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COMPARISON OF COSTS AND COMPLICATIONS OFRADICAL AND PARTIAL NEPHRECTOMY FOR TREATMENT

OF LOCALIZED RENAL CELL CARCINOMABIJAN SHEKARRIZ, JYOTI UPADHYAY, HODJAT SHEKARRIZ, AZIZ GOES, JR,

FERNANDO J. BIANCO, JR, RABI TIGUERT, E. GHEILER, AND DAVID P. WOOD, JR

ABSTRACT

Objectives. To compare the complications and costs of radical and partial nephrectomy (PN) and to

investigate the impact of increasing experience on costs and complications during a 7-year period. Nephron-

sparing surgery has found increasing applications in the past decade. PN has achieved similar long-term

results in localized renal cell carcinoma with respect to cancer control compared with radical nephrectomy

(RN). However, data are limited on the direct comparison of complications and hospital costs between thesetwo modalities.

Methods. A retrospective case-matched study was performed comparing 60 RNs and 60 PNs during a

7-year period with respect to complications and hospital costs. A longitudinal comparison was also per-

formed between the various periods to assess the impact of surgical experience on these parameters.

Results. The mean length of stay was 6.4 3 days in the RN group and 6.4 3.3 days in the PN group. The

hospital costs were comparable between the two procedures during the observed interval. The mean

operative time was 176.6 51.6 minutes for RN and 220.1 59.6 minutes for PN (P 0.0001). This

difference was accentuated during the observed period. No differences were found in the blood loss and

transfusion rates between the groups. The complication rate was 3.3% and 10% for RN and PN, respectively

(P 0.2).

Conclusions. Our data suggest that RN and PN can be performed with a similar rate of complications and

comparable hospital costs. This is of practical importance when comparing these modalities as treatmentoptions for localized renal cell carcinoma. UROLOGY 59: 211215, 2002. 2002, Elsevier Science Inc.

Surgical management of localized renal cell car-cinoma has experienced remarkable advances

in the past two decades. Radical nephrectomy(RN), which was the treatment of choice for thesetumors for many years, has been used in fewerpatients, because of an increased acceptance ofnephron-sparing surgery.14 This was the conse-

quence of advances in diagnostic methods, allow-ing early tumor detection, improvement in surgicaltechnique, pre and postoperative patient manage-ment, and a general trend toward organ-sparingsurgery.

Incidentally found renal tumors are often of

lower grade and stage compared with those caus-ing clinical symptoms, and patients who wouldotherwise become anephric after RN benefit from asurgical approach that preserves renal function.This is also true for patients who are at risk oflosing the contralateral kidney because of othersystemic or local diseases.

The experience with nephron-sparing surgeryhas demonstrated the safety and efficacy of thisapproach. Several reports have demonstrated thatthe 5-year cancer-specific mortality rate is similarin patients undergoing RN or partial nephrectomy(PN) for localized, smaller than 4 cm, renal cellcarcinoma (RCC).14 That success has encouragedthe application of nephron-sparing surgery for alarger population group, and some have advocatedthe use of nephron-sparing surgery for the treat-ment of patients with localized tumors, even in thepresence of a normal contralateral kidney.5 Withthis form of treatment gaining popularity and

From the Department of Urology, Wayne State University andBarbara Ann Karmanos Cancer Institute, Detroit, Michigan

Reprint requests: David P. Wood, Jr., M.D., Department ofUrology, Wayne State University, Harper Professional Building,4160 John R, Suite 1017, Detroit, MI 48201

Submitted: March 20, 2001, accepted (with revisions): Septem-ber 17, 2001

ADULT UROLOGY

2002, ELSEVIER SCIENCE INC. 0090-4295/02/$22.00

ALL RIGHTS RESERVED PII S0090-4295(01)01514-X 211

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wider acceptance, it is essential to evaluate thecosts and complications of this approach com-pared with RN. PN requires additional technicalskills for complete mobilization of the kidney, in-duction of organ hypothermia, and meticulous dis-section. An intraoperative pathology consultationis also necessary. Furthermore, intervention on theurinary system renders the patient susceptible tourinary fistulas, which theoretically may pose ad-ditional postoperative costs and morbidity.

Few studies have compared the costs and com-plications of these two modalities.68 In a recentstudy, both procedures were associated with simi-lar hospital costs and complication rates, but otherreports supporting this evidence are lacking.7

This study was designed to compare the costsand complication rates between RN and PN fortreatment of localized RCC. Furthermore, a longi-tudinal comparison was made during a 7-yearperiod to evaluate whether increasing surgical ex-perience is associated with a change in the compli-cation rates or costs of the procedures.

MATERIAL AND METHODS

The medical records of all patients who underwent RN orPN between January 1991 and December 1997 at the WayneState University and Karmanos Cancer Institute were ana-lyzed. Patients were selected for RN or PN on the basis of thestatus of the contralateral kidney and surgeon preference. Ofthe PN group, the contralateral kidney was absent in 11(18.3%), nonfunctional in 6 (10%), had a future risk of im-

pairment in 12 (20%), and normal in 31 (51.6%) of the 60patients studied. We used the 1997 AJCC TNM classification.Inclusion criteria for this study included a single renal tumorless than 7 cm in size, pathologic Stage T3a or less, and noconcomitant abdominal procedures. Patients with a previoushistory of abdominal surgery or radiation therapy, and multi-focal, bilateral, hereditary, or metastatic disease were ex-cluded. A total of 60 patients who had undergone PN andfulfilled these criteria were matched for age, sex, location andsize of tumor, and pathologic stage to 60 patients who under-went RN during the same interval.

RN was performed in the conventional manner, but lymph-adenectomy was not routinely performed, unless enlargednodes were found. In the PN group, surgery was done accord-

ing to the principles described previously.2

At least 0.5 cm ofhealthy parenchyma was removed with the specimen. Themargins were evaluated immediately by frozen section, and ifpositive, more parenchyma was resected. Closed suctiondrains were used on all patients andremoved when the outputwas less than 50 mL/day and proved not to be urine. Themedical records were reviewed with regard to hospital lengthof stay, operative time, estimated blood loss, number of trans-fusions, and complications related to the surgery occurringwithin 30 days of the intervention. Furthermore, to evaluatethe trend in surgical outcome, patients were divided into threegroups according to time interval (1991 to 1992, 1993 to1994, and 1995 to 1997).The groups were always matchedforage, sex, location and size of tumor, and pathologic stage. Themeanhospital costwas determined from the hospital database.The total cost was derived from the addition of the variablecosts plus fixed costs. The professional fees (charges by the

attending) were billed directly from the practice and were not

included. The variable cost per encounter included room andboard charges (hospital bed, directly proportional to thelength of stay), laboratory, electrocardiography, operatingroom time, radiology charges, occupational and physical ther-apy, medications, pharmacy, and nursing. The professionalfees for resident, physician assistants, nursing personnel, andintravenous technicians formed part of the complex equationof the fixed cost. The fixed costs are billed to the patientsthrough an algorithm used by the accounting software, whichlinks the use of services during the patient encounter. Theseservices include utilities, overhead, charges for informationsystems and automatization, malpractice and other insurance,medical record maintenance, and transportation. These costsare directly proportional to the volume or occupation (beds)

of the hospital at a particular time. A hospital software pro-gram, ECLYPSIS was used. This software calculates the costback to the encounter based on the use of services.

STATISTICAL ANALYSIS

The mean values were compared using the two-tailed t test.The Pearson chi-square test was used to compare the differ-ences between the groups with regard to various intraopera-tive and postoperative parameters. A statistical software pro-gram (Statistical Analysis System) was used for this analysis.

RESULTS

The mean age in the RN and PN groups was 65

years (range 46 to 81) and 62 years (range 40 to76), respectively (P value not significant). The tu-mor characteristics are summarized in Table I. Themean tumor size was 4.2 cm in the RN group and3.8 cm in the PN group. The histologic type wasclear cell RCC in 92 (80%) of the 120 patientsstudied, and 17 (14.1%) had papillary tumors.Other less frequent tumors accounted for the restof the cases. The pathologic stage was T1 in 26(21.6%), T2 in 76 (63.3%), and T3a in 18 (15%) ofthe 120 patients. Both groups had the same num-ber in each pathologic stage. Most (69.1%) of the

tumors were grade I or II.A comparison of the surgical data between the

TABLE I. Characteristics of tumors treated

with partial and radical nephrectomy

ParametersPN

(n 60)RN

(n 60)

Mean tumor size (cm) 3.8 2.46 4.2 1.9

Side (left/right) 28/32 31/29

Pathologic stage

T1 13 (21.6) 13 (21.6)T2 38 (63.3) 38 (63.3)

T3a 9 (15) 9 (15)

Tumor grade

I 14 (23) 4 (6.6)

II 31 (51) 34 (56.6)

III 13 (21) 19 (31.6)

IV 2 (3.3) 3 (5)

KEY: PNpartial nephrectomy; RN radical nephrectomy.Numbers in parentheses are percentages.

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two groups is presented in Tables II and III. The

mean operative time showed significant differ-ences between the two groups during the observedperiod. During the first period (1991 to 1992), theoperative time was similar in both groups: 211.5minutes in the RN group and 225 minutes in thePN group (P 0.58). However, in the subsequentperiod (1993 to 1994), a decrease was observed inthe operative time for the RN group (195 minutes),and the operative time for the PN group remainedstable (216.9 minutes) (P 0.05). This tendencywas accentuated during the last period (1995 to1997), with a mean operating room time for the RN

group of 176.59 minutes compared with 224.55minutes for the PN group (P 0.004).

The mean estimated blood loss was 506.91 mLfor the RN group and 415.16 mL for the PN group(P 0.05). Four patients (6%) required bloodtransfusions in the PN group and 11 (18%) did soin the RN group.

The mean amount of transfused blood was 2 U ofpacked red blood cells (650 mL) in the RN groupand 2.5 U of packed red blood cells (813 mL) in thePN group (P 0.05).

The length of stay was 6.38 days for RN group

and 6.36 days for the PN group (P 0.96). Thelength of stay and the costs for RN and PN did not

show any statistically significant differences in any

of the observed periods (P 0.05). Furthermore,the cost and hospital stay did not vary significantlyalong the total period of study (Table III).

Complications occurred in 2 patients in the RNgroup (Table II). One patient had a fatal pulmo-nary embolus and another had wound dehiscence.In the PN group, 6 patients had surgery-relatedcomplications. One patient developed phlebitis ofthe lower limb, and 5 patients had urinary fistulas,defined as urine leakage at a rate of 50 mL/day ormore, after the 10th postoperative day. These pa-tients were treated conservatively; only one re-

quired stent placement.

COMMENT

PN has gained increasing popularity for localizedRCC, and comparable cancer control has beendemonstrated in several recent studies.13,9 How-ever, few studies have evaluated and compared thecomplications and economic implications of differ-ent treatment options for localized RCC.68 In anera of increased managed care and emphasis oncost-effective treatment, it is crucial to present

clinical data demonstrating such comparisons.This becomes even more important when perform-

TABLE II. Comparison of operative parameters between radical

and partial nephrectomy

Parameters PN (n 60) RN (n 60) P Value

Operating time (min) 220.1 59.6 176.6 51.6 0.0001

Estimated blood loss (mL) 415.2 273.5 506.9 443.4 0.77

Blood transfusion (mL) 812.5 245.6 650 187.6 0.64

Hospital stay (days) 6.4 3 6.4 3.3 0.96

Complications (n) 6 (10) 2 (3.3) 0.2Abbreviations as in Table I.Data presented as the mean SD, unless otherwise noted; numbers in parentheses are percentages.

TABLE III. Comparison of intraoperative parameters, hospital stay, and costs stratified by year

Time PeriodsOR Time

(min) EBL (mL)LOS

(days) Overall Cost (USD)

19911992

PN (n 14) 225 91.3 367.9 176 6.29 2.4 19,164.1 962.5

RN (n 14) 211.5 25.4 403.6 153.5 6.1 0.4 20,468.2 1,978.1

P value 0.58 0.57 0.75 0.55

19931994

PN (n 24) 216.9 39.6 466.7 384.7 5.9 2.2 18,743.4 1,211.6

RN (n 24) 195 30.1 363.8 144.8 5.5 1.4 18,877.8 1,090.9

P value 0.037 0.22 0.5 0.9

19951997

PN (n 22) 224 446.6 305.7 6.4 2.3 20,819 6,750

RN (n 22) 176 579.6 436.6 4.9 0.7 19,759 20,183.3

P value 0.004 0.24 0.1 0.81

KEY: OR operating room; EBL estimated blood loss; LOS length of hospital stay; other abbreviations as in Table I.Data presented as the mean SD, unless otherwise noted.

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ing PN in patients with a normal contralateral kid-ney and no other absolute medical indications fornephron-sparing surgery. Only one previous studyhas evaluated the hospital costs of PN comparedwith RN.7 Uzzo et al.7 compared 28 RNs and 52PNs and demonstrated that the hospital cost andcomplications were not significantly different in

the two groups. The tumor size, however, was sig-nificantly smaller in the patients who underwentPN. Overall, 71% of their patients in the RN grouphad Stage T2 disease compared with 33% in the PNgroup. In our study, we matched the two groupswith regard to tumor stage to avoid differences re-lated to tumor size. Overall, PN was performed inrelatively larger tumors compared with previousstudies. Similarly, we found no differences in thehospital costs between the two groups. Further-more, no difference was observed during a 7-yearperiod. Uzzo et al.7 reported that the length of hos-

pital stay was a strong predictor of total costs andtumor stage and size did not have an impact on thetotal cost and length of stay by multivariate analy-sis. In our study, the mean length of stay was 6 daysin both groups, which contributed to the similaroverall hospital costs. The length of hospital stayand costs were not different from 1991 to 1997.One reason for this finding may be that the proce-dures were standardized and no technical modifi-cation was introduced during this period to resultin improved patient recovery, which would be re-flected in the length of hospital stay and costs.

With the recent introduction of laparoscopic RNfor RCC, the standard of care is changing, and thiswould also have an impact on the comparison ofcosts and complications of RN versus PN in thefuture.

The operative time showed a significant differ-ence between the two groups, which was accentu-ated over the years. This was due to the decreasingoperative time in the RN group with time, whichwas not accompanied by a similar decrease in timein the PN group. One explanation for thisfinding is

that RN can be performed in a more standardizedfashion, but PN often poses different operative sit-uations that may require frequent adaptations insurgical strategy, particularly in the larger tumorsincluded in this study.

The overall perioperative complication rate wassimilar to published data.10 With regard to bloodtransfusion rates, controversial results have beenreported. In a recent comparison of RN and PN, theestimated blood loss was higher in patients under-going nephron-sparing surgery.8 The subsequentneed for blood transfusion in patients undergoing

RN for localized disease was 18% compared with30% in those undergoing PN (P 0.009). In con-

trast, a comparative Veterans Affairs study did notdemonstrate any difference in the transfusion ratein a large group of patients undergoing PN com-pared with RN.6 Similarly, in our study, the bloodtransfusion rate was 18% in the RN group and 6%in the PN group. No differences were found in theblood transfusion rates or number of transfusedunits between the two groups. The impact of asignificant difference in transfusion rate on thehospital cost is unclear, because this was not re-ported in the previous studies.7,8

Urinary fistula is a known complication of PN.10

Urine leak occurred in 10% of our patients. How-ever, this did not result in a longer hospital stayand thus did not increase the hospital course. Thiscomplication was managed conservatively in mostpatients on an outpatient basis, resulting in a favor-able outcome in our patients. The only fatal com-plication was a pulmonary embolism in 1 patientafter RN. No patients in the PN group needed dial-ysis postoperatively, indicating the efficiency of PNin the preservation of renal function.

A shortcoming of this study was that it was notpossible to assess the follow-up costs, becausemost patients were followed up by their referringphysicians after surgical treatment. However, con-sidering that most tumors were Stage T1 or T2(85%), for which follow-up is the same as for RN, itis likely that the postoperative management doesnot contribute to a cost increase in the PN group.

CONCLUSIONS

The results of this study demonstrate that RNand PN can be performed with similar hospitalcosts and complication rates and that increasingsurgical experience did not have an impact on thehospital costs. Additional studies are needed to in-vestigate the impact of preoperative and postoper-ative management on the total cost of each modal-ity of treatment.

REFERENCES

1. Steinbach F, Stockle M, Muller SC, et al: Conservativesurgery of renal cell tumors in 140 patients: 21 years of expe-rience. J Urol 148: 24 30, 1992.

2. Novick AC: Renal-sparing surgery for renal cell carci-noma. Urol Clin North Am 20: 277282, 1993.

3. Moll V, Becht E, and Ziegler M: Kidney preserving sur-gery in renal cell tumors: indications, techniques and resultsin 152 patients. J Urol 150: 319 323, 1993.

4. Licht MR, and Novick AC: Nephron sparing surgery forrenal cell carcinoma. J Urol 149: 17, 1993.

5. Belldegrun A, Tsui KH, deKernion JB, et al: Efficacy ofnephron-sparing surgery for renal cell carcinoma: analysisbased on the new 1997 tumor-node-metastasis staging system.

J Clin Oncol 17: 2868 2875, 1999.6. Corman JM, Penson DF, Hur K, et al: Comparison of

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complications after radical and partial nephrectomy: resultsfrom the national veterans administration surgical quality im-provement program. BJU Int 86: 782789, 2000.

7. Uzzo RG, Wei JT, Hafez K, et al: Comparison of directhospital costs and length of stay for radical nephrectomy ver-sus nephron-sparing surgery in the management of localizedrenal cell carcinoma. Urology 54: 994 998, 1999.

8. Shvarts O, Tsui KH, Smith RB, et al: Blood loss and theneed for transfusion in patients who undergo partial or radical

nephrectomy for renal cell carcinoma. J Urol 164: 1160 1163,2000.

9. Lerner SE, Hawkins CA, Blute ML, et al: Disease out-come in patients with low stage renal cell carcinoma treatedwith nephron sparing or radical surgery. J Urol 155: 1868 1873, 1996.

10. Campbell SC, Novick AC, Streem SB, et al: Complica-tions of nephron sparing surgery for renal tumors. J Urol 151:11771180, 1994.

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