title: Role of the laparoscopic approach to cytoreductive nephrectomy in metastatic renal-cell carcinoma: does size matter?
abstract: OBJECTIVE
  Retrospective studies have shown laparoscopic cytoreductive nephrectomy (LCN) to be a safe procedure in selected patients. The objective of this article is to identify characteristics that may predict when a laparoscopic procedure may offer improved postoperative outcome and whether it affects the timing of postoperative systemic therapy compared with open surgery.
  
  
  METHODS
  A cohort of 43 LCN cases were matched with 43 open cytoreductive nephrectomy (OCN) cases based on both pathologic size of tumor and stage. Eleven cases were laparoscopic converted to open nephrectomy. Cases excluded from the analysis were adjacent organ involvement, inferior vena cava involvement, and bulky lymphadenopathy. Data analysis of 11 variables was performed using the t test, log-rank, and Wilcoxon tests. Significance was at P = 0.05. Survival data were calculated using the Kaplan-Meier estimate.
  
  
  RESULTS
  Significant differences between LCN vs OCN were estimated blood loss (mean 277 ml vs 816 ml) and length of hospitalization (3.2 days vs 5.1 days). The median size of tumor for LCN cases was 7.5 cm and for OCN, 9.5 cm. The mean size of tumor of LCN vs laparoscopic converted to open cases was 6.8 cm vs 11.2 cm, and this difference was significant. There was no significant difference in postoperative performance status, time to commencement of systemic treatment, or in survival time between both groups. This study provides further evidence that a laparoscopic approach with cytoreductive nephrectomy in metastatic renal-cell carcinoma is a safe option for tumors 10 cm and smaller. The approach (laparoscopic vs open) had no effect on postoperative complications or time to systemic therapy.
  
  
  CONCLUSIONS
  Procedures with tumors larger than 10 cm were more likely to be converted to an open procedure. Tumors larger than 10 cm may be best approached via an open procedure, especially in the presence of involvement of adjacent organs or bulky lymphadenopathy.
authors.affiliation: Department of Urology, Indiana University School of Medicine, Indianapolis, Indiana, USA. aganesha@iupui.edu
authors.forename: Anjana
authors.initials: A
authors.lastname: Ganeshappa
authors.forename: Chandru
authors.initials: C
authors.lastname: Sundaram
authors.forename: Michelle A
authors.initials: MA
authors.lastname: Lerner
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Gardner
mesh_terms: D002292:Carcinoma, Renal Cell / Q000473:pathology* / Q000601:surgery*; D006801:Humans; D053208:Kaplan-Meier Estimate; D007680:Kidney Neoplasms / Q000473:pathology* / Q000601:surgery*; D010535:Laparoscopy / Q000379:methods*; D009362:Neoplasm Metastasis; D009367:Neoplasm Staging; D009392:Nephrectomy / Q000379:methods*