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ADULT UROLOGY

COMPARISON OF COSTS AND COMPLICATIONS OF RADICAL AND PARTIAL NEPHRECTOMY FOR TREATMENT OF LOCALIZED RENAL CELL CARCINOMA
BIJAN SHEKARRIZ, JYOTI UPADHYAY, HODJAT SHEKARRIZ, AZIZ GOES, JR, FERNANDO J. BIANCO, JR, RABI TIGUERT, E. GHEILER, AND DAVID P. WOOD, JR

ABSTRACT Objectives. To compare the complications and costs of radical and partial nephrectomy (PN) and to investigate the impact of increasing experience on costs and complications during a 7-year period. Nephronsparing surgery has found increasing applications in the past decade. PN has achieved similar long-term results in localized renal cell carcinoma with respect to cancer control compared with radical nephrectomy (RN). However, data are limited on the direct comparison of complications and hospital costs between these two modalities. Methods. A retrospective case-matched study was performed comparing 60 RNs and 60 PNs during a 7-year period with respect to complications and hospital costs. A longitudinal comparison was also performed between the various periods to assess the impact of surgical experience on these parameters. Results. The mean length of stay was 6.4 3 days in the RN group and 6.4 3.3 days in the PN group. The hospital costs were comparable between the two procedures during the observed interval. The mean operative time was 176.6 51.6 minutes for RN and 220.1 59.6 minutes for PN (P 0.0001). This difference was accentuated during the observed period. No differences were found in the blood loss and transfusion rates between the groups. The complication rate was 3.3% and 10% for RN and PN, respectively (P 0.2). Conclusions. Our data suggest that RN and PN can be performed with a similar rate of complications and comparable hospital costs. This is of practical importance when comparing these modalities as treatment options for localized renal cell carcinoma. UROLOGY 59: 211–215, 2002. © 2002, Elsevier Science Inc.

urgical management of localized renal cell carcinoma has experienced remarkable advances in the past two decades. Radical nephrectomy (RN), which was the treatment of choice for these tumors for many years, has been used in fewer patients, because of an increased acceptance of nephron-sparing surgery.1– 4 This was the consequence of advances in diagnostic methods, allowing early tumor detection, improvement in surgical technique, pre and postoperative patient management, and a general trend toward organ-sparing surgery. Incidentally found renal tumors are often of
From the Department of Urology, Wayne State University and Barbara Ann Karmanos Cancer Institute, Detroit, Michigan Reprint requests: David P. Wood, Jr., M.D., Department of Urology, Wayne State University, Harper Professional Building, 4160 John R, Suite 1017, Detroit, MI 48201 Submitted: March 20, 2001, accepted (with revisions): September 17, 2001 © 2002, ELSEVIER SCIENCE INC.
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lower grade and stage compared with those causing clinical symptoms, and patients who would otherwise become anephric after RN benefit from a surgical approach that preserves renal function. This is also true for patients who are at risk of losing the contralateral kidney because of other systemic or local diseases. The experience with nephron-sparing surgery has demonstrated the safety and efficacy of this approach. Several reports have demonstrated that the 5-year cancer-specific mortality rate is similar in patients undergoing RN or partial nephrectomy (PN) for localized, smaller than 4 cm, renal cell carcinoma (RCC).1– 4 That success has encouraged the application of nephron-sparing surgery for a larger population group, and some have advocated the use of nephron-sparing surgery for the treatment of patients with localized tumors, even in the presence of a normal contralateral kidney.5 With this form of treatment gaining popularity and
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T2 in 76 (63. it is essential to evaluate the costs and complications of this approach compared with RN.9 31/29 13 (21.6) 38 (63.1%) had papillary tumors. RESULTS The mean age in the RN and PN groups was 65 years (range 46 to 81) and 62 years (range 40 to 76). and no concomitant abdominal procedures. respectively (P value not significant). nursing personnel.6) 38 (63. operating room time. physician assistants. occupational and physical therapy. and nursing. which theoretically may pose additional postoperative costs and morbidity.3%). Patients with a previous history of abdominal surgery or radiation therapy.2 At least 0. had a future risk of impairment in 12 (20%). The professional fees for resident. and multifocal. and pathologic stage to 60 patients who underwent RN during the same interval. A statistical software program (Statistical Analysis System) was used for this analysis. sex.6 – 8 In a recent study. patients were divided into three groups according to time interval (1991 to 1992. The mean hospital cost was determined from the hospital database. and 17 (14.6) (56. Closed suction drains were used on all patients and removed when the output was less than 50 mL/day and proved not to be urine. charges for information systems and automatization. overhead. and intravenous technicians formed part of the complex equation of the fixed cost. operative time. pharmacy. The margins were evaluated immediately by frozen section. Numbers in parentheses are percentages. pathologic Stage T3a or less. which links the use of services during the patient encounter.8 2. the contralateral kidney was absent in 11 (18. radiology charges. The total cost was derived from the addition of the variable costs plus fixed costs. 1993 to 1994.8 cm in the PN group.46 28/32 13 (21. MATERIAL AND METHODS The medical records of all patients who underwent RN or PN between January 1991 and December 1997 at the Wayne State University and Karmanos Cancer Institute were analyzed.6) (31. and T3a in 18 (15%) of the 120 patients. nonfunctional in 6 (10%).3) 4. a longitudinal comparison was made during a 7-year period to evaluate whether increasing surgical experience is associated with a change in the complication rates or costs of the procedures. and normal in 31 (51. The fixed costs are billed to the patients through an algorithm used by the accounting software. and transportation. and pathologic stage. and if positive. These costs are directly proportional to the volume or occupation (beds) of the hospital at a particular time. intervention on the urinary system renders the patient susceptible to urinary fistulas. to evaluate the trend in surgical outcome. and meticulous dissection.6%). number of transfusions. surgery was done according to the principles described previously. The tumor characteristics are summarized in Table I.3%). The medical records were reviewed with regard to hospital length of stay. bilateral. but lymphadenectomy was not routinely performed. medications. sex. In the PN group. both procedures were associated with similar hospital costs and complication rates. The Pearson chi-square test was used to compare the differences between the groups with regard to various intraoperative and postoperative parameters.3) 9 (15) 4 34 19 3 (6.wider acceptance. medical record maintenance. We used the 1997 AJCC TNM classification. location and size of tumor. more parenchyma was resected. hereditary. Furthermore. Both groups had the same number in each pathologic stage. The histologic type was clear cell RCC in 92 (80%) of the 120 patients studied.2 1. The variable cost per encounter included room and board charges (hospital bed.2 cm in the RN group and 3. and complications related to the surgery occurring within 30 days of the intervention. This software calculates the cost back to the encounter based on the use of services. Most (69.7 This study was designed to compare the costs and complication rates between RN and PN for treatment of localized RCC. laboratory. RN was performed in the conventional manner. The groups were always matched for age.1%) of the tumors were grade I or II. ECLYPSIS was used. or metastatic disease were excluded. Patients were selected for RN or PN on the basis of the status of the contralateral kidney and surgeon preference. malpractice and other insurance. PN requires additional technical skills for complete mobilization of the kidney. A hospital software program. A total of 60 patients who had undergone PN and fulfilled these criteria were matched for age. Other less frequent tumors accounted for the rest of the cases. The mean tumor size was 4. Furthermore. Few studies have compared the costs and complications of these two modalities. Characteristics of tumors treated with partial and radical nephrectomy Parameters Mean tumor size (cm) Side (left/right) Pathologic stage T1 T2 T3a Tumor grade I II III IV (n PN 60) (n RN 60) 3. and 1995 to 1997). unless enlarged nodes were found.3) 9 (15) 14 31 13 2 (23) (51) (21) (3. STATISTICAL ANALYSIS The mean values were compared using the two-tailed t test. The professional fees (charges by the 212 TABLE I. Furthermore. Inclusion criteria for this study included a single renal tumor less than 7 cm in size. 2002 . Of the PN group. but other reports supporting this evidence are lacking.6) (5) KEY: PN partial nephrectomy. directly proportional to the length of stay).5 cm of healthy parenchyma was removed with the specimen. These services include utilities. The pathologic stage was T1 in 26 (21. RN radical nephrectomy. induction of organ hypothermia. An intraoperative pathology consultation is also necessary. A comparison of the surgical data between the UROLOGY 59 (2).6%) of the 60 patients studied. electrocardiography. location and size of tumor. attending) were billed directly from the practice and were not included. estimated blood loss.

9 However. In the PN group. a decrease was observed in the operative time for the RN group (195 minutes).16 mL for the PN group (P 0.36 days for the PN group (P 0.1 0.4 3.81 KEY: OR operating room.7 579. Data presented as the mean PN (n 60) RN (n 60) P Value 0.5 25.5 0. During the first period (1991 to 1992).877.004).978.96 0.7 363.4 650 187.9 2. the operative time was similar in both groups: 211.5 6. COMMENT PN has gained increasing popularity for localized RCC. The mean operative time showed significant differences between the two groups during the observed period.1–3.0001 0. One patient had a fatal pulmonary embolus and another had wound dehiscence.05).1 0.58 216.2 273.75 5. with a mean operating room time for the RN group of 176.5 minutes in the RN group and 225 minutes in the PN group (P 0. few studies have evaluated and compared the complications and economic implications of different treatment options for localized RCC. Comparison of operative parameters between radical and partial nephrectomy Parameters Operating time (min) Estimated blood loss (mL) Blood transfusion (mL) Hospital stay (days) Complications (n) Abbreviations as in Table I. Complications occurred in 2 patients in the RN group (Table II). and comparable cancer control has been demonstrated in several recent studies. This becomes even more important when perform213 . only one required stent placement.22 446. unless otherwise noted. The mean estimated blood loss was 506.57 466.64 0. TABLE III. hospital stay.1 59.750 19.743.9 39.4 3 6 (10) 176.5 U of packed red blood cells (813 mL) in the PN group (P 0.8 144. The length of stay and the costs for RN and PN did not UROLOGY 59 (2). EBL estimated blood loss.9 0.6 0.6 18.38 days for RN group and 6. LOS Data presented as the mean SD. Four patients (6%) required blood transfusions in the PN group and 11 (18%) did so in the RN group. These patients were treated conservatively.6 506.183.4 0. two groups is presented in Tables II and III.090.037 224 176 0.96). The length of stay was 6.05).6 305.5 20.9 176 403.58).759 20.8 1.9 0.6 6. Comparison of intraoperative parameters.5 812.2 220. the cost and hospital stay did not vary significantly along the total period of study (Table III).6 415.9 443.2 1.1 0. numbers in parentheses are percentages.6 51.468. unless otherwise noted.3 2 (3.1 962. This tendency was accentuated during the last period (1995 to 1997). and costs stratified by year Time Periods 1991–1992 PN (n 14) RN (n 14) P value 1993–1994 PN (n 24) RN (n 24) P value 1995–1997 PN (n 22) RN (n 22) P value OR Time (min) 225 91.4 0.7 384. However. length of hospital stay. after the 10th postoperative day.77 0.6 436.24 LOS (days) 6.6 6. Furthermore. it is crucial to present clinical data demonstrating such comparisons.05).29 2.7 0.004 EBL (mL) 367.TABLE II.3) SD. other abbreviations as in Table I.4 0.3 4.1 Overall Cost (USD) 19. defined as urine leakage at a rate of 50 mL/day or more. and 5 patients had urinary fistulas.55 18. 6 patients had surgery-related complications. and the operative time for the PN group remained stable (216.05).5 1.4 2.2 5.4 6.5 245.59 minutes compared with 224.91 mL for the RN group and 415.55 minutes for the PN group (P 0.211.6 153.6 195 30.3 211.8 0. The mean amount of transfused blood was 2 U of packed red blood cells (650 mL) in the RN group and 2.9 minutes) (P 0. One patient developed phlebitis of the lower limb.3 0.4 1.819 6.164. 2002 show any statistically significant differences in any of the observed periods (P 0. in the subsequent period (1993 to 1994).9 20.6 – 8 In an era of increased managed care and emphasis on cost-effective treatment.

et al: Efficacy of nephron-sparing surgery for renal cell carcinoma: analysis based on the new 1997 tumor-node-metastasis staging system. however.7 Uzzo et al. 6. Overall. we found no differences in the hospital costs between the two groups.10 With regard to blood transfusion rates. Furthermore.ing PN in patients with a normal contralateral kidney and no other absolute medical indications for nephron-sparing surgery. which contributed to the similar overall hospital costs. Becht E. REFERENCES 1. which was accentuated over the years. Hur K. The operative time showed a significant difference between the two groups. CONCLUSIONS The results of this study demonstrate that RN and PN can be performed with similar hospital costs and complication rates and that increasing surgical experience did not have an impact on the hospital costs. Stockle M. However. 2002 . indicating the efficiency of PN in the preservation of renal function. a comparative Veterans Affairs study did not demonstrate any difference in the transfusion rate in a large group of patients undergoing PN compared with RN. In our study. This complication was managed conservatively in most patients on an outpatient basis. 1992. The overall perioperative complication rate was similar to published data. One reason for this finding may be that the procedures were standardized and no technical modification was introduced during this period to result in improved patient recovery. One explanation for this finding is that RN can be performed in a more standardized fashion. Similarly.7 compared 28 RNs and 52 PNs and demonstrated that the hospital cost and complications were not significantly different in the two groups. Penson DF. but PN often poses different operative situations that may require frequent adaptations in surgical strategy. considering that most tumors were Stage T1 or T2 (85%). PN was performed in relatively larger tumors compared with previous studies. the blood transfusion rate was 18% in the RN group and 6% in the PN group. 1993. However. J Urol 148: 24 –30. 71% of their patients in the RN group had Stage T2 disease compared with 33% in the PN group. Overall. and this would also have an impact on the comparison of costs and complications of RN versus PN in the future. Corman JM. A shortcoming of this study was that it was not possible to assess the follow-up costs. techniques and results in 152 patients. resulting in a favorable outcome in our patients. this did not result in a longer hospital stay and thus did not increase the hospital course. In a recent comparison of RN and PN. In our study. 3.8 Urinary fistula is a known complication of PN. no difference was observed during a 7-year period. J Urol 149: 1–7. because this was not reported in the previous studies. Moll V. Uzzo et al. 1993.6 Similarly. was significantly smaller in the patients who underwent PN. No patients in the PN group needed dialysis postoperatively. The impact of a significant difference in transfusion rate on the hospital cost is unclear.009).8 The subsequent need for blood transfusion in patients undergoing RN for localized disease was 18% compared with 30% in those undergoing PN (P 0. With the recent introduction of laparoscopic RN for RCC. Additional studies are needed to investigate the impact of preoperative and postoperative management on the total cost of each modality of treatment. Only one previous study has evaluated the hospital costs of PN compared with RN. Tsui KH. Steinbach F. particularly in the larger tumors included in this study. because most patients were followed up by their referring physicians after surgical treatment. Belldegrun A. controversial results have been reported. the mean length of stay was 6 days in both groups. Licht MR. 1993. deKernion JB. No differences were found in the blood transfusion rates or number of transfused units between the two groups.10 Urine leak occurred in 10% of our patients. In con214 trast. 2. 5. Novick AC: Renal-sparing surgery for renal cell carcinoma.7. 1999. we matched the two groups with regard to tumor stage to avoid differences related to tumor size. and Ziegler M: Kidney preserving surgery in renal cell tumors: indications. et al: Conservative surgery of renal cell tumors in 140 patients: 21 years of experience. This was due to the decreasing operative time in the RN group with time. for which follow-up is the same as for RN. the standard of care is changing. 4. the estimated blood loss was higher in patients undergoing nephron-sparing surgery. Urol Clin North Am 20: 277–282. The only fatal complication was a pulmonary embolism in 1 patient after RN. it is likely that the postoperative management does not contribute to a cost increase in the PN group. which was not accompanied by a similar decrease in time in the PN group. which would be reflected in the length of hospital stay and costs. J Urol 150: 319 –323. and Novick AC: Nephron sparing surgery for renal cell carcinoma. The tumor size. in our study. J Clin Oncol 17: 2868 –2875.7 reported that the length of hospital stay was a strong predictor of total costs and tumor stage and size did not have an impact on the total cost and length of stay by multivariate analysis. Muller SC. The length of hospital stay and costs were not different from 1991 to 1997. et al: Comparison of UROLOGY 59 (2).

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