Surgical management of low-stage renal cell carcinoma: Technology does not supersede biology

Objectives. To address the concern that laparoscopic radical nephrectomy (LRN) is being applied in cases of small renal masses in which nephron-sparing surgery (NSS) might be more appropriate. Methods. From 1998 to 2003, 381 consecutive patients underwent 391 procedures at our institution for renal cell carcinoma, of which 336 were for organ-confined tumors. The temporal trends in the application of LRN and NSS were assessed relative to the clinical stage. Results. During the transition from early (1998 to 2000) to late (2001 to 2003) experience with laparoscopy, the use of LRN among patients with Stage T1a (4 cm or smaller) lesions remained infrequent (21% and 20%, respectively). In contrast, LRN increased among patients with larger lesions during this same interval (Stage T1b, 36% versus 56%, P = 0.017 and Stage T2, 24% versus 41%, P = 0.056). Concurrently, the use of NSS (open surgical or laparoscopic partial nephrectomy) increased for both Stage T1a (25% and 31% versus 34% and 37%, P = 0.082) and T1b (8% and 6% versus 19% and 5%, P = 0.017) tumors. Multivariate analysis demonstrated that the use of both NSS and LRN increased significantly with time (P = 0.002 and P = 0.001, respectively). Neither NSS nor LRN were associated with a greater risk of perioperative complications relative to radical or open surgery (P > 0.05 for both). Conclusions. During a 6-year period at our institution, most Stage T1 a lesions were managed with NSS, and a significant increase occurred in the use of NSS for Stage T1b tumors, despite the concurrent increasing application of LRN. These findings suggest that oncologic, rather than technologic, concerns were determining our practice patterns.