Laparoscopic Partial Nephrectomy Versus Laparoscopic Radical Nephrectomy In The Treatment Of Clinically Localized Renal Cell Carcinoma Over 4cm

Objective: The most widely accepted surgical treatments for renal cell cancer(RCC)were laparoscopic partial nephrectomy(LPN)and laparoscopic radical nephrectomy(LRN).With the application and development of laparoscopic techniques,LPN has become the standard method for the surgical treatment of T1 a RCC.However,the “optimal” surgical treatment for renal masses over 4cm is still disputed.Therefore,this present study aims to compare the short-term and long-term clinical and survival outcomes of LPN and LRN in patients with RCC > 4cm.So as to provide references for the clinical treatment of RCC.Methods: 151 patients with RCC who underwent LPN or LRN,including 54 and 97 patients treated with LPN and LRN,in Zhejiang Provincial People’s Hospital from January 2012 to December 2017 were retrospectively analyzed.All patients were selected according to the inclusion criteria of the 2022 RCC guideline of NCCN[1].Demographic information such as age,gender,height,weight,body mass index(BMI),social history,formerly medical history,the side of tumors,the size of tumors,the stage of tumors,and the American Society of Anaesthesiologists(ASA)score performed according to the ASA physical status classification were also collected.Meanwhile,the information was also collected for monitoring renal function,like serum creatinine(SCr),emission computed tomography for glomerular filtration rate measurement(ECT-GFR),and other clinical indicators like hemoglobin(Hb),calcium(Ca),and lactic dehydrogenase(LDH).A 1:1 propensity score matching(PSM)was performed to eliminate the baseline differences between the two groups.A total of 102 patients,including 51 patients treated with LPN and 51 patients treated with LRN,were enrolled and completed the study.The tumor histology,renal function,CKD after the operation,and surgery-related indicators,including operative time,intraoperative bleeding,postoperative hospital stay,and incidence rate of postoperative complications,were statistically analyzed.All patients included in the study were followed up until February 2023,and their survival information was recorded.Survival such as overall survival(OS),cancer-specific survival(CSS),metastasisfree survival(MFS),and progression-free survival(PFS)were calculated using the Kaplan-Meier method and Log-rank test.Multivariable Cox regression analysis was done to assess predictors of survival.Results: 1.Baseline characteristics 1.1 Comparison result before PSM matching A total of 151 patients with localized renal cell carcinoma > 4cm were included,including 54 patients in the LPN group and 97 patients in the LRN group.In contrast to the LPN group,the LRN group had a larger tumor size(6cm vs.5cm),and more patients with tumors in clinical stage Ⅱ(29 vs.4).Other preoperative baseline indicators such as SCr and Hb also had significant differences between the two groups(P < 0.05).There were no significant differences in other indexes such as age,sex,BMI,social history,formerly medical history,Ca,LDH,and ECT-GFR(P > 0.05).1.2 Comparison result after PSM matching After matching,all baseline parameters are comparable between the two groups.There was no significant difference in any of the baseline characteristics(P > 0.05).2.Comparison results in surgery-related indicators Compared with the LRN group,the LPN group had a longer operative time(135min vs.102.5min),larger intraoperative bleeding(150ml vs.50ml),and longer postoperative hospital stay(8 days vs.6 days),with statistically significant differences(P < 0.05).There was no significant difference in the Clavien-Dindo classification of postoperative complications between the two groups as well as the blood transfusion(P > 0.05).The LPN group had higher intraoperative or postoperative complications than the LRN group.Hemorrhage occurred in both groups,with four patients in the LPN group and one in the LRN group,but there was no statistical difference(P > 0.05).Postoperative complications included postoperative fever,anemia,hypoproteinemia,postoperative bleeding,vomiting,pleural effusion,pulmonary infection,hematuria,abdominal distension,abdominal pain,abdominal effusion,acute kidney injury(AKI),heart failure,septic shock,and pulmonary insufficiency.Although there was no difference in the total number of postoperative complications between groups(P > 0.05),patients in the LRN group were more likely to experience postoperative nausea and vomiting than those in the LPN group(P < 0.05).3.Comparison results in the tumor histology In this study,surgical margins were negative in both groups.Postoperative histology can be divided into 7 types,including clear cell renal cell carcinoma,papillary renal cell carcinoma,chromophobe renal cell carcinoma,multilocular cystic renal neoplasm of low malignant potential,Mi T family translocation carcinomas,succinate dehydrogenase(SDH)-deficient renal carcinoma,and unclassified renal cell carcinoma.There were no significant differences between the two groups in pathological type,WHO/ISUP grade,or p TNM stage(P > 0.05).4.Comparison results in the renal function 4.1 Comparison results in the serum creatinine(SCr)before and after the operation In the LRN group,SCr was significantly increased at postoperative,3 months,6 months,and 12 months(P < 0.05).However,only at postoperative(P = 0.034)was it significantly higher than preoperative,and no significant difference was found at 3,6,or 12 months in the LPN group(P > 0.05).Postoperative SCr in the LRN group was significantly higher than that in the LPN group(P > 0.05).In addition,the value and percentage of postoperative SCr changes in the LRN group were more significant than those in the LPN group(P < 0.05).4.2 Comparison results in the ECT-GFR before and after the operation In the LRN group,ECT-GFR was significantly decreased at 3 months,6 months,and 12 months after the operation(P < 0.05).However,it was no significant difference was found at the following 3,6,or 12 months in the LPN group(P > 0.05).Postoperative ECT-GFR in the LRN group was significantly lower than that in the LPN group(P < 0.05).In addition,the value and percentage of postoperative ECT-GFR changes in the LRN group were more significant than those in the LPN group(P < 0.05).5.Comparison results of CKD In the LPN group,CKD was significantly decreased at 3 months,6 months,and 12 months after the operation(P < 0.05).Sankey diagram showed that patients with preoperative GFR ≥ 60ml/min in the LPN group rarely experienced renal function deterioration and CKD in the following 12 months after the operation.In addition,some patients with preoperative CKD had improved at 12 months of follow-up.Most patients with preoperative GFR ≥ 60ml/min in the LRN group developed CKD and did not improve at the last follow-up in patients with preoperative CKD.6.Comparison results of long-term survival 92 patients received follow-up,and the median follow-up time was 88 months and 98 months in LPN and LRN groups,respectively.By the end of the follow-up,no patients died in the LPN group and 5 patients(11.4%)in the LRN group,with a statistical difference(P = 0.022).Kaplan-Meier chart and the log-rank test showed that although patients in the LPN group had longer OS than that in the LRN group,there was no statistical difference between the two groups(P = 0.060).In addition,there were no significant differences in 5-year OS,CSS,MFS,and PFS between the two groups(P > 0.05).Multivariate analysis showed that age(HR,4.776e+02;95%CI,2.763e+02 – 8.254e+02;P < 0.001),CHD(HR,1.831e-57;95%CI,3.581e-60 – 9.362e-55;P < 0.001),Hb(HR,0.460;95%CI,0.360 – 0.590;P < 0.001),ASA score(HR,1.224e+26;95%CI,2.485e+23 – 6.033e+28;P < 0.001),and postoperative histology(HR,2.851e+25;95%CI,6.885e+23 – 1.180e+27;P < 0.001)were the independent prognostic factors of OS.Univariate analysis showed that drinking(HR,5.476;95%CI,1.105 – 27.139;P = 0.037)and ASA score(HR,4.998;95%CI,1.575 – 15.792;P = 0.006)were the prognostic factors of MFS and PFS,respectively.Conclusion: 1.Both LPN and LRN are safe and effective methods for localized renal cell carcinoma > 4cm.2.The short-term efficacy and long-term prognosis of LPN in the treatment of localized renal cell carcinoma > 4cm were similar to those of LRN.In our study,the surgical methods did not affect the survival prognosis of patients.However,LPN preserves renal function well and has the potential value of significantly reducing the risk of postoperative CKD.Therefore,if technology and conditions permit,LPN may be a better choice for the surgical treatment of patients with localized renal cell carcinoma > 4cm.However,the risk of intraoperative and postoperative bleeding and the long hospital stay associated with LPN still need to be addressed.