Immediate preoperative renal artery embolization in the resection of complex renal tumors (UroCCR-48 Reinbol study)

Preoperative Embolization Followed by Tumor Resection Without Time Interval in Advanced Juvenile Nasopharyngeal Angiofibroma

PURPOSE

This study explored the feasibility and security of the clinical application of preoperative embolization and tumor resection for advanced juvenile nasopharyngeal angiofibroma (JNA) without a time interval, performed on the same date, and under the same general anesthesia (GA).

MATERIALS AND METHODS

Between December 2020 and December 2023, patients with JNA underwent embolization and resection at our hospital. All patients underwent preoperative embolization using liquid embolic material under GA with partial coil assistance; the tumor was removed immediately under the same GA. Both embolization and resection were performed on the same date in the same hybrid operating room without a time interval. Outcome measures included adverse events, blood loss, residual disease, and recurrence.

RESULTS

Complete tumor embolization and complete tumor resection (R0) were achieved in 27 patients under a single GA. 1/27 patient (3.7%) experienced adverse events related to nontarget embolization of the cerebral vessels. However, due to timely detection and treatment, no functional disability occurred after delayed tumor resection and active treatment for cerebral infarction. During a mean follow-up of 12 months, 25/27 patients (92.6%) had no residual tumor seen on imaging or endoscopic evaluation, while residual tumor was observed in 2/27 patients (7.4%). No further treatments were performed. The mean blood loss in tumor resection was 911 mL (100-3400 mL).

CONCLUSION

No interval between preoperative embolization and tumor resection is a feasible and safe treatment modality in patients with advanced JNA.

Surgical options for advanced renal cell carcinoma

Detection of advanced renal cell carcinoma (RCC) is not uncommon, although there has been a stage migration due to frequent use of abdominal imaging allowing early detection of renal masses. Since open IVC thrombectomy was introduced in 1972, minimally invasive approaches such as laparoscopic approach, hand-assisted approach and robotic approach have been adopted. While robotic surgery has potential benefits to improve perioperative outcomes, and our experience with robotic surgery has grown significantly over the last decade, open surgery at an academic center remains the standard of care in this setting. In the setting of metastatic RCC, cytoreductive nephrectomies have been discussed for many years but their indications are unclearly defined, although cytoreductive nephrectomy can be considered in patients with disease largely limited to the kidney or on-going or impending symptomatic disease. Significant advances have been made in systematic therapy for RCC which will eventually lead to the evolution of neoadjuvant and adjuvant therapy in patients with advanced RCC. The surgical management of advanced RCC is a major and complex undertaking but has shown to be feasible and effective.

Mixed Reality: A Step Further for Planning Complex Renal Tumors(RENAL nephrometry score of 7 or higher)

OBJECTIVES

Mixed reality (MR) technology has emerged in recent years and allows three-dimensional visualization, multi-angle observation, remote vision, and virtual-real interaction. This study aims to explore the influence of MR technology on the outcomes and strategy planning of robotic surgery for complex renal tumors.

PATIENTS AND METHODS

A total of 92 patients with complex renal tumors were enrolled in this study from June 2018 to June 2020. All patients were diagnosed in our department by magnetic resonance imaging（MRI）. This trial follows CONSORT guidelines and adopts a parallel single blind design and randomizes patients with a random number table. The study was approved by the institutional review board, and written informed consent was obtained from each participant. All surgeries were performed by 3 experienced and high-volume surgeons. The demographic indicators, intraoperative and postoperative complications, renal function outcomes, pathological results, and surgical strategies were recorded. Student's t-test and Wilcoxon rank-sum were used to compare continuous variables, and Pearson's chi-squared and Fisher's exact tests were used to compare categorical variables.

RESULTS

WIT is mainly composed of tumor resection time and reconstruction time, and the reconstruction time accounts for a larger proportion. For urologists treating complex renal tumors, MR technology can help them reduce warm ischemia time (21.3±4.0 vs 23.6±5.9min, P=0.031), reconstruction time (15.4±3.8 vs 17.2±4.2min, P=0.034), estimated blood loss (P=0.044), operation time (125.7±26.3 vs 144.6±27.9min, P=0.001) and intraoperative complications (P=0.030).

CONCLUSIONS

MR assisted surgery can reduce the incidence of intraoperative complications, improve perioperative outcomes, which may be a good preoperative tool for planning complex renal tumors.

Utility of preoperative vascular embolization of renal tumors with left renal vein tumor thrombus

INTRODUCTION AND OBJECTIVES

Preoperative renal artery embolization (PRAE) for large renal masses may be performed prior to nephrectomy in order to simplify the procedure and reduce intraoperative bleeding. The objective of this work is to determine the role of PRAE on intraoperative bleeding and postoperative complications in left renal tumors with tumor thrombus limited to the left renal vein (level 0).

MATERIAL AND METHODS

Retrospective analysis to evaluate 46 patients who underwent left radical nephrectomy and thrombectomy for the treatment of renal cell carcinoma with level 0 tumor thrombus during the period 1990-2020. PRAE was limited to those cases in which surgical access to the main renal artery was presumed a priori difficult in the preoperative imaging study (n = 9; 19.6%). Intraoperative bleeding was estimated based on the perioperative transfusion rate, and postoperative complications were categorized according to the Clavien-Dindo classification. The Chi-squared test was used for comparisons. A multivariate analysis was performed to identify predictors of transfusion and complications.

RESULTS

There were no significant differences in the overall complication rate (11.1% vs. 32.4%, p = 0.19), major complication rate (0% vs. 8.1%, p = 0.51), or transfusion rate (11.1% vs. 19%, p = 0.49) between both groups (PRAE vs. non-PRAE). In the multivariate analysis, PRAE did not behave as a predictor of complications (OR: 0.11, 95%CI 0.01-2.86; p = 0.18) nor transfusion (OR: 0.46, 95%CI 0.02-7.38; p = 0.58).

CONCLUSIONS

In our study on left RCC with level 0 tumor thrombus and difficult access to the main renal artery, PRAE was not associated with increased bleeding or postoperative complications, and it did not behave as an independent predictor of these variables. Therefore, it could be used as a preoperative maneuver to facilitate vascular management in selected cases.

Utility of preoperative vascular embolization of renal tumors with left renal vein tumor thrombus

INTRODUCTION AND OBJECTIVES

Preoperative renal artery embolization (PRAE) for large renal masses may be performed prior to nephrectomy in order to simplify the procedure and reduce intraoperative bleeding. The objective of this work is to determine the role of PRAE on intraoperative bleeding and postoperative complications in left renal tumors with tumor thrombus limited to the left renal vein (level 0).

MATERIAL AND METHODS

Retrospective analysis to evaluate 46 patients who underwent left radical nephrectomy and thrombectomy for the treatment of renal cell carcinoma with level 0 tumor thrombus during the period 1990-2020. PRAE was limited to those cases in which surgical access to the main renal artery was presumed a priori difficult in the preoperative imaging study (n=9; 19.6%). Intraoperative bleeding was estimated based on the perioperative transfusion rate, and postoperative complications were categorized according to the Clavien-Dindo classification. The Chi-squared test was used for comparisons. A multivariate analysis was performed to identify predictors of transfusion and complications.

RESULTS

There were no significant differences in the overall complication rate (11.1% vs. 32.4%, P=.19), major complication rate (0% vs.8.1%, P=.51), or transfusion rate (11.1% vs. 19%, P=.49) between both groups (PRAE vs. non-PRAE). In the multivariate analysis, PRAE did not behave as a predictor of complications (OR:0.11, 95%CI 0.01-2.86; P=.18) nor transfusion (OR:0.46, 95%CI 0.02-7.38;P=.58).

CONCLUSIONS

In our study on left renal cell carcinomas with level 0 tumor thrombus and difficult access to the main renal artery, PRAE was not associated with increased bleeding or postoperative complications, and it did not behave as an independent predictor of these variables. Therefore, it could be used as a preoperative maneuver to facilitate vascular management in selected cases.