Laparoscopic versus open nephrectomy in resource-constrained developing world hospitals: a retrospective analysis

Background: Laparoscopic nephrectomy is the standard of care for nephrectomy in most developed countries. Its adoption in our setting has been limited due to lack of equipment and expertise. This paper sets out to show that laparoscopic nephrectomy is technically feasible in the state sector in South Africa. Methods: A retrospective chart review was performed of all patients having undergone nephrectomy over a five-year period at two state hospitals in KwaZulu-Natal Province, South Africa. Demographic information, pre-operative imaging findings, operative information and post-operative outcomes were analysed. Results: Nephrectomy was performed in 196 patients. Open nephrectomy (ON) was the intended surgical approach in 73% (n = 143) and laparoscopic nephrectomy (LN) in 27% (n = 53). The conversion rate from LN to ON was 11% (n = 6). For malignancies, there was no difference in surgical resection margin status across the ON, LN and conversion groups; however, tumour size was larger in the conversion group compared to the LN group. Estimated blood loss and transfusion rates were lower in the LN group. The average length of hospital stay was shorter in the LN group (5 vs 10 days). High dependency unit (HDU) admission rate was lower in the LN group (12.1%) compared to the ON group (50%) and the conversion group (40%). No difference in high-grade complications was noted between the ON and LN groups, and more patients in the LN group (82.5%) had no complications compared to the open group (9.9%). Conclusion: LN is non-inferior to ON in terms of operative time, oncology outcomes and high-grade complications. LN is superior in terms of blood loss, transfusion rate, length of hospital stay and overall complication rate. LN appears to show technical feasibility in the state sector and highlights the need for laparoscopic training.