title: The operative safety and oncological outcomes of laparoscopic nephrectomy for T3 renal cell cancer.
abstract: What's known on the subject? and What does the study add? Laparoscopic radical nephrectomy is a well established treatment for localized RCC, where nephron-sparing approaches are not appropriate. As surgeon and departmental experience grow more extensive tumours will be tackled laparoscopically. However, little is known about the operative safety and oncological outcomes of the laparoscopic approach for locally advanced RCC. The present study describes the largest reported cohort of patients receiving laparoscopic radical nephrectomy for locally advanced RCC. In the context of suitably experienced personnel in an established centre, we have established that this approach is safe from operative, postoperative and oncological standpoints, with comparable data to existing open series.
  
  
  OBJECTIVE
  To determine the operative, postoperative and oncological outcomes of laparoscopic radical nephrectomy (LRN) for locally advanced renal cell cancer (RCC), which, as surgeon and departmental experience increases, is being performed more often.
  
  
  METHODS
  In total, 94 consecutive patients receiving LRN for pathologically confirmed T3 or T4 RCC at a tertiary referral centre between March 2002 and May 2010 were analyzed. Preoperative, operative, tumour and postoperative characteristics were evaluated together with recurrence and outcome data. Survival was estimated using the Kaplan-Meier method. Cox's proportional hazards model was used for multivariate analysis.
  
  
  RESULTS
  In total, 77 patients had LRN with curative intent and 17 patients had LRN with cytoreductive intent. There were six LRNs (6.4%) that were converted to open procedures. Overall, there were two (2.1%) Clavien grade IIIa complications, one (1.1%) grade IVa complication and one (1.1%) postoperative death. Overall median follow-up was 17.4 months. In total, 22 (28.6%) patients receiving curative LRN developed a recurrence after a median of 13.9 months; 12 (54.5%) patients developed distant metastases, five (22.7%) patients had local recurrences and three (13.6%) patients had transcoelomic spread. Median predicted progression free survival was 48.4 months in patients undergoing LRN with curative intent. Median predicted overall survival was 65.6 months after curative LRN and 15.7 months after cytoreductive LRN. Multivariate analysis did not reveal any variables influencing recurrence or survival.
  
  
  CONCLUSIONS
  In the context of suitably experienced personnel in an established centre, LRN for locally advanced RCC is safe from an operative and oncological standpoint. Patients clinically staged as T3 RCC must still be selected carefully for LRN in a multidisciplinary setting.
authors.affiliation: Edinburgh Urological Cancer Group, University of Edinburgh, Western General Hospital, Edinburgh, UK. grant.stewart@ed.ac.uk
authors.forename: Grant D
authors.initials: GD
authors.lastname: Stewart
authors.forename: W Jensen
authors.initials: WJ
authors.lastname: Ang
authors.forename: Alexander
authors.initials: A
authors.lastname: Laird
authors.forename: David A
authors.initials: DA
authors.lastname: Tolley
authors.forename: Antony C P
authors.initials: AC
authors.lastname: Riddick
authors.forename: S Alan
authors.initials: SA
authors.lastname: McNeill
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002292:Carcinoma, Renal Cell / Q000473:pathology* / Q000601:surgery*; D005260:Female; D006801:Humans; D007680:Kidney Neoplasms / Q000473:pathology* / Q000601:surgery*; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D009392:Nephrectomy / Q000009:adverse effects / Q000379:methods*; D012189:Retrospective Studies; D016896:Treatment Outcome