166: 6. 15. Ramani AP, Desai MM, Steinberg AP et al: Complications of laparoscopic partial nephrectomy in 200 cases. J Urol 2005; 173: 42. 16. Gill IS, Ramani AP, Spaliviero M et al: Improved hemostasis during laparoscopic partial nephrectomy using gelatin matrix thrombin sealant. Urology 2005; 65: 463.
EDITORIAL COMMENT An important trend in kidney cancer is the increasing number of incidentally discovered, small renal tumors. This epidemiological trend has enabled 2 corresponding trends in the surgical management of kidney cancer, namely increased nephron sparing
and minimally invasive surgical techniques. Since the oncological outcomes of open partial nephrectomy and LRN in properly selected patients appear to be equivalent to those achieved by open radical nephrectomy, management of localized RCC has
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more recently also focused on outcomes other than oncological ones. Perioperative and renal function outcomes are now given greater attention to optimize treatment for localized RCC with the goal of providing better quality of life and functional outcomes while preserving the oncological success associated with more radical and invasive techniques. Initial enthusiasm for LRN was mainly related to its shorter hospital stay and decreased narcotic requirements after surgery. However, even if LRN shows these advantages compared to open radical nephrectomy for many perioperative outcomes, there remain additional reasons to consider partial nephrectomy rather than LRN. Accumulating evidence from population based analyses shows that impaired renal function has effects on important health outcomes, including increased hospitalization, cardiovascular events and all cause mortality rates. Evidence such as this heightens interest in techniques that can maximally preserve renal function. Initially restricted to imperative cases such as solitary kidney or preexisting renal insufficiency, encouraging results in those cases prompted many groups to use open partial nephrectomy electively and open partial nephrectomy has now become a reference standard for the treatment of smaller renal masses in the setting of a normal contralateral kidney. On the other hand, LPN is a more technically demanding, challenging surgery than LRN, requiring advanced laparoscopic techniques such as suturing, with fewer tumors considered safely managed this way, with historically higher complication rates and with fewer surgeons having the training to treat
these cases. Thus, for many urologists and patients increasingly a decision had to be made between open partial nephrectomy and LRN when tumors were anything but small, superficially located cortical masses with a trade-off required between the goals of nephron sparing and a minimally invasive incision. In this milestone study the authors report outstanding functional and oncological results in 800 consecutive LPNs in a 9-year period. As their skills and confidence increased with time, they performed LPN for increasingly challenging tumors that were more frequently larger, and central and/or hilar in location. Despite this increase in the technical challenges of these cases the 4 key outcomes of ischemia time, surgical complications, renal function preservation and cancer specific survival were excellent and improved with time, showing that in properly trained, experienced surgical hands outstanding outcomes can be achieved without requiring this trade-off. These remarkably good results should serve as a reference standard and further highlight the importance of continuing to improve laparoscopic instrumentation and training, which are necessary for the broad dissemination of the expertise required to make LPN widely available beyond tertiary referral centers in the future. Allan J. Pantuck Institute of Urologic Oncology David Geffen School of Medicine University of California-Los Angeles Los Angeles, California