title: Laparoscopic partial nephrectomy: beyond the straightforward T1a.
abstract: What's known on the subject? and What does the study add? Complex tumour features (e.g. size, hilar location, multifocality) are generally considered contraindicative for LPN and only a handful of studies reporting encouraging outcomes with more complex tumours. Herein we suggest that in experience hands the benefits of minimally-invasive surgery may be safely extended to patients with more complex renal masses.
  
  
  OBJECTIVE
  To report on our experience in extending the indications for LPN beyond the single, T1a renal mass assessing the perioperative outcomes in a comparative fashion.
  
  
  METHODS
  Retrospective review of consecutive patients undergoing LPN for a renal mass in an academic centre between 2005-2010. 150 patients were divided into two groups based on tumours characteristics: straightforward T1a (group 1: single, <4 cm, n = 84) and complex (group 2: multiple and/or hilar and/or ≥4 cm, n = 66). Comparison of demographic, clinical, radiographic and perioperative outcomes (operative times, blood loss, warm ischemia times, intra- and postoperative complications).
  
  
  RESULTS
  In group 2, 19 tumours were hilar, 15 were multifocal and 44 measured ≥4 cm; 2 of these criteria were present in 7, and all three in 3 cases. Warm ischemia times and blood loss were comparable (medians of 21 vs 20 min, and 100 vs 100 mL). Operative times were longer in group 2 (190 vs 140min, P < 0.001). Complications occurred in 11.9% and 12.1% of patients in group 1 and 2, with Clavien grade 3 events in 8.3 and 10.9%, respectively (P = 1.00 and P = 0.547). There were 4 conversions to laparoscopic radical nephrectomy (1 in group 1, 3 in group 2).
  
  
  CONCLUSIONS
  With adequate laparoscopic expertise, the indications for LPN can be safely extended beyond the single, small, peripheral T1a renal mass. In this series, more complex masses were effectively treated with LPN combining the advantages of minimally-invasive surgery to those of nephron-sparing approach.
authors.affiliation: Department of Urologic Surgery, The E. Wolfson Medical Center, Holon and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel. atsivian@hotmail.com
authors.forename: Alexander
authors.initials: A
authors.lastname: Tsivian
authors.forename: Matvey
authors.initials: M
authors.lastname: Tsivian
authors.forename: Yury
authors.initials: Y
authors.lastname: Stanevsky
authors.forename: Shalva
authors.initials: S
authors.lastname: Benjamin
authors.forename: A Ami
authors.initials: AA
authors.lastname: Sidi
mesh_terms: D000368:Aged; D016063:Blood Loss, Surgical / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D007431:Intraoperative Complications / Q000209:etiology; D007680:Kidney Neoplasms / Q000601:surgery*; D010535:Laparoscopy / Q000379:methods*; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D009392:Nephrectomy / Q000379:methods*; D059351:Organ Sparing Treatments; D011183:Postoperative Complications / Q000209:etiology; D011446:Prospective Studies; D012189:Retrospective Studies; D016896:Treatment Outcome; D052096:Warm Ischemia