Editorial Comment on: Perioperative Morbidity of Open Versus Minimally Invasive Partial Nephrectomy: A Contemporary Analysis of the National Surgical Quality Improvement Program by Pereira et al .

Partial nephrectomy (PN) is the gold standard for management of small renal masses. ¹ Initially open approaches were commonly performed but eventually made way to minimally invasive modalities (i.e., laparoscopic and robotic assisted). In the past decade, the robotic-assisted approach has increasingly flourished and proliferated because of its comparatively lower technical challenge and learning curve. ² However, standard laparoscopy still maintains a role in centers with the necessary technical expertise. ³

In this interesting report, Pereira et al. evaluated the outcomes of open partial nephrectomy (OPN) vs those of minimally invasive partial nephrectomy (MIPN) cases derived from the well-known National Surgical Quality Improvement Program (NSQIP). ⁴ The study included >13,000 cases sampled from 2010 to 2015 and specifically analyzed relevant surgical outcomes and factors associated with perioperative morbidity. Interestingly, about 40% of cases were done through an open approach. The authors conclude that MIPN performs better among various perioperative indices than OPN, namely 30-day complication rate, blood transfusion rate, hospital stay, readmission rate, and reoperation rate. Although these study findings are notable, there are a few caveats that should be pointed out that are mainly related to this kind of population-based analysis. The NSQIP database is unable to discern between minimally invasive techniques (i.e., laparoscopic and robotic-assisted). Therefore, the improved outcomes associated with MIPN can only be assumed to be attributable to robotic surgery primarily because of its increasingly disseminated use. ² Moreover, the analysis is particularly limited by the inability to assess or adjust for tumor staging and characteristics. Many would argue that open surgery was intuitively reserved for challenging or larger masses. Consequently, conclusions drawn regarding MIPN may be biased to some extent toward lower complexity masses. Regardless, the findings of this study are generally in agreement with those of previous studies. In another recent study based on NSQIP data, it was found that contemporary MIPN seems to carry lower odds of readmission than OPN. ⁵ Large multicenter series have also suggested a lower morbidity rate for robotic vs OPN. ⁶

In summary, evidence supporting the implementation of minimally invasive techniques for nephron sparing surgery keeps building. Open surgery will probably always have a role for selected cases amenable to PN, but it is unquestionable that a paradigm shift toward laparoscopic and mainly robotic approaches can translate into better outcomes for our patients.