Background:
Adoption of laparoscopy in Urology has become widespread with broadening of indications concurrent with increasing experience. In terms of laparoscopic radical nephrectomy, larger tumor sizes, patients with greater numbers of comorbidities unable to tolerate major surgery, and increasingly technically challenging tumor conditions have become commonplace. The breakpoint at which benefit versus harm occurs between a time-limited, relatively morbid open surgical approach versus a prolonged minimally invasive procedure has not been defined. We undertook a retrospective review of open versus laparoscopic nephrectomy procedures stratified by American Society of Anesthesiology (ASA) perioperative risk score.
Methods:
All laparoscopic and open simple and radical nephrectomy procedures were reviewed between two urologic surgeons (PL and JI) over a 2 year period between 09/2002 and 12/2004. Fifty laparoscopic and 35 open nephrectomies were undertaken within the study period. A retrospective chart review was undertaken to document patient demographics, surgical indications, perioperative parameters and post surgical outcomes. Inclusion criteria restricted patients to ASA 3 or 4 for the purposes of the study.
Results:
No significant differences were observed in demographic parameters between laparoscopic and open nephrectomy procedures including; patient age, gender, serum creatinine, body mass index and laterality of procedure. Equal distribution of high category ASA (3+4) patients were found between laparoscopic and open groups. Estimated blood loss and operative duration were not significantly different at 155.3mL vs 283.3mL (p>0.05) and 268.1min vs 217.5min (p>0.05) respectively. Intraoperative complications were classified as 2 major and 2 minor in the open group compared to 0 major and 2 minor complications in the laparoscopic group. Similarly, 2 major and 3 minor complications were found in the open group versus 2 major and 1 minor complications with a laparoscopic approach. Postoperative parameters significantly different analyses was length of stay; lap/open, 5.1/11.7 days (p=0.0017) and analgesic requirements; lap/open 83/176 mg (p=0.01).
Conclusions:
In high risk surgical patients as categorized by ASA scores greater than 3, laparoscopic nephrectomy is a viable alternative to open surgical approaches. No significant differences were noted in intraoperative and postoperative parameters other than total length of hospital stay and narcotics required for pain control. This study confirms the fact that a laparoscopic approach to high risk patients is safe and efficacious
compared to open procedures in similar populations and that these patients tolerate these procedures with comparable complication rates while enjoying the established benefits of less postoperative morbidity and earlier return to routine life.

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