Radical nephrectomy and nephroureterectomy in the octogenarian and nonagenarian: comparison of laparoscopic and open approaches

Objectives. To retrospectively compare the outcome of laparoscopic and open radical nephrectomy or nephroureterectomy in patients 80 years old or older, inasmuch as the tolerance profile of major laparoscopic renal surgery in comparison to open surgery in the elderly patient has not been previously reported.Methods. Since September 1997, 11 patients 80 years old or older underwent retroperitoneal laparoscopic radical nephrectomy or nephroureterectomy for cancer. These patients were compared with 6 consecutive patients 80 years old or older who underwent comparable open surgery at our institution since January 1994. No tumor had computed tomographic evidence of lymphatic, vascular, or perirenal extension.Results. Baseline parameters were comparable between the laparoscopic and open groups. The laparoscopic group had a similar median surgical time (210 minutes versus 175 minutes; P = 0.1) and blood loss (150 mL versus 125 mL; P = 0.8) compared with the open group. However, specimen weight was larger in the laparoscopic group (568 g versus 292 g; P = 0.04). Moreover, the laparoscopic group had a quicker resumption of oral intake (less than 1 day versus 4 days; P <0.001), decreased narcotic requirements (14 mg versus 326 mg; P = 0.004), shorter hospital stay (2 days versus 6 days; P <0.001), and faster convalescence (14 days versus 42 days; P <0.001) compared with the open group.Conclusions. Retroperitoneal laparoscopic radical nephrectomy and nephroureterectomy are well tolerated by the elderly patient. Although our sample size was small, it appears that laparoscopy is an excellent alternative to open surgery for excision of selected renal malignancies in the octogenarian and nonagenarian population.     

Early comparison of nephrectomy options in children (open, transperitoneal laparoscopic, laparo-endoscopic single site (LESS), and robotic surgery)

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? For pediatric patients with nonfunctioning or poorly‐functioning kidneys, laparoscopic nephrectomy has been shown to be a safe, viable option to traditional open surgery, with potential advantages of shorter hospital stays, decreased postoperative pain medication usage, and improved cosmesis. Technological advances have expanded the surgical options for nephrectomy beyond traditional laparoscopy to robot‐assisted laparoscopy and, more recently, to laparo‐ endoscopic single‐site (LESS) surgery, which is also known as single incision laparoscopic surgery (SILS) or “belly‐button” surgery. This study compares the perioperative parameters of three minimally invasive modalities for pediatric nephrectomy: traditional laparoscopic nephrectomy (LAP), robotic‐assisted laparoscopic nephrectomy (RALN), and laparo‐endoscopic single‐site nephrectomy (LESS), where these parameters are compared to those of a comparable series of patients undergoing traditional open nephrectomy (OPEN) during the same time period. This study demonstrates that the minimally invasive modalities for nephrectomy in children, including LESS nephrectomy, are associated with shorter lengths of hospital stay and decreased postoperative pain medication usage when compared to open surgery, and where LESS nephrectomy is associated with similar surgical times, lengths of hospital stay, and postoperative pain medication usage as the other minimally invasive modalities (LAP and RALN).

OBJECTIVE

• ? To compare the perioperative parameters of paediatric patients who underwent nephrectomy via laparo‐endoscopic single site (LESS) surgery (also known as single incision laparoscopic surgery or SILS) with those who underwent nephrectomy via conventional laparoscopy (LAP), robotic‐assisted laparoscopy (RALN), and open surgery (OPEN).

PATIENTS AND METHODS

• ? The medical records of 69 paediatric patients at a single institution who underwent nephrectomies for non‐functioning kidneys in 72 renal units (39 OPEN, 11 LAP, 11 RALN and 11 LESS) were reviewed for patient demographics and perioperative clinical parameters.

RESULTS

• ? The minimally invasive modalities in children, including LESS nephrectomy, were associated with shorter lengths of hospital stay (P < 0.001) and decreased postoperative pain medication usage (P < 0.001) than with open surgery.
• ? Similar surgical times were noted with LESS and the other minimally invasive modalities (LAP and RALN) (P= 0.056). However, the minimally invasive modalities (LESS, LAP and RALN) were associated with slightly longer surgical times when compared with open surgery (P < 0.001), which may, in part, be secondary to learning curve factors.
• ? No differences were noted among the minimally invasive modalities for postoperative pain medication usage (P= 0.354) and length of hospital stay (P= 0.86).

CONCLUSIONS

• ? The minimally invasive modalities for nephrectomy in children, including LESS nephrectomy, are associated with shorter lengths of hospital stay and decreased postoperative pain medication use when compared with open surgery.
• ? LESS nephrectomy in children is associated with similar surgical times, lengths of hospital stay and postoperative pain medication use as the other minimally invasive modalities (LAP and RALN).
• ? Slightly longer surgical times are noted with the minimally invasive modalities, including LESS nephrectomy, when compared with open surgery, which may, in part, be secondary to learning curve factors.

     

Completely laparoscopic versus open radical nephrectomy and infrahepatic tumor thrombectomy: Comparison of surgical complexity and prognosis

ObjectiveTo compare the operation complexity and prognosis of completely laparoscopic versus open radical nephrectomy and infrahepatic tumor thrombectomy.MethodsWe reviewed and analyzed the clinical data of 87 patients with infrahepatic tumor thrombus from January 2015 to April 2019 retrospectively. Completely laparoscopic infrahepatic tumor thrombectomy was completed in 41 cases, and open surgery was completed in 46 cases.ResultsAll 41 patients successfully completed laparoscopic operation, and there were no cases of death during the operation. The completely laparoscopic group were older, had smaller renal tumor diameter, shorter median operation time, lower median intraoperative hemorrhage volume, and lower median transfusion volume of suspended red blood cells compared with open surgeries. The proportion of low-level tumor thrombus (Mayo I) in the completely laparoscopic group was higher (63.4%), while the proportion of low-level tumor thrombus in the open surgery group was lower (30.4%) (P = 0.002). The postoperative complications incidence of laparoscopic surgery was 19.5%, which was lower than that of open surgery (47.8%) (P = 0.004). The mean cancer-specific survival time of the laparoscopic surgery group was 36.6 ± 2.5 months, while that of the open surgery group was 32.3 ± 2.7 months (P = 0.277). There was no statistical difference between the two groups.ConclusionAlthough completely laparoscopic radical nephrectomy and infrahepatic tumor thrombectomy is a challenging operation, it could be feasible and safely performed, especially in the hands of highly-experienced laparoscopic urologists for well selected cases.     

The cost of radical prostatectomy: retrospective comparison of open, laparoscopic, and robot-assisted approaches

New technologies are regularly being used for surgical treatment of prostate cancer, however the cost associated is often a secondary issue. We assessed the operative costs incurred by using the daVinci robot assisted prostatectomy (RAP) method compared to pure laparoscopic radical prostatectomy (LRP) and open radical prostatectomy (ORP). We retrospectively analyzed three techniques of radical prostatectomies: ORP, LRP, and RAP (n = 70, 57, 106, respectively). The mean patient age was 53.6, 57.6, and 60 with a mean preoperative prostate specific antigen (PSA) of 7.2, 8.4, and 6.6, respectively. The mean Gleason score was 6. Operative cost was measured for each patient. Charts were reviewed to assess individual patients postoperative requirements, and hospital length of stay (LOS). Intraoperative data show costs to be higher with the RAP and LRP compared to open surgery. Average total operating room (OR) costs per case were $5410, $3876, and $1870 for RAP, LRP, and open prostatectomy, respectively. However when comparisons are made in the postoperative period with regard to LOS, there is a significant advantage of the RAP and LRP groups over open surgery (P < 0.05). Intraoperative costs are highest for RAP. Both LRP and RAP are associated with a shorter hospital stay.     

Health-related quality of life after hand-assisted laparoscopic and open radical nephrectomies of renal cell carcinoma

Aim  To compare the health-related quality of life (HRQOL) in contemporaneous groups of patients undergoing hand-assisted laparoscopic radical nephrectomy (HALRN) or open radical nephrectomy (ORN) for renal cell carcinoma (RCC). Patients and methods  The clinical data of 20 cases receiving hand-assisted laparoscopic radical nephrectomy (the HALRN group) and 51 cases receiving open radical nephrectomy (the ORN group) were analyzed retrospectively and health questionnaires were mailed to these patients at 1 year postoperatively. The two groups were compared in terms of general surgery-related information, tumor characteristics, days to return to work or routine daily activities, and health-related quality-of-life scales. Results  Patients in the HALRN group had significantly less mean incision length (6.25 versus 17.8 cm), faster return to work or routine daily activities (5.3 versus 8.6 weeks), and earlier out-of-bed activity (4.76 versus 6.59 days) compared with those in the ORN group (P < 0.05). There were no significant differences in HRQOL scales at 1 year between the both groups (P > 0.05). Conclusion  The results showed that hand-assisted laparoscopic surgery is a minimally invasive surgical technique for RCC offering earlier recovery and similar long-term HRQOL compared with open surgery.     

Laparoscopic versus open nephrectomy in 210 consecutive patients: Outcomes,cost, and changes in practice patterns

Background: Initially slow to gain widespread acceptance within the urological community, laparoscopic nephrectomy is now becoming the standard of care in many centers. Our institution has seen a dramatic transformation in practice patterns and patient outcomes in the 2 years following the introduction of laparoscopic nephrectomy. We compare the experience with laparoscopic and open nephrectomy within a single medical center. Methods: Data were collected for all patients undergoing elective nephrectomy (live donor, radical, simple, partial, and nephroureterectomy) between August 1998 and September 2002. Data were analyzed by Wilcoxon rank sum, chi-square, and Fishers exact test. A p-value <0.05 was considered significant. Results: Of the patients, 92 underwent open nephrectomy, and 118 were treated laparoscopically (87 hand-assisted laparoscopic nephrectomy, 31 totally laparoscopic). There was one conversion (0.8%). Patient demographics and indications for surgery were equivalent for both groups. Mean operative time for laparoscopic nephrectomy (230 min) was longer than for open (187 min, p = 0.0001). Blood loss (97 ml vs 216 ml, p = 0.0001), length of stay (3.9 days vs 5.9 days, p = 0.0001), perioperative morbidity (14% vs 31%, p = 0.01), and wound complications (6.8% vs 27.1%, p = 0.0001) were all significantly less for laparoscopic nephrectomy. For live donors, time to convalescence was less (12 days vs 33 days, p = 0.02), but hospital charges were more for patients treated laparoscopically ($19,007 vs $13,581, p = 0.0001). Conclusions: Laparoscopic nephrectomy results in less blood loss, fewer hospital days, fewer complications, and more rapid recovery than open surgery. We believe that these benefits outweigh the higher hospital charges associated with the laparoscopic approach.     

A contemporaneous comparison of hospital charges for laparoscopic and open Nissen fundoplication

Surgical treatment of gastroesophageal reflux disease is increasingly recognized as a costeffective alternative to long-term medical therapy. This fact, coupled with the advent of laparoscopic fundoplication as a safe and efficacious alternative to open surgery, underscores the importance of determining the costs associated with laparoscopic treatment.Hospital costs and charges of patients undergoing open (N=9) and laparoscopic (N=11) fundoplication were retrospectively analyzed. Both procedures were performed during the same time period (6/91–6/93), at the same hospital, and by the same surgical team. Operative time, and hospital stay, were recorded in addition to total, operating room, anesthesia, sterile supplies, and hospital room charges. Figures are reported as mean values ± standard error of the mean. The Wilcoxon signed rank test was used for comparison of groups.Operative time (221±18 vs 165±12 min, P=0.033) was longer in the laparoscopic group, while hospital stay (5.8±02 vs 8.8±04 days, P<0.001) was significantly shorter. Total hospital costs were similar for both groups of patients ($14,615±863 vs $15,891±921, P=0.247). Overall hospital charges were nearly identical ($26,634±1376 vs $27,189±1753, P=0.803). A detailed analysis demonstrated cost shifting, with laparoscopic fundoplication resulting in significantly higher charges associated with events in the operating room. Operating room ($6,064±252 vs $4,283±380, P=0.001), sterile supplies ($6,214±508 vs $5,403±390), and anesthesia charges ($1,593±76 vs $1,122±95, P<0.001) were all greater in the laparoscopic group. This was offset by significantly lower hospital-room charges following laparoscopy ($5,098±355 vs $6,983±511, P=0.006).Laparoscopic Nissen fundoplication is not more expensive than its open counterpart. At present, laparoscopy results in higher operating-room charges which offsets savings from a shorter hospital stay. Improvements in technique and attention to limiting the cost of sterile supplies may ultimately result in a cost savings in favor of laparoscopy.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Nashville, Tennessee, USA, 18–19 April 1994     

A prospective comparison of laparoscopic and robotic radical nephrectomy for T1-2N0M0 renal cell carcinoma

Objectives  We prospectively evaluated the safety, feasibility, and efficiency of robotic radical nephrectomy (RRN) for localized renal tumors (T1-2N0M0) and compared this with laparoscopic radical nephrectomy (LRN). Materials and methods  Between October 2006 to August 2007, a prospective data analysis of 15 cases of renal cell carcinoma (RCC) stage T1-2N0M0, undergoing RRN was done. These patients were compared with a contemporary cohort of 15 patients of RCC with clinical stage T1-2N0M0, undergoing LRN. To keep comparison robust, all cases were performed by a single surgeon. Demographic, intra-operative, post-operative outcomes, pathological characteristics and follow-up data of the two groups were recorded and analyzed statistically. Results  Patients in group A (RRN) experienced significantly (P = 0.001) long operating time than group B (LRN). However, mean estimated blood loss, intra-operative and post-operative complications, blood transfusion rate, analgesic requirement, hospital stay and convalescence were comparable in two groups (P < 0.05). There was one conversion to open surgery in group A, and none in group B. The mean follow-up was comparable in two groups (8.3 and 9.1 months, respectively, in group A and B, P = 0.09). There were no local, port-site or distal recurrences in either group. Conclusions  Robotic radical nephrectomy is a safe, feasible and effective for performing radical nephrectomy for localized RCC. Both groups (RRN and LRN) had comparable intra-operative, peri-operative, post-operative and oncological outcomes except for longer operating time with increased cost for RRN. In this comparative study, there were no outstanding benefits of RRN observed over LRN for localized RCC.     

Long-term oncologic outcomes of laparoscopic radical nephrectomy for kidney cancer resection: Dundee cohort and metaanalysis of observational studies

Background  

The long-term oncologic outcome of laparoscopic radical nephrectomy compared with that of open radical nephrectomy remains unclear. A few case series with follow-up periods longer than 5 years are reported in the literature. The existing literature is focused primarily on early and intermediate outcomes of laparoscopic radical nephrectomy. This study aimed to assess the outcome of laparoscopic radical nephrectomy for localized disease compared with open surgery.     

Comparison of 1,800 laparoscopic and open partial nephrectomies for single renal tumors

PURPOSE: Laparoscopic partial nephrectomy is an increasingly performed, minimally invasive alternative to open partial nephrectomy. We compared early postoperative outcomes in 1,800 patients undergoing open partial nephrectomy by experienced surgeons with the initial experience with laparoscopic partial nephrectomy in patients with a single renal tumor 7 cm or less. MATERIALS AND METHODS: Data on 1,800 consecutive open or laparoscopic partial nephrectomies were collected prospectively or retrospectively in tumor registries at 3 large referral centers. Demographic, intraoperative, postoperative and followup data were compared between the 2 groups. RESULTS: Compared to the laparoscopic partial nephrectomy group of 771 patients the 1,028 undergoing open partial nephrectomy were a higher risk group with a greater percent presenting symptomatically with decreased performance status, impaired renal function and tumor in a solitary functioning kidney (p<0.0001). More tumors in the open partial nephrectomy group were more than 4 cm and centrally located and more proved to be malignant (p<0.0001 and 0.0003, respectively). Based on multivariate analysis laparoscopic partial nephrectomy was associated with shorter operative time (p<0.0001), decreased operative blood loss (p<0.0001) and shorter hospital stay (p<0.0001). The chance of intraoperative complications was comparable in the 2 groups. However, laparoscopic partial nephrectomy was associated with longer ischemia time (p<0.0001), more postoperative complications, particularly urological (p<0.0001), and an increased number of subsequent procedures (p<0.0001). Renal functional outcomes were similar 3 months after laparoscopic and open partial nephrectomy with 97.9% and 99.6% of renal units retaining function, respectively. Three-year cancer specific survival for patients with a single cT1N0M0 renal cell carcinoma was 99.3% and 99.2% after laparoscopic and open partial nephrectomy, respectively. CONCLUSIONS: Early experience with laparoscopic partial nephrectomy is promising. Laparoscopic partial nephrectomy offered the advantages of less operative time, decreased operative blood loss and a shorter hospital stay. When applied to patients with a single renal tumor 7 cm or less, laparoscopic partial nephrectomy was associated with additional postoperative morbidity compared to open partial nephrectomy. However, equivalent functional and early oncological outcomes were achieved.     

Comparison of direct hospital costs and length of stay for radical nephrectomy versus nephron-sparing surgery in the management of localized renal cell carcinoma

Objectives. Recent work has demonstrated comparable surgical results and 5-year cancer-specific survival rates between radical nephrectomy and nephron-sparing surgery (NSS) in the treatment of patients with small (4 cm or smaller) solitary renal cell carcinomas (RCCs). However, differences exist in the intraoperative management and postoperative care of patients undergoing NSS versus radical nephrectomy, and we sought to compare direct hospital costs and length of stay (LOS) between these two groups to determine whether either treatment imparts a specific cost advantage.Methods. Data were retrieved from medical records and administrative data sets containing billing encounters for all costs incurred during hospitalization at the Cleveland Clinic Foundation. Individual costs were grouped together using nine cost center categories encompassing every aspect of direct hospital care, including anesthesiology, laboratory, radiology, nursing, pharmaceutical, and emergency services, and medical care, surgical care, and miscellaneous costs. Each cost center was further subdivided, and a total of 52 cost subcategories were assessed. The total direct costs of hospitalization were compared using a multivariate regression model in which patient demographics and tumor characteristics, type and year of surgery, LOS, and cost center categories were assessed as single and interactive factors. Postoperative complication and cancer-specific survival rates were also compared to identify any potential therapeutic differences between the two groups.Results. Between 1991 and 1995, 80 patients underwent surgery at the Cleveland Clinic Foundation for solitary RCCs 4 cm or smaller, including 52 partial and 28 radical nephrectomies. We found no difference in the postoperative complication rate or cancer-specific survival rate between the two surgical groups. Total direct hospital costs and LOS were not statistically different between the NSS and radical nephrectomy groups (P >0.05). This was further supported by our multivariate model, which accounted for 61% of the observed variance in the total costs (F = 12.11, P = 0.0001). The type of surgery was not associated with total cost when controlling for all other factors, including age, sex, year of surgery, tumor size, grade, and stage, and postoperative complications (P = 0.7). There was no significant interaction between the type of surgery and the LOS (P = 0.5).Conclusions. This study demonstrated that elective NSS can be performed with equivalent direct hospital costs and LOS when compared with patients undergoing radical nephrectomy for small solitary RCCs. These data have significant economic implications for the comparison of competing surgical treatment strategies for localized RCC.     

Hand-assisted laparoscopic partial nephrectomy after 60 cases: comparison with open partial nephrectomy

Background  Partial nephrectomy is the surgical standard of care for favorably located, small renal tumors. As the incidence of renal cell carcinoma (RCC) and detection of small kidney masses have increased over the past 20 years, minimally invasive management of these lesions has become more common. We report our single-institution experience with hand-assisted laparoscopic partial nephrectomy (HALPN) compared with open partial nephrectomy (OPN). Methods  Relevant outcome and demographic information was collected prospectively for HALPNs (N = 60) and retrospectively for OPNs (N = 40). A p-value of < 0.05 denotes statistical significance. Results  Average tumor size (2.6 cm HALPN versus 2.6 cm OPN, p = 0.97) was similar. Mean operative times were shorter for HALPN compared with OPN (161 versus 191 min, p = 0.027). HALPN was also associated with less blood loss (mean 120 cc versus 353 cc, p = 0.0003). Warm ischemia time was shorter for HALPN (mean 27.0 min versus 33.0 min, p = 0.035), as was hospital stay (mean 4.9 days versus 6.9 days, p = 0.007). Although four HALPN renal tumors required intraoperative margin re-excision (based on immediate gross evaluation by a pathologist), the final positive margin rate was 0%. A 5% final positive margin rate was observed in the OPN group. There were two conversions from HALPN to HAL radical nephrectomy and no conversions to an open technique. The HALPN minor complication rate was 18.3% versus 32.5% for OPN (p = 0.10). Complications included delayed bleeding (1, 2.5% OPN), urine leak (2, 5% OPN; 2, 3.3% HALPN), hypoxia, and nausea or fever lasting >3 days. Tumor pathology was as follows: 80.7% and 80% RCC, 12.3% and 8% oncocytoma, and 7% and 12% angiomyolipoma, for HALPN and OPN, respectively in each case. Conclusions  HALPN is associated with diminished blood loss, operating time, warm ischemia time, positive margin rates, and length of stay compared with OPN. In our institution, HALPN is the standard approach for patients with small, surgically accessible renal tumors.     

Robot-assisted laparoscopic combined nephroureterectomy and cystoprostatectomy: an initial report and review of the literature

Patients presenting with invasive, high-grade, or recurrent bladder cancer and synchronous upper urinary tract malignancy may be considered for simultaneous nephroureterectomy and radical cystectomy. We present the first known reported case of robot-assisted laparoscopic combined nephroureterectomy and cystoprostatectomy, describing a 62-year-old man with recurrent T1 bladder cancer and concomitant upper urinary tract transitional cell carcinoma. Patient underwent robot-assisted laparoscopic combined nephroureterectomy and radical cystoprostatectomy with extended pelvic lymph node dissection and extracorporeal ileal conduit urinary diversion. Robotic surgery was completed successfully without need for conversion to open procedure. There were no operative or perioperative complications. Blood loss (200 ml) and hospital stay (7 days) were less than prior reported laparoscopic experience with combined surgery. Although indications may be rare, robotic nephroureterectomy with simultaneous radical cystoprostatectomy is a feasible and safe surgical option.     

Minimally Invasive and Open Donor Nephrectomy: Lessons Learned From a French Multicenter Experience

BackgroundWe evaluated different techniques of donor nephrectomy.MethodsOutcomes of 4 surgical approaches (open surgery [OS], standard laparoscopy [SL], hand-assisted laparoscopy [HAL], and robot-assisted la`paroscopy [RAL]) were compared.ResultsA total of 264 nephrectomies were performed: 65 in the OS group, 65 in the SL group, 65 in the HAL group, and 69 in RAL group. Operative time was longer for the RAL group (P < .001) with a mean time of 202 minutes (RAL), 182 minutes (OS), 173 minutes (SL), and 157 minutes (HAL). Complications (P = .002) and consumption of morphine derivates (P = .31) were lower for the RAL group (P = .0002). The visual analog scale pain scores (P = .002), hospital stay (P = .023), and time to return to full activities (P = .79) were higher for OS.ConclusionsThe 4 different nephrectomy surgical approaches had similar favorable results. The robot-assisted technique presented as an alternative option, with low incidence of complications, less pain, and results comparable to the other techniques.     

The impact of obesity on outcomes in patients receiving extracorporeal life support

Extracorporeal life support (ECLS) has been increasingly utilized to manage cardiac and pulmonary dysfunction. The impact of obesity on outcomes of ECLS is poorly defined. The purpose of the study was to compare in-hospital mortality, resource use, complications, and readmissions in obese versus non-obese patients receiving ECLS. We performed a retrospective cohort study of all adult ECLS patients with and without an obesity diagnosis using the 2010–2016 Nationwide Readmissions Database (NRD). Mortality, length of stay (LOS), hospital charges, complications, and readmissions were evaluated using multivariable logistic and linear regression. Of 23 876, patients who received ECLS, 1924 (8.1%) were obese. Obese patients received ECLS more frequently for respiratory failure (29.5% vs. 23.7%, P = .001). After adjustment for patient and hospital factors, obesity was not associated with increased odds of mortality (AOR = 1.06, P = .44) and was associated with decreased LOS (13.7 vs. 21.2 days, P < .001), hospital charges ($171 866 vs. $211 445, P < .001), and 30-day readmission (AOR = 0.71, P = .03). Obesity was also associated with reduced odds of hemorrhage (AOR = 0.43, P < .001), neurologic complications (AOR = 0.55, P = .004), and acute kidney injury (AOR=0.83, P = .04). After stratification by ECLS indication, obesity remained predictive of shorter LOS (AOR range: 0.53-0.78, all P < .05 ) and did not impact mortality (all P > .05). Respiratory support remains the most common indication for ECLS among obese patients. Among all patients, as well as by individual ECLS indication, obesity was not associated with increased odds of mortality. These findings suggest that obesity should not be considered a high-risk contraindication to ECLS.     

Comparison of Outcome of Open and Laparoscopic Resection for Stage II and Stage III Rectal Cancer

Background  Laparoscopic resection for advanced rectal cancer has not been widely accepted, and there are only few studies with survival data. This study aimed to compare the survival of patients who underwent laparoscopic and open resection for stage II and III rectal cancer. Materials and Methods  Consecutive patients (open resection: n = 310; laparoscopic resection: n = 111) who underwent curative resection for stage II and III rectal cancer from June 2000 to December 2006 were included. The operative details, postoperative complications, postoperative outcomes, and survival data were collected prospectively. Comparison was made between patients who had laparoscopic and open surgery. Results  The age, gender, medical morbidity, types of operation, and American Society of Anesthesiologists (ASA) status were similar between the two groups. There was also no difference in the mortality, morbidity, and pathological staging. Laparoscopic resection was associated with significantly less blood loss and shorter hospital stay. With the median follow-up of 34 months, there was no difference in local recurrence rates. The 5-year actuarial survivals were 71.1% and 59.3% in the laparoscopic and open groups, respectively (P = .029). In the multivariate analysis, laparoscopic resection was one of the independent significant factors associated with better survival (P = .03, hazards ratio: 0.558, 95% confidence interval: 0.339–0.969). Other independent poor prognostic factors included lymph node metastasis, poor differentiation, perineural invasion, presence of postoperative complications, and no chemotherapy. Conclusions  Laparoscopic resection for locally advanced rectal cancer is associated with more favorable overall survival when compared with open resection.     

Inpatient safety trends in laparoscopic and open nephrectomy for renal tumours

Study Type – Cohort study Level of Evidence 2b What's known on the subject? and What does the study add? Laparoscopic radical nephrectomy for renal cancer provides equivalent long‐term cancer control with shorter hospital stays, less postoperative pain, and faster resumption of normal activities, but it has diffused slowly into clinical practice, perhaps as a result of perceptions about safety. Patient safety outcomes for laparoscopic and open radical nephrectomy using validated measures remain incompletely characterized. This is the first study to investigate peri‐operative outcomes of radical nephrectomy using validated patient safety measures. We found a 32% decreased probability of adverse patient safety events occurring in laparoscopic compared with open radical nephrectomy. The safety benefits of laparoscopy were attained only after 10% of cases were completed laparoscopically – a proportion some have proposed as the ‘tipping point’ for the adoption of surgical innovations. This observation could have implications for patient safety in the setting of diffusion of new surgical techniques.

OBJECTIVE

• ? To compare peri‐operative adverse patient safety events occurring in laparoscopic radical nephrectomy (LRN) with those occurring in open radical nephrectomy (ORN).

METHODS

• ? We used the US Nationwide Inpatient Sample to identify patients undergoing kidney surgery for renal tumours from 1998 to 2008.
• ? We used patient safety indicators (PSIs), which are validated measures of preventable adverse outcomes, and multivariate regression to analyse associations of surgery type with patient safety.

RESULTS

• ? Open radical nephrectomy accounted for 235 098 (89%) cases while 28 609 (11%) cases were LRN.
• ? Compared with ORN, LRN patients were more likely to be male (P= 0.048), have lower Charlson comorbidity scores (P < 0.001), and to undergo surgery at urban (P < 0.001) and teaching (P < 0.001) hospitals.
• ? PSIs occurred in 18 714 (8%) of ORN and 1434 (5%) of LRN cases (P < 0.001).
• ? On multivariate analysis, LRN was associated with a 32% decreased probability of any PSI (adjusted odds ratio 0.68, 95% confidence interval: 0.6 to 0.77, P < 0.001). Stratification by year showed that this difference was initially manifested in 2003, when the proportion of LRN cases first exceeded 10%.

CONCLUSIONS

• ? We found that LRN was associated with substantially superior peri‐operative patient safety outcomes compared with ORN, but only after the national prevalence of LRN exceeded 10%.
• ? Further study is needed to explain these patterns and promote the safe diffusion of novel surgical therapies into broad practice.

     

Indications and contraindications for the use of laparoscopic surgery for renal cell carcinoma

Surgery remains the only treatment with a chance of cure for renal cell carcinoma. Laparoscopic radical nephrectomy (LRN) has developed to be a standard treatment for the management of suspected renal malignancy in many centers worldwide, with oncologic efficacy equal to that of open radical nephrectomy. LRN has considerable advantages over open surgery, such as decreased postoperative morbidity, decreased analgesic requirements, and shorter hospital stay and convalescence. Current indications for LRN include all patients with localized stage T1-2 renal tumors. LRN for stage T3 renal tumors may be technically feasible in individual situations, but cannot be considered standard treatment. Open radical nephrectomy is reserved for advanced renal tumors, according to the surgeon's judgment. Partial nephrectomy is well established and considered to be the standard management for all organ-confined tumors of 相似文献   

A comparison of costs for abdominal, laparoscopic, and robot-assisted sacral colpopexy

The aim of this study was to compare the short-term estimated hospital costs and charges for open, laparoscopic, and robot-assisted sacral colpopexy. The null hypothesis was that there would be no difference in costs and charges. Fifteen comparable cases were reviewed for demographics, surgical information, and estimated hospital charges and costs and then compared with analysis of variance. There were no differences in demographics and surgical variables among the three groups. For estimated hospital charges, minimally invasive sacral colpopexy was most expensive; open was the least expensive approach. The estimated direct costs were significantly higher for robot-assisted compared with open sacral colpopexy, but not different between robot-assisted and laparoscopic sacral colpopexy. Robot-assisted sacral colpopexy produces the highest estimated hospital charges and is more expensive than open sacral colpopexy. The least expensive surgical approach from the hospital costs perspective is open abdominal sacral colpopexy. Presented at the 34th American Urogynecologic Society Meeting, September 4–6, 2008, Chicago, Illinois     

Robot-assisted laparoscopic partial nephrectomy during pregnancy

We present a case of a 36-year-old pregnant woman with renal cell carcinoma who underwent a successful robot-assisted laparoscopic partial nephrectomy (RLPN) at 14 weeks gestational age. The operative time, including da Vinci™ setup, was 165 min. The warm ischemic time was 28 min, and the estimated blood loss was 100 ml. The final pathologic evaluation was conventional-type renal cell carcinoma with Fuhrman nuclear grade 3, stage T1a disease with a negative margin. The remainder of the pregnancy was uneventful. Although previous cases of laparoscopic nephrectomy performed during pregnancy have been reported, this is the first case in which it has been performed using robotics. RLPN during pregnancy can be a safe and feasible alternative to open and laparoscopic surgery.