Home Medicine Comparison of laparoscopy and open radical nephrectomy of renal cell cancer
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Comparison of laparoscopy and open radical nephrectomy of renal cell cancer

  • Dong Wang , Zejun Xiao EMAIL logo , Jianzhong Shou , Changling Li and Nianzeng Xing
Published/Copyright: May 17, 2019
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Open Medicine
From the journal Open Medicine Volume 14 Issue 1

Abstract

Objective

The aim of this study was to summarize the current evidence to evaluate the effects of laparoscopic radical nephrectomy (LRN) and open radical nephrectomy (ORN) in the treatment of renal cell carcinoma.

Methods

A comprehensive literature search was performed using PubMed, Embase and Google Scholar to identify all relevant studies. 8 published studies were included in this meta-analysis. We pooled the odds ratios (OR), standardised mean difference (SMD) and conducted heterogeneity, and quality assessment.

Results

The outcome of treatment effects included surgical blood loss, surgical time, postoperative complications, and post-operative length of hospital stay. Comparing open radical nephrectomy for kidney cancer patients, the pooled SMD of surgical time was 0.47, (95% confidential index CI = [0.09, 0.85]), the pooled SMD of operative blood loss was -68.98, (95% CI = [-99.63, -38.34]), the pooled SMD of post-operative length of hospital stay was -4.32, (95% CI = [-4.62, -4.03]), and the pooled OR of postoperative complications was 0.52, (95% CI = [0.30, 0.91]).

Conclusion

LRN was found to significantly decrease patients’ blood loss. In addition, LRN offers less post-operative length of hospital stay.

Keywords: Laparoscopic radical nephrectomy; Open radical nephrectomy; Meta-analysis

1 Introduction

Renal cell carcinoma (RCC) is a malignant tumor originating from renal tubular epithelial cells and accounts for roughly 90% of all malignant kidney cancer [1]. Kidney cancers account for 2% to 3% of all malignant tumors, with an incidence of 5.8/100000 [2]. According to reports, in the past 20 years, the incidence of kidney cancer is annually growing at a rate of 2% all the world [3]. RCC is not sensitive to chemotherapy and radiotherapy, and surgical resection, of which radical nephrectomy is recognized as a possible cure for kidney cancer [4]. In 1968, Roson et al first reported the use of open radical nephrectomy (ORN) for the treatment of renal cancer, which was to release the kidney outside the perirenal fascia, and then the perirenal fascia, perirenal fat, kidney and tumor, ipsilateral adrenal gland were all resected [5]. Parallel regional lymph node dissection was performed, including the abdominal aorta or the inferior vena cava lymph node from the diaphragm angle to the abdominal aorta bifurcation. The method described by Roson for the next few decades is recognized as the standard method for surgical treatment of kidney cancer. Regardless of the intraperitoneal route ORN or the lumbar route ORN, due to the huge incision in the operation area, postoperative patients recover slowly, and can have potential complications such as incisional hernia, wound infection, and liquefaction [6]. In 1991, Clayman et al first reported successful laparoscopic nephrectomy by intraperitoneal route. Subsequently, Guar invented a simple and practical balloon dilator to establish a retroperitoneal space technique, which enabled retroperitoneal laparoscopic renal surgery [7]. It is generally believed that the indication for laparoscopic radical nephrectomy (LRN) is that the renal tumor is confined to the renal capsule, and there is no peripheral tissue invasion and no local lymph node metastasis and venous tumor thrombus.

Meta-analysis is a powerful comprehensive method, which can perform systematic analysis and determination of multiple independent research results with the same research purposes. When individual experiments cannot be made clear, and the results or multiple results of the same purpose are contradictory, meta-analysis can be used to synthesize multiple identical experiments. Therefore, meta-analysis is especially suitable for multiple research results that are contradictory or different. This study aims to systematically review and analysize randomized controlled trials of LRN and ORN. Comparing the operation time of the two operations, the amount of intra-operative blood loss, the post-operative length of hospital stay, and the postoperative complications, can provide a basis for the choice of clinical surgical methods.

2 Methods

2.1 Searching method

We conducted a search of PubMed, Embase, Ovid, Splinger and Google Scholar databases that were published between 1993 and 2018. We limited the search to studies published in English. The medical subject heading terms and keywords used included “renal cell carcinoma”, “RCC”, “Laparoscopic”, “open”, “radical nephrectomy”. Duplicate articles and unpublished studies from international meetings were excluded.

2.2 Inclusion criteria

Studies were selected carefully on the basis of following criteria: Compared studies of the effects of LRN with ORN in the treatment of renal cell carcinoma prospective and retrospective controlled studies; patients with renal cell carcinoma; information collected including surgical blood loss, surgical time, postoperative complications, postoperative hospital stay.

2.3 Excluding standard

Non-clinical controlled trials; non-kidney cancer research; other surgical treatment; data description is not clear.

2.4 Data extraction

Subjects and abstracts of the literature were independently collected by two authors, and if they were considered to be inconsistent with the inclusion criteria, they would be considered as unqualified studies. For all possible related trials, the full report was obtained as much as possible. Once the full text was obtained, the two authors independently extracted the following data: the author of the literature, the age of the publication, the type of design, the basic data of the patient, the operation time, the amount of blood loss, postoperative hospital stay, postoperative follow-up, etc. The independently extracted data were then compared. If there was any disagreement on any data extraction details, it was resolved through discussion and indicated on the data collection form.

2.5 Statistical analysis

We used RevMan (version 5.3) to perform all the statistical analyses. To obtain the pooled odds ratios (ORs), SMD with 95% confidence intervals (CIs), a random effects model was applied. The heterogeneity between and within trials was evaluated using chi-square test p value < 0.1 or an I2 measure > 50%, based on a statement from the Cochrane Handbook.

3 Results

3.1 Literature searches and characteristics of eligible studies

Figure 1 shows the flow diagram of study selection process. After screening, we obtained 8 studies. The detailed characteristics for the 8 eligible studies are summarized in Table 1.

Figure 1 The study selection process
Figure 1

The study selection process

Table 1

Baseline characeristics of included studies

References country Group NO. of patients Age (years) Male/female
Abbou 1999 (13) France LRN 29 63.0 17/12
ORN 29 58.8 16/13
Bensalah 2009 (14) France LRN 44 65±13 28/16
ORN 135 63±11 86/49
Jeon 2011 (15) Korea LRN 88 57.8±12.4 58/30
ORN 167 55.1±13.2 104/63
Kwon 2011 (16) Korea LRN 33 56.1±11.9 24/9
ORN 35 55.0±10.8 22/13
Laird 2015 (17) UK LRN 25 66.7 (60.6-73.2) 16/9
ORN 25 65.6 (58.0-74.8) 16/9
Vasdev 2011 (18) UK LRN 29 81.8±0.5 16/13
ORN 36 82.6±0.4 20/16
Wang 2009 (19) China LRN 185 60.4±17.5 102/83
ORN 167 63.1±18.3 89/78
Xu 2014 (20) China LRN 88 56.5±13.3 55/33
ORN 526 57.32±12.4 341/185

  1. Age is exhibited as the mean ± standard deviation (SD) or median (range)

3.2 Meta-analysis of the operating time of LRN and ORN

The operating time is reported in four studies (Figure 2). The pooled SMD from these 4 studies was -0.60 (95% CI, [-1.96, 0.76], P=0.39). We performed a sensitivity analysis for included studies where we sequentially excluded each study from our meta-analysis. Using this approach, we found that heterogeneity was mainly caused by the studies of Vasdev 2011. Subsequently, the I2 estimate of the variance between the studies is 63% and P= 0.06, which showed moderate heterogeneity. According to our analysis, the operating time of between LRN and ORN was significant (P = 0.01) and the operating time of LRN was less than ORN.

Figure 2 The forest plot for the operating time between LRN and ORN group
Figure 2

The forest plot for the operating time between LRN and ORN group

3.3 Meta-analysis of the operative blood loss of LRN and ORN

The operative blood loss is reported in four studies (Figure 3). Compared with ORN, LRN was associated with a 68.98ml reduction in blood loss (95% CI, [-99.63, -38.34]. The heterogeneity of the data was moderate (P = 0.03) while the I2 estimate of the variance between the studies was 67%. According to our analysis, the difference between LH and OH was significant (P < 0.00001). LRN significantly decreases patients’ blood loss.

Figure 3 The forest plot for the operative blood loss between LRN and ORN group
Figure 3

The forest plot for the operative blood loss between LRN and ORN group

3.4 Meta-analysis of the post-operative length of hospital stay of LRN and ORN

The post-operative length of hospital stay is reported in three studies (Figure 4). Data from these 3 studies was analyzed in a random-effects model and the pooled OR was -3.55 (95% CI, [-5.62, -1.47]). The I2 estimate of the variance between the studies was 97% and P < 0.00001, which showed high heterogeneity. We performed a sensitivity analysis for included studies where we sequentially excluded each study from our meta-analysis. Using this approach, we found that heterogeneity was mainly caused by the studies of Xu 2014. Subsequently, the I2 estimate of the variance between the studies is 0% and P = 0.44, which showed low heterogeneity. According to our analysis, the operating time of between LRN and ORN was significant (P < 0.00001) and the post-operative length of hospital stay of LRN was less than ORN.

Figure 4 The forest plot for the post-operative length of hospital stay between LRN and ORN group
Figure 4

The forest plot for the post-operative length of hospital stay between LRN and ORN group

3.5 Meta-analysis of the postoperative complications of LRN and ORN

The postoperative complications are reported in four studies (Figure 5). Random-effects meta-analysis demonstrated that patients with LRN had higher postoperative complications compared with ORN (OR=0.52; 95% CI, [0.30, 0.91]). The I2 estimate of the variance between these studies was 27% and P = 0.25, which showed no significant heterogeneity. According to our analysis, the perioperative mortality of LRN was higher than ORN (P = 0.02).

Figure 5 The forest plot for the postoperative complications between LRN and ORN group
Figure 5

The forest plot for the postoperative complications between LRN and ORN group

4 Discussion

Open radical nephrectomy has a clear clinical effect and simple operation features. At the same time, it is accompanied by radical nephrectomy, which can easily damage blood vessels, cause massive hemorrhage, damage the pleura, cause postoperative infection and other complications. There are many layers of muscles that need to be cut off during surgery, and the wounds are long. Besides, every muscle layer needs stitches so that the recovery time is long. Compared with open radical nephrectomy, laparo-scopic radical nephrectomy has a very obvious advantage. The therapeutic effect of laparoscopic radical nephrectomy is similar to that of open radical nephrectomy, which avoids damage to blood vessels during surgery.

This study systematically analyzed the clinical effects of LRN and ORN. The operative time, operative blood loss, post-operative length of hospital stays and postoperative complications were selected in the laparoscopic radical nephrectomy group and the open radical nephrectomy group. Studies have shown that after surgery with LRN, the operation time, intraoperative blood loss, hospital stay were better than ORN (P < 0.05). In summary, LRN can safely and effectively remove renal tumors, which can achieve the same clinical effects as ORN.

Due to the development of partial nephrectomy, ablation and cryoablation, LRN is becoming less in the application of small renal cancer and small renal cell carcinoma [8]. With the continuous development of laparoscopic technology, the application range of LRN is expanding. For large size renal tumor, technical problems have also been raised for the application of LRN [9]. An increase in tumor volume will reduce the space for surgery, causing the corresponding lymph nodes to enlarge. The possibility of cancer rupture and the possibility of surgery to cause tumors to invade other organs are enhanced [10]. For these reasons, open radical nephrectomy is a technical challenge for larger tumor treatments. However, LRN has the advantages of sufficient operation space, clear anatomical landmark position and mature technology. In theory, the treatment of larger tumors is a more sensible choice. There should be a clear range for the size of the tumor to which the LRN is applied. Dunn et al reported that LRN can be selected for tumor size range <10 cm [11]. Hemal et al reported a tumor size range of 7 to 10 cm [12]. However, the extent of tumor size is not a factor in determining LRN use. Advances in laparoscopic techniques and increasing surgeon experience have helped to improve the adverse effects of LRN on larger kidney cancers.

Meta-analysis is based on existing literature for analysis, belonging to the second analysis, so the quality of the literature will affect the accuracy and objective of the analysis. This meta-analysis has the some shortcomings. Renal cancer surgery is a surgical procedure taken in view of the patient’s basic condition. There is no randomized and double-blind approach. However, the baseline level between the two groups is not statistically significant, and the level of surgery performed by the doctor at the same time will cause certain quality bias. The length of the study varies, especially in studies without long-term survival, some of which affect the accuracy of the analysis, and the data is a retrospective analysis. The length of the study varies, especially in studies without long-term survival, some of which affect the accuracy of the analysis. This meta-analysis cannot be further stratified from other possible confounding factors. The conclusions of this study need to be confirmed by more detailed data. Meta-analysis is not an experimental study, and publication bias may occur during the study, which is an inherent limitation of meta-analysis. Therefore, in order to obtain more scientific experimental results, large-sample, high-quality randomized controlled double-blind experiments are still needed to obtain high-quality evidence-based medical evidence.

  1. Funding: This work was supported by The National Science and Technology Major Project of the Ministry of Science and Technology of China (2017ZX09304015).

  2. Conflict of interest

    Conflicts of interest: The authors have no conflicts of interest to declare.

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Received: 2019-02-12
Accepted: 2019-04-17
Published Online: 2019-05-17

© 2019 Dong Wang et al., published by De Gruyter

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

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https://doi.org/10.1515/med-2019-0040
Keywords for this article
Laparoscopic radical nephrectomy; Open radical nephrectomy; Meta-analysis
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  6. Associations between ambient temperature and acute myocardial infarction
  7. Case Report
  8. Discontinuation of imatinib mesylate could improve renal impairment in chronic myeloid leukemia
  9. Research Article
  10. METTL3 promotes the proliferation and mobility of gastric cancer cells
  11. The C677T polymorphism of the methylenetetrahydrofolate reductase gene and susceptibility to late-onset Alzheimer’s disease
  12. microRNA-1236-3p regulates DDP resistance in lung cancer cells
  13. Review Article
  14. The link between thyroid autoimmunity, depression and bipolar disorder
  15. Research Article
  16. Effects of miR-107 on the Chemo-drug sensitivity of breast cancer cells
  17. Analysis of pH dose-dependent growth of sulfate-reducing bacteria
  18. Review Article
  19. Musculoskeletal clinical and imaging manifestations in inflammatory bowel diseases
  20. Research Article
  21. Regional hyperthermia combined with chemotherapy in advanced gastric cancer
  22. Analysis of hormone receptor status in primary and recurrent breast cancer via data mining pathology reports
  23. Morphological and isokinetic strength differences: bilateral and ipsilateral variation by different sport activity
  24. The reliability of adjusting stepped care based on FeNO monitoring for patients with chronic persistent asthma
  25. Comparison of the clinical outcomes of two physiological ischemic training methods in patients with coronary heart disease
  26. Analysis of ticagrelor’s cardio-protective effects on patients with ST-segment elevation acute coronary syndrome accompanied with diabetes
  27. Computed tomography findings in patients with Samter’s Triad: an observational study
  28. Case Report
  29. A spinal subdural hematoma induced by guidewire-based lumbar drainage in a patient with ruptured intracranial aneurysms
  30. Research Article
  31. High expression B3GAT3 is related with poor prognosis of liver cancer
  32. Effects of light touch on balance in patients with stroke
  33. Oncoprotein LAMTOR5 activates GLUT1 via upregulating NF-κB in liver cancer
  34. Effects of budesonide combined with noninvasive ventilation on PCT, sTREM-1, chest lung compliance, humoral immune function and quality of life in patients with AECOPD complicated with type II respiratory failure
  35. Prognostic significance of lymph node ratio in ovarian cancer
  36. Case Report
  37. Brainstem anaesthesia after retrobulbar block
  38. Review Article
  39. Treating infertility: current affairs of cross-border reproductive care
  40. Research Article
  41. Serum inflammatory cytokines comparison in gastric cancer therapy
  42. Behavioural and psychological symptoms in neurocognitive disorders: Specific patterns in dementia subtypes
  43. MRI and bone scintigraphy for breast cancer bone metastase: a meta-analysis
  44. Comparative study of back propagation artificial neural networks and logistic regression model in predicting poor prognosis after acute ischemic stroke
  45. Analysis of the factors affecting the prognosis of glioma patients
  46. Compare fuhrman nuclear and chromophobe tumor grade on chromophobe RCC
  47. Case Report
  48. Signet ring B cell lymphoma: A potential diagnostic pitfall
  49. Research Article
  50. Subparaneural injection in popliteal sciatic nerve blocks evaluated by MRI
  51. Loneliness in the context of quality of life of nursing home residents
  52. Biological characteristics of cervical precancerous cell proliferation
  53. Effects of Rehabilitation in Bankart Lesion in Non-athletes: A report of three cases
  54. Management of complications of first instance of hepatic trauma in a liver surgery unit: Portal vein ligation as a conservative therapeutic strategy
  55. Matrix metalloproteinase 2 knockdown suppresses the proliferation of HepG2 and Huh7 cells and enhances the cisplatin effect
  56. Comparison of laparoscopy and open radical nephrectomy of renal cell cancer
  57. Case Report
  58. A severe complication of myocardial dysfunction post radiofrequency ablation treatment of huge hepatic hemangioma: a case report and literature review
  59. Solar urticaria, a disease with many dark sides: is omalizumab the right therapeutic response? Reflections from a clinical case report
  60. Research Article
  61. Binge eating disorder and related features in bariatric surgery candidates
  62. Propofol versus 4-hydroxybutyric acid in pediatric cardiac catheterizations
  63. Nasointestinal tube in mechanical ventilation patients is more advantageous
  64. The change of endotracheal tube cuff pressure during laparoscopic surgery
  65. Correlation between iPTH levels on the first postoperative day after total thyroidectomy and permanent hypoparathyroidism: our experience
  66. Case Report
  67. Primary angiosarcoma of the kidney: case report and comprehensive literature review
  68. Research Article
  69. miR-107 enhances the sensitivity of breast cancer cells to paclitaxel
  70. Incidental findings in dental radiology are concerning for family doctors
  71. Suffering from cerebral small vessel disease with and without metabolic syndrome
  72. A meta-analysis of robot assisted laparoscopic radical prostatectomy versus laparoscopic radical prostatectomy
  73. Indications and outcomes of splenectomy for hematological disorders
  74. Expression of CENPE and its prognostic role in non-small cell lung cancer
  75. Barbed suture and gastrointestinal surgery. A retrospective analysis
  76. Using post transplant 1 week Tc-99m DTPA renal scan as another method for predicting renal graft failure
  77. The pseudogene PTTG3P promotes cell migration and invasion in esophageal squamous cell carcinoma
  78. Lymph node ratio versus TNM system as prognostic factor in colorectal cancer staging. A single Center experience
  79. Review Article
  80. Minimally invasive pilonidal sinus treatment: A narrative review
  81. Research Article
  82. Anatomical workspace study of Endonasal Endoscopic Transsphenoidal Approach
  83. Hounsfield Units on Lumbar Computed Tomography for Predicting Regional Bone Mineral Density
  84. Communication
  85. Aspirin, a potential GLUT1 inhibitor in a vascular endothelial cell line
  86. Research Article
  87. Osteopontin and fatty acid binding protein in ifosfamide-treated rats
  88. Familial polyposis coli: the management of desmoid tumor bleeding
  89. microRNA-27a-3p down-regulation inhibits malignant biological behaviors of ovarian cancer by targeting BTG1
  90. PYCR1 is associated with papillary renal cell carcinoma progression
  91. Prediction of recurrence-associated death from localized prostate cancer with a charlson comorbidity index–reinforced machine learning model
  92. Colorectal cancer in the elderly patient: the role of neo-adjuvant therapy
  93. Association between MTHFR genetic polymorphism and Parkinson’s disease susceptibility: a meta-analysis
  94. Metformin can alleviate the symptom of patient with diabetic nephropathy through reducing the serum level of Hcy and IL-33
  95. Case Report
  96. Severe craniofacial trauma after multiple pistol shots
  97. Research Article
  98. Echocardiography evaluation of left ventricular diastolic function in elderly women with metabolic syndrome
  99. Tailored surgery in inguinal hernia repair. The role of subarachnoid anesthesia: a retrospective study
  100. The factors affecting early death in newly diagnosed APL patients
  101. Review Article
  102. Oncological outcomes and quality of life after rectal cancer surgery
  103. Research Article
  104. MiR-638 repressed vascular smooth muscle cell glycolysis by targeting LDHA
  105. microRNA-16 via Twist1 inhibits EMT induced by PM2.5 exposure in human hepatocellular carcinoma
  106. Analyzing the semantic space of the Hippocratic Oath
  107. Fournier’s gangrene and intravenous drug abuse: an unusual case report and review of the literature
  108. Evaluation of surgical site infection in mini-invasive urological surgery
  109. Dihydromyricetin attenuates inflammation through TLR4/NF-kappaB pathway
  110. Clinico-pathological features of colon cancer patients undergoing emergency surgery: a comparison between elderly and non-elderly patients
  111. Case Report
  112. Appendix bleeding with painless bloody diarrhea: A case report and literature review
  113. Research Article
  114. Protective effects of specneuzhenide on renal injury in rats with diabetic nephropathy
  115. PBF, a proto-oncogene in esophageal carcinoma
  116. Use of rituximab in NHL malt type pregnant in I° trimester for two times
  117. Cancer- and non-cancer related chronic pain: from the physiopathological basics to management
  118. Case report
  119. Non-surgical removal of dens invaginatus in maxillary lateral incisor using CBCT: Two-year follow-up case report
  120. Research Article
  121. Risk factors and drug resistance of the MDR Acinetobacter baumannii in pneumonia patients in ICU
  122. Accuracy of tumor perfusion assessment in Rat C6 gliomas model with USPIO
  123. Lemann Index for Assessment of Crohn’s Disease: Correlation with the Quality of Life, Endoscopic Disease activity, Magnetic Resonance Index of Activity and C- Reactive Protein
  124. Case report
  125. Münchausen syndrome as an unusual cause of pseudo-resistant hypertension: a case report
  126. Research Article
  127. Renal artery embolization before radical nephrectomy for complex renal tumour: which are the true advantages?
  128. Prognostic significance of CD276 in non-small cell lung cancer
  129. Potential drug-drug interactions in acute ischemic stroke patients at the Neurological Intensive Care Unit
  130. Effect of vitamin D3 on lung damage induced by cigarette smoke in mice
  131. CircRNA-UCK2 increased TET1 inhibits proliferation and invasion of prostate cancer cells via sponge miRNA-767-5p
  132. Case report
  133. Partial hydatidiform mole and coexistent live fetus: a case report and review of the literature
  134. Research Article
  135. Effect of NGR1 on the atopic dermatitis model and its mechanisms
  136. Clinical features of infertile men carrying a chromosome 9 translocation
  137. Review Article
  138. Expression and role of microRNA-663b in childhood acute lymphocytic leukemia and its mechanism
  139. Case Report
  140. Mature cystic teratoma of the pancreas: A rare cystic neoplasm
  141. Research Article
  142. Application of exercised-based pre-rehabilitation in perioperative period of patients with gastric cancer
  143. Case Report
  144. Predictive factors of intestinal necrosis in acute mesenteric ischemia
  145. Research Article
  146. Application of exercised-based pre-rehabilitation in perioperative period of patients with gastric cancer
  147. Effects of dexmedetomidine on the RhoA /ROCK/ Nox4 signaling pathway in renal fibrosis of diabetic rats
  148. MicroRNA-181a-5p regulates inflammatory response of macrophages in sepsis
  149. Intraventricular pressure in non-communicating hydrocephalus patients before endoscopic third ventriculostomy
  150. CyclinD1 is a new target gene of tumor suppressor miR-520e in breast cancer
  151. CHL1 and NrCAM are primarily expressed in low grade pediatric neuroblastoma
  152. Epidemiological characteristics of postoperative sepsis
  153. Association between unstable angina and CXCL17: a new potential biomarker
  154. Cardiac strains as a tool for optimization of cardiac resynchronization therapy in non-responders: a pilot study
  155. Case Report
  156. Resuscitation following a bupivacaine injection for a cervical paravertebral block
  157. Research Article
  158. CGF treatment of leg ulcers: A randomized controlled trial
  159. Surgical versus sequential hybrid treatment of carotid body tumors
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