Mini-subcostal incision technique for open radical nephrectomy: A practical alternative for complex renal masses

To describe the open radical nephrectomy mini-subcostal incision technique (msRN) and evaluate renal function, perioperative, and oncological outcomes as an alternative to traditional or minimally invasive nephrectomy for complex renal masses. This study aims to document the msRN approach, highlighting its value in preserving open nephrectomy skills for selected cases.

Patients undergoing msRN from 2013 to 2016 were retrospectively analyzed. An 8 to 12 cm incision between the costal margin and 11th rib was used, with all patients managed using a rapid recovery pathway. Clinicopathologic, perioperative, and renal function metrics were analyzed. Statistical analyses included univariable and multivariable logistic regression for predictors of length of stay (LOS) >2 days and 30-day complications. Kaplan-Meier analysis was used to evaluate overall survival, and significance was set at P < 0.05.

In 193 patients (median age 59.5, IQR 58.4-68.8), median tumor size was 7.2 cm (IQR 5.0-9.6), and 67.9% were ≥pT3. Notably, 56% of patients had a high R.E.N.A.L. Nephrometry score, and 41.5% had a moderate score, highlighting the complexity of the cases. Median incision was 10 cm, operating time 123 minutes (IQR 102-151), and EBL 300 mL (IQR 100-550). Twenty-three (11.9%) received blood transfusions, and median LOS was 2 days. Predictors of LOS >2 days included age (OR 1.27, P = 0.003) and operating time (OR 1.12, P = 0.015). The 30-day complication rate was 18.1%, with predictors including tumor size (OR 1.14, P = 0.032) and transfusion (OR 3.04, P = 0.031). Median eGFR decreased 34.1%, with no dialysis requirements.

msRN provides favorable outcomes, serving as a practical alternative to traditional and MIS approaches. Its documented utility supports the continued relevance of open surgical techniques for complex renal cases.