title: Single-center comparison of purely laparoscopic, hand-assisted laparoscopic, and open radical nephrectomy in patients at high anesthetic risk.
abstract: OBJECTIVE
  The laparoscopic approach for management of high-risk patients with renal-cell carcinoma (RCC) may reduce perioperative and postoperative morbidity. The aim of this study was to compare the outcome of purely laparoscopic radical nephrectomy (LRN), hand-assisted laparoscopic radical nephrectomy (HALRN), and open radical nephrectomy (ORN) for renal tumors in a population of patients at high risk for perioperative complications.
  
  
  METHODS
  All patients undergoing radical nephrectomy for presumed RCC between August 1999 and August 2001 at Vanderbilt University Medical Center and having an American Society of Anesthesiologists (ASA) score of >/=3 were reviewed. Patients with known metastasis, local invasion, caval thrombi, or additional simultaneous surgical procedures were excluded from analysis. Thirteen patients underwent LRN, eight patients underwent HALRN, and 26 underwent ORN. The patient demographics were similar in the three groups. The groups were compared with regard to intraoperative and postoperative parameters. Statistical analysis was done using chi-square testing for categorical variables and analysis of variance (ANOVA) for continuous variables. Differences in outcomes were examined using ANOVA and Dunnett's T for pairwise comparisons.
  
  
  RESULTS
  The ASA 4 patients had significantly longer hospital stays and total hospital costs than the ASA 3 patients. The mean operative time in the ASA 3 patients was similar in the three groups: 2.8 hours, 2.8 hours, and 2.5 hours for the LRN, HALRN, and ORN patients, respectively. Both the LRN patients (22.9 mg of morphine sulfate equivalent) and the HALRN patients (42.1 mg) required less pain medication than the open surgery patients (97.7 mg). When the total hospital costs were compared, LRN was less costly than HALRN ($6089 v $7678; P = 0.57) and open surgery ($6089 v $7694; P = 0.04). The complication rate in the LRN, HALRN, and ORN group was 0%, 25%, and 27%, respectively, although the differences were not statistically different (P = 0.12).
  
  
  CONCLUSIONS
  Both LRN and HALRN can be performed safely in patients with significant comorbid conditions. Careful preoperative preparation, intraoperative monitoring, and awareness of laparoscopy-induced oliguria can preclude inadvertent overhydration, hemodilution, and congestive heart failure. Both LRN and HALRN result in less pain medication requirement and faster return to oral intake than ORN, and LRN results in fewer perioperative complications than HALRN or ORN in patients at high perioperative risk. The LRN technique has a 21% lower total cost than both HALRN and ORN.
authors.affiliation: Department of Urologic Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
authors.forename: D Duane
authors.initials: DD
authors.lastname: Baldwin
authors.forename: Jennifer A
authors.initials: JA
authors.lastname: Dunbar
authors.forename: Dipen J
authors.initials: DJ
authors.lastname: Parekh
authors.forename: Nancy
authors.initials: N
authors.lastname: Wells
authors.forename: Matthew D
authors.initials: MD
authors.lastname: Shuford
authors.forename: Michael S
authors.initials: MS
authors.lastname: Cookson
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Smith
authors.forename: S Duke
authors.initials: SD
authors.lastname: Herrell
authors.forename: Sam S
authors.initials: SS
authors.lastname: Chang
authors.forename: Elspeth M
authors.initials: EM
authors.lastname: McDougall
mesh_terms: D000328:Adult; D000368:Aged; D000758:Anesthesia / Q000009:adverse effects*; D016063:Blood Loss, Surgical; D002292:Carcinoma, Renal Cell / Q000191:economics / Q000601:surgery*; D017721:Hospital Costs; D006801:Humans; D007680:Kidney Neoplasms / Q000191:economics / Q000601:surgery*; D010535:Laparoscopy / Q000191:economics; D007902:Length of Stay; D008875:Middle Aged; D009392:Nephrectomy / Q000191:economics / Q000379:methods*; D010149:Postoperative Pain / Q000188:drug therapy; D012189:Retrospective Studies; D012307:Risk Factors; D013714:Tennessee