Upper pole kidney tumors: Open or laparoscopic partial nephrectomy?

Abstract

429 Background: Partial nephrectomy in upper pole kidney tumors represents a distinct surgical challenge. Data on minimally invasive nephron sparing surgery in this context are scarce. We set out to investigate the role of laparoscopic and open approaches to partial nephrectomy in these tumors. Methods: The Roswell Park Cancer Institute prospective, IRB-approved kidney surgery database was reviewed containing 690 patients. Only patients completing a radical or partial nephrectomy for unilateral, localized, non-metastatic tumors < 7cm were included. The resulting cohort contained 400 patients. Average patient age at surgery was 59.9 ± 13.2 years (range: 22-88). Tumor stages included benign (13.5%), T1a (53.0%), T1b (25.0%), T2 (1.5%), T3a (7.0%). Upper pole tumors (n=128; 27%) and lower pole/ mid-pole tumors (n=270; 67.5%) were recorded. Intraoperative complications were recorded; postoperative complications were tabulated as low or high grade per Clavien-Dindo classification. SPSS (version 19.0) software was used to analyze the dataset. Results: Total intraoperative complication rate was 11.3% (45/400 cases). After stratification by tumor location and partial vs. radical nephrectomy, intraoperative complication rates were higher for laparoscopic/robotic partial nephrectomies involving upper pole tumors (72.7% of all intraoperative complications) compared to lower pole tumors (27.3%, p=0.04), in Chi-Square test. In the delayed postoperative period, total low-grade Clavien complication rate was 97.8% (391/400 cases); high-grade complication rate was 2.3% (9/400). After controlling for tumor location and nephrectomy extent, the high-grade delayed complications were present only in the open nephrectomies involving upper-pole tumors. However, laparoscopic/robotic partial nephrectomies involving upper-pole tumors had significantly more delayed low-grade complications (92.4% of all delayed complications) compared to lower-pole tumors (7.6%, p<0.01), in Chi-Square. Conclusions: Upper pole kidney tumors represent a challenging surgical situation. We here demonstrate that minimally invasive partial nephrectomy in this context requires significant surgical expertise and an open approach could be considered.