EAU 2018: Trends and Morbidity for Minimally Invasive vs Open Cytoreductive Nephrectomy in the Management of Metastatic Renal Cell Carcinoma
In this study, rather than focusing on the utility of CN prior to systemic therapy, the authors of this study assess the modality of CN. They sought to compare the trends and morbidity of laparoscopic, robotic, and open CN for patients with metastatic RCC. However, it should be noted that patients with metastatic RCC often have bulky primary disease, lending to open approach. As MIS technology and experience increases, this may be changing.
They used the Premier Hospital Database (Premier, Inc., Charlotte, NC), through which they identified 24,145 patients who underwent elective radical nephrectomy for metastatic RCC in the United States between 2003 and 2015. They compared the 3 modalities (laparoscopic, robotic, and open CN) using propensity weighting on rates of 90-day complications, blood transfusion, intensive care unit (ICU) admission, prolonged length of stay (LOS), discharge destination, 90-day readmission, operative time, and direct hospital costs.
In terms of demographics, the patients in each of the arms was pretty evenly matched based on propensity weighting.
Looking at the rates of each type of nephrectomy: open CN decreased from 76.7% to 66.4%, laparoscopic CN decreased from 22.3% to 11.4%, and robotic CN increased from 0.6% to 22.1%. Robotic surgery continues to make gains within the field of urology.
Compared to open CN, the laparoscopic approach was associated with a 30% decreased odds of 90-day major complications (OR 0.70, 95% CI 0.50 - 0.97, p<0.05) – but robotic surgery was not found to have the same benefit. Compared to open CN, both laparoscopic and robotic approaches were associated with significantly decreased odds of blood transfusion (OR 0.46 and 0.38, respectively), ICU admission (OR 0.57 and 0.48, respectively), and LOS (OR 0.50 and 0.35, respectively).
Direct costs were lowest for laparoscopic CN. This is an important fact, as healthcare costs have come under scrutiny. Indeed, if a nephrectomy can be done safely in an MIS approach, laparoscopy may be the more cost-effect approach. Robotic surgery may be overkill.
Presented by: D. Zlatev
Co-Authors: Mossanen M., Pucheril D., Ozambela M., Wang Y., Ingham M., Chung B., Chang S.
Written by: Thenappan Chandrasekar, MD Clinical Fellow, University of Toronto, twitter: @tchandra_uromd at the 2018 European Association of Urology Meeting EAU18, 16-20 March, 2018 Copenhagen, Denmark