Conservative surgery of renal cell tumors in 140 patients: 21 years of experience

Does routine intraoperative Double J stent insertion avoid urine leakage after open partial nephrectomy?

OBJECTIVE

To evaluate the impact of Double J stent (DJS) insertion during open partial nephrectomy (OPN) on postoperative prolonged urinary leakage.

MATERIALS AND METHODS

A retrospective study was made in consecutive cases of OPN performed between 2002 and 2020 for localized kidney tumors at our tertiary center. Urinary leakage was defined as drainage > 72 hours after surgery by biochemical analysis consistent with urine or radiographic evidence of urine leakage. The patients were divided into two groups according to intraoperative DJS placement, and compared regarding clinicopathologic characteristics, perioperative and postoperative outcomes. Univariate and multivariate logistic regression analyses were performed to determine the factors associated with urinary leakage after the operation.

RESULTS

Review of records identified 182 patients who were included in the study. In 73 (40%) patients PN was performed without insertion of a DJS. Thus, 109 (60%) of patients had a DJS inserted. Apart from higher preoperative eGFR values among patients with DJS (96.6 vs. 94.3 mL/min/1.73 m²; p = 0.03), demographic characteristics were similar between groups. The two groups were not different regarding perioperative, postoperative and clinicopathologic outcomes. Patients with DJS had longer ischemia times (31 vs. 23 min; p = 0.02) and longer length of stay (6 vs. 5 days; p = 0.04). Urinary leakage was seen in 7.6% (n = 14) of all patients and it did not differ according to DJS placement (DJS+ 9.2 vs. DJS- 5.5%; p = 0.41). On multivariate analysis, the tumor nearness to the collecting system was the sole independently significant factor (p = 0.04) predicting postoperative urine leak.

CONCLUSIONS

Routine intraoperative DJS insertion during OPN does not appear to reduce the probability of postoperative urine leak.

Natural and Clinical Course of Renal Cell Carcinoma — Better Prospect for the Patients

The many improvements in diagnostic and therapeutic tools over the last half-century have changed the prospects for patients with renal cell carcinoma (RCC). Higher survival rates and less morbidity have been achieved. The disease is, however, still unpredictable and represents many unsolved problems.

In this paper we focus on determinants of the natural and clinical course of RCC and the changes in regard to this over the last decades.

Nephron-Sparing Surgery — Strategies for Partial Nephrectomy in Renal Cell Carcinoma

The use of partial nephrectomy for renal cell carcinoma has continuously changed in the clinical practice. Previously it was mostly used in imperative cases, in patients with a solitary kidney or in patients with a risk of renal failure. An increased number of incidentally detected renal cell carcinomas are diagnosed due to the advances of the radiological methods. These tumours tend to be smaller and generally with a lower stage. The reported excellent results of partial nephrectomy have promoted the use of nephron-sparing surgery also in patients with a normal contralateral kidney and tumours smaller than 4-5 cm. The technical outcome is excellent with a low operative morbidity and a good oncologic control. Therefore partial nephrectomy has become a standard technique in the treatment of properly selected patients. Laparoscopy with its reduced postoperative pain and shorter rehabilitation time, has encouraged the interest in minimally invasive nephron sparing surgical techniques. Although low, the risk of local tumour recurrence and surgical complications are higher after nephron-sparing surgery compared with radical nephrectomy. Furthermore, long-term renal function remains adequate in most patients with a normally functioning contralateral kidney also after radical nephrectomy. Albeit these facts, there is convincing evidence justifying nephron-sparing surgery to be used routinely for patients with a small renal cell carcinoma and a normal functioning contralateral kidney.

Urinary fistula after robot-assisted partial nephrectomy: a multicentre analysis of 1 791 patients

OBJECTIVE

To evaluate the incidence of and risk factors for a urine leak in a large multicentre, prospective database of robot-assisted partial nephrectomy (RPN).

PATIENTS AND METHODS

A database of 1 791 RPN from five USA centres was reviewed for urine leak as a complication of RPN. Patient and tumour characteristics were compared between patients with and those without postoperative urine leaks. Fisher's exact test was used for qualitative variables and Wilcoxon sum-rank tests were used for quantitative variables. A review of the literature on PN and urine leak was conducted.

RESULTS

Urine leak was noted in 14/1 791 (0.78%) patients who underwent RPN. The mean (sd) nephrometry score of the entire cohort was 7.2 (1.9), and 8.0 (1.9) in patients who developed urine leak. The median (range) postoperative day of presentation was 13 (3-32) days. Patients with urine leak presented in delayed fashion with fever (two of the 14 patients, 14%), gastrointestinal complaints (four patients, 29%), and pain (five patients, 36%). Eight of the 14 patients (57%) required admission, while eight (57%) and nine (64%) had a drain or stent placed, respectively. Drains and stents were removed after a median (range) of 8 (4-13) days and 21 (8-83) days, respectively. Variables associated with urine leak included tumour size (P = 0.021), hilar location (P = 0.025), operative time (P = 0.006), warm ischaemia time (P = 0.005), and pelvicalyceal repair (P = 0.018). Upon literature review, the historical incidence of urine leak ranged from 1.0% to 17.4% for open PN and 1.6-16.5% for laparoscopic PN.

CONCLUSION

The incidence of urine leak after RPN is very low and may be predicted by some preoperative factors, affording better patient counselling of risks. The low urinary leak rate may be attributed to the enhanced visualisation and suturing technique that accompanies the robotic approach.

Estimated functional renal parenchymal volume predicts the split renal function following renal surgery

PURPOSE

The change in functional renal volume (FRV) has an absolute influence on renal function after nephrectomy (Nx) or nephron-sparing surgery (NSS). In this study, we prospectively examined whether the postoperative renal function following Nx and NSS could be accurately predicted and assessed the reproducibility of our newly developed 3-D image reconstruction system (Kashihara) to measure the FRV.

METHODS

We enrolled 98 patients who underwent Nx and 41 patients who underwent NSS from April 2006 to September 2009 to predict postoperative FRV and renal function. FRV was measured before and after (1 month and 1 year) renal surgery. The postoperative estimated glomerular filtration rate (eGFR) was predicted from the preoperative eGFR calculated from the serum creatinine (sCr) level and the ratio of the postoperative/preoperative FRV. To assess the reproducibility and accuracy of our newly developed 3-dimensional (3-D) image reconstruction system, FRV was measured by five examiners using images obtained by CT (five cases) and MRI (five cases).

RESULTS

Significant correlation was found both for FRV and for renal function between the predictive values and the actually measured values at 1 month and 1 year after surgery, not only in the Nx group, but also in the NSS group. The accuracy and reproducibility could be confirmed both with CT and MRI studies.

CONCLUSIONS

The postoperative FRV and renal function could be predicted preoperatively using a 3-D image reconstructive system, preoperative routine diagnostic imaging, and preoperative sCr level.

[Positive surgical margins in nephron sparing surgery for renal cell carcinoma]

Nephron sparing surgery (NSS) with a minimal tumor-free margin is considered the cornerstone in the contemporary management of renal cell carcinoma (RCC) stage T1. The aim of this study is to review incidence, predictive risk factors, clinical significance and oncologic outcomes of positive surgical margins (PSM) in NSS. English articles published before March 2014 have been searched in Medline Databank.PSM are present in 0-7% of patients in all surgical approaches considered. Some predictive factors,such as tumor size, localization, and histology have been identified in the past. Other topics concerning surgical technique and approach are discussed.The majority of patients with PSM do not experience disease recurrence and PSM impact on overall survival and cancer-specific survival seems to be irrelevant. These results lead to more conservative clinical strategies. However, an active surveillance is mandatory for all patients with PSM and especially for those with high risk disease. Generalization of these results is limited by the low level of evidence of available studies. Further efforts are necessary to avoid PSM intraoperatively and to provide prospective information in order to standardize the postoperative management.

Renal cell carcinoma : clinical features and management

In 1999 it was estimated that renal cell carcinoma (RCC) would account for 29,990 new cancer cases diagnosed in the United States (61% in men and 39% in women), and lead to 11,600 deaths. RCC accounts for 2-3% of all malignancies in adults and causes 2.3% of all cancer deaths in the United States annually (1). Approx 4% of all RCC cases are bilateral at some point in the life of the patient. Data from over 10,000 cases of renal cancer entered in the Connecticut Tumor Registry suggests an increase in the incidence of renal cancer from 1935-1989; in women the incidence increased from 0.7 to 4.2 in 100,000, and in men from 1.6 to 9.6 in 100,000 (2). Factors implicated in the development of RCC include cigarette smoking, exposure to petroleum products, obesity, diuretic use, cadmium exposure, and ionizing radiation (3-9).

Cryoablation vs radiofrequency ablation for the treatment of renal cell carcinoma: a meta-analysis of case series studies

Study Type - Therapy (systematic review). Level of Evidence 2b What's known on the subject? and What does the study add? The oncological success of partial nephrectomy in the treatment of small renal masses is well established. However, partial nephrectomy has largely supplanted the radical approach. In the last decade, laparoscopy has been adopted as the new surgical approach for the treatment of renal cell carcinoma. Laparoscopy offers the advantage of lower analgesic use, shorter hospital stay, and quicker recovery time. More recently, ablative technologies have been investigated as an alternative to laparoscopic partial nephrectomy. These techniques can often be performed percutaneously in the radiology suite, or laparoscopically without the need for hilar clamping. However, only the cryoablation and radiofrequency ablation modalities have had widespread use with several series reporting short to intermediate results. This review shows that both cryoablation and radiofrequency ablation are promising therapies in patients with small renal tumours (<4 cm), who are considered poor candidates for more involved surgery.

OBJECTIVE

• To determine the current status of the literature regarding the clinical efficacy and complication rates of cryoablation vs radiofrequency ablation in the treatment of small renal tumours.

METHODS

• A review of the literature was conducted. There was no language restriction. Studies were obtained from the following sources: MEDLINE, EMBASE and LILACS. • Inclusion criteria were (i) case series design with more than one case reported, (ii) use of cryoablation or radiofrequency ablation, (iii) patients with renal cell carcinoma and, (iv) outcome reported as clinical efficacy. • When available, we also quantified the complication rates from each included study. • Proportional meta-analysis was performed on both outcomes with a random-effects model. The 95% confidential intervals were also calculated.

RESULTS

• Thirty-one case series (20 cryoablation, 11 radiofrequency ablation) met all inclusion criteria. • The pooled proportion of clinical efficacy was 89% in cryoablation therapy from a total of 457 cases. There was a statistically significant heterogeneity between these studies showing the inconsistency of clinical and methodological aspects. • The pooled proportion of clinical efficacy was 90% in radiofrequency ablation therapy from a total of 426 cases. There was no statistically significant heterogeneity between these studies. • There was no statistically significant difference regarding complications rate between cryoablation and radiofrequency ablation.

CONCLUSIONS

• This review shows that both ablation therapies have similar efficacy and complication rates. • There is urgency for performing clinical trials with long-term data to establish which intervention is most suitable for the treatment of small renal masses.

[Open partial nephrectomy: standard of minimal invasive surgery]

OBJECTIVE

Partial nephrectomy is now recognized as the standard treatment for tumors less than 7cm. The oncological results are comparable to those obtained by total nephrectomy, while preserving kidney function. Our objective was to describe our experience and research factors associated with complications, recurrence and death.

PATIENTS AND METHODS

Partial nephrectomy performed in our center by June 1996 to December 2008 were reviewed retrospectively. Demographic and tumors characteristics, postoperative complications and patient outcomes were identified. Factors associated with complications and survival were investigated by regression tests.

RESULTS

Of the 96 patients enrolled (mean age 61.4 years±12.8), 13 had renal insufficiency (serum creatinine 120 to 212μmol/L). The mean tumor size was 32mm (±13.9) and 57 (79.2%) corresponded to clear cell carcinoma. The overall rate of postoperative complications was 26%, including 8.3% of hemorrhagic complications and 3.1% of urinary complications. None of the analyzed variables were associated with the occurrence of complications. With a mean of 2 years and 9 months follow-up (±28months), eight patients (11.1%) had tumor recurrence. Multifocal tumors as well as postoperative complications were associated with risk of recurrence. Three patients with positive tumor margins were monitored with no evidence of progression (with 71, 42 and 12 months of follow-up).

CONCLUSION

Our single-center retrospective study of partial nephrectomy for renal tumor showed medium-term oncological results similar to those reported in the total nephrectomy with the advantage of nephron preservation. The results of studies by conventional surgery such as that we report should be a benchmark for laparoscopic surgery.

Efficacy and safety of nephron-sparing surgery

To analyse the current evidence of efficacy and safety of nephron-sparing surgery (NSS) that encompasses open partial nephrectomy (OPN), laparoscopic partial nephrectomy (LPN) and robotic partial nephrectomy in the management of localized renal cell carcinoma (RCC). Oncological data, complications and postoperative renal function were reviewed for the most important series of partial nephrectomy. Partial nephrectomy (PN) provides similar oncological control as radical nephrectomy (RN) and is superior to RN with respect to preserving renal function and preventing chronic kidney disease. OPN remains the first treatment option for T1 renal tumors in centers without advanced laparoscopic expertise. Indications for LPN have expanded as such that LPN is suited for most renal tumors provided that the procedure is carried out in selected patients by an experienced laparoscopic surgeon. Warm ischemia time should be kept within 20 min, which is currently recommended regardless of surgical approach. In experienced hands, LPN yields intermediate oncological efficacy and renal function outcome comparable to open surgery in the treatment of pT1 renal tumors. Positive surgical margin rates are comparable after LPN and OPN. In contemporary series, the morbidity of LPN is decreasing to become similar to that of OPN. Preliminary results with robotic PN are comparable to results obtained with LPN. Additional studies are required to validate these results and compare with other current methods, such as thermal ablation. NSS is effective and safe for the management of localized RCC and is the gold standard to which new ablative techniques need to be compared.

Renal masses herniating into the hilum: technical considerations of the "ball-valve phenomenon" during nephron-sparing surgery

OBJECTIVES

To describe our technique to recognize and resect renal tumors "ball-valving" into the sinus. Partial nephrectomy (PN) offers a functional advantage over radical nephrectomy for many cases of localized renal cell carcinoma. However, PN is underutilized particularly in anatomically challenging cases. Often unrecognized is the tendency for central renal tumors to herniate into the renal sinus.

METHODS

From our prospective kidney cancer database, we identified 36 patients who underwent open, laparoscopic, or robotic PN for solitary localized renal cell carcinoma herniating into the renal sinus.

RESULTS

Axial and reformatted radiographs were reviewed for all renal hilar lesions. Intraoperative techniques include hilar dissection, establishment of a sinus plane allowing tumor and parenchymal retraction, reduction of the tumor out of the sinus, resection, and repair. Mean preoperative lesion size was 3.8 cm. Indications for PN included 15 of 36 (42%) absolute, 13 of 36 (36%) relative, and 2 of 36 (6%) reoperative PN. No procedure was converted to radical nephrectomy. Of the 36 PN, 5 (14%) were performed using a minimally invasive approach and no minimally invasive surgery procedures were converted to open. No patient required renal replacement.

CONCLUSIONS

Recognition of the tendency for hilar masses to herniate or "ball-valve" into the renal sinus is essential for effective PN of central tumors. By using our technique, we have demonstrated success in nephron-sparing surgery with minimal intraoperative complications and favorable postoperative outcomes in patients with central tumors herniating into the renal sinus.

Implications of computer tomography measurement in the management of renal tumours

Background

To compare radiographic measurement and pathological measurement of renal tumours to see if there was a significant difference between the two as this may have implications in the management.

Methods

We retrospectively analyzed CT measurements of 106 consecutive patients who underwent either radical or nephron sparing surgery in our institution and compared this to the actual measurement of the surgical specimen. The largest axial measurement was compared as this is the primary consideration before offering either treatment modality.

Results

The mean age of the patients was 64 years (range 31–92). There were 76 males and 30 females. The median tumour size was 70 mm (range 16–175) on CT and 65 mm (range 15–90) on pathological measurement. 25 patients had a CT size ≤ 40 mm. CT tended to overestimate the size of tumours in 41 patients, underestimate in 45 and agree with surgical size in 20 patients. Statistically there was no significant difference between the two measurements (p = 0.7, Wilcoxon sign ranked test). When subdivided into tumours less than 40 mm (p = 0.7) and more than 40 mm (p = 0.09) again there was no statistically significant difference between the two measurements. However in 5(5%) patients who were not offered nephron sparing surgery based on CT findings (size > 40 mm) the pathological size was ≤ 40 mm (p = < 0.001, Fishers Exact test). Pathologically the tumours were classified as renal cell carcinoma (n = 98), angiomyolipoma (3), and oncocytoma (5).

Conclusion

CT measurement of renal tumour size correlates well with the actual size of the tumour. However CT does tend to overestimate the size in a small number of patients which may have a bearing on the modality of treatment offered.

[Elective organ-sparing surgery for renal tumors in patients with a normal contralateral kidney: long-term results]

Continuous improvements in radiological imaging techniques have enabled an earlier diagnosis of incidental renal tumors. The share of small renal tumors (<or=4 cm, T1a) amongst the incidentally detected renal masses is reported to be as high as 60%. Fortunately, the classic clinical triad of pain, hematuria, and a palpable flank mass is nowadays the exception of clinical presentation. Concerns regarding development of chronic renal failure after radical nephrectomy have resulted in an increasing use and steady improvement of organ-sparing surgical techniques for patients with small unilateral renal tumors in the presence of a normal contralateral kidney (elective indication). Nephron-sparing surgery has become the gold standard for treating these small tumors. Newer long-term oncological results have demonstrated that carefully selected patients with unilateral renal tumors >4 cm can also be treated with nephron-sparing surgery. We report in this article our long-term oncological results of nephron-sparing surgery in patients with an elective indication.

Carbon ion radiation therapy for primary renal cell carcinoma: initial clinical experience

PURPOSE

Renal cell carcinoma (RCC) is known as a radioresistant tumor, and there are few reports on radiotherapy for primary RCC. We evaluated the efficacy of carbon ion radiotherapy (CIRT) for patients with RCC.

METHODS AND MATERIALS

Data for patients with RCC who received CIRT were analyzed. A median total dose of 72 GyE (gray equivalents) in 16 fractions was administered without any additional treatment. Clinical stage was determined based on TNM classification by the International Union Against Cancer (UICC). Local recurrence was defined as definite tumor regrowth after treatment.

RESULTS

Data for 10 patients were included in the analyses, including 7 patients with Stage I and 3 patients with Stage IV (T4NxM0 or TxN2M0) disease. The median maximum diameter of the tumor was 43 mm (24-120 mm). The median follow-up for surviving patients was 57.5 months (9-111 months). The 5-year local control rate, progression-free survival rate, cause-specific survival rate, and overall survival rates were 100%, 100%, 100%, and 74%, respectively. Interestingly, treated tumors showed very slow shrinkage, and the tumor in 1 case has been shrinking for 9 years. One patient with muscular invasion (T4 tumor) developed Grade 4 skin toxicity, but no other toxicity greater than Grade 2 was observed.

CONCLUSIONS

This is one of the few reports on curative radiotherapy for primary RCC. The response of the tumor to treatment was uncommon. However despite inclusion of T4 and massive tumors, favorable local controllability has been shown. The results indicate the possibility of radical CIRT, as well as surgery, for RCC.

Correlation between loss of renal function and loss of renal volume after partial nephrectomy for tumor in a solitary kidney

PURPOSE

We assessed the correlation between reduced renal function and parenchymal volume following partial nephrectomy.

MATERIALS AND METHODS

In 21 of 42 patients with tumors in a solitary kidney who were enrolled in a study measuring function before and after surgery underwent computerized tomography, and measurement of the glomerular filtration rate and estimated glomerular filtration rate (the latter at baseline and 2 to 6 months) before and after surgery. A segmentation algorithm was used to measure renal parenchymal volume. The percent of renal parenchymal volume loss was correlated with the percent loss in glomerular filtration rate using the Pearson correlation coefficient.

RESULTS

Mean +/- SD net preoperative volume was 284 +/- 67 cc (range 179 to 413) and mean net postoperative volume was 240 +/- 61 cc (range 119 to 346) with an absolute functional volume loss of between 5 and 160 cc. The average percent of parenchymal volume loss was 15% (range -2% to 47%). The mean loss of the measured glomerular filtration rate 3 days postoperatively was 33.9% (range -70.7% to 74.4%) and the estimated glomerular filtration rate 2 to 6 months postoperatively was 19.7 % (-6.0% to 45.5%). There was a low degree of correlation between the percent volume loss and the percent measured glomerular filtration rate loss at 3 days (r = 0.28, p = 0.22). However, there was a moderate degree of correlation between the percent volume loss and the percent estimated glomerular filtration rate loss at 2 to 6 months (r = 0.48, p = 0.03).

CONCLUSIONS

In patients with partial nephrectomy the renal parenchymal volume loss correlates best with the renal function loss several months after surgery. Estimates of volume loss may be useful for predicting postoperative renal function when planning partial nephrectomy in patients with a solitary kidney.

Laparoscopic versus open partial nephrectomy: analysis of the current literature

OBJECTIVES

To critically review the current scientific evidence about open partial nephrectomy (OPN) and laparoscopic partial nephrectomy (LPN) to define the current role of these techniques in the treatment of renal tumours.

METHODS

PubMed and Medline were searched for reports about OPN and LPN that were published from 1990 to 2007 and the most relevant papers were reviewed.

RESULTS

OPN is an established curative approach for the treatment of small renal tumours. LPN is challenging and the technique is still under development. The intermediate-term oncologic and functional outcomes of LPN are similar to those of OPN in experienced centres. However, the ischaemia time is longer in laparoscopy and a long learning curve is needed to decrease the risk of complications. In the first phase of a surgeon's experience with LPN, a careful case selection based on the tumour growth pattern is required.

CONCLUSION

OPN is today the first treatment option for small renal tumours. LPN is technically challenging, but has been shown to achieve similar intermediate-term cancer cure and renal function results in centres with advanced laparoscopic expertise. Larger series with longer follow-up and prospective randomised studies are needed to confirm the safety and efficacy of LPN.

Open partial nephrectomy in renal cancer: a feasible gold standard technique in all hospitals

Introduction. Partial nephrectomy (PN) is playing an increasingly important role in localized renal cell carcinoma (RCC) as a true alternative to radical nephrectomy. With the greater experience and expertise of surgical teams, it has become an alternative to radical nephrectomy in young patients when the tumor diameter is 4 cm or less in almost all hospitals since cancer-specific survival outcomes are similar to those obtained with radical nephrectomy. Materials and Methods. The authors comment on their own experience and review the literature, reporting current indications and outcomes including complications. The surgical technique of open partial nephrectomy is outlined. Conclusions. Nowadays, open PN is the gold standard technique to treat small renal masses, and all nonablative techniques must pass the test of time to be compared to PN. It is not ethical for patients to undergo radical surgery just because the urologists involved do not have adequate experience with PN. Patients should be involved in the final treatment decision and, when appropriate, referred to specialized centers with experience in open or laparoscopic partial nephrectomies.

Differential gene expression in anticancer drug- and TRAIL-mediated apoptosis in renal cell carcinomas

Renal cell carcinomas (RCC) exhibit marked differences in susceptibility towards anticancer drug- and TRAIL-induced apoptosis. However, the underlying mechanisms determining apoptosis-sensitivity or -resistance are not well understood. The purpose of this study was to compare gene expression patterns induced by DNA-damage- and death receptor-induced apoptosis and to detect differentially expressed genes responsible for differences in apoptosis-susceptibility. Therefore, we performed a comparative cDNA-array analysis in an apoptosis-resistant and an apoptosis-sensitive RCC cell line. In the sensitive cell line an upregulation of multiple E2F1- and p53-inducible proapaptotic and cell-cycle regulating target genes by Topotecan as well as TRAIL was observed. Interestingly, several antiapoptotic NFkappaB-dependent target genes were also induced. In the resistant cell line, however, only a small number of E2F1-, p53- and NFkappaB-dependent target genes were differentially regulated. Conclusively, anticancer drug- as well as TRAIL-sensitivity go along with an upregulation of multiple proapoptotic genes. In contrast, the mechanisms of apoptosis-resistance are-at least in part-located upstream of gene induction and seem not to depend upon upregulation of de-novo-synthesized antiapoptotic genes. Conclusively, the proapoptotic stimuli are confronted with a cellular context which allows apoptosis to be conducted-in the sensitive cell line-or not-in the resistant cell line.

[Laparoscopic approach in partial nephrectomy]

Except for segmental parenchymal atrophies, partial nephrectomy is more and more often indicated when treating isolated small renal tumours. During the last few years this technique has been increasingly accepted for the excision of tumours less than 4 centimetres. In order to diminish the operative morbidity, the laparoscopic approach has been proposed. During the last decade, laparoscopic partial nephrectomy "has come to maturity" and this technique is now well standardized. Knowledge and operative skills are required for both trans-peritoneal and extra-peritoneal route. Extra-peritoneal approach is more suitable for posterior lesions or at the level of the lower pole while the trans-peritoneal route is preferred in case of tumours near the renal hilum or on the anterior surface. Different methods offering temporary arrest of renal perfusion have been elaborated. There is a clear tendency for renal parenchyma sectioning without the use of any kind of thermal energy. This allows a better identification of renal lesions. Sectioned collecting system, blood vessels and renal parenchyma are systematically sutured. Despite its complexity, this technique has become reproducible and reliable in specialized laparoscopic centres.

Enucleoresection for the Elective Treatment of Small Renal Cell Carcinoma: Can It Be the Treatment of Choice?

BACKGROUND

We present our findings in a series of T1 renal cell carcinomas (RCC) treated with excision of the tumor surrounded by a minimal layer of grossly normal parenchyma.

PATIENTS AND METHODS

A total of 43 patients who underwent elective nephron-sparing surgery performed with enucleoresection were studied retrospectively. None of the patients had preoperative or intraoperative suspicion of positive nodes and were free from distant metastases before surgery (N0, M0). Patients status was last evaluated in January 2006.

RESULTS

Median age was 58.7 years (35-78). Median tumor size was 3.3 cm (1.5-7). There were no major complications such as bleeding and urinary leakage/ urinoma requiring re-operation. Pathological stage was pT1a in 38 (89%), pT1b in 4 (9%) and pT3a in 1 (2%) patient. Median followup was 32 months (6-89). A total of 5 patients with RCC had died as of January 2006. Overall, 3 (6.9%) patients had disease progression, of whom 2 (4.6%) were local recurrence, 1 alone and 1 associated with distant metastases. The overall cancer-specific survival was 95.4%, and the overall progression-free survival was 93%.

CONCLUSIONS

Enucleoresection reproduces the results of partial and radical nephrectomy with minimal morbidity. It is a safe and acceptable approach for elective nephronsparing surgery.

A prospective randomized EORTC intergroup phase 3 study comparing the complications of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma

OBJECTIVES

This study compared the complications and the cancer control of elective nephron-sparing surgery (NSS) and radical nephrectomy (RN) in patients with a small (<or=5 cm), solitary, low-stage N0 M0 tumour suspicious for renal cell carcinoma (RCC) and a normal contralateral kidney.

METHODS

541 patients were randomised in a prospective, multicentre, phase 3 trial to undergo NSS (n=268) or RN (n=273) together with a limited lymph node dissection.

RESULTS

This publication reports only on the complications reported for both surgical methods. The rate of perioperative blood loss<0.5l was slightly higher after RN (96.0% vs. 87.2%) and the rate of severe haemorrhage was slightly higher after NSS (3.1% vs. 1.2%). Ten patients (4.4%), all of whom were treated with NSS, developed urinary fistulas. Pleural damage (11.5% for NSS vs. 9.3% for RN) and spleen damage (0.4% for NSS and 0.4% for RN) were observed with similar rates in both groups. Postoperative computed tomography scanning abnormalities were seen in 5.8% of NSS and 2.0% of RN patients. Reoperation for complications was necessary in 4.4% of NSS and 2.4% of RN patients.

CONCLUSIONS

NSS for small, easily resectable, incidentally discovered RCC in the presence of a normal contralateral kidney can be performed safely with slightly higher complication rates than after RN. The oncologic results are eagerly awaited to confirm that NSS is an acceptable approach for small asymptomatic RCC.

Comparison between open partial and radical nephrectomy for renal tumours: perioperative outcome and health-related quality of life

OBJECTIVE

To compare perioperative outcome and health-related quality of life (HRQOL) after open partial and radical nephrectomy for renal tumours.

METHODS

Literature search of Medline and additional references from non-Medline-indexed journals for documents concerning treatment of renal tumours, perioperative outcome, and HRQOL after radical and partial nephrectomy.

RESULTS

A total of 39 references were used of which 7 discussed complications, 3 included hospital costs and length of stay, and 7 each discussed renal function and QOL. No statistical difference was found concerning perioperative complications although there seems to be a trend towards a slightly higher complication rate after partial nephrectomy. No statistical difference was reported between the two procedures concerning hospital costs and length of stay. For postoperative renal function, a higher incidence of chronic renal failure was noted after radical nephrectomy. When considering the HRQOL a benefit was found after elective partial nephrectomy. In case of mandatory partial nephrectomy the fear of recurrence and the worry about having fewer than two normal kidneys were significantly higher.

CONCLUSIONS

Partial nephrectomy achieves a better HRQOL due to better preservation of renal function and overall quality of life. Considering perioperative outcome no statistical difference was found for hospital costs and length of stay. A trend towards a higher perioperative complication rate was found after partial nephrectomy.

Open partial nephrectomy for tumor in a solitary kidney: experience with 400 cases

PURPOSE

We present a series of 400 patients with tumor in a solitary kidney who underwent open surgical partial nephrectomy performed by a single surgeon (ACN) with a primary focus on postoperative long-term kidney function.

MATERIALS AND METHODS

A total of 400 patients with sporadic nonfamilial kidney tumors in a solitary kidney underwent open partial nephrectomy between 1980 and 2002. In 323 patients (81%) the contralateral kidney had been surgically removed, while the remaining 77 (19%) had a congenital solitary kidney. Renal insufficiency was present preoperatively in 184 patients (46%). Adverse risk factors for partial nephrectomy were present in a large percent of patients. Intraoperative and postoperative parameters were evaluated at a mean followup of 44 months.

RESULTS

In the overall series 5 and 10-year cancer specific survival was 89% and 82%, respectively. Surgical complications occurred in 52 patients (13%), most commonly urinary leakage. Early postoperative renal function was achieved in 398 patients (99.5%). Only 2 patients required permanent dialysis postoperatively. Satisfactory long-term renal function was achieved in 382 patients (95.5%). A total of 18 patients had progressed to renal failure a mean of 3.6 years after surgery. Patient age, the amount of renal parenchyma resected, a congenitally absent or atrophic contralateral kidney and the time of contralateral nephrectomy were noted to be significantly associated with postoperative renal function.

CONCLUSIONS

Open surgical partial nephrectomy can be safely performed in patients with tumor in a solitary kidney. Long-term cancer-free survival with the preservation of renal function can be reliably expected in most of these cases.

Nephron Sparing Surgery for Renal Cell Carcinoma With Normal Contralateral Kidney: 25 Years of Experience

PURPOSE

We report the long-term results of our consecutive series of 504 patients who underwent NSS for cancer suspicious, solid renal tumors in the presence of a normal opposite kidney at our institution since 1979.

MATERIALS AND METHODS

A total of 715 patients underwent NSS since 1969, including 504 for an elective indication, that is with a normal opposite kidney. Of these patients 381 (75.6%) had RCC, 123 (24.4%) had cancer suspicious benign lesions, including 53 (10.5%) with oncocytoma, 33 (6.5%) with angiomyo(lipo)ma, 23 (4.6%) with a complicated cyst and 13 (2.8%) with other benign lesions. Of the 381 patients with RCC 283 (74.3%) had clear cell, 68 (17.8%) had papillary and 30 (7.9%) had chromophobic RCC. Mean tumor diameter was 3.0 cm (range 0.5 to 11.0). Mean followup was 6.77 years (range 0.2 to 24.1). The oncological outcome was studied, including pathological features associated with tumor progression.

RESULTS

Estimated cancer specific survival rates at 5 and 10 years were 98.5% and 96.7%, respectively. Estimated survival rates free of distant metastasis at 5 and 10 years were 97.5% and 95.1%, respectively. Nine patients with localized RCC experienced local recurrence after NSS. Estimated survival rates free of local recurrence at 5 and 10 years were 98.3% and 95.7%, respectively.

CONCLUSIONS

The long-term results of our series support the concept of organ sparing surgery for RCC in the presence of a normal opposite kidney with excellent long-term survival and a low tumor recurrence rate.

Excellent long-term cancer control with elective nephron-sparing surgery for selected renal cell carcinomas measuring more than 4 cm

OBJECTIVES

Elective nephron-sparing surgery (NSS) for renal cell carcinoma (RCC) < 4 cm has been accepted as alternative to radical nephrectomy (RN). However, NSS for tumours > 4 cm is controversial. We present our experiences and long-term oncologic outcome of RCC > 4 cm treated with NSS in a retrospective single-institutional analysis of 69 patients.

METHODS

Between 1975 and 2004, elective NSS was performed in 368 patients at our institution, including 69 patients with sporadic, nonmetastatic RCC > 4 cm. Overall and cancer-specific survivals were estimated using the Kaplan-Meier method.

RESULTS

Complications were seen in nine patients (13.0%). After a mean follow-up of 6.2 yr (median, 5.8 yr) seven patients (10.1%) had died, none of them of tumour-related causes. Tumour recurrence was detected in four patients (5.8%). The 5-yr overall survival probability was 94.9%. The 10-yr and 15-yr overall survival rates were both 86.7%. Cancer-specific survival was 100% after 5, 10, and 15 yr.

CONCLUSIONS

Selected patients with localized RCC even > 4 cm can be treated with elective NSS providing optimal long-term outcome. The surgeon's decision for organ-preserving surgery should depend on tumour localisation and technical feasibility rather than on tumour size.

Nephron-Sparing Surgery for Renal Cell Carcinoma: Detailed Analysis of Complications Over a 15-Year Period

PURPOSE

To assess the incidence of complications of conservative renal surgery for renal cell carcinoma in both elective and imperative indications, and its evolution over a 15 year period.

PATIENTS AND METHODS

From 1988 to 2003, 127 patients underwent partial nephrectomy or tumorectomy for renal cell carcinoma in our department. INDICATIONs were imperative in 42% (n = 53) and elective in 58% (n=74) of cases. Morbidity was retrospectively assessed according to four parameters: 1- Period of surgery: A, from 1988 to 1999 and B, from 2000 to 2003. 2- INDICATION: elective vs. imperative. 3- experience of surgeon: senior vs. junior. 4- Nature of complications: minor or major. Comparative analysis was conducted using Chi-square and Fischer exact tests.

RESULTS

Global incidence of complications was 30.7% (n = 39) corresponding to 18.1% minor (n = 23) and 12.6% (n = 16) major complications. Results show a moderate decrease of complication rate during Period B: 28.1% versus 32.9% during period A (p = 0.69). Complications occurred more frequently in imperative indications (49.1%) than in elective indications (17.6%) (p = 0.002), mostly regarding major complications (respectively 28.3% and 1.4%. (p < 0.001)). Overall re-intervention rate was 15.7%: 22.6% in imperative and 10.8% in elective indications (p = 0.008). Mean length of hospital stay was 14.1 days and significantly longer during period A (p = 0.003) and in imperative indications (p = 0.009).

CONCLUSION

In our study, conservative renal surgery has a significant rate of complications which is extremely variable regarding to different parameters. Most discriminating factor was indication: in imperative indications, we observed a high rate of major complications (28.3%) that we consider acceptable to prevent anephria in clearly informed patients. Major complications are exceptional in elective indications. Decreased incidence of complications during the later period (B) is modest, and the role played by systematic pedicular clampage is discussed. As results published in medical literature are difficult to compare, we agree with authors who recently proposed to standardize complications data analysis, using a gravity scale, in order to provide relevant information to patients about statistical risks before surgery.

Renal Cell Carcinoma of 4 cm or Less: An Appraisal of Its Clinical Presentation and Contemporary Surgical Management

OBJECTIVE

Greater availability and utilization of modern radiological imaging modalities have resulted in an increase in the incidental discovery of renal cell carcinoma. Such tumours tend to be smaller than their symptomatic counterparts and may potentially be adequately treated using nephron-sparing surgery.

METHODS

A retrospective review of all patients who were diagnosed with renal cell carcinoma of 4 cm or less between January 1990 and December 2001 was conducted to review clinical presentation, surgical management and survival.

RESULTS

The cohort comprised 102 patients who underwent surgery, of 402 patients diagnosed with renal cell carcinoma over the study period. Sixty-eight patients (67%) had tumours detected incidentally. Thirty patients (29%) were managed with partial nephrectomy and 72 (71%) with radical nephrectomy. The median tumour size was 3.0 cm (range, 1.5-4.0 cm). Overall, median follow-up was 60 months (range, 1-148 months). Overall 5-year survival for patients who underwent partial nephrectomy and radical nephrectomy was 96.6% and 85.8%, respectively. Cancer-specific 5-year survival was 100%.

CONCLUSION

A significant proportion of patients had incidental diagnosis of small renal cell carcinoma. Local control may be achieved with either radical or partial nephrectomy, with excellent survival expected.

Renal oncocytoma in Taiwan

BACKGROUND

Renal oncocytoma has been repeatedly reported in Western countries, but only a few cases have been reported in Eastern countries. This study aims to review the clinical course of renal oncocytoma in an Eastern country such as Taiwan.

MATERIALS AND METHODS

Sixteen cases of renal oncocytoma seen between 1987 and 2002 at Chang Gung Memorial Hospital, Taipei, Taiwan, were studied.

RESULTS

Preoperatively, all patients were diagnosed to have renal cell carcinoma, following various radiologic studies. Perioperatively, frozen sections of three patients indicated renal oncocytoma in two and renal cell carcinoma in one. Renal oncocytoma has marked similarities to renal cell carcinoma, according to various radiologic, cytologic, and pathological investigations, so an accurate diagnosis is difficult to achieve, either preoperatively or perioperatively. Therefore, rather than being treated with partial nephrectomy, all patients were treated aggressively with unilateral radical nephrectomy. Postoperatively, all 16 patients were followed up, from 12 to 189 months, with a mean of 58.7 months. Notably, all patients survived with no evidence of tumor recurrence.

CONCLUSIONS

The experience in Taiwan is generally that renal oncocytoma behaves benignly, as reported in other areas. The excellent prognosis associated with this tumor appears to indicate that partial nephrectomy may suffice for removing the tumor, while sparing other unaffected renal parenchyma.

Elective nephron sparing surgery should become standard treatment for small unilateral renal cell carcinoma: Long-term survival data of 216 patients

OBJECTIVES

Our experiences with elective nephron-sparing surgery (NSS) for renal cell carcinoma (RCC) in a consecutive series of 216 patients are presented. Clinicopathological features and long-term oncological outcome is compared to patients treated with radical nephrectomy (RN).

METHODS

Between 1975 and 2002, NSS was performed in 488 patients; 311 of these patients had elective indications. Renal cell carcinoma was found in 241/311 patients (77.5%). Long-term follow up data could be obtained in 216/311 patients. Cancer-specific survival was estimated using the Kaplan-Meier method. Cox's regression analysis and log-rank tests were used to evaluate independent predictive values of different clinicopathological features. Survival data of the 216 patients after NSS surgery were compared to 369 patients with small RCC treated with RN.

RESULTS

After a mean follow up of 66 months (median 64 months) 29 (13.4%) of 216 patients treated with NSS had died, 4 of them (1.8%) tumour-related. Tumour recurrence was detected in 12 patients (5.6%). 204 patients (94.4%) were free of tumour at last follow-up. Cancer specific survival rates at 5 and 10 years for patients treated with NSS (RN) were 97.8% (95.5%) and 95.8% (84.4%).

CONCLUSIONS

Elective NSS surgery provides optimal long-term outcome in patients with small localized RCC. Compared to RN, renal parenchyma is preserved without any disadvantage in survival rates. Consequently elective NSS should be accepted as gold standard for small renal tumours.

Long term results of excision of small renal cancer surrounded by a minimal layer of grossly normal parenchyma: review of 94 cases

OBJECTIVE

To assess safety and effectiveness of excision of small renal cancer.

METHODS

We reviewed the records of 94 patients, who underwent, from 1992 to 2001, excision of renal tumor leaving around it a thin layer of grossly normal parenchyma and adjacent perinephric fat. This technique has been called enucleoresection, as it is not a simple enucleation but neither a conventional partial nephrectomy. Patients were followed up mean routine blood examination, ultrasound and computed tomography scan every 6 months for 2 years and annually thereafter.

RESULTS

Median age was 63 years (35-76). Median tumour size was 2.1cm (1.1-4.5). Clamping of renal pedicle was performed in 54 cases. Major complications included 4 cases of haemorrhage; only 1 patient required surgical exploration. Pathological stage was pT1a in 87, pT1b in 4 and pT3a in 3 patients. Surgical margins were always negative. Median follow-up was 59 months (range 10-128). Eight patients died without evidence of tumour recurrence. One pT3a patient developed distant metastases and died 2 years after surgery. Five years survival rate was 95.7% (90/94 patients), cancer specific survival rate 98.9% (93/94) and disease free survival rate 98.9% (93/94).

CONCLUSIONS

Enucleoresection of small renal tumors surrounded by a minimal layer of grossly normal renal parenchyma reproduces the results of partial and radical nephrectomy with minimal morbidity.

Laparoscopic partial nephrectomy using a microwave tissue coagulator for treating small peripheral renal tumors

BACKGROUND

Laparoscopic partial nephrectomy has been recently applied as a minimally invasive procedure. Several non-ischemic operation devices in partial nephrectomy have been developed. However, the problem related to maintenance of renal homeostasis remains. We investigated the efficacy and safety of a microwave tissue coagulator in laparoscopic partial nephrectomy.

METHODS

Between April 2001 and February 2003, eleven patients with small renal tumors underwent laparoscopic partial nephrectomy using a microwave tissue coagulator. Seven patients underwent hand-assisted laparoscopic procedure and 4 pure laparoscopic procedure.

RESULTS

The mean tumor size on preoperative CT scan was 2.5 cm (range: 2.0 to 4.0 cm), the mean operative time was 307 minutes (range: 160 to 580 minutes), and the mean estimated blood loss was 154.4 ml (range: 50 to 1,140 ml). The microwave tissue coagulator well controlled the renal bleeding and maintained renal function. All patients safely underwent partial nephrectomy without inducing renal ischemia. A complication of urine leakage was recognized in only one patient with hypoproteinemia caused by nephrotic syndrome.

CONCLUSIONS

Laparoscopic partial nephrectomy using a microwave tissue coagulator was a useful method for achieving homeostasis, and was less invasive for treating small renal tumors.

Elective open nephron-sparing surgery for renal masses: single-center experience with 129 consecutive patients

OBJECTIVES

To present our experience with elective, open, nephron-sparing surgery for renal masses in a contemporary, consecutive series.

METHODS

In this retrospective study, the files of all patients who underwent elective nephron-sparing surgery between January 1996 and December 2002 at our institution were reviewed. The preoperative workup included renal ultrasonography and abdominal computed tomography. The histologic findings, complications, and oncologic outcome were studied. The surgical technique (ischemia and regional hypothermia) was identical in all patients.

RESULTS

A total of 129 patients (mean age 61 years) were analyzed. The mean +/- standard deviation tumor size on preoperative computed tomography was 4.0 +/- 2.4 cm. Renal cell carcinoma was present in 86 patients (66.7%), a benign cyst in 18 (13.9%), oncocytoma in 10 (7.8%), angiomyolipoma in 7 (5.5%), adenoma in 4 (3.1%), xanthogranulomatous pyelonephritis in 3 (2.3%), and metastasis of a malignant melanoma in 1 patient. Two patients (1.6%) required secondary nephrectomy because of postoperative bleeding. After a median follow-up of 34 months (range 2 to 91), no patient had developed local recurrence, one (0.8%) had developed lymph node metastasis, and two (1.6%) had developed distant metastases. The creatinine clearance decreased from 77 +/- 27 mL/min before surgery to 64 +/- 23 mL/min after a median of 34 months.

CONCLUSIONS

The results of this contemporary, monocenter experience underline the role of open, elective, nephron-sparing surgery for patients with small renal masses, particularly because benign histologic findings were present in almost one third of patients.

Partial nephrectomy for patients with a solitary kidney: the Memorial Sloan-Kettering experience

OBJECTIVE

To report the experience of partial nephrectomy in patients with a solitary kidney at one institution, with analysis of renal function, complications, oncological efficacy and survival.

PATIENTS AND METHODS

We identified 54 consecutive patients with a solitary kidney who had a partial nephrectomy between December 1989 and July 2003. Variables examined included patient age and gender, renal function, renal ischaemia time, surgical margin status and complications. Pathological features, e.g. tumour size, histological subtype and tumour stage, were also assessed. Disease-free probability and overall and cancer-specific survivals were determined.

RESULTS

The histological subtype was clear cell in 35 cases (65%), papillary in 10 (19%), oncocytoma in four (7%), chromophobe in two (4%), unclassified in one (2%) and multiple subtypes in two (2%). The median creatinine level before surgery was 14 mg/L, which increased to 16 mg/L 6 months afterward, and at 1 and 2 years after surgery it was 15 mg/L. Two patients developed end-stage renal disease requiring haemodialysis, one soon after surgery and another 8 years after nephron-sparing surgery. In all, 26% of patients developed at least one perioperative complication, with acute renal failure and urinary fistula being the most common. At 5 years the overall and cancer-specific survival, and disease-free probability were 68%, 88% and 73%, respectively.

CONCLUSIONS

Partial nephrectomy is safe in patients with a solitary kidney, with an acceptable decline in renal function and low likelihood of requiring temporary or permanent haemodialysis. After an initial decline, renal function appears to stabilize during the first year.

Phase II clinical trial of interactive MR imaging-guided interstitial radiofrequency thermal ablation of primary kidney tumors: initial experience

PURPOSE

To perform a phase II clinical trial to evaluate efficacy and safety of interactive magnetic resonance (MR) imaging-guided radiofrequency (RF) interstitial thermal ablation (ITA) of primary renal tumors.

MATERIALS AND METHODS

Ten male patients (age range, 25-83 years) with peripheral renal cell carcinoma and contraindications to surgery were treated with percutaneous RF ITA entirely guided and monitored with a 0.2-T MR imaging unit. By using a 200-W RF ablation system and custom-fabricated MR imaging-compatible cool-tip electrodes, pulsed RF current was applied for single or multiple ablation cycle(s) of 12-15 minutes until the entire tumor was replaced by an enlarging zone of low signal intensity on T2-weighted and/or short inversion time inversion-recovery images acquired intermittently during the procedure. Kidney MR images were acquired before, immediately after, and 2 weeks after ablation and then every 3 months for 1 year and every 6 months thereafter. Intra- and postprocedural complications were assessed with clinical evaluation of patients for pain and hemodynamic instability and evaluation of MR images for evidence of hemorrhage or other unexpected findings. Follow-up images were assessed for delayed complications such as renal ischemia, infarct, urinoma, or tumor recurrence.

RESULTS

Treated tumors ranged between 0.63 and 16.90 mL in volume and 1.0 and 3.6 cm in maximum diameter. Successful RF electrode insertion and/or repositioning into the renal mass was achieved in all cases with direct MR "fluoroscopic" guidance. Thirty ablation cycles were conducted at 21 electrode positions in the 10 procedures, and complete ablation, as defined with MR imaging, was achieved in all cases by the end of the procedure. Apart from two small self-limited perirenal hematomas, no intra- or postprocedural complications were observed. No delayed complications or tumor recurrence occurred during a mean follow-up period of 25 months +/- 9.4 (standard deviation).

CONCLUSION

Although these results are preliminary, interactive MR imaging-guided RF ITA for treatment of primary renal tumors has a high success rate.

Contrast-enhanced second-harmonic sonography in the detection of pseudocapsule in renal cell carcinoma

OBJECTIVE

Our purpose was to assess the capacity of contrast-enhanced second-harmonic sonography to detect a pseudocapsule in renal masses compared with conventional gray-scale sonography. SUBJECTS AND METHODS. Thirty-two patients with 40 renal masses suspicious for renal cancer (mean diameter, 3.1 cm) were prospectively studied with contrast-enhanced second-harmonic sonography during IV administration of a second-generation sonographic contrast agent. The sonographic criteria for the presence of a pseudocapsule were a peritumoral hypoanechoic halo on conventional gray-scale imaging and a rim of perilesional enhancement, increasing in the tardive phase of the examination, on contrast-enhanced second-harmonic imaging. Multiphasic helical CT or dynamic MRI or both were performed in all patients.

RESULTS

Final diagnoses of the 40 renal masses were as follows: hemorrhagic cysts, five; angiomyolipomas, four; lymphomas, four; metastasis from lung cancer, one; and renal cell carcinomas (RCCs), 26. Histologic diagnosis of RCC was surgically obtained in all patients. Nephron-sparing surgery was performed in 12 of 26 RCCs, and radical nephrectomy was performed in the remaining 14. At pathologic examination, pseudocapsule was found in 14 (53.8%) of 26 RCCs. On conventional sonography, the presence of a pseudocapsule was detected in 3 of 14 RCCs (sensitivity, 21%). Sonographic contrast-enhanced harmonic imaging revealed the presence of pseudocapsule in 12 of 14 RCCs (sensitivity, 85.7%). In the remaining 12 RCCs with either absent or extensive neoplastic infiltration of pseudocapsule seen at pathologic evaluation, pseudocapsule was not visible on either conventional or contrast-enhanced second-harmonic sonography. The pseudocapsule was not visible in any of the 14 noncancerous renal masses on either conventional or contrast-enhanced sonography.

CONCLUSION

Sonographic contrast-specific imaging with a second-generation contrast agent is effective in improving the sonographic visualization of tumoral pseudocapsule. This finding could be useful both in the sonographic diagnosis and in the choice of conservative surgery for renal cell carcinoma. The potential role of second-harmonic contrast-enhanced sonography in the management of renal cell carcinoma should be investigated in larger series and compared with the findings of state-of-the-art MRI and CT.

NECESSITY OF URETERAL CATHETER DURING LAPAROSCOPIC PARTIAL NEPHRECTOMY

PURPOSE

Laparoscopic partial nephrectomy (LPN) is a relatively recently introduced method of treating renal tumors and, as such, surgical technique is evolving. In open series urinary fistula formation represents a common postoperative complication. In the laparoscopic approach investigators have advocated the placement of a ureteral catheter with retrograde dye injection to visualize caliceal entry to aid in closure. In this study we assessed the necessity of ureteral catheter placement during LPN in decreasing urinary leakage.

MATERIALS AND METHODS

From February 1998 until November 2002 laparoscopic partial nephrectomy was performed in 103 patients with renal tumors. The patients were assessed retrospectively and divided into 2 groups according to placement (group 1) or no placement (group 2) of an external ureteral catheter. Group 1 included 54 patients (mean age +/- SD 57.4 +/- 13.4 years) and group 2 included 49 patients (mean age +/- SD 57.5 +/- 10.9). Intraoperative and postoperative parameters including blood loss, operative time, ischemia time, mass size, complications and hospital stay were reviewed and compared between the 2 groups.

RESULTS

There were no differences between the 2 groups in mean estimated blood loss (group 1, 394.7 cc vs group 2, 291.5 cc, p = 0.07), postoperative serum creatinine (group 1, 0.95 mg/dl vs group 2, 0.89 mg/dl, p = 0.12), requirement for pain medication (group 1, 8.9 mg vs group 2, 4.9 mg morphine equivalents, p = 0.12), hospital stay (group 1, 3.1 vs group 2, 2.9, p = 0.29) and warm ischemia time (group 1, 28 minutes vs group 2, 26.5 minutes, p = 0.18). Mean total operative time was significantly longer for group 1 compared to group 2 (191.1 vs 149.4 minutes, respectively, p = 0.001). Postoperative urinary leakage requiring prolonged drainage occurred in 1 patient in group 1 and 1 in group 2. In both cases caliceal entry was identified and sutured.

CONCLUSIONS

With experience caliceal entry can be identified without the need for a ureteral catheter in patients undergoing LPN for a tumor less than 4.5 cm. Urinary fistula may occur despite caliceal entry and repair. A ureteral catheter may not decrease urinary fistula in patients undergoing LPN.

Safety and efficacy of partial nephrectomy for all T1 tumors based on an international multicenter experience

PURPOSE

We compared cancer specific survival of patients undergoing partial and radical nephrectomies for T1N0M0 renal tumors according to tumor size in a large multicenter series.

MATERIALS AND METHODS

A retrospective analysis of 1454 patients undergoing partial or radical nephrectomy for T1N0M0 renal tumors from 7 international academic centers was performed. Data were obtained for each patient including TNM stage (determined according to the 2002 TNM criteria), tumor size, type of surgery (partial versus radical nephrectomy) and cancer specific survival. Recurrence events were recorded when available.

RESULTS

Partial and radical nephrectomies were performed in 379 (26.1%) and 1075 (73.9%) cases, respectively. Mean followup +/- SD was 62.5 +/- 51.8 months. Recurrence data were available on 544 patients. There were no significant differences in local or distant recurrence rates between patients undergoing partial or radical nephrectomy for either T1a (p = 0.6) or T1b tumors (p = 0.5). For patients with T1a tumors, there was no significant difference in the rate of cancer specific deaths between the partial (314) and radical (499) nephrectomy groups (2.2% versus 2.6%, respectively, p = 0.8). For patients with T1b tumors there was also no significant difference in the rate of cancer specific deaths between patients undergoing partial (65) and patients undergoing radical (576) nephrectomy (6.2% versus 9%, respectively, p = 0.6).

CONCLUSIONS

Partial nephrectomy is becoming the gold standard for renal tumors less than 4 cm but this treatment is much more controversial for larger T1 tumors. This large multicenter study suggests that it is safe to expand the indications of partial nephrectomy to include patients with T1N0M0 tumors up to 7 cm. However, careful patient selection remains necessary.

PARENCHYMAL SPARING SURGERY FOR CENTRAL RENAL TUMORS IN PATIENTS WITH HEREDITARY RENAL CANCERS

PURPOSE

Nephron sparing surgery has become accepted surgical practice for removing of renal tumors. The resection of central lesions has been thought to be more surgically challenging than that of peripheral tumors. We analyzed our experience with renal preservation surgery in patients with small hereditary central renal tumors.

MATERIALS AND METHODS

From 1992 to 2000 we performed 116 partial nephrectomies with 44 kidneys (38%) demonstrating central renal masses. Central renal tumors were defined radiologically as those completely encircled by parenchyma or transgressing the interpapillary line on computerized tomography. We compared this group to a similar series of 67 patients with hereditary renal cancer with only peripheral based tumors.

RESULTS

Mean tumor size was 3.2 cm (range 1.5 to 7.5). Mean operative time was 352 minutes (range 70 to 830). Renal hypothermia and vascular clamping were used in 19 of 44 procedures (41%). Mean ischemic time was 55 minutes (range 16 to 143). Mean blood loss was 4.6 l (range 0.1 to 23). The complication rate was 23% (10 of 44 cases) and with 18% (8 of 44) directly related to surgical technique. The mean transfusion requirement was 6.7 U (range 0 to 32) and 12 of 44 procedures (27%) required no blood products. Mean preoperative and postoperative serum creatinine was 1.05 (range 0.6 to 1.8) and 1.08 mg/dl (range 0.6 to 2.1), respectively. Mean followup was 33.7 months. No metastasis developed during followup.

CONCLUSIONS

Central renal tumors are a common manifestation of hereditary renal cell carcinoma. There was no statistical difference found between common operative parameters when central and peripheral nephron sparing surgeries were compared. However, mean operative blood loss and transfusion requirements were increased in the central tumor group.

Utility of frozen section analysis of resection margins during partial nephrectomy

OBJECTIVES

To evaluate the utility of routine intraoperative frozen-section histologic analysis during partial nephrectomy to ensure negative surgical margins. Partial nephrectomy has gained acceptance for surgical treatment of small renal cancers. Many surgeons send specimens for intraoperative frozen section histologic analysis to ensure negative margins.

METHODS

We reviewed the records of 78 patients who underwent partial nephrectomy for presumed malignancy. Patient demographics, intraoperative findings, and pathologic and clinical outcomes were analyzed.

RESULTS

Seventy-nine partial nephrectomies were performed in 78 patients. Frozen sections were obtained intraoperatively in 76 cases. In 1 case (1.3%), a single margin was interpreted as positive for carcinoma, prompting deeper resection. The final histopathologic finding was interpreted as angiomyolipoma rather than carcinoma. The final pathologic examination revealed renal cell carcinoma in 52 (66%) of 79 cases. The mean oncologic follow-up was 16.2 months. One local recurrence was noted (1.9%). It arose in the resection bed 19 months after removal of a 4.5-cm tumor (pathologic Stage T3a). Both intraoperative frozen section margins and final pathologic margins were negative in this case. One patient developed pulmonary metastases and represented the only metastatic recurrence, as well as the only cancer-related death in our cohort (1.9%).

CONCLUSIONS

Our data suggest that when partial nephrectomy is performed with attention to excising a perimeter of grossly normal-appearing parenchyma, sending specimens for intraoperative frozen section analyses may provide an unnecessary expense without providing meaningful, reliable information. Additional studies, including larger cohorts and extended follow-up, are needed to support these results.