Open partial nephrectomy is the gold standard approach for small renal masses (SRM). A study comparing 100 patients who underwent laparoscopic partial nephrectomy (Lap) to 100 who underwent open partial nephrectomy (Open) found that despite tumors being significantly larger in the Open group, ischemia time was significantly shorter in Open. Intraoperative complications were nil in Open but 5% in Lap. Lap had significantly prolonged ischemia time and more postoperative complications, though operative time was shorter. While outcomes were comparable, the learning curve for Lap is very long and it is relatively contraindicated for complex cases.

1. Partial nephrectomy for SRM

2. Open partial nephrectomy
• Open partial nephrectomy is the gold
standard approach for SRM.

3. functional &Oncological
outcome
• Lap.Vs open partial nephrectomy
- Gill IS,Matin,Desai, et al;J Urol. 2003
- 200 cases( 100 in each arm.)

4. Lap.Vs open partial nephrectomy
Item Lap. Open P value
No. of pts. 100 100
Med. Tumor
size.
2.8 cm 3.3 cm 0.005
Solitary kidney 7 28 0.001
Central tumor 35% 33% 0.83
Med.Preop.
Creatinine
1.0 mg/dL 1.0 mg/dL

5. Lap.Vs open partial nephrectomy
Item Lap. Open P value
Warm ischemia
time
28 min 18 min < 0.001
Intraop. Comp. 5% 0% 0.02
+ surgical
margin
3 0 0.11

6. Lap.Vs open partial nephrectomy
• Despite the tumor size was significantly
larger in open group, the ischemia time
was highly significant shorter in the open
group .
• The intraoperative complication was nil in
the open group.

7. functional &Oncological
outcome

8. functional &Oncological
outcome
• It shows significant prolonged ischemia time in lap
groups (p<0.0001)
• Significant more post operative complication .
p<0.001
• Although the operative time was less in lap groups,
but it the open group show significant difference in
the percent of high risk pts (tumor size, site, single
kidney)p<0.001

9. functional &Oncological
outcome

10. functional &Oncological
outcome
• Although comparable outcome ,but
ischemia time was significant longer
• An important points is the learning
curve which was too long
• In the non-experienced hands the result
will be worse in the lap groups

11. Learning curve
• The lap NSS is difficult procedure to
master and need long time learning
curve.
• It should be for exophytic non hilar
lesion.

12. Hilar tumor
 Increase complication rate with up to
50% of pts have urinary leak and up to
7% of pts have positive surgical
margin.
Venkatesh et al 2005

13. Solitary kidney
In solitary kidney:
The GFR decreased by 21% and 28% in the open
and laparoscopic groups, respectively (P = 0.24).

14. Solitary kidney
• Postoperative dialysis was required acutely in
0.6% of OPNs versus 10% of LPN (P = 0.01)
• Dialysis-dependent end-stage renal failure
within 1 year occurred in 0.6% of OPN versus
6.6% of LPNs (P = 0.06).

15. LAP limitation
- LAP is contraindicated in :
I. Ischemic heart disease
II. End stage respiratory disease
III. Significant renal dysfunction
IV. Severe un corrected hypovolaemia
Burns EM et al 2010

16. LAP limitation
- LAP is contraindicated in :
I. Uncorrected coagulopathy
II. Intestinal obstruction
III. Massive haemopretoneum
IV. Peritonitis and malignant ascites.
Burns EM et al 2010

17. LAP limitation
- LAP is relatively contraindicated in :
I. pregnancy
II. Morbid obesity
III. Previous renal surgery
IV. Organomegaly
Burns EM et al 2010

18. • The 2D vision:
• The lack of depth perception is a significant sensory
loss for the surgeon.
• The learning curve is long.
• The 3D version is limited due to cost.

19. port site metastasis

20. Why open? Why not lap?
• It has the best oncologic and functional
outcome.
• It is the best choice in more complex
tumor.
• The ischemia time was lower than lap.
• It overly the difficulties encountered in
any lap surgery.