**2.2.1 Complication rates of NNS vs. RN**

Haemorrhage is the most common intra-operative complication (1.2 -4.5%). Post-operative complications are urinary fistula formation (1.4-17%), acute renal failure (0.7-26%), postoperative bleeding (0-4.5%), wound infection (1.2-5.9%), perinephric abscess (0.6-3.2%), chronic renal insufficiency (3.2-12%) and urinary retention (Lesage et al., 2007). Nonurological complications include pulmonary and cardiac complications, and also delirium.

We have recently published results of an uncontrolled and retrospective study of 67 patients who underwent NSS for T1b RCC at our institution. A rate of 3% of post-operative haemorrhage requiring embolization was observed, and none developed a urinary fistula. Four patients (6%) had positive resection margins; none of these developed tumour recurrence. After a median (range) follow-up of 40.1 (1-98.3) months, 10 patients (15%) had died, of whom only one death was related to NSS (postoperative hypovolemic shock). The recurrence rate was 10%: 3 patients (4%) developed a local recurrence and 4 (6%) loco-regional or distant disease but all of these patients were alive at last follow-up (Joniau et al., 2009).

In our recently updated series of 98 open partial nephrectomies for cT1b tumours, two patients died in the peri-operative period, but both had extensive cardiac histories. We encountered 7 post-operative acute kidney haemorrhages: of those, 3 required a reoperation, 2 were embolized and 2 were treated conservatively. There was one urinary fistula which was successfully managed by placing a double–J stent. Thus, major complication rate (Dindo score 3) was 9.2%.

Coffin (Coffin et al., 2011) encountered a higher complication rate in NSS compared to RN. Total complication rate was 37.7% (of 69 patients) versus 24.5%, respectively. Rates of pulmonary complications and delirium were comparable in both techniques (9.4% versus 9.6% and 3.1% versus 1.1%, respectively) while cardiac complications were more frequent after RN (20.2% versus 1.5% after NSS). Urinary fistula rate was 5.8%. Transfusion rate was higher in NSS (23.2%) versus RN (13.8%). Spleen damage was not encountered during NSS but occurred three times during RN. Contrary to most studies, NSS did not require surgical revision but one patient was re-operated after a RN. (Roos et al., 2010)


C= Conversion

332 Chronic Kidney Disease

Becker (Becker et al., 2006) evaluated the oncologic outcomes of NSS in tumours larger than 4 cm with mean follow up of 6.2 years. There were 10% of deaths but none was cancer related. The Cancer specific survival was 100% after 5, 10 and 15 years. Of the 69 patients, 5.8% experienced disease recurrence. 5-, 10- and 15-year overall survival rates were 94.9%,

In carefully selected patients with tumours >4 cm, NSS appears to obtain equivalent oncologic outcomes compared to those achieved with RN. Although higher morbidity rates

Publication TNM Single n= DFS Local Distant Median mean vs multi- 5 years Reccurence Metastase FU diam institution % % % months cm Margulis (2007) pT2-pT3b single 34 82 0 12 62.1 5.2 Antonelli (2008) pT1b Single 52 93 1.9 5.3 54.3 4.8 Roos (J Urol 2010) pT1b Single 73 95 1.3 9.6 55.2 5.0 Coffin (2011) all sizes Single 155 81.8 \* \* 95 3.7 Coffin (2011) pT1b Single 59 74 \* \* 95 ? Joniau (2008) pT1b Single 67 84 4 6 40.2 4.5 Patard (2004) pT1b multi 65 93.8 3.6 7.1 51 5.3 Becker (2006) pT1b Single 69 100 5.8 5.8 70 5.3 Leibovitch (2004) pT1b Single 91 98 5.4 4.4 64 4.9 Hafez (1999) 175 86 0.8 ? 47

Haemorrhage is the most common intra-operative complication (1.2 -4.5%). Post-operative complications are urinary fistula formation (1.4-17%), acute renal failure (0.7-26%), postoperative bleeding (0-4.5%), wound infection (1.2-5.9%), perinephric abscess (0.6-3.2%), chronic renal insufficiency (3.2-12%) and urinary retention (Lesage et al., 2007). Nonurological complications include pulmonary and cardiac complications, and also delirium. We have recently published results of an uncontrolled and retrospective study of 67 patients who underwent NSS for T1b RCC at our institution. A rate of 3% of post-operative haemorrhage requiring embolization was observed, and none developed a urinary fistula. Four patients (6%) had positive resection margins; none of these developed tumour recurrence. After a median (range) follow-up of 40.1 (1-98.3) months, 10 patients (15%) had died, of whom only one death was related to NSS (postoperative hypovolemic shock). The recurrence rate was 10%: 3 patients (4%) developed a local recurrence and 4 (6%) loco-regional or distant disease but all of these patients were alive at last follow-up (Joniau et al., 2009).

In our recently updated series of 98 open partial nephrectomies for cT1b tumours, two patients died in the peri-operative period, but both had extensive cardiac histories. We encountered 7 post-operative acute kidney haemorrhages: of those, 3 required a reoperation,

were seen after NSS, the complication type and severity were acceptable.

86.7% and 86.7%, respectively.

Table 2. Oncologic outcomes.

**2.2.1 Complication rates of NNS vs. RN** 

**2.2 Complications** 

SR = Surgical Revision

RN = Radical Nephrectomy

CR = Complication rate

I, II, III, IV, V = Complication rate according to the Dindo-Clavien classification

Table 3. Complication Rate.

NSS has a higher rate of complications, however this remains acceptable. Most complications can be managed in a conservative or minimally invasive fashion and therefore in none of the reports, an impact on the length of hospital stay or the hospital costs was found.
