gms | German Medical Science

Background: Today, there are still indications for open renal surgery despite the trend towards minimal invasive procedures: large tumors, extensive inflammation, hostile abdomens and patient related factors just to name four common ones. In this study, we compared the two main approaches in our institution for that matter: extraperitoneal flank incision vs. transperitoneal approach.

Methods: From 2005 to 2021, a total of n=543 patients were identified receiving open renal surgery at our institution. Here, n=366 patients approached by a flank incision and n=177 patients transperitoneally. n=326 patients were managed with partial nephrectomy and n=217 patients received nephrectomy. Median follow-up was 9 months.

Results: Clinical baseline characteristics were comparable between flank and transperitoneal approached patient groups. For patients receiving nephrectomy, the flank approach was associated with less operating time (150 vs. 185 min., p=<0.01), shorter hospital stay (12 vs. 13 days, p=0.004) and less surgical complications (35,5% vs. 52,5%, p=0.04), whereas median tumor size (7cm vs. 8,5 cm, p=<0.01) was higher but not tumor stage (median pT3a vs. pT2b, p=0.48) in the transperitoneal approach. Patients who underwent nephrectomy via a transperitoneal approach had more complex tumors, which were coded using the RENAL (7 vs. 8, p=0,034) and PADUA (9,5 vs. 10, p= 0,028) scores, than those who underwent surgery via a flank incision

For partial nephrectomy, the flank approach was also associated with less operating time (180 vs. 200 min., p=<0.01) and lower rates of surgical complications (39% vs. 44% p=0,03), whereas no significant differences were found for hospital stay (11 vs. 11 days, p=0,75), tumor size (4,5 vs. 4,5 cm, p=0,76) or tumor stage (median pT1a vs. pT1a, p=0.78). In this cohort, the patients who underwent a transperitoneal approach had also more complex tumors (RENAL: 6 vs 7, p=0,005; PADUA: 8 vs. 9. P=0,005) than those who underwent surgery via a flank incision.

Conclusion: In our series, especially for partial nephrectomy, both flank and transperitoneal approaches were found to be safe and comparable. The observed inferiority of the transperitoneal approach in patients receiving renal surgery with regards to complications and operating time was most likely attributed to bigger and more complex tumors with their respective elevated surgical complexity.