Reply by the Authors

Abstract

In our series of patients undergoing laparoscopic nephrectomy for large (>7 cm) renal masses, 20% of patients had undergone lymphadenectomy concurrent with nephrectomy either for lymphadenopathy on preoperative imaging or for known metastatic disease in the case of cytoreduction. Of these, 3 patients had node-positive disease. No convincing evidence has been published to suggest that routine lymphadenectomy provides a survival advantage for clinically node-negative patients with large renal masses presenting for laparoscopic nephrectomy. This is likely because of the low prevalence of isolated nodal metastases, the unpredictable pattern of nodal spread, and the high likelihood of visceral metastatic recurrence among patients with high localized risk disease. 1 Godoy G. O'Malley R.L. Taneja S.S. Lymph node dissection during the surgical treatment of renal cell carcinoma in the modern era. Int Braz J Urol. 2008; 34: 132-142 Crossref PubMed Scopus (18) Google Scholar In the only prospective trial of lymphadenectomy to date, only 3.3% of patients with clinically node-negative disease had positive nodes on the final pathologic examination and routine lymphadenectomy imparted no survival benefit. 2 Blom J.H. van Poppel H. Marechal J.M. et al. Radical nephrectomy with and without lymph node dissection: preliminary results of the EORTC randomized phase III protocol 30881. Eur Urol. 1999; 36: 570-575 Crossref PubMed Scopus (151) Google Scholar In the 2003 report by Pantuck et al. 3 Pantuck A.J. Zisman A. Dorey F. et al. Renal cell carcinoma with retroperitoneal nodes. Cancer. 2003; 97: 2995-3002 Crossref PubMed Scopus (150) Google Scholar quoted by the authors of the above letter, positive lymph nodes at cytoreduction were not an independent predictor of cancer-specific survival on multivariate analysis. Although lymphadenectomy was recommended in their report, it was specifically in the context of patients with gross nodal disease who were undergoing cytoreduction before systemic immunotherapy. As the authors of the above letter point out, Chapman et al. 4 Chapman T.N. Sharma S. Zhang S. et al. Laparoscopic lymph node dissection in clinically node-negative patients undergoing laparoscopic nephrectomy for renal cell carcinoma. Urology. 2008; 71: 287-291 Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar reported that regional lymphadenectomy is safe and feasible in patients with large renal masses undergoing laparoscopic nephrectomy. The clinical context and indication were not provided. Canfield et al. 5 Canfield S.E. Kamat A.M. Sanchez-Ortiz R.F. et al. Renal cell carcinoma with nodal metastases in the absence of distant metastatic disease (clinical stage TxN1-2M0): the impact of aggressive surgical resection on patient outcome. J Urol. 2006; 175: 864-869 Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar have also demonstrated decreased recurrence-free and overall survival in patients with lymph node metastases who undergo cytoreductive nephrectomy before systemic therapy for metastatic disease, and thereby concluded that these patients, in particular, should undergo aggressive lymph node resection. We agree with the conclusions of these authors. In a recent review of the role of lymph node dissection in the treatment of renal cell carcinoma, we concluded that lymphadenectomy has no role in patients without radiologic or clinical evidence of lymph node disease. 1 Godoy G. O'Malley R.L. Taneja S.S. Lymph node dissection during the surgical treatment of renal cell carcinoma in the modern era. Int Braz J Urol. 2008; 34: 132-142 Crossref PubMed Scopus (18) Google Scholar Therefore, although we agree it is technically feasible (and generally simple), we do not believe any evidence is available to suggest that patients with large renal masses who have clinically node-negative disease will derive any benefit from routine lymphadenectomy at laparoscopic nephrectomy. Re: Berger AD, et al.: Transperitoneal Laparoscopic Radical Nephrectomy for Large (>7 cm) Renal Masses (Urology 2008;71:421-424)UrologyVol. 73Issue 2PreviewIn the March issue of Urology, Berger et al.1 reported on a relatively large series of 40 patients who had a large renal mass (>7 cm) and had undergone laparoscopic radical nephrectomy (LRN). According to their findings, LRN is a safe and feasible procedure for large renal tumors with minimally increased perioperative morbidity compared with LRN for masses <7 cm. In addition, the efficacy of cancer control is also comparable.1 As we know, the technique of laparoscopy has advanced and the indication has been expanded such that most advanced renal cell carcinoma (RCC) cases will be managed using a laparoscopic procedure. Full-Text PDF