Original research

Laparoscopic nephroureterectomy is associated with higher risk of

adverse events compared to laparoscopic radical nephrectomy

1,2

Ravin Bastiampillai, MD; Luke T. Lavallée, MD; Sonya Cnossen, MSc; Kelsey Witiuk, MSc;

Ranjeeta Mallick, PhD; Dean Fergusson, PhD; David Schramm, MD; Christopher Morash, MD;

Ilias Cagiannos, MD; Rodney H. Breau, MD

1,2

Division of Urology, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada; Ottawa Hospital Research Institute, Department of Clinical Epidemiology, Ottawa, ON, Canada;

Division of Otolaryngology, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada

Cite as: Can Urol Assoc J 2016;10(3-4):126-31. http://dx.doi.org/10.5489/cuaj.3362

limitations of this study included the lack of information on tumour

stage and management of the distal ureter.

Abstract

Introduction: Laparoscopic radical nephrectomy (LRN) and lapa-

roscopic nephroureterectomy (LNU) are similar procedures and

some surgeons may believe the perioperative risks are the same.

The purpose of this study is to characterize and compare complica-

tions following LRN and LNU.

Methods: A historical cohort of patients who received either LRN

or LNU between 2006 and 2012 was reviewed from the National

Surgical Quality Improvement Program (NSQIP) database. Patient

characteristics, surgical characteristics, and perioperative outcomes

up to 30 days postoperatively were abstracted. Unadjusted and

adjusted associations between procedure (LRN or LNU) and any

adverse event were determined.

Results: During the study period, 4904 patients met study inclu-

sion criteria; 4159 (84.8%) received a LRN while 745 (15.2%)

received a LNU. Overall, 651 (13.3%) patients experienced at

least one postoperative complication. LNU was associated with

more complications than LRN (21% and 12%, respectively, p value

Introduction

Cancers of the upper urinary tract are common, with an

estimated 63 920 new cases involving the kidney/renal pel-

vis and at least 3000 new cases involving the ureter in the

U.S. in 2014. Tumours originating in the renal parenchyma

are usually treated with radical or partial nephrectomy, and

tumours originating in the upper tract urothelium (ureter and

renal pelvis) are usually treated with nephroureterectomy,

-4

where the ureter is removed in addition to the kidney.

Laparoscopic renal surgery has become the standard

of care for patients with low-stage malignancies because

this approach is associated with easier convalescence and

equivalent cancer outcomes. Both laparoscopic radical

nephrectomy (LRN) and laparoscopic nephroureterectomy

(

LNU) have been associated with reduced blood loss, com-

<0.01). The most common complications were: bleeding requiring

plications, postoperative pain, and length of hospital stay

compared to open surgery.

blood transfusion (9.0% LNU vs. 6.0% LRN), urinary tract infec-

tion (4.6% LNU vs. 1.5% LRN), wound infection (1.3% LNU vs.

,4,6,7

While LRN and LNU are performed for different malig-

nancies, the operative steps are similar, with the exception

of the distal ureter and bladder dissection required for LNU.

Because LRN and LNU are technically similar, some sur-

geons and patients may believe the perioperative risks are

the same. Furthermore, since LRN is performed more often

than LNU, surgeons may be disproportionately inﬂuenced

by the experience of LRN patients.

The objective of this study was to compare postoperative

complications up to 30 days following surgery for patients

undergoing LRN and LNU. We hypothesized that the fre-

quency and type of postoperative complications experienced

after LRN and LNU would be different. Directly comparing

postoperative complications of LRN and LNU will allow

clinicians to better prepare and counsel patients for surgery.

After adjusting for potential confounders, LNU was associated with

higher risk of any complication compared to LRN (relative risk [RR]

.8% LRN), and unplanned intubation (2.3% LNU vs. 0.9% LRN).

.41, 95% conﬁdence interval [CI] 1.16‒1.72). Other variables

independently associated with an increased risk of complications

included: increasing patient age (RR 1.01, 95% CI 1.01 ‒1.02),

American Society of Anesthesiologists (ASA) classiﬁcation >3 (RR

.34, 95% CI 1.10‒1.63), higher preoperative creatinine (RR 1.11,

5% CI 1.06‒1.17), >4 units of blood transfused within 72 hours

before surgery (RR 1.93, 95% CI 1.29‒2.86), and operative time

6 hours (RR 2.17, 95% CI 1.71‒2.75).

Conclusions: Postoperative complications within 30 days of surgery

are common after LNU and LRN. Despite having technical simi-

larities, LNU carries a signiﬁcantly higher risk of developing short-

term complications compared to LRN. This information should

be considered when counseling patients prior to surgery. Notable

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2016 Canadian Urological Association

Poꢀtopꢁꢂꢃtꢄvꢁ ꢅompꢆꢄꢅꢃtꢄoꢇꢀ of lnU vꢀ. lrn

Methods

combination of automated data collection and abstraction

by trained study nurses is used to populate the data from

each hospital. At some centres, data from all procedures

is collected, while a rotating eight-day cycle of cases is

The American College of Surgeons National Surgical Quality

Improvement Program (NSQIP) is a validated program that

measures perioperative outcomes at over 500 academic

and community hospitals located predominantly in North

America. The NSQIP database includes patient demograph-

ics, patient comorbidities, surgical procedure type, and

perioperative adverse events up to 30 days after surgery. A

used at other centres. Previous data audits have revealed

an inter-rater reliability of approximately 98% for surgical

complications. NSQIP hospitals are the source of data used

in this analysis; however, NSQIP administrators have not

reviewed the methodology of this study.

Table 1. Baseline patient and surgical characteristics of LNU and LRN cases in NSQIP from 2006–2012

Laparoscopic nephroureterectomy Laparoscopic radical nephrectomy

Variable

p value

n (%)

TOTAL

745 (15.2)

4159 (84.8)

Patient characteristics

Age (years)

Mean age (SD)

68.7 (SD 14.1)

233 (31.3)

97 (13.0)

132 (17.7)

283 (38.0)

61.1 (SD 14.3)

2343 (56.3)

579 (13.9)

493 (11.9)

744 (17.9)

<65

<0.01

5–70

0–75

Race

White

599 (90.9)

3135 (86.6)

485 (13.4)

<0.01

0.13

Other

Missing: 625 (12.7)

60 (9.1)

Gender

Female

Male

291 (39.1)

453 (60.9)

1747 (42.1)

2404 (57.9)

Body mass index (BMI)

Mean BMI (SD)

28.4 (SD 6.2)

219 (29.6)

282 (38.1)

154 (20.8)

86 (11.5)

30.0 (SD 6.8)

939 (22.8)

1434 (34.8)

932 (22.6)

822 (19.9)

<25

<0.01

25–<30

30–<35

≥35

ASA score

–2

–5

243 (32.7)

501 (67.3)

1590 (38.3)

2566 (61.7)

<0.01

Bleeding disorder

24 (3.2)

12 (1.6)

5 (0.7)

119 (2.9)

99 (2.4)

46 (1.1)

0.59

0.19

0.28

Preoperative weight loss (>10% over six months)

Preoperative sepsis

Preoperative pneumonia

Missing

0 (0.0)

353 (47.4)

1 (0.1)

1942 (46.7)

1.00

Preoperative ascites

Chronic steroid use

Diabetes

1 (0.1)

16 (2.1)

152 (20.4)

27 (3.6)

1 (0.1)

4 (0.1)

225 (5.4)

819 (19.7)

274 (6.6)

18 (0.4)

0.56

<0.01

0.65

Dialysis preoperatively

Acute renal failure

Disseminated cancer

<0.01

0.34

18 (2.4)

169 (4.1)

0.03

Chemotherapy (≤30 days before surgery)

Yes

7 (1.8)

18 (0.8)

0.09

Missing

353 (47.4)

1942 (46.7)

Radiotherapy (≤90 days preoperatively)

Yes

Missing

0 (0.0)

357 (47.9)

9 (0.4)

1959 (47.1)

0.37

0.15

Dyspnea

83 (11.1)

393 (9.4)

*Missing data not shown for variables with <1% missing data. ASA: American Society of Anesthesiologists; LRN: laparoscopic radical nephrectomy; LNU: laparoscopic nephroureterectomy;

NSQIP: National Surgical Quality Improvement Program; PRBC: packed red blood cells; SD: standard deviation.

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127

Bꢃꢀtꢄꢃmpꢄꢆꢆꢃꢄ ꢁt ꢃꢆ.

Data was queried from NSQIP Participant Data Use Files

from 2006 to 2012. All LRN (CPT code 50545) and LNU

would be expected for those procedures. Partial nephrec-

tomy or isolated ureterectomy patients were also excluded,

as these operations are associated with unique complication

proﬁles and were outside of our primary study question.

Numerous complications are abstracted per-protocol in

the NSQIP. NSQIP nurses use speciﬁc deﬁnitions to deter-

mine if a complication occurred or not. The deﬁnitions are

modiﬁed as needed over time, but are consistently used

(

CPT code 50548) cases were included. Since tumour stage

information is not available in the NSQIP database, patients

were chosen based on whether they were treated with a

laparoscopic approach, as this likely selected for patients

with similarly localized disease. Open procedures were not

included because signiﬁcant heterogeneity in tumour stage

Table 1. Baseline patient and surgical characteristics of LNU and LRN cases in NSQIP from 2006–2012 (cont’d)

Laparoscopic nephroureterectomy Laparoscopic radical nephrectomy

Variable

p value

n (%)

TOTAL

745 (15.2)

4159 (84.8)

Patient characteristics

Alcohol use (>2 drinks/day)

Yes

12 (3.1)

73 (3.3)

0.81

Missing

353 (47.4)

1942 (46.7)

Current smoker

Smoking history

180 (24.2)

807 (19.4)

<0.01

≤

Missing

50 pack years

292 (89.0)

36 (11.0)

417 (56.0)

1712 (93.5)

119 (6.5)

2328 (56.0)

<0.01

Functional status

Independent

Dependent

727 (98.0)

15 (2.0)

4053 (97.7)

97 (2.3)

0.60

Hemiplegia

Missing

4 (1.0)

353 (47.4)

18 (0.8)

1942 (46.7)

0.56

Cerebrovascular accident/stroke with neurological

deﬁcit

7 (1.8)

51 (2.3)

0.52

Missing

353 (47.4)

1942 (46.7)

Cerebrovascular accident/stroke with no neurological

deﬁcit

Missing

14 (3.6)

353 (47.4)

55 (2.5)

1942 (46.7)

0.21

0.07

Chronic obstructive pulmonary disease (severe)

54 (7.2)

231 (5.6)

Transient ischemic attacks

Missing

12 (3.1)

353 (47.4)

71 (3.2)

1942 (46.7)

0.88

Congestive heart failure (≤30 days preoperatively)

3 (0.4)

34 (0.8)

0.23

Preoperative albumin concentration (g/dl)

4.1

156 (37.3)

90 (21.5)

93 (22.3)

79 (18.9)

327 (43.9)

952 (39.8)

565 (23.6)

411 (17.2)

467 (19.5)

1764 (42.4)

.8–4.1

.5–3.7

0.09

<3.5

Missing

Preoperative creatinine level (mg/dl)

≤

1.3

1.3–<2

522 (73.3)

143 (20.1)

47 (6.6)

3120 (78.43)

503 (12.6)

355 (8.9)

<0.01

≥2

Missing

33 (4.4)

181 (4.3)

Emergency case

5 (0.7)

20 (0.5)

33 (0.8)

0.57

0.01

>4 units PRBC transfusion (≤72 hours preoperatively)

13 (1.7)

Surgical characteristics

Operative time

≤

6 hours

Missing

623 (89.9)

70 (10.1)

52 (7)

3476 (96.8)

116 (3.2)

567 (13.6)

<0.01

*Missing data not shown for variables with <1% missing data. ASA: American Society of Anesthesiologists; LRN: laparoscopic radical nephrectomy; LNU: laparoscopic nephroureterectomy;

NSQIP: National Surgical Quality Improvement Program; PRBC: packed red blood cells; SD: standard deviation.

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Table 2. Complications after LNU compared to LRN cases in NSQIP from 2006–2012

Variable

LNU n (%)

LRN n (%)

Relative risk* (95% CI)

p value

Hematologic complications

Blood transfusion

67 (9.0)

10 (1.3)

2 (0.3)

6 (0.8)

251 (6.0)

16 (0.4)

10 (0.2)

5 (0.1)

1.49 (1.15–1.92)

3.49 (1.59–7.66)

1.12 (0.25–5.09)

6.70 (2.05–21.90)

<0.01

0.89

DVT/thrombophlebitis

Pulmonary embolism

Cerebrovascular accident/stroke with neurological deﬁcit

Infectious complications

Urinary tract infection

Wound infection

<0.01

34 (4.6)

10 (1.3)

11 (1.5)

63 (1.5)

75 (1.8)

34 (0.8)

3.01 (2.00–4.54)

0.74 (0.39–1.43)

1.81 (0.92–3.55)

<0.01

0.38

0.09

Pneumonia

Respiratory complications

Unplanned intubation

Prolonged ventilation >48 hours

Renal complications

17 (2.3)

14 (1.9)

39 (0.9)

17 (0.4)

2.43 (1.38–4.28)

4.60 (2.28–9.29)

<0.01

Progressive renal failure

Acute renal failure

19 (2.6)

12 (1.6)

26 (0.6)

21 (0.5)

4.08 (2.27–7.33)

3.19 (1.58–6.46)

<0.01

Cardiac and other complications

Myocardial infarction

Wound dehiscence

9 (1.2)

4 (0.5)

18 (0.4)

15 (0.4)

2.79 (1.26–6.19)

1.49 (0.50–4.47)

2.23 (0.70–7.10)

1.73 (1.47–2.04)

0.01

0.48

Cardiac arrest requiring CPR

Any complication

4 (0.5)

10 (0.2)

0.17

154 (20.7)

497 (12.0)

<0.01

Median: 4

IQR 3–6

Median: 3

IQR 2–4

Length of total hospital stay

<0.01

*Denotes the relative risk of LNU when compared to LRN. CI: conﬁdence interval; CPR: cardiopulmonary resuscitation; DVT: deep vein thrombosis; IQR: interquartile range; LRN: laparoscopic

radical nephrectomy; LNU: laparoscopic nephroureterectomy; NSQIP: National Surgical Quality Improvement Program.

Pulmonary embolism

Cardiac arrest

Wound dehiscence

Cerebrovascular accident/stroke

Myocardial infarction

LRN

DVT/thrombophlebitis

LNU

Pneumonia

Acute renal failure

Wound infection

Prolonged ventilation >48 hours

Unplanned intubation

Progressive renal failure

Urinary tract infection

Bleeding requiring transfusions

1 2 3 4 5 6 7

9 10

Incidence (%)

Fig. 1. Complications after laparoscopic nephroureterectomy (LNU) and laparoscopic radical

nephrectomy (LRN) cases in NSQIP from 2006‒2012.

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Bꢃꢀtꢄꢃmpꢄꢆꢆꢃꢄ ꢁt ꢃꢆ.

Table 3. Multivariable analysis of patient and surgical

factors associations with complications following LNU and

LRN in NSQIP from 2006–2012

dure type. Those who had LNU were older, more likely to

be current smokers, and had higher American Society of

Anesthesiologists (ASA) physical status classiﬁcation system

scores.

One hundred fifty-four (20.7%) of the LNU patients

experienced at least one complication compared to 497

Variable

Relative risk

1.41

95% CI

p value

<0.01

0.16

LNU vs. LRN

1.16–1.72

1.01–1.02

0.6 –1.08

0.70–1.18

1.10–1.63

0.79–1.61

0.43–1.09

0.96–1.93

0.73–1.14

Age (increase of one year)

Non-White vs. White

BMI >35 vs. <25

1.01

0.82

(

both groups, the most common complication was bleeding

requiring at least one transfusion within 72 hours of surgery

12.0%) of LRN patients (RR 1.73; 95% CI 1.47‒2.04). For

0.91

0.49

ASA class 3–5 vs. 1–2

Chronic steroid use

Dialysis preoperatively

Disseminated cancer

Current smoker

1.34

<0.01

0.50

1.13

(

9% for LNU vs. 6% for LRN, p value <0.01). For the LNU

0.68

0.11

group, other common complications included urinary tract

infections (4.6%), progressive renal insufﬁciency (2.6%), and

unplanned intubations (2.3%). In the LRN group, wound

infections (1.8%) and urinary tract infections (1.5%) were

most common (Table 2, Fig. 1).

A multivariable model was created to adjust for patient

and surgical factors that may confound the association

between procedure type and risk of complication. After

adjusting for potential confounders, LNU was independently

associated with a higher risk of experiencing any complica-

tion vs. LRN (RR 1.41, 95% CI 1.16‒1.72). The following

patient and surgical factors were also independently associ-

ated with complications: older age, ASA class 3‒5, higher

preoperative creatinine, transfusion of >4 units of red blood

cells within 72 hours prior of surgery, and >6 hours of oper-

ating time (Table 3).

1.36

0.08

0.91

0.43

Preoperative creatinine

1.11

1.06–1.17

<0.01

(increase by one)

Transfusion of >4 units

PRBC within 72 hours prior

to surgery

1.93

2.17

1.29–2.86

1.71–2.75

<0.01

>6 hours of operating time

ASA: American Society of Anesthesiologists; BMI: body mass index; LNU: laparoscopic

nephroureterectomy; LRN: laparoscopic radical nephrectomy; NSQIP: National Surgical

Quality Improvement Program; PRBC: packed red blood cells.

across all participating hospitals. Complications evaluated in

this study included superﬁcial and deep surgical site infec-

tion, wound disruption, pneumonia, unplanned intubation,

pulmonary embolism, requiring ventilator for >48 hours,

progressive renal insufﬁciency, acute renal failure, urinary

tract infection, stroke with neurological deﬁcits, cardiac

arrest requiring cardiopulmonary resuscitation (CPR), myo-

cardial infarction, intraoperative or postoperative bleeding

within 72 hours requiring transfusion, and deep vein throm-

bosis (DVT).⁸

The data were summarized using descriptive statistics.

Patient and surgical factors were compared between the LRN

and LNU groups using t-tests and chi-squared analyses. The

associations between surgery type (LRN vs. LNU) and the

occurrence of any complication by 30 days were calculated

using log binomial regression and presented as relative risks

Discussion

Accurate knowledge of perioperative risk is important for

valid patient consent and to identify patients most in need of

prophylactic interventions. Since similar anatomic dissection

is performed during LRN and LNU, surgeons may believe the

associated risks to patients are similar. Furthermore, since

LRN is performed more frequently than LNU, the experience

of LRN patients may be predominately used by surgeons

when counseling patients prior to a LNU. Using a large

contemporary cohort of patients, LNU was associated with

a 40% higher risk of perioperative complications compared

to LRN.

(

RR) with 95% conﬁdence intervals (CI). To more accurately

characterize the association between surgery type and com-

plications, a multivariable model adjusting for statistically

signiﬁcant and clinically relevant potential confounders was

created. Variables with >25% missing data were excluded

from the multivariable model. A p value of ≤0.05 was con-

sidered to be statistically signiﬁcant. All statistical calcula-

tions were performed using SAS 9.3 (SAS institute Inc., Cary,

NC, U.S.).

The observed complications in this study are consistent

with those reported in previous studies of laparoscopic renal

surgery. To our knowledge, this is the ﬁrst study that has

compared complications of LRN and LNU. Previous studies

examining each procedure alone report complication rates

, 9-12

of 11‒31% and 21‒37% for LRN and LNU, respectively.

Higher morbidity with LNU may be due to the distal ureter

and bladder dissection or may be related to differences in

Results

patient populations. Indeed, LNU patients in NSQIP were

older, had worse functional status, and were more likely

to smoke. Additionally, upper tract urothelial carcinoma is

generally more challenging to clinically stage than renal

From 2006 to 2012, 4159 patients who received LRN and

45 who received LNU were abstracted into the NSQIP

database and were included in this study. Table 1 lists

baseline patient and surgical factors stratiﬁed by proce -

parenchymal tumours. LNU patients might, therefore, have

CUAJ • March-April 2016 • Volume 10, Issues 3-4

Poꢀtopꢁꢂꢃtꢄvꢁ ꢅompꢆꢄꢅꢃtꢄoꢇꢀ of lnU vꢀ. lrn

Competing interests: Dr. Morash has been an Advisory Board member for Abbvie, Astellas, Ferring,

Janssen, and Sanoꢀ; and has participated in clinical trials for Abbvie. The remaining authors declare

no competing ꢀnancial or personal interests.

more advanced disease than was expected based on preop-

erative images and this advanced stage could contribute to

the higher postoperative morbidity. Lymph node dissection

may also be more commonly performed during LNU and

this aspect of the procedure may add to morbidity.

This paper has been peer-reviewed.

The results of this study are more generalizable than

previous studies because they were derived from a diverse

group of hospitals and surgeons. In addition, NSQIP data

are collected to prevent bias by recording all cases or an

eight-day cycle at some centres. Finally, trained research

nurses collect the data from each site, and previous studies

have shown the data to be highly accurate with very low

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comprehensive review of the current literature. Eur Urol 2012; 62:100-14.http://dx.doi.org/10.1016/j.

eururo.2012.02.030

Conclusion

Postoperative complications are common in laparoscopic

renal surgery, with LNU having a higher incidence than

LRN. Surgeons should be aware of these differences and

incorporate this information in preoperative counseling and

perioperative management of their patients.

4. Ghavamian R. Complications of laparoscopic radical nephrectomy and nephroureterectomy (2010). In:

Complications of Laparoscopic and Robotic Urologic Surgery (113-126). New York, NY: Springer.

Correspondence: Dr. Rodney H. Breau, Ottawa Hospital Research Institute, Division of Urology,

Department of Surgery, University of Ottawa, Ottawa, ON, Canada; rbreau@toh.on.ca

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