Open Nephron-Sparing Surgery for Renal Tumors is an Effective Surgical Option for Low HealthResource Settings in the Era of Laparoscopic Surgery.

Abstract

Introduction: Open nephron-sparing surgery (NSS) is known to have good outcomes in terms of renal function and oncology. Its role in the laparoscopic and robotic surgery era requires further evaluation in low-income countries. This study evaluated the renal function and oncological outcomes of open NSS surgery for renal tumors to provide insight into the future role of open NSS alongside laparoscopic and robotic surgery.

Patients and methods: A cohort of 52 patients who underwent NSS for RCC were included in this study. Clinical data were recorded using a predesigned questionnaire covering epidemiology, patient presentation, comorbidities, laboratory investigation, imaging studies, TNM classification, CTU findings, selection criteria, intra- and postoperative complications, hospital stay, and follow-up outcome data. Data are expressed as mean ± SD, and dependent and independent variables were considered statistically significant at a P-value level <0.05.

Results: Of the 52 patients, 44.2% were male, and 55.8% were female, with an average age of 57.5 ± 14.8. Incidental renal masses were observed in 36.5% of patients, while flank pain was observed in 55.8% of patients. The average size was 5.9 ± 1.7 cm. A transcostal extraperitoneal approach was used, with a mean operative time of 87.6 ± 16.2 minutes. The main artery was clamped in 92.3% of the patients, and selective apical artery ligation was performed in one patient under specific conditions. There were no instances of bleeding during or after the surgery, and the typical period of ischemia during tumor removal lasted approximately 12.5 ± 4.8 minutes. Histological results showed malignant tumors in 86.5% of the cases and benign lesions in 13.5%. Positive surgical margins were observed in one patient with a small entophytic upper pole mass of 3.7 cm. The average hospital stay was five days ± 1.6; however, 49 (94.2%) patients had their drain removed in less than three days. Only three (5.8%) patients developed a urinary fistula and responded well to conservative treatment. Of the 52 patients, 21 (40.4%) were monitored for > 5 years, while 31 (59.6%) were observed for less than 5 years. Follow-up CTU analysis showed no evidence of recurrence or metastases, and serum creatinine levels at three months and one year were 1.4 (SD 0.6) and 1.2 (SD 0.7), respectively. The correlation between ischemia time and tumor size was statistically significant (P = 0.034). Moreover, histological type was also significantly correlated with tumor size, with a P-value of 0.000.

Discussion and conclusion: The study concluded that open NSS is a secure procedure that maintains renal function without compromising oncological outcomes. A warm ischemia time of 20 min did not compromise oncological outcomes or renal function. Tumor sizes of 7 cm or more can be safely managed. A double-layer suturing technique and follow-up scheme using serum creatinine and CTU at three months and then annually seems practical and applicable even in low-currency income countries.