- Email: [email protected]
Laparoscopic Partial Nephrectomy in Octogenarians
Laparoscopy and Robotics Laparoscopic Partial Nephrectomy in Octogenarians Anil A. Thomas, Monish Aron, Adrian V. Hernandez, Brian R. Lane, and Inderbir S. Gill OBJECTIVES
METHODS
RESULTS
CONCLUSIONS
To assess the safety and technical feasibility of laparoscopic partial nephrectomy in patients aged ⱖ80 years at our institution to determine whether this treatment modality may be justifiable in select octogenarians. As the US population ages, an increasing number of elderly patients with renal masses are considered for partial nephrectomy. We present our experience with laparoscopic partial nephrectomy in octogenarians to determine the safety and technical feasibility of this procedure in an elderly population. Between 1999 and 2007, we reviewed 832 patients who underwent laparoscopic partial nephrectomy for renal tumors at our institution. Demographics, perioperative data, and renal function of patients aged ⱖ80 years were compared with younger patients. A total of 791 patients aged ⬍80 years (median 59, range 17-79) and 41 patients aged ⱖ80 years (median 82, range 80-88) underwent laparoscopic partial nephrectomy. In comparison with patients aged ⬍80 years, octogenarians had higher overall American Society of Anesthesiology (P ⫽ .002) and Charlson Comorbidity Scores (P ⫽ .006) with an increased incidence of chronic kidney disease (P ⫽ .008); however, intraoperative and postoperative complications were similar between the groups (P ⫽ .3, P ⫽ .5). Despite a lower preoperative glomerular filtration rate in the octogenarian group (median 68 vs 82, P ⬍.0001), the overall decline in glomerular filtration rate between age groups was not significantly different (P ⫽ .7). Laparoscopic partial nephrectomy can be performed safely in appropriately selected patients aged ⱖ80 years, with rates of perioperative morbidity similar to those observed in younger patients. On the basis of our data, age alone should not be a contraindication to laparoscopic partial nephrectomy. UROLOGY 74: 1042–1048, 2009. © 2009 Elsevier Inc.
A
dvancing age is one of the most significant risk factors for renal cell carcinoma (RCC). Most cases of kidney cancer are diagnosed in individuals aged ⬎65 years, with the highest incidence in the age group of 75-85 years(56/100 000).1,2 Furthermore, the US population is aging rapidly and octogenarians are the fastest growing segment of this population.3 Combined with a rising incidence of RCC and an aging population, urologists are facing a growing demand for the treatment of kidney cancer in the elderly population. Nephron-sparing surgery has become an established treatment modality to preserve renal function while maintaining equivalent oncological efficacy for the management of small renal masses. Indications for partial nephrectomy have expanded to include patients with low-stage, localized RCC with normal contralateral kidneys as patients undergoing radical (vs partial) nephrectomy have increased rates of chronic kidney disease after
From the Section of Laparoscopic and Robotic Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio Reprint requests: Inderbir S. Gill, M.D., Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, 9500 Euclid Ave, A100, Cleveland, OH 44195. E-mail: [email protected] Submitted: December 2, 2008, accepted (with revisions): April 14, 2009
1042
© 2009 Elsevier Inc. All Rights Reserved
surgery.4,5 Additionally, a direct correlation between chronic renal dysfunction and an increased risk of cardiovascular events and mortality has been observed, which is especially significant in the elderly population.6 Recently, laparoscopic partial nephrectomy (LPN) has emerged as a viable treatment option for localized renal masses in select patients, demonstrating equivalent oncological efficacy and renal function preservation with shortened postoperative recovery in comparison with open surgery.7,8 Whether the benefits of LPN extend to the elderly population remains unknown and studies assessing the effect of minimally invasive surgery in this population are limited. Older patients are thought to have greater perioperative morbidity and mortality from surgery in comparison with their younger counterparts, in part because of physiological changes and increased medical comorbidities. Furthermore, treatment options for the elderly people are often influenced by clinician biases, patient preferences, or from the lack of study in this elderly age group.9 In the present study, we assessed the safety and technical feasibility of LPN in patients aged ⱖ80 years at our institution to determine whether this treatment modality may be justifiable in select octogenarians. 0090-4295/09/$34.00 doi:10.1016/j.urology.2009.04.099
180 160
Total cases
140 120 100
≥ 80 years
80
< 70 years
60 40 20 0 1999
2000
2001
2002
2003
2004
2005
2006
2007
Year
Figure 1. Annual distribution of patients undergoing laparoscopic partial nephrectomy at the Cleveland Clinic.
MATERIAL AND METHODS Between 1999 and 2007, we retrospectively reviewed the records of patients who underwent LPN at our institution for the management of renal tumors (Fig. 1). Patients with radiographic evidence of enhancing solid or cystic renal masses suspicious for neoplasms were included. Percutaneous renal mass biopsies were not routinely performed and all imaging was reviewed by radiologists at our institution. All patients selecting LPN were counseled regarding available treatment options including active surveillance, laparoscopic and open partial nephrectomy, radical nephrectomy, and tumor ablation. Patients were then carefully screened and evaluated by a multidisciplinary team involving urologists, internists, and anesthesiologists to identify preoperative risk factors and to optimize performance status before surgery. LPN was performed as described previously.10 Briefly, our surgical techniques included transient en bloc renal hilar control, real-time laparoscopic contact ultrasonography, tumor excision with cold scissors, sutured reconstruction of the pelvicaliceal system, and sutured hemostatic renal parenchymal reapproximation. Histopathologic review of all specimens was performed by a genitourinary pathologist to determine histologic diagnosis, surgical margins, and stage. Perioperative complications were classified into intraoperative or postoperative complications, with attention to previously established criteria.8,11 Postoperative complications were further categorized into urological (hemorrhage and urine leak) or nonurological (cardiac, gastrointestinal, pulmonary, thromboembolic, incisional, or other) complications. Perioperative mortality was defined as in-hospital death or death within 30 days of surgery. The glomerular filtration rate (GFR) was calculated using the modification of diet in renal disease formula preoperatively and at a mean of 11 months postoperatively. The distribution of categorical variables in both groups was compared with Fisher exact tests and continuous variables were analyzed using the Wilcoxon rank sum tests when appropriate. Statistical significance was assessed on the basis of a 2-sided significance level of 0.05. We used S-Plus 7.0 (Insightful, WA) for all statistical analyses.
RESULTS During the 9-year period in this study, 832 patients underwent LPN for renal tumors. A total of 791 patients aged ⬍80 years (range 17-79) and 41 patients aged ⱖ80 years (range 80-88) underwent LPN (Table 1). LPN was performed by 5 operating urologists, with 1 surgeon performing 78% of all cases (I. G.). Comorbidities were UROLOGY 74 (5), 2009
higher in octogenarian patients, with higher overall American Society of Anesthesiology scores (P ⫽ .002) and Charlson Comorbidity Index Scores (P ⫽ .006). The indication for nephron-sparing surgery was imperative or absolute in 76% of patients aged ⱖ80 years, compared with 54% of younger patients (P ⫽ .02). Perioperative data are presented in Table 2. The octogenarian patient group was comparable with that of younger patients in terms of mean operating time, transfusion rates, and open conversion rates. However, the median estimated surgical blood loss (200 vs 150 mL, P ⫽ .04) and the duration of hospital stay (93 vs 68 hours, P ⬍.0001) were increased in the octogenarian group. In the entire LPN series, mortality within 30 days of surgery was 0% for the octogenarians and a single perioperative death occurred in the younger patient cohort. A 64-yearold woman, without known coronary artery disease, died 6 days after an uncomplicated LPN from a massive myocardial infarction. It is important to note that although octogenarians had increased preoperative comorbidity, intraoperative (2% vs 6%, P ⫽ .3) and postoperative complications (30% vs 25%, P ⫽ .5) were not significantly higher in this elderly patient group. Overall, 34 (4%) and 2 (5%) secondary procedures, including ureteral stent placement, angioembolization, reoperation for hemorrhage, or nephrectomy were performed to manage postoperative complications for the younger and older patient groups, respectively (P ⫽ .8). Postoperative hemorrhage occurred in 7% of patients in each age group. Conservative management including bed rest and transfusion was used to manage postoperative bleeding in 1 octogenarian (50%) and in 24 patients (65%) in the younger patient group, whereas angioembolization or nephrectomy was used in the remaining cases. Postoperative urine leakage occurred in 3% of the younger age group and in 7% of octogenarian patients. The presence of RCC detected in pathologic specimens was similar between the younger and octogenarian groups (74% vs 61%, P ⫽ .5), with a low incidence of advanced pathologic stage (⬎T1) in both groups (2% vs 0%). However, the distribution of histologic subtypes differed in the older and younger patient groups, with clear cell RCC representing 32% and 47% of overall tumors, respectively. Despite an overall higher preoperative serum creatinine and lower estimated GFR in octogenarians, no significant difference in the change in renal function between groups was observed (Table 3). The median postoperative GFR in the 2 groups was 54 and 66 mL/ min/1.73 m2, representing a 21% (IQR) decline in GFR relative to pre-LPN levels for both octogenarians and younger patients, respectively (P ⫽ .7).
COMMENT With an aging population and an increasing incidence of renal tumors, a greater number of elderly patients are presenting for the management of renal masses. Clini1043
Table 1. Clinical and pathological data regarding patients undergoing laparoscopic partial nephrectomy for renal tumors Total (n ⫽ 832)
Characteristics Median age, years (IQR) No. males (%) Mean BMI (kg/m2) (SD) Median ASA score (IQR) No. ASA score ⱖ3 (%) Charlson comorbidity score (IQR) No. score ⬎1 (%) Comorbidities No. hypertension No. diabetes No. solitary kidney (%) Indication Absolute (solitary, bilateral, GFR ⬍45) Imperative (DM, HTN, GFR 45-60) Elective No. right side (%) Median clinical tumor size, cm (IQR) No. clinical stage T1b or greater (⬎4 cm) (%) No. renal pathological diagnosis (%): Conventional renal cell carcinoma Other cancer (ie, papillary RCC, chromophobe RCC, etc.) Benign kidney findings No. pathologic stage ⬎T1 (%)
LPN in Patients ⬍80 y (n ⫽ 791)
LPN in Patients ⱖ80 y (n ⫽ 41)
P
82 (80-83) 29 (71) 25.7 (2.9) 3 (3-3) 27 (75) 1 (0-2) 12 (29)
⬍.00001 .1 .0001 .002 .001 .006 .022
24 (63) 7 (18) 4 (10)
.046 .5 .07 .02
60 (51-69) 502 (60) 29.1 (5.9) 2 (2-3) 339 (48) 0 (0-1) 126 (15)
59 (50-67) 473 (60) 29.3 (6.0) 2 (2-3) 312 (47) 0 (0-1) 114 (14)
339 (47) 102 (14) 33 (4)
315 (46) 95 (14) 29 (4)
113 (14) 321 (41) 357 (45) 454 (55) 2.6 (2.0-3.5) 111 (13)
105 (14) 298 (40) 347 (46) 430 (54) 2.6 (2.0-3.5) 105 (13)
381 (46) 232 (28)
368 (47) 220 (28)
13 (32) 12 (29)
218 (26) 15 (2)
202 (26) 15 (2)
16 (39) 0
8 (20) 23 (56) 10 (24) 24 (59) 2.8 (2.2-3.5) 6 (15)
.6 .1 .8 .1
1.0
IQR indicates interquartile range; ASA ⫽ American Society of Anesthesiology.
Table 2. Perioperative data on patients undergoing laparoscopic partial nephrectomy for renal tumors Characteristic
Total (n ⫽ 832)
LPN in Patients ⬍80 yr (n ⫽ 791)
LPN in Patients ⱖ80 yr (n ⫽ 41)
Transperitoneal approach (%) Median operative time (min) (IQR) Median estimated blood loss (mL) (IQR) Median warm ischemia time (min) (IQR) ⬎1 U of blood transfused (%) Conversion to open (%) Median hospital stay (h) (IQR) Mortality (30 d) Intraoperative complications (%) Postoperative complications (%) Hemorrhage Urinary leak Nonurological complications Reoperation/secondary procedure
634 (76) 210 (180-240) 200 (100-300) 30 (21-36) 28 (4) 7 (2) 71 (58-95) 1 48 (6) 148 (25) 39 (7) 19 (3) 90 (15) 36 (4)
600 (76) 210 (180-240) 150 (100-300) 30 (21-36) 26 (4) 7 (3) 68 (48-91) 1 47 (6) 139 (25) 37 (7) 16 (3) 86 (16) 34 (4)
34 (83) 240 (203-300) 200 (180-300) 22 (14-32) 2 (6) 0 93 (68-120) 0 1 (2) 9 (30) 2 (7) 3 (10) 4 (13) 2 (5)
P .3 .3 .04 .005 .6 .5 ⬍.0001 1.0 .3 .5
.8
IQR indicates interquartile range.
cians should consider factors such as life expectancy, comorbidities, and the expected morbidity from surgery when counseling patients, regarding available treatment options. Furthermore, minimizing surgically induced renal dysfunction by using a nephron-sparing approach may prevent cardiovascular-related morbidity and mortality on the basis of well-established association of chronic kidney disease with these endpoints.4,6 Nephron-sparing surgery has been demonstrated to have equivalent oncological efficacy to radical nephrectomy, with a decreased risk of subsequent renal failure.5,12,13 Although several studies have demonstrated that laparoscopic radical nephrectomy is well tolerated in the elderly people,14-17 outcomes of LPN in this population are limited. 1044
In this retrospective single-center experience, we demonstrate that LPN is both safe and feasible in select patients aged ⱖ80 years, with similar perioperative outcomes to those observed in younger patients. Octogenarian patients were a higher-risk group defined by their age, increased median American Society of Anesthesiology scores, greater Charlson Comorbidity Scores, and decreased baseline renal function. Although octogenarians had increased estimated blood loss, the perioperative complication rates were not significantly different between the groups. Additionally, most complications were minor and were managed conservatively without significant sequelae, and perioperative complication rates for both groups were also comparable with similar surgical UROLOGY 74 (5), 2009
Table 3. Effect of LPN on renal function Characteristic
Total (n ⫽ 832)
LPN in Patients ⬍80 yr (n ⫽ 791)
LPN in Patients ⱖ80 y (n ⫽ 41)
P
Median preoperative serum creatinine (IQR) Median postoperative serum creatinine (IQR) Median preoperative GFR (IQR) Median postoperative GFR (IQR) Median % decrease in GFR (IQR) No. pts. with ⱖstage 3 chronic kidney disease (%) (GFR ⬍60 mL/min/1.73 m2) No. patients with stage 5 chronic kidney disease or dialysis (%) (GFR ⬍15 mL/min/1.73 m2) Preoperative Postoperative No. patients with ⱖ2 stage upgrading in chronic kidney disease stage (%)
0.9 (0.8-1.1) 1.3 (0.9-1.4) 82 (68-97) 66 (50-80) ⫺21 (⫺33; ⫺7) 113 (14)
0.9 (0.8-1.1) 1.1 (0.9-1.4) 82 (69-97) 66 (50-80) ⫺21 (⫺33; ⫺2) 101 (13)
1.1 (0.9-1.3) 1.3 (1.1-1.7) 68 (56-85) 54 (41-66) ⫺21 (⫺35; ⫺10) 12 (29)
.01 .008 ⬍.0001 .001 .7 .008
0 9 (1) 49 (6)
0 9 (1) 47 (6)
0 0 2 (5)
— .5 .7
IQR indicates interquartile range.
series of LPN.8,16 It is important to note that no perioperative deaths occurred in the octogenarian patient group with only 1 perioperative mortality in the entire LPN series. The median length of hospital stay was greater for octogenarians; however, this value remains lower than the average length of hospital stay for all ages of patients undergoing open partial nephrectomy in other studies.8 Finally, despite a greater percentage of elderly patients with solitary kidneys in this study (10% vs 4%, P ⫽ .07) and a lower preoperative GFR, the preservation of renal function (as determined by change in estimated GFR) was similar in both age groups. Small renal masses encompass a heterogeneous group with varied clinical outcomes.18 Most patients in the present study had low T-stage tumors and 39% of octogenarians were found to have benign renal masses on final pathologic analysis. This large proportion of benign pathologic findings in octogenarian patients lends further support for the conservative management of small renal masses in select elderly patients. It is important to note that all patients in the current study were offered various treatment options including active surveillance; however, these patient groups elected LPN. Further studies evaluating the natural history of small renal masses in the elderly with an assessment of the role of percutaneous renal mass biopsy will also be useful to guide clinical decision-making in this population. There are several limitations to the present study. First, in this retrospective, nonrandomized review, biases likely play a significant role in the selection of patients to undergo LPN compared with other options. Nevertheless, we feel that the current series demonstrates that with careful patient selection, LPN can be performed safely in older patients and with comparable perioperative morbidity to that expected with younger patients. Comparisons between LPN and other nephron-sparing approaches, such as open partial nephrectomy, cryosurgical ablation, and radiofrequency ablation, with an evaluation of survival and quality of life measures, would further enhance our knowledge of the effect of surgery in octogenarians; but this is beyond the scope of the present study. UROLOGY 74 (5), 2009
CONCLUSIONS Although active surveillance continues to be a valid consideration for many elderly patients, LPN for the management of renal tumors is safe and feasible in select patients aged ⱖ80 years. Medical decision-making for elderly patients with renal tumors must take into account oncological risks, competing medical comorbidities, as well as the predicted life expectancy of the individual patient. Given that renal dysfunction is associated with an increased likelihood of cardiovascular events and mortality, the impetus to use nephron-sparing surgery should not be avoided in elderly patients. Advanced age alone should not be a contraindication for curative surgery, and properly selected patients can benefit from similar advantages of laparoscopic surgery as their younger counterparts. References 1. SEER surveillance, epidemiology, and end results. National Cancer Institute, United States National Health Institutes of Health. Available at http://www.census.gov/ipc/www/usinterimproj. 2. Kader AK, Tamboli P, Luongo T, et al. Cytoreductive nephrectomy in the elderly patient: the M. D. Anderson Cancer Center experience. J Urol. 2007;177:855-860; discussion:860-861. 3. Hem W, Sengupta M, Velkoff V, et al. Current population reports: special studies. 65⫹ in the United States; 2005. Washington, DC: U.S. Census Bureau, 2005. 4. Huang WC, Levey AS, Serio AM, et al. Chronic kidney disease after nephrectomy in patients with renal cortical tumours: a retrospective cohort study. Lancet Oncol. 2006;7:735-740. 5. Lau WK, Blute ML, Weaver AL, et al. Matched comparison of radical nephrectomy vs nephron-sparing surgery in patients with unilateral renal cell carcinoma and a normal contralateral kidney. Mayo Clin Proc. 2000;75:1236-1242. 6. Go AS, Chertow GM, Fan D, et al. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med. 2004;351:1296-1305. 7. Lane BR, Gill IS. 5-Year outcomes of laparoscopic partial nephrectomy. J Urol. 2007;177:70-74; discussion:74. 8. Gill IS, Kavoussi LR, Lane BR, et al. Comparison of 1800 laparoscopic and open partial nephrectomies for single renal tumors. J Urol. 2007;178:41-46. 9. Dale DC. Poor prognosis in elderly patients with cancer: the role of bias and undertreatment. J Support Oncol. 2003;1:11-17.
1045
10. Gill IS, Desai MM, Kaouk JH, et al. Laparoscopic partial nephrectomy for renal tumor: duplicating open surgical techniques. J Urol. 2002;167:469-467; discussion:475-476. 11. Campbell SC, Novick AC, Streem SB, et al. Complications of nephron sparing surgery for renal tumors. J Urol. 1994;151:1177-1180. 12. Fergany AF, Hafez KS, Novick AC. Long-term results of nephron sparing surgery for localized renal cell carcinoma: 10-year follow up. J Urol. 2000;163:442-445. 13. Lee CT, Katz J, Shi W, et al. Surgical management of renal tumors 4 centimetres or less in a contemporary cohort. J Urol. 2000;163: 730-736. 14. Hsu TH, Gill IS, Fazeli-Matin S, et al. Radical nephrectomy and nephroureterectomy in the octogenarian and nonagenarian: comparison of laparoscopic and open approaches. Urology. 1999;53: 1121-1125. 15. Varkarakis I, Neururer R, Harabayashi T, et al. Laparoscopic radical nephrectomy in the elderly. BJU Int. 2004;94:517520. 16. Matin SF, Abreu S, Ramani A, et al. Evaluation of age and comorbidity as risk factors after laparoscopic urological surgery. J Urol. 2003;170:1115-1120. 17. Staehler M, Haseke N, Stadler T, et al. Renal surgery in the elderly: morbidity in patients aged ⬎75 years in a contemporary series. BJU Int. 2008;102:684-687. 18. Lane BR, Samplaski MK, Herts BR, et al. Renal mass biopsy—a renaissance? J Urol. 2008;179:20-27.
EDITORIAL COMMENT The current manuscript demonstrates that laparoscopic partial nephrectomy can be performed safely in octogenarians. However, it must be noted that the authors represent extremely talented and experienced laparoscopic surgeons and are considered pioneers in the field of laparoscopic renal surgery. Although it is doubtful that these findings can be generalized to all practicing Urologists, the manuscript details several critical concepts in the contemporary management of renal tumors, including proper patient selection, preservation of renal function, and limiting treatment-associated morbidity. The presented findings should not be surprising for patients of any age if appropriate selection criteria are used. Although not the focus of the current manuscript, an interesting analysis by evaluating factors influencing treatment decisions and outcomes of all octogenarians diagnosed with renal tumors would be valuable, as not all octogenarians will be appropriate surgical candidates. Although laparoscopic partial nephrectomies have been associated with a higher complication rate as compared with open partial nephrectomies, the complication rate in the current series was low.1 In addition to performing minimally invasive surgery in a challenging patient population, the authors appropriately treated the small renal tumors with a nephron-sparing approach and documented preservation of renal function. Regardless of the treatment modality used, potential treatment-related morbidity must be considered given the observed indolent behavior in most small renal tumors during active surveillance. This is especially relevant to the current series, in which 39% of patients were discovered to have benign pathology after partial nephrectomy. Alternatives to immediate extirpative therapy include planned intervention pending a percutaneous biopsy or delayed intervention after a period of observation. With the improved accuracy and limited morbidity of percutaneous renal tumor biopsies, there has been a renewed interest in their potential application, especially in elderly 1046
patients with multiple commodities.2 Despite the improvements in biopsy outcomes, routine application is still not generally accepted or used. The outcomes of delayed treatment of renal tumors after an initial period of observation have recently been reported. In the largest series to date of 87 patients with cT1a renal tumors, treatment options after a period of observation were not altered and a low rate of pathologic upstaging was noted.3 An additional report focusing on laparoscopic partial nephrectomy suggests that a period of active surveillance did not significantly affect the type of treatment, treatment-associated morbidity, or early oncological outcomes. Although delayed intervention after a period of observation may not alter treatment choice or patient outcome, the clinical and radiographic thresholds for intervention have yet to be defined or validated.4 The authors have demonstrated, with appropriate patient selection, a balance between minimally invasive surgery and preservation of renal function can be achieved in an elderly population with minimal complications. Future development and application of alternative treatment algorithms may limit extirpative surgery in patients with benign disease and decrease potential treatment related morbidity. Paul L. Crispen, M.D., and Michael L. Blute, M.D., Department of Urology, Mayo Clinic, Rochester, Minnesota
References 1. Gill IS, Kavoussi LR, Lane BR, et al. Comparison of 1,800 laparoscopic and open partial nephrectomies for single renal tumors. J Urol. 2007;178:41-46. 2. Lane BR, Samplaski MK, Herts BR, et al. Renal mass biopsy—A renaissance? J Urol. 2008;179:20-27. 3. Crispen PL, Viterbo R, Fox EB, et al. Delayed intervention of sporadic renal masses undergoing active surveillance. Cancer. 2008; 112:1051-1060. 4. Crispen PL, Viterbo R, Boorjian SA, et al. Natural history, growth kinetics, and outcomes of untreated clinically localized renal tumors under active surveillance. Cancer. 2009;115:2844-2852.
doi:10.1016/j.urology.2009.05.081 UROLOGY 74: 1046, 2009. © 2009 Elsevier Inc.
REPLY Although fundamental, the question, “Should we excise SRMs in the elderly?” is not the topic of our retrospective review. We agree whole-heartedly that in the elderly and the infirm population, the risk of competing comorbidities must be weighed against the admittedly limited oncological risk of the small renal mass (SRM).1 The goal of our manuscript is less lofty; namely, to evaluate the technical feasibility, safety, and outcomes of LPN surgery in an elderly subgroup. All patients underwent LPN for an “enhancing” SRM, on the basis of CT imaging performed at our institution. The nearly 40% benign rate on final pathology reflects the inherent issues with radiologic imaging. Although an overall 32% complication rate was seen in our elderly cohort, this included minor nonurologic complications (atelectasis, ileus) and was not significantly different from the younger cohort. Furthermore, none of the elderly patients studied required postoperative dialysis. UROLOGY 74 (5), 2009
METHODS
RESULTS
CONCLUSIONS
To assess the safety and technical feasibility of laparoscopic partial nephrectomy in patients aged ⱖ80 years at our institution to determine whether this treatment modality may be justifiable in select octogenarians. As the US population ages, an increasing number of elderly patients with renal masses are considered for partial nephrectomy. We present our experience with laparoscopic partial nephrectomy in octogenarians to determine the safety and technical feasibility of this procedure in an elderly population. Between 1999 and 2007, we reviewed 832 patients who underwent laparoscopic partial nephrectomy for renal tumors at our institution. Demographics, perioperative data, and renal function of patients aged ⱖ80 years were compared with younger patients. A total of 791 patients aged ⬍80 years (median 59, range 17-79) and 41 patients aged ⱖ80 years (median 82, range 80-88) underwent laparoscopic partial nephrectomy. In comparison with patients aged ⬍80 years, octogenarians had higher overall American Society of Anesthesiology (P ⫽ .002) and Charlson Comorbidity Scores (P ⫽ .006) with an increased incidence of chronic kidney disease (P ⫽ .008); however, intraoperative and postoperative complications were similar between the groups (P ⫽ .3, P ⫽ .5). Despite a lower preoperative glomerular filtration rate in the octogenarian group (median 68 vs 82, P ⬍.0001), the overall decline in glomerular filtration rate between age groups was not significantly different (P ⫽ .7). Laparoscopic partial nephrectomy can be performed safely in appropriately selected patients aged ⱖ80 years, with rates of perioperative morbidity similar to those observed in younger patients. On the basis of our data, age alone should not be a contraindication to laparoscopic partial nephrectomy. UROLOGY 74: 1042–1048, 2009. © 2009 Elsevier Inc.
A
dvancing age is one of the most significant risk factors for renal cell carcinoma (RCC). Most cases of kidney cancer are diagnosed in individuals aged ⬎65 years, with the highest incidence in the age group of 75-85 years(56/100 000).1,2 Furthermore, the US population is aging rapidly and octogenarians are the fastest growing segment of this population.3 Combined with a rising incidence of RCC and an aging population, urologists are facing a growing demand for the treatment of kidney cancer in the elderly population. Nephron-sparing surgery has become an established treatment modality to preserve renal function while maintaining equivalent oncological efficacy for the management of small renal masses. Indications for partial nephrectomy have expanded to include patients with low-stage, localized RCC with normal contralateral kidneys as patients undergoing radical (vs partial) nephrectomy have increased rates of chronic kidney disease after
From the Section of Laparoscopic and Robotic Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio Reprint requests: Inderbir S. Gill, M.D., Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, 9500 Euclid Ave, A100, Cleveland, OH 44195. E-mail: [email protected] Submitted: December 2, 2008, accepted (with revisions): April 14, 2009
1042
© 2009 Elsevier Inc. All Rights Reserved
surgery.4,5 Additionally, a direct correlation between chronic renal dysfunction and an increased risk of cardiovascular events and mortality has been observed, which is especially significant in the elderly population.6 Recently, laparoscopic partial nephrectomy (LPN) has emerged as a viable treatment option for localized renal masses in select patients, demonstrating equivalent oncological efficacy and renal function preservation with shortened postoperative recovery in comparison with open surgery.7,8 Whether the benefits of LPN extend to the elderly population remains unknown and studies assessing the effect of minimally invasive surgery in this population are limited. Older patients are thought to have greater perioperative morbidity and mortality from surgery in comparison with their younger counterparts, in part because of physiological changes and increased medical comorbidities. Furthermore, treatment options for the elderly people are often influenced by clinician biases, patient preferences, or from the lack of study in this elderly age group.9 In the present study, we assessed the safety and technical feasibility of LPN in patients aged ⱖ80 years at our institution to determine whether this treatment modality may be justifiable in select octogenarians. 0090-4295/09/$34.00 doi:10.1016/j.urology.2009.04.099
180 160
Total cases
140 120 100
≥ 80 years
80
< 70 years
60 40 20 0 1999
2000
2001
2002
2003
2004
2005
2006
2007
Year
Figure 1. Annual distribution of patients undergoing laparoscopic partial nephrectomy at the Cleveland Clinic.
MATERIAL AND METHODS Between 1999 and 2007, we retrospectively reviewed the records of patients who underwent LPN at our institution for the management of renal tumors (Fig. 1). Patients with radiographic evidence of enhancing solid or cystic renal masses suspicious for neoplasms were included. Percutaneous renal mass biopsies were not routinely performed and all imaging was reviewed by radiologists at our institution. All patients selecting LPN were counseled regarding available treatment options including active surveillance, laparoscopic and open partial nephrectomy, radical nephrectomy, and tumor ablation. Patients were then carefully screened and evaluated by a multidisciplinary team involving urologists, internists, and anesthesiologists to identify preoperative risk factors and to optimize performance status before surgery. LPN was performed as described previously.10 Briefly, our surgical techniques included transient en bloc renal hilar control, real-time laparoscopic contact ultrasonography, tumor excision with cold scissors, sutured reconstruction of the pelvicaliceal system, and sutured hemostatic renal parenchymal reapproximation. Histopathologic review of all specimens was performed by a genitourinary pathologist to determine histologic diagnosis, surgical margins, and stage. Perioperative complications were classified into intraoperative or postoperative complications, with attention to previously established criteria.8,11 Postoperative complications were further categorized into urological (hemorrhage and urine leak) or nonurological (cardiac, gastrointestinal, pulmonary, thromboembolic, incisional, or other) complications. Perioperative mortality was defined as in-hospital death or death within 30 days of surgery. The glomerular filtration rate (GFR) was calculated using the modification of diet in renal disease formula preoperatively and at a mean of 11 months postoperatively. The distribution of categorical variables in both groups was compared with Fisher exact tests and continuous variables were analyzed using the Wilcoxon rank sum tests when appropriate. Statistical significance was assessed on the basis of a 2-sided significance level of 0.05. We used S-Plus 7.0 (Insightful, WA) for all statistical analyses.
RESULTS During the 9-year period in this study, 832 patients underwent LPN for renal tumors. A total of 791 patients aged ⬍80 years (range 17-79) and 41 patients aged ⱖ80 years (range 80-88) underwent LPN (Table 1). LPN was performed by 5 operating urologists, with 1 surgeon performing 78% of all cases (I. G.). Comorbidities were UROLOGY 74 (5), 2009
higher in octogenarian patients, with higher overall American Society of Anesthesiology scores (P ⫽ .002) and Charlson Comorbidity Index Scores (P ⫽ .006). The indication for nephron-sparing surgery was imperative or absolute in 76% of patients aged ⱖ80 years, compared with 54% of younger patients (P ⫽ .02). Perioperative data are presented in Table 2. The octogenarian patient group was comparable with that of younger patients in terms of mean operating time, transfusion rates, and open conversion rates. However, the median estimated surgical blood loss (200 vs 150 mL, P ⫽ .04) and the duration of hospital stay (93 vs 68 hours, P ⬍.0001) were increased in the octogenarian group. In the entire LPN series, mortality within 30 days of surgery was 0% for the octogenarians and a single perioperative death occurred in the younger patient cohort. A 64-yearold woman, without known coronary artery disease, died 6 days after an uncomplicated LPN from a massive myocardial infarction. It is important to note that although octogenarians had increased preoperative comorbidity, intraoperative (2% vs 6%, P ⫽ .3) and postoperative complications (30% vs 25%, P ⫽ .5) were not significantly higher in this elderly patient group. Overall, 34 (4%) and 2 (5%) secondary procedures, including ureteral stent placement, angioembolization, reoperation for hemorrhage, or nephrectomy were performed to manage postoperative complications for the younger and older patient groups, respectively (P ⫽ .8). Postoperative hemorrhage occurred in 7% of patients in each age group. Conservative management including bed rest and transfusion was used to manage postoperative bleeding in 1 octogenarian (50%) and in 24 patients (65%) in the younger patient group, whereas angioembolization or nephrectomy was used in the remaining cases. Postoperative urine leakage occurred in 3% of the younger age group and in 7% of octogenarian patients. The presence of RCC detected in pathologic specimens was similar between the younger and octogenarian groups (74% vs 61%, P ⫽ .5), with a low incidence of advanced pathologic stage (⬎T1) in both groups (2% vs 0%). However, the distribution of histologic subtypes differed in the older and younger patient groups, with clear cell RCC representing 32% and 47% of overall tumors, respectively. Despite an overall higher preoperative serum creatinine and lower estimated GFR in octogenarians, no significant difference in the change in renal function between groups was observed (Table 3). The median postoperative GFR in the 2 groups was 54 and 66 mL/ min/1.73 m2, representing a 21% (IQR) decline in GFR relative to pre-LPN levels for both octogenarians and younger patients, respectively (P ⫽ .7).
COMMENT With an aging population and an increasing incidence of renal tumors, a greater number of elderly patients are presenting for the management of renal masses. Clini1043
Table 1. Clinical and pathological data regarding patients undergoing laparoscopic partial nephrectomy for renal tumors Total (n ⫽ 832)
Characteristics Median age, years (IQR) No. males (%) Mean BMI (kg/m2) (SD) Median ASA score (IQR) No. ASA score ⱖ3 (%) Charlson comorbidity score (IQR) No. score ⬎1 (%) Comorbidities No. hypertension No. diabetes No. solitary kidney (%) Indication Absolute (solitary, bilateral, GFR ⬍45) Imperative (DM, HTN, GFR 45-60) Elective No. right side (%) Median clinical tumor size, cm (IQR) No. clinical stage T1b or greater (⬎4 cm) (%) No. renal pathological diagnosis (%): Conventional renal cell carcinoma Other cancer (ie, papillary RCC, chromophobe RCC, etc.) Benign kidney findings No. pathologic stage ⬎T1 (%)
LPN in Patients ⬍80 y (n ⫽ 791)
LPN in Patients ⱖ80 y (n ⫽ 41)
P
82 (80-83) 29 (71) 25.7 (2.9) 3 (3-3) 27 (75) 1 (0-2) 12 (29)
⬍.00001 .1 .0001 .002 .001 .006 .022
24 (63) 7 (18) 4 (10)
.046 .5 .07 .02
60 (51-69) 502 (60) 29.1 (5.9) 2 (2-3) 339 (48) 0 (0-1) 126 (15)
59 (50-67) 473 (60) 29.3 (6.0) 2 (2-3) 312 (47) 0 (0-1) 114 (14)
339 (47) 102 (14) 33 (4)
315 (46) 95 (14) 29 (4)
113 (14) 321 (41) 357 (45) 454 (55) 2.6 (2.0-3.5) 111 (13)
105 (14) 298 (40) 347 (46) 430 (54) 2.6 (2.0-3.5) 105 (13)
381 (46) 232 (28)
368 (47) 220 (28)
13 (32) 12 (29)
218 (26) 15 (2)
202 (26) 15 (2)
16 (39) 0
8 (20) 23 (56) 10 (24) 24 (59) 2.8 (2.2-3.5) 6 (15)
.6 .1 .8 .1
1.0
IQR indicates interquartile range; ASA ⫽ American Society of Anesthesiology.
Table 2. Perioperative data on patients undergoing laparoscopic partial nephrectomy for renal tumors Characteristic
Total (n ⫽ 832)
LPN in Patients ⬍80 yr (n ⫽ 791)
LPN in Patients ⱖ80 yr (n ⫽ 41)
Transperitoneal approach (%) Median operative time (min) (IQR) Median estimated blood loss (mL) (IQR) Median warm ischemia time (min) (IQR) ⬎1 U of blood transfused (%) Conversion to open (%) Median hospital stay (h) (IQR) Mortality (30 d) Intraoperative complications (%) Postoperative complications (%) Hemorrhage Urinary leak Nonurological complications Reoperation/secondary procedure
634 (76) 210 (180-240) 200 (100-300) 30 (21-36) 28 (4) 7 (2) 71 (58-95) 1 48 (6) 148 (25) 39 (7) 19 (3) 90 (15) 36 (4)
600 (76) 210 (180-240) 150 (100-300) 30 (21-36) 26 (4) 7 (3) 68 (48-91) 1 47 (6) 139 (25) 37 (7) 16 (3) 86 (16) 34 (4)
34 (83) 240 (203-300) 200 (180-300) 22 (14-32) 2 (6) 0 93 (68-120) 0 1 (2) 9 (30) 2 (7) 3 (10) 4 (13) 2 (5)
P .3 .3 .04 .005 .6 .5 ⬍.0001 1.0 .3 .5
.8
IQR indicates interquartile range.
cians should consider factors such as life expectancy, comorbidities, and the expected morbidity from surgery when counseling patients, regarding available treatment options. Furthermore, minimizing surgically induced renal dysfunction by using a nephron-sparing approach may prevent cardiovascular-related morbidity and mortality on the basis of well-established association of chronic kidney disease with these endpoints.4,6 Nephron-sparing surgery has been demonstrated to have equivalent oncological efficacy to radical nephrectomy, with a decreased risk of subsequent renal failure.5,12,13 Although several studies have demonstrated that laparoscopic radical nephrectomy is well tolerated in the elderly people,14-17 outcomes of LPN in this population are limited. 1044
In this retrospective single-center experience, we demonstrate that LPN is both safe and feasible in select patients aged ⱖ80 years, with similar perioperative outcomes to those observed in younger patients. Octogenarian patients were a higher-risk group defined by their age, increased median American Society of Anesthesiology scores, greater Charlson Comorbidity Scores, and decreased baseline renal function. Although octogenarians had increased estimated blood loss, the perioperative complication rates were not significantly different between the groups. Additionally, most complications were minor and were managed conservatively without significant sequelae, and perioperative complication rates for both groups were also comparable with similar surgical UROLOGY 74 (5), 2009
Table 3. Effect of LPN on renal function Characteristic
Total (n ⫽ 832)
LPN in Patients ⬍80 yr (n ⫽ 791)
LPN in Patients ⱖ80 y (n ⫽ 41)
P
Median preoperative serum creatinine (IQR) Median postoperative serum creatinine (IQR) Median preoperative GFR (IQR) Median postoperative GFR (IQR) Median % decrease in GFR (IQR) No. pts. with ⱖstage 3 chronic kidney disease (%) (GFR ⬍60 mL/min/1.73 m2) No. patients with stage 5 chronic kidney disease or dialysis (%) (GFR ⬍15 mL/min/1.73 m2) Preoperative Postoperative No. patients with ⱖ2 stage upgrading in chronic kidney disease stage (%)
0.9 (0.8-1.1) 1.3 (0.9-1.4) 82 (68-97) 66 (50-80) ⫺21 (⫺33; ⫺7) 113 (14)
0.9 (0.8-1.1) 1.1 (0.9-1.4) 82 (69-97) 66 (50-80) ⫺21 (⫺33; ⫺2) 101 (13)
1.1 (0.9-1.3) 1.3 (1.1-1.7) 68 (56-85) 54 (41-66) ⫺21 (⫺35; ⫺10) 12 (29)
.01 .008 ⬍.0001 .001 .7 .008
0 9 (1) 49 (6)
0 9 (1) 47 (6)
0 0 2 (5)
— .5 .7
IQR indicates interquartile range.
series of LPN.8,16 It is important to note that no perioperative deaths occurred in the octogenarian patient group with only 1 perioperative mortality in the entire LPN series. The median length of hospital stay was greater for octogenarians; however, this value remains lower than the average length of hospital stay for all ages of patients undergoing open partial nephrectomy in other studies.8 Finally, despite a greater percentage of elderly patients with solitary kidneys in this study (10% vs 4%, P ⫽ .07) and a lower preoperative GFR, the preservation of renal function (as determined by change in estimated GFR) was similar in both age groups. Small renal masses encompass a heterogeneous group with varied clinical outcomes.18 Most patients in the present study had low T-stage tumors and 39% of octogenarians were found to have benign renal masses on final pathologic analysis. This large proportion of benign pathologic findings in octogenarian patients lends further support for the conservative management of small renal masses in select elderly patients. It is important to note that all patients in the current study were offered various treatment options including active surveillance; however, these patient groups elected LPN. Further studies evaluating the natural history of small renal masses in the elderly with an assessment of the role of percutaneous renal mass biopsy will also be useful to guide clinical decision-making in this population. There are several limitations to the present study. First, in this retrospective, nonrandomized review, biases likely play a significant role in the selection of patients to undergo LPN compared with other options. Nevertheless, we feel that the current series demonstrates that with careful patient selection, LPN can be performed safely in older patients and with comparable perioperative morbidity to that expected with younger patients. Comparisons between LPN and other nephron-sparing approaches, such as open partial nephrectomy, cryosurgical ablation, and radiofrequency ablation, with an evaluation of survival and quality of life measures, would further enhance our knowledge of the effect of surgery in octogenarians; but this is beyond the scope of the present study. UROLOGY 74 (5), 2009
CONCLUSIONS Although active surveillance continues to be a valid consideration for many elderly patients, LPN for the management of renal tumors is safe and feasible in select patients aged ⱖ80 years. Medical decision-making for elderly patients with renal tumors must take into account oncological risks, competing medical comorbidities, as well as the predicted life expectancy of the individual patient. Given that renal dysfunction is associated with an increased likelihood of cardiovascular events and mortality, the impetus to use nephron-sparing surgery should not be avoided in elderly patients. Advanced age alone should not be a contraindication for curative surgery, and properly selected patients can benefit from similar advantages of laparoscopic surgery as their younger counterparts. References 1. SEER surveillance, epidemiology, and end results. National Cancer Institute, United States National Health Institutes of Health. Available at http://www.census.gov/ipc/www/usinterimproj. 2. Kader AK, Tamboli P, Luongo T, et al. Cytoreductive nephrectomy in the elderly patient: the M. D. Anderson Cancer Center experience. J Urol. 2007;177:855-860; discussion:860-861. 3. Hem W, Sengupta M, Velkoff V, et al. Current population reports: special studies. 65⫹ in the United States; 2005. Washington, DC: U.S. Census Bureau, 2005. 4. Huang WC, Levey AS, Serio AM, et al. Chronic kidney disease after nephrectomy in patients with renal cortical tumours: a retrospective cohort study. Lancet Oncol. 2006;7:735-740. 5. Lau WK, Blute ML, Weaver AL, et al. Matched comparison of radical nephrectomy vs nephron-sparing surgery in patients with unilateral renal cell carcinoma and a normal contralateral kidney. Mayo Clin Proc. 2000;75:1236-1242. 6. Go AS, Chertow GM, Fan D, et al. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med. 2004;351:1296-1305. 7. Lane BR, Gill IS. 5-Year outcomes of laparoscopic partial nephrectomy. J Urol. 2007;177:70-74; discussion:74. 8. Gill IS, Kavoussi LR, Lane BR, et al. Comparison of 1800 laparoscopic and open partial nephrectomies for single renal tumors. J Urol. 2007;178:41-46. 9. Dale DC. Poor prognosis in elderly patients with cancer: the role of bias and undertreatment. J Support Oncol. 2003;1:11-17.
1045
10. Gill IS, Desai MM, Kaouk JH, et al. Laparoscopic partial nephrectomy for renal tumor: duplicating open surgical techniques. J Urol. 2002;167:469-467; discussion:475-476. 11. Campbell SC, Novick AC, Streem SB, et al. Complications of nephron sparing surgery for renal tumors. J Urol. 1994;151:1177-1180. 12. Fergany AF, Hafez KS, Novick AC. Long-term results of nephron sparing surgery for localized renal cell carcinoma: 10-year follow up. J Urol. 2000;163:442-445. 13. Lee CT, Katz J, Shi W, et al. Surgical management of renal tumors 4 centimetres or less in a contemporary cohort. J Urol. 2000;163: 730-736. 14. Hsu TH, Gill IS, Fazeli-Matin S, et al. Radical nephrectomy and nephroureterectomy in the octogenarian and nonagenarian: comparison of laparoscopic and open approaches. Urology. 1999;53: 1121-1125. 15. Varkarakis I, Neururer R, Harabayashi T, et al. Laparoscopic radical nephrectomy in the elderly. BJU Int. 2004;94:517520. 16. Matin SF, Abreu S, Ramani A, et al. Evaluation of age and comorbidity as risk factors after laparoscopic urological surgery. J Urol. 2003;170:1115-1120. 17. Staehler M, Haseke N, Stadler T, et al. Renal surgery in the elderly: morbidity in patients aged ⬎75 years in a contemporary series. BJU Int. 2008;102:684-687. 18. Lane BR, Samplaski MK, Herts BR, et al. Renal mass biopsy—a renaissance? J Urol. 2008;179:20-27.
EDITORIAL COMMENT The current manuscript demonstrates that laparoscopic partial nephrectomy can be performed safely in octogenarians. However, it must be noted that the authors represent extremely talented and experienced laparoscopic surgeons and are considered pioneers in the field of laparoscopic renal surgery. Although it is doubtful that these findings can be generalized to all practicing Urologists, the manuscript details several critical concepts in the contemporary management of renal tumors, including proper patient selection, preservation of renal function, and limiting treatment-associated morbidity. The presented findings should not be surprising for patients of any age if appropriate selection criteria are used. Although not the focus of the current manuscript, an interesting analysis by evaluating factors influencing treatment decisions and outcomes of all octogenarians diagnosed with renal tumors would be valuable, as not all octogenarians will be appropriate surgical candidates. Although laparoscopic partial nephrectomies have been associated with a higher complication rate as compared with open partial nephrectomies, the complication rate in the current series was low.1 In addition to performing minimally invasive surgery in a challenging patient population, the authors appropriately treated the small renal tumors with a nephron-sparing approach and documented preservation of renal function. Regardless of the treatment modality used, potential treatment-related morbidity must be considered given the observed indolent behavior in most small renal tumors during active surveillance. This is especially relevant to the current series, in which 39% of patients were discovered to have benign pathology after partial nephrectomy. Alternatives to immediate extirpative therapy include planned intervention pending a percutaneous biopsy or delayed intervention after a period of observation. With the improved accuracy and limited morbidity of percutaneous renal tumor biopsies, there has been a renewed interest in their potential application, especially in elderly 1046
patients with multiple commodities.2 Despite the improvements in biopsy outcomes, routine application is still not generally accepted or used. The outcomes of delayed treatment of renal tumors after an initial period of observation have recently been reported. In the largest series to date of 87 patients with cT1a renal tumors, treatment options after a period of observation were not altered and a low rate of pathologic upstaging was noted.3 An additional report focusing on laparoscopic partial nephrectomy suggests that a period of active surveillance did not significantly affect the type of treatment, treatment-associated morbidity, or early oncological outcomes. Although delayed intervention after a period of observation may not alter treatment choice or patient outcome, the clinical and radiographic thresholds for intervention have yet to be defined or validated.4 The authors have demonstrated, with appropriate patient selection, a balance between minimally invasive surgery and preservation of renal function can be achieved in an elderly population with minimal complications. Future development and application of alternative treatment algorithms may limit extirpative surgery in patients with benign disease and decrease potential treatment related morbidity. Paul L. Crispen, M.D., and Michael L. Blute, M.D., Department of Urology, Mayo Clinic, Rochester, Minnesota
References 1. Gill IS, Kavoussi LR, Lane BR, et al. Comparison of 1,800 laparoscopic and open partial nephrectomies for single renal tumors. J Urol. 2007;178:41-46. 2. Lane BR, Samplaski MK, Herts BR, et al. Renal mass biopsy—A renaissance? J Urol. 2008;179:20-27. 3. Crispen PL, Viterbo R, Fox EB, et al. Delayed intervention of sporadic renal masses undergoing active surveillance. Cancer. 2008; 112:1051-1060. 4. Crispen PL, Viterbo R, Boorjian SA, et al. Natural history, growth kinetics, and outcomes of untreated clinically localized renal tumors under active surveillance. Cancer. 2009;115:2844-2852.
doi:10.1016/j.urology.2009.05.081 UROLOGY 74: 1046, 2009. © 2009 Elsevier Inc.
REPLY Although fundamental, the question, “Should we excise SRMs in the elderly?” is not the topic of our retrospective review. We agree whole-heartedly that in the elderly and the infirm population, the risk of competing comorbidities must be weighed against the admittedly limited oncological risk of the small renal mass (SRM).1 The goal of our manuscript is less lofty; namely, to evaluate the technical feasibility, safety, and outcomes of LPN surgery in an elderly subgroup. All patients underwent LPN for an “enhancing” SRM, on the basis of CT imaging performed at our institution. The nearly 40% benign rate on final pathology reflects the inherent issues with radiologic imaging. Although an overall 32% complication rate was seen in our elderly cohort, this included minor nonurologic complications (atelectasis, ileus) and was not significantly different from the younger cohort. Furthermore, none of the elderly patients studied required postoperative dialysis. UROLOGY 74 (5), 2009