Re: Laparoscopic Resection of Local Recurrence After Previous Radical Nephrectomy for Clinically Localized Renal-Cell Carcinoma: Perioperative Outcomes and Initial Observations (From: Yohannan J,Feng T,Berkowitz J,et al. J Endourol 2010;24:1609–1612)

Dear Editor:

I t is with great interest that we read the article by Yohannan and colleagues whereby the authors report on their minimally invasive treatment of four patients with disease recurrence after radical nephrectomy for renal-cell carcinoma (RCC). While local recurrence of RCC is a rare event, reports on its minimally invasive treatment are even more rare in the literature. Reading this work in detail brings up several issues that we would like to discuss.

First, the authors claim that this is the “first reported experience with pure laparoscopic resection of isolated RCC recurrences.” This statement does not appear to be entirely correct, because we have reported on our experience in 2006 at the European Association of Urology meeting ¹ and published our experience in 2009. ²

Moreover, the authors claim that four patients underwent “resection of a local RCC recurrence.” When examining the clinical characteristics of these patients, however, one cannot miss the flexibility of defining “local recurrence” used in this article. In fact, in two patients, the recurrence was not located in the nephrectomy bed but in the adrenal gland and should have been qualified for the definition of metastases instead of local recurrence. In the remaining two patients, recurrent disease was located in lymph nodes (para-aortic and retrocaval) and does not represent local recurrence but rather metastatic progression. Furthermore, in one patient, there were multiple sites of recurrent disease (additional lung nodules were present), and another had an additional tumor in the contralateral kidney; hence, the indications for surgical intervention should have been discussed thoroughly. In the presence of multiple metastatic sites, the role of surgical intervention remains unclear.

In addition, in our opinion, the readers would have benefited from a detailed description of the resection technique. The authors admit not performing any formal lymph node dissection nor do they propose a scheme of the resection margins to be used in such challenging cases. We strongly believe in minimally invasive treatment as a good option for many patients with locally recurrent RCC, but this should not come at a price of potentially compromising oncologic outcomes. One wonders whether the same approach—ie, resection of the mass only—would have been undertaken if the authors had performed open surgery.

In summary, while introducing the benefits of laparoscopy into urologic oncology, we should attempt to reproduce the open counterpart of the technique, adhering to the established definitions and oncologic principles of surgery. Failure to comply with these points will inevitably bring criticisms on the minimally invasive treatment as a whole.