title: Perioperative efficacy of laparoscopic partial nephrectomy for tumors larger than 4 cm.
abstract: BACKGROUND
  Laparoscopic partial nephrectomy (LPN) is typically reserved for kidney tumors < or = 4 cm in size. The use of LPN in patients with larger tumors (> 4 cm) has not been systematically evaluated.
  
  
  OBJECTIVE
  To examine technical feasibility and perioperative safety and efficacy of LPN for clinical stage pT1b-T2 tumors > 4 cm.
  
  
  METHODS
  This is a retrospective review of data from an Institutional Review Board-approved, prospectively maintained database of 425 LPN procedures over a 6-yr period (September 1999 through December 2005). Patients were grouped according to tumor size: control group 1: < 2 cm (n=89; 21% of patients); control group 2: 2-4 cm (n=278; 65% of patients); and study group 3: > 4 cm (n=58; 14% of patients).
  
  
  METHODS
  Retroperitoneal and transperitoneal LPN.
  
  
  METHODS
  Serum creatinine levels, estimated glomerular filtration rates.
  
  
  CONCLUSIONS
  For groups 1, 2, and 3, mean tumor size was 1.5 cm, 2.9 cm, and 6 cm in diameter, respectively (p<0.001). Study group 3 patients more often had an American Society of Anesthesiologists score > or = 3 (p<0.05), central tumors (p<0.001), pelvicalyceal repair (p=0.004), and heminephrectomy (p<0.001). Total operative time, estimated blood loss, and duration of hospital stay were equivalent. Mean warm ischemia time was 30 min, 32 min, and 38 min in groups 1, 2, and 3, respectively (p=0.007). Tumor size > 4 cm did not increase significant risk for positive tumor margins, intraoperative complications, or postoperative genitourinary complications. In each group preoperative stage > or = 3 chronic kidney disease (CKD) was present in 31%, 35%, and 44% of patients in groups 1, 2, and 3, respectively (p=0.15); postoperatively, stage 3-5 CKD incidence increased to 52%, 52%, and 63% in groups 1, 2, and 3, respectively (p=0.20). Patients with tumor size > 4 cm and preoperative stage 3-5 CKD had an 8-fold increase in risk for CKD stage progression. Limitations of the study include retrospective analysis and a relatively low number of patients in group 3.
  
  
  CONCLUSIONS
  Given laparoscopic expertise and appropriate patient selection, LPN is feasible and efficacious for kidney tumors > 4 cm. Indications for LPN should be expanded to include patients with amenable tumors > 4 cm in order to maximally preserve kidney function in these patients.
authors.affiliation: Center for Laparoscopic & Robotic Surgery, Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Matthew N
authors.initials: MN
authors.lastname: Simmons
authors.forename: Benjamin I
authors.initials: BI
authors.lastname: Chung
authors.forename: Inderbir S
authors.initials: IS
authors.lastname: Gill
mesh_terms: D005240:Feasibility Studies; D006801:Humans; D007680:Kidney Neoplasms / Q000473:pathology* / Q000601:surgery*; D010535:Laparoscopy; D008875:Middle Aged; D009392:Nephrectomy / Q000379:methods*; D012189:Retrospective Studies; D016896:Treatment Outcome