Abstract
The authors present a retrospective nonrandomized comparison of minimally invasive partial nephrectomy versus open surgery in obese patients. They utilized the National Surgical Quality Improvement Program database and defined obesity as a body mass index >30 kg/m2. They come to the conclusion that the 30-day postoperative morbidity was significantly lower in the minimally invasive partial nephrectomy group than the open surgery. The conclusions appear logical as there are obvious advantages of the minimally invasive approach with regard to wound healing and postoperative pulmonary status in obese patients.
However, one important missing piece of information is the reason for selecting minimally invasive or open approach. In our practice, >90% of the partial nephrectomies are done minimally invasive with the open surgeries being reserved for those with complicating factors such as high nephrometry score, severely hostile abdomen, or risk of dialysis with loss of the renal unit (i.e., solitary kidney). Other institutions follow a similar practice pattern with an emphasis on renal salvage. If a surgeon is only doing open surgery for the most complex cases, we would expect to see a much higher complication rate than the minimally invasive cases. There is no way to account for these factors in this evaluation nor is this fully recognized in the discussion.
I feel that minimally invasive approaches have made a dramatic impact in the area of partial nephrectomy especially in obese patients, but there are still some advantages with the open approach. I am not aware of any series that shows a true advantage (especially with regard to renal salvage) with the minimally invasive approach when we look at the highest complexity cases. Thus, some of the reasons for improved outcomes with a minimally invasive approach may, in part, be because of case selection. There is still a role for open partial nephrectomy and the decision on which approach to choose is dependent upon patient factors and surgeon experience.