title: Laparoscopic radical nephrectomy for large renal masses: critical assessment of perioperative and oncologic outcomes of stage T2a and T2b tumors.
abstract: OBJECTIVE
  To analyze the perioperative and oncologic outcomes of >7 cm renal tumors treated with laparoscopic radical nephrectomy (LRN) at a high-volume academic center. The indications for LRN have expanded to include larger (>7 cm) lesions.
  
  
  METHODS
  The Institutional Minimally Invasive Urologic Surgery Database (1994 to the present) was reviewed for patients undergoing LRN for >7-cm masses (American Joint Committee on Cancer clinical Stage T2N0M0).
  
  
  RESULTS
  Of 200 patients, 138 (69.0%) had tumors >7.0-10 cm and 62 (31.0%) had tumors >10 cm. The patients with tumors >10 cm presented more often with symptoms, most often hematuria, and more often had high-grade tumors (68% vs 44%, P = .005). Also, a greater proportion were papillary renal cell carcinoma (23% vs 14%, P = .09) and were more often upstaged (21% vs 9%, P = .02). Of the 200 tumors, 74 (37%) were upstaged, 58 (29%) with perinephric extension and 26 (13%) with renal vein invasion. Larger tumors had greater blood loss on average (406 vs 288 mL, respectively, P = .1) and were converted to open surgery more often (13.8% vs 2.1%, P = .001). A total of 47 patients (22.3%) experienced a postoperative complication. The 5-year recurrence-free survival and cancer-specific survival rate was 62.4% and 92.9%, respectively. The significant predictors of recurrence-free survival in the multivariate model were clear cell histologic type, high Fuhrman grade, renal vein invasion, and perinephric extension. Of note, pT2b was not a predictor of recurrence.
  
  
  CONCLUSIONS
  LRN can have favorable perioperative and oncologic outcomes for large (>7 cm) renal masses, with an open conversion rate and complication rate of 5% and 20%, respectively. Clear cell histologic features, high-grade tumors, renal vein invasion, and perinephric extension, but not tumor size, were poor prognostic indicators in this cohort.
authors.affiliation: Brady Urological Institute, Johns Hopkins University, Baltimore, Maryland 21287, USA.
authors.forename: Phillip M
authors.initials: PM
authors.lastname: Pierorazio
authors.forename: Elias S
authors.initials: ES
authors.lastname: Hyams
authors.forename: Brian M
authors.initials: BM
authors.lastname: Lin
authors.forename: Jeffrey K
authors.initials: JK
authors.lastname: Mullins
authors.forename: Mohamad E
authors.initials: ME
authors.lastname: Allaf
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002292:Carcinoma, Renal Cell / Q000401:mortality / Q000473:pathology* / Q000601:surgery*; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D007680:Kidney Neoplasms / Q000401:mortality / Q000473:pathology* / Q000601:surgery*; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D009392:Nephrectomy / Q000379:methods*; D055815:Young Adult