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COMMENTARY

R. C. Flanigan

Department of Urology, Loyola University of Chicago, Chicago, Ilinois, U.S.A.

Certainly no one should underestimate the current value of laparoscopic nephrectomy or the skill and foresight of those who developed this technique. Nor should we underestimate the potential benefits to a patient who may experience less morbidity after nephrectomy when it is accomplished laparoscopi-cally. On the other hand, there remain several important unanswered questions regarding the use of laparoscopic nephrectomy:

1. Will it be widely available?

2. How does a clinician retain the necessary skills to perform it safely and effectively?

3. Are decisions concerning the appropriateness of nephron-sparing surgery versus laparoscopic nephrectomy being made appropriately?

4. What are the limits of laparoscopic nephrectomy; is it indicated for large or high-stage cancers?

In this excellent review, Drs. Kim and Clayman have detailed the current experience with the various laparoscopic approaches to nephrectomy. As with many other areas of emerging practices, the real problem with comparative analyses of techniques is patient selection. Comparing "contemporary" series of open and laparoscopic cases or even cases of hand-assisted versus pure laparoscopy, even when patients are "matched" for tumor size, etc., by definition excludes the thought process that caused the surgeon to select one technique over another. This being said, there does not seem to be a disadvantage in terms of cancer management of organ-confined renal cancers when laparoscopic nephrectomy is used. What are the limits of this technique? Recent experience suggests that in very experienced hands, large tumors (greater than 7 cm) can be treated with similar complication rates as that seen in smaller tumors. The real issue for the individual surgeon is to know his/her limits, i.e., patient selection is imperative.

Given the facts that (i) the average urologist currently performs one to two nephrectomies per year and (ii) urology does not have a "commonly performed" laparoscopic procedure (e.g., cholecystectomy in general surgery practice), how does a surgeon, even one who is adequately trained, maintain competency in laparoscopy nephrectomy? It seems that the only realistic answer to this problem is referral of these procedures to experienced laparo-scopically trained urologists inside or outside of one's practice.

Another area of concern is the dilemma of nephron-sparing surgery versus laparoscopic total nephrectomy. To date, nephron-sparing surgery seems to provide equal oncologic value in selected patients with localized renal cancer. What are the appropriate limits of nephron-sparing surgery and is it better for the patient to undergo a laparoscopic total nephrectomy or open nephron-sparing surgery? Patient selection, based on the depth of tumor involvement of the kidney, patient age, comorbidities, etc., is the key. Again the physician's self-judgment of his/her ability to perform any procedure safely and effectively should direct the approach used.

Finally, what limits should we apply to laparoscopic nephrectomy? Recent data from institutions with a wide experience with laparoscopic nephrectomy suggests that tumors greater than 7 cm in diameter can be removed with similar safety (complication rates, blood loss, length of stay, etc.) as is seen with smaller tumors. On the other hand, when large tumors involve extension to adjacent organs, blood vessels, and/or lymphatics, laparoscopic techniques probably are not currently indicated.

In summary, although laparoscopic nephrectomy is a gold standard (along with open nephrectomy and nephron-sparing surgery) for the management of localized renal cancers, it cannot be said too often that patient selection and an honest appraisal of one's expertise with any procedure is the key to management.

The surgical approach to removal of renal tumors is, and will continue to be, a moving target, as new techniques and systemic therapies are developed. It would seem clear that the urologic community should embrace research, which will yield less invasive, more effective therapies for this disease, which kills over 10,000 Americans annually.

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