A COMPARISON OF OPEN, LAPAROSCOPIC, AND ROBOTIC RADICAL NEPHRECTOMY WITH TUMOR THROMBECTOMY FROM THE INTERCONTINENTAL COLLABORATION ON RENA CELL CARCINOMA (ICORCC) DATABASE

Abstract

Introduction

The gold standard treatment for renal cell carcinoma (RCC) with a tumor thrombus is radical nephrectomy with tumor thrombectomy. This operation carries a high morbidity and mortality rate for patients. Operative approaches to this vary across the world and can be done open, laparoscopic, and robotic, with open being the most common. Most studies on radical nephrectomy and tumor thrombectomy are small case series and lack patient diversity from different regions across the world. The purpose of this is to compare peri- and post-operative outcomes to radical nephrectomy with tumor thrombectomy between open, laparoscopic, and robotic approaches using the Intercontinental Collaboration on Renal Cell Carcinoma (ICORCC) database.

Methods

Patient records were reviewed from the ICORCC database, which is a multi-institutional database that pulls cases from the United States of America, Central/South America, Europe, and South Korea. All patients included in the study underwent radical nephrectomy and tumor thrombectomy for RCC from 2006-present. Tumor thrombus level was graded using the Neves classification system. Tumors were graded using the International Society of Urologic Pathology classification system. Statistical analysis was carried out using analysis of variance, chi-squared test, and Kaplan-Meier survival curves with log-rank test to compare a variety of pre, peri-, and post-operative variables based on surgical approach.

Results

A total of 366 patients were included (Table 1; 278 male and 88 female). Of all operations, 28 were robotic, 72 laparoscopic, and 266 open. Charlson comorbidity index was lowest in laparoscopic cases (p=0.018). Age at surgery was similar across all approaches (p=0.968). Female patients were more likely to undergo robotic surgery compared to males (p=0.032). Operative time (p=0.153) and length of stay were not different by operative choice (p=0.514). The rate of cytoreductive surgery was similar across all approaches (p=0.594). Thrombus level differed by approach, with open and laparoscopic surgery utilized more as thrombus level increased (p=0.013). Preoperative tumor size on computerized tomography scan was not different (p=0.464). Final tumor stage (p=0.396), grade (p=0.060), and subtype (p=0.971) were similar across all operative approaches. Soft tissue margin positivity did not differ (p=0.541), but renal vein margin positivity was more likely to be seen with laparoscopic surgery (p<0.001). Incidence of cancer-specific death was most likely in the robotic approach (p<0.001) but overall survival (p=0.242), metastasis-free survival (p=0.833), and time to die after a metastatic RCC diagnosis (p=0.231) was not different. Figure 1 compares overall survival (p=0.275), metastasis-free survival (p=0.988), and time to die after metastatic diagnosis (p=0.957) with log-rank tests using a Kaplan-Meier survival curve.

Conclusions

Most pre-operative patient characteristics are similar across the surgical approaches for RCC with tumor thrombectomy. Notably though, females were more likely to undergo robotic surgery. Both operative time and length of stay do not appear to be affected by surgical choice. As thrombus level increases, it appears that robotic surgery becomes less likely to be chosen by the operating surgeon. Laparoscopic surgery patients did have a higher rate of death from RCC, but overall survival did not differ by approach. Metastasis-free survival was also similar. There is no definitive superiority of one operative approach compared to another, and the risks, benefits, and resources the surgeon has at his/her disposal should all play into final operative choice for the patient.