Editorial Comment for Sharma et al.

The authors have used data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) to examine and compare results after open and minimally invasive partial nephrectomy—specifically, the impact of body mass index (BMI) on surgical outcomes. This robust, surgeon-driven resource has been important in not only collecting relevant data and establishing relevant outcomes-based measures, but also may lead to improved outcomes and reduction in complications. Although urologic procedures are contained within NSQIP and informative analyses have been performed, I anticipate that more procedure- and specialty-specific lessons (e.g., surgical risk calculators ¹ ) will emerge from ongoing efforts such as the American Urological Association Quality Registry.

It appears that the minimally invasive approach to partial nephrectomy is associated with lower rates of postoperative complications compared with open surgery (7% vs 18%, respectively), although this was consistent across BMI groups. In addition, while obese patients had significantly longer operative times for both types of surgery, the absolute time differences were relatively small (20 min). It is important to note that the difference in complication rates for minimally invasive techniques was because of a lower number of Clavien I–II complications and that rates of ≥grade III complications were comparable.

Several things should be kept in mind. First, NSQIP is unable to differentiate between laparoscopic and robot-assisted laparoscopic surgery, and I would be curious as to whether this is relevant. In addition, it would be interesting to evaluate the changes over time with evolution in experience and technology. Second, granularity is lacking with respect to details about tumor stage, and future studies including anatomic complexity (e.g., R.E.N.A.L. or PADUA nephrometry scores) will be informative; similarly, surgeon and center level data would be interesting. Third, the postoperative complications are limited to those occurring within 30 days after operation. One wonders whether extending the period to 90 days is more accurate, as for radical cystectomy, ² although I would think that this may only further support the benefits of the minimally invasive approach.