Nephron-sparing surgery for localized renal cell carcinoma with a normal contralateral kidney: a European three-center experience

Is there a clinical role for frozen section analysis during partial nephrectomy? A multicenter experience over 10 years

BACKGROUND

Frozen section analysis (FSA) is frequently performed during partial nephrectomy (PN). We investigate the utility of intraoperative FSA by evaluating its impact on final surgical margin (SM) status.

METHODS

Between January 1995 and December 2005, a series of patients who were treated with open PN for renal cell carcinoma was prospectively analyzed. During PN, each patient underwent a FSA on renal parenchyma distal margin. If FSA was positive for infiltration a deeper excision was performed till obtaining a negative FSA. SM outcome of the FSA was compared with the final pathology report. Recurrence-free survival (RFS) and cost analysis on the FSA performed were analyzed.

RESULTS

A total number of 373 patients were enrolled. FSA was performed in all the patients considered for PN. Fifteen patients had a conversion to radical nephrectomy. Positive SMs at the definitive pathological outcome were found in 36 patients (9.6%). FSA was positive in eight patients (2.1%). In that eight cases after a deeper excision the definitive pathological outcome on SM was still positive in two cases. FSA revealed just 14.3% of the positive SM. Patients with positive SM had a worse follow up considering RFS (P<0.05). Kaplan-Meier analysis revealed that FSA did not considerably contribute to prevent recurrence (P=0.35). 1438 euros was the mean cost of performing a FSA during PN.

CONCLUSIONS

FSA during PN does not reduce the risk of positive SMs. The use of FSA has also a higher cost related to the procedure.

Algorithm for Bosniak 2F Cyst in Kidney Donation

Patient: Female, 54

Final Diagnosis: Multilocular cystic renal cell carcinoma with clear cells

Symptoms: None

Medication: —

Clinical Procedure: Hand-assisted retroperitoneal donor nephrectomy

Specialty: Transplantology

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.

Clinical results of renal artery embolization to control postoperative hemorrhage after partial nephrectomy

Background

With the wider application of nephron-sparing surgery, there has been an increase in the occurrence of postoperative hemorrhage. However, despite such an increase, there are only a limited number of reports regarding renal artery embolization (RAE) for the management of postoperative bleeding after nephron-sparing surgery, especially after robot-assisted laparoscopic partial nephrectomy (RALPN).

Purpose

To evaluate the safety and clinical efficacy of transcatheter RAE for postoperative hemorrhage after open partial nephrectomy (OPN) and RALPN.

Material and Methods

A total of 29 patients (17 men, 12 women; age range, 31–70 years) who were referred to our hospital for postoperative hemorrhage after partial nephrectomy, between December 2003 and December 2014, were selected. We retrospectively reviewed patients’ clinical data, angiographic findings, embolization details, and clinical outcomes.

Results

Embolization was performed in patients who underwent OPN (25/29) and RALPN (4/29). The angiographic findings were as follows: renal artery pseudoaneurysm (n = 18), contrast extravasation (n = 8), and arteriovenous fistula (n = 3). Fiber-coated microcoil and n-butyl-2-cyanoacrylate (NBCA) was administered to the targeted bleeding renal arteries in 12 and 11 patients, respectively. In six patients, fiber-coated microcoil and NBCA were used concurrently. Technical and clinical successes were achieved in all patients (100%). Bleeding cessation was achieved in all patients, and no further relevant surgeries or interventions were required for hemorrhage control. There were no episodes of hemorrhagic recurrence during the follow-up period (median, 20 days; range, 7–108 days).

Conclusion

Angiography and RAE identified the origin of bleeding and could successfully preserve the residual renal function.

Nephron sparing surgery for De Novo kidney graft tumor: results from a multicenter national study

Nephron sparing surgery (NSS) results in the transplanted population remain unknown because they are only presented in small series or case reports. Our objective was to study renal sparing surgery for kidney graft renal cell carcinomas (RCC) in a multicenter cohort. Data were collected from 32 French transplantation centers. Cases of renal graft de novo tumors treated as RCC since the beginning of their transplantation activity were included. Seventy-nine allograft kidney de novo tumors were diagnosed. Forty-three patients (54.4%) underwent renal sparing surgery. Mean age of grafted kidneys at the time of diagnosis was 47.5 years old (26.1-72.6). The mean time between transplantation and tumor diagnosis was 142.6 months (12.2-300). Fifteen tumors were clear cell carcinomas (34.9%), and 25 (58.1%) were papillary carcinomas. Respectively, 10 (24.4%), 24 (58.3%) and 8 (19.5%) tumors were Fuhrman grade 1, 2 and 3. Nine patients had postoperative complications (20.9%) including four requiring surgery (Clavien IIIb). At the last follow-up, 41 patients had a functional kidney graft, without dialysis and no long-term complications. NSS is safe and appropriate for all small tumors of transplanted kidneys with good long-term functional and oncological outcomes, which prevent patients from returning to dialysis.

[Eight years of experience in robot-assisted partial nephrectomy: oncological and functional outcomes]

INTRODUCTION

Partial nephrectomy (PN) is currently the reference treatment for renal tumors of less than 4 cm in size (T1a). Laparoscopic PN is difficult to perform, with the main consequence being an increase in warm ischemia time and morbidity. In facilitating the surgical procedure, robotics combines the benefits of minimally invasive and conservative surgery. We report here 8 years of experience with 110 robot-assisted partial nephrectomies (RAPN). The objective of this study was to analyze the oncological and functional outcomes.

PATIENTS AND METHODS

Between March 2005 and September 2012, 110 patients underwent RAPN. The epidemiological and surgical data and the oncological and functional outcomes were retrospectively collected and analyzed.

RESULTS

Seventy-six men and 34 women underwent surgery. The mean age was 59.6 ± 14.2 years. Mean operative time was 141.3 ± 36.1 minutes with a warm ischemia time of 21.2 ± 8.8 minutes. Mean hospital stay was 5.3 ± 2.2 days. Mean tumor size was 27.4 ± 9.8mm with 82.7% malignant tumors, of which 62.7% were clear cell carcinomas. Surgical margins were healthy in 100% of cases. After a mean follow-up of 28.7 ± 18.5 months, no recurrence was noted. On a functional level, there was no short-term or medium-term impairment of renal function. The frequency of postoperative complications was estimated as 12% including 7% of surgical complications (3 arterial pseudoaneurysms, 4 episodes of bleeding from the cut surface and 1 conversion to laparotomy).

CONCLUSION

Robotics brought surgeon dexterity, meticulousness and precision. These qualities are essential in conservative renal surgery and made RAPN a safe and effective technique that gives good short and medium-term oncological and functional results.

Morphometric profile of the localised renal tumors managed either by open or robot-assisted nephron-sparing surgery: the impact of scoring systems on the decision making process

BACKGROUND

Nephrometric scoring systems aim to improve the manner in which tumoral complexity is measured and reported. Each system provides a way to objectively measure specific tumor features that influence technical feasibility. In this study we aimed to determine how nephrometric scoring systems tailored our approach to the surgical treatment of localised renal masses.

METHODS

Charts of the patients with localised renal tumors, who were managed by either open or robot-assisted nephron-sparing surgery between May 2010 and June 2012, were retrospectively reviewed. Nephrometric scores [radius, exophytic/endophytic, nearness, anterior/posterior, location (R.E.N.A.L.) score, preoperative aspects and dimensions used for anatomic (P.A.D.U.A.) classification and centrality index (C-index)] were calculated based on preoperative imaging findings. Perioperative data were recorded. Morphometric characteristics of the renal masses were compared. Additionally, the difference between surgical alternative subgroups in terms of morphometric variables and the predictive power of each scoring system in determining the details of the surgical plan were investigated. Furthermore, surgical preferences in different nephrometric categories were compared.

RESULTS

Mean R.E.N.A.L. and P.A.D.U.A. scores of the tumors treated with robotic surgery were significantly lower than those managed by open surgery. R.E.N.A.L. nephrometry score showed significant differences between most of the surgical alternative subgroups. P.A.D.U.A. and C-index differences were significant only between robotic off-clamp and open clamped cases. Tumors that required open conversion had significantly higher mean R.E.N.A.L. and P.A.D.U.A. score. High R.E.N.A.L. score (cut-off: 6.5) and high P.A.D.U.A. score (cut-off: 7.5) were found to be significant predictors of the surgical route. Significantly more tumors with moderate R.E.N.A.L. score were managed through the open approach, while the significant majority of those with low R.E.N.A.L. and low P.A.D.U.A. score were operated by robotic assistance.

CONCLUSIONS

R.E.N.A.L. and P.A.D.U.A. scores influenced our surgical treatment strategy for localized renal masses. High R.E.N.A.L. and P.A.D.U.A. scores increased the likelihood of an open NSS.

Multilocular cystic renal cell carcinoma a diagnostic dilemma: A case report in a 30-year-old woman

Multilocular cystic renal cell carcinoma (MCRCC), also known as multilocular clear cell renal cell carcinoma (RCC), is a rare cystic tumor of the kidney with an excellent outcome. It occurs in about 3.1-6% of the conventional RCC. It is usually included in the group of tumors of undetermined malignant potential with low nuclear grade. We present a case of MCRCC in a 30-year-old female patient presenting incidentally as an apparently benign-looking multicystic space occupying lesion in the upper pole of right kidney. Right-sided simple nephrectomy was performed, and on histopathologic examination it was found to be MCRCC, stage 1 with Fuhrman nuclear grade 1. Immunohistochemistry with epithelial membrane antigen and vimentin confirmed the diagnosis.

Decreasing the indications for radical nephrectomy: a study of multifocal renal cell carcinoma

Multifocal renal cell carcinoma (RCC) has been reported in 5-25% of cases worldwide. Although management of patients with multifocal RCC has not been clearly defined, presence of multifocal renal masses in one kidney and a normal contralateral kidney has often been considered a reason for performing radical nephrectomy. This study reviews the world literature to provide an accurate estimate of the prevalence of multifocal RCC and evaluates the oncologic outcomes of multifocal RCC after exclusion of patients with known hereditary and familial renal syndromes. A PubMed search of the literature was performed for articles in the English language using the following terms for the query: "multifocal RCC," "multifocality and RCC," "multicentric RCC," or "bilateral RCC." The references of the published articles were also reviewed for additional publications. Articles that did not specifically exclude patients with familial RCC or known hereditary RCC syndromes were excluded for estimation of multifocality prevalence and oncologic outcomes. After applying our exclusion criteria, nine articles were selected and form the basis of the current analysis. Weighted averages were used to calculate the prevalence of multifocality. Multifocal RCC was found in 6.8% of cases (373 of 5433 patients). Ipsilateral multifocality was found in 6.8% of cases. Bilateral multifocality was found in 11.7% of cases. Of all cases reported in this study, only 10% underwent partial nephrectomy. The rest of the study cohort underwent radical nephrectomy. The review of the literature showed that the use of nephron-sparing techniques in patients with multifocal disease did not compromise oncologic outcomes, despite the need for reoperation in certain cases. In conclusion, multifocal RCC remains a prevalent entity. Most clinicians still prefer to perform radical nephrectomies in these patients despite proven equivalent oncologic outcomes compared to nephron-sparing techniques. Urologists should be aware of these data when proposing treatment options to patients with multifocal RCC.

Current status of robot-assisted laparoscopic partial nephrectomy

With increased incidence of diagnosis of small renal masses, partial nephrectomy has been preferred over radical nephrectomy as the surgical treatment of choice. The transition from open to laparoscopic partial nephrectomy had been challenging for many urologists. Robotic-assisted laparoscopic partial nephrectomy(RLPN) is increasingly used to facilitate this transition . In this review, we examine the recent technical advances and clinical outcomes in RLPN. Many series had successfully reported the feasibility of using the da Vinci Surgical (Intuitive Surgical Inc, Sunnyvale, CA) System in laparoscopic partial nephrectomy. Recent advances had focused on reducing risk of renal damage by shortening the warm ischaemia time. These techniques included unclamped excision, selective arterial clamping and improved renorrhaphy methods. Operative times and warm ischaemia times have also improved once the learning curve are overcome, which is less steep than conventional laparoscopy. With longer follow-up and more widespread experience, the outcome of RLPN could be favourable compared to conventional laparoscopy. Improving techniques had made this surgery a safe and efficacious treatment option for small renal masses.

[Partial nephrectomy for cancer and percutaneous biopsy: Oncologic results]

OBJECTIVES

To evaluate the results of partial nephrectomy (NP) for cancer in 60 patients selected by the biopsy of the tumor by analyzing the information, oncologic follow-up.

PATIENTS

It was a cohort study unicenter retrospective from 1994 to 2006. The biopsy was systematically done for patients who were candidates for elective NP. The criteria for elective indications NP tumors were less than 4cm, low grade Fuhrman (I and II). The tubulopapillary tumors (TBP) on biopsy were excluded from the elective indications. The parameters studied were the biopsy data, overall survival, disease-free survival.

RESULTS

The median age was 59 years (32-79 years) and 69% of tumor were fortuitous discovery. Indications of need accounted for 30% of cases (single kidney, bilateral tumors and chronic renal failure [CRF]). Biopsy allowed a diagnosis in 89% of cases. There was one death in specific postoperative immediately. A final histology was 75% of clear cell carcinoma, 13.3% of chromophobe and 11.7% of TBP, 96.6% of T1a including 86.6% of low grade and no surgical margin. The median follow-up was 49 months with 98.5% of specific survival at 5 years, one local recurrence and no general recurrence.

CONCLUSION

The study has shown that the selection of patients by biopsy gives satisfactory carcinologic results with 98.5% specific survival at the end of follow-up; it is between 89 and 100% in the literature.

Focal therapy and imaging in prostate and kidney cancer: high-intensity focused ultrasound ablation of small renal tumors

The rising incidence of small, incidentally detected renal masses in elderly, infirm patients has raised interest in minimally invasive, energy ablative techniques. High-intensity focused ultrasound (HIFU) delivers ultrasonic energy, resulting in heat and tissue destruction in the targeted tissue at a selected depth. In contrast to radiofrequency ablation and cryoablation, HIFU does not require puncturing the tumor, avoiding the high risk of hemorrhage or tumor spillage. While the extracorporeal approach shows unsatisfactory results, laparoscopic HIFU appears to be a promising alternative treatment option. Problems with respiratory movement and interphases, as seen in extracorporeal HIFU, are avoided when the transducer is brought directly to the target by laparoscopic HIFU. Potential benefits of laparoscopic HIFU are decreased morbidity, shorter hospitalization and convalescence, and preservation of renal function. Nevertheless, further prospective studies have to be performed to define the oncological success of HIFU as an alternative to open and laparoscopic surgery in small renal masses.

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.

Management of small renal masses: a review

INTRODUCTION

Recently, small renal masses (SRMs) (< or =4 cm) are found more frequently, especially in the elderly and co-morbid patients. Standard treatment for SRMs is nephron-sparing surgery (NSS). New techniques like energy ablation and surveillance have been introduced.

MATERIALS AND METHODS

Overview of treatment options for SRMs, based mainly on the meta-analyses available for NSS, cryoablation, radio-frequency ablation (RFA), and surveillance.

RESULTS

NSS for SRMs is the standard therapy with excellent cancer-specific survival rates up to 97%. Cryoablation was mainly performed laparoscopically, and RFA mainly percutaneously. Pretreatment biopsies were used frequently for cryoablation (80%) and less frequently for RFA (50%). Primary failure rate for cryoablation was 4.8% and for RFA 13%. Major complication rates for both procedures are around 5%. Based on 6-month post-ablative biopsies, non-contrast enhancement seems to be an effective surrogate marker after cryoablation, but not after RFA. Follow-up after energy ablation is too short to draw final conclusion. Data on surveillance are based on small, retrospective data with insufficient follow-up. Growth patterns during follow-up do not correlate with the underlying tumour entity.

CONCLUSION

Standard therapy for SRMs is still NSS. Energy ablation should be reserved for the elderly patients with co-morbidities and surveillance for the elderly and infirm patients.

Localized renal cell carcinoma management: an update

OBJECTIVE

To review the current modalities of treatment for localized renal cell carcinoma.

MATERIALS AND METHODS

A literature search for keywords: renal cell carcinoma, radical nephrectomy, nephron sparing surgery, minimally invasive surgery, and cryoablation was performed for the years 2000 through 2008. The most relevant publications were examined.

RESULTS

New epidemiologic data and current treatment of renal cancer were covered. Concerning the treatment of clinically localized disease, the literature supports the standardization of partial nephrectomy and laparoscopic approaches as therapeutic options with better functional results and oncologic success comparable to standard radical resection. Promising initial results are now available for minimally invasive therapies, such as cryotherapy and radiofrequency ablation. Active surveillance has been reported with acceptable results, including for those who are poor surgical candidates.

CONCLUSIONS

This review covers current advances in radical and conservative treatments of localized kidney cancer. The current status of nephron-sparing surgery, ablative therapies, and active surveillance based on natural history has resulted in great progress in the management of localized renal cell carcinoma.

Adrenal metastasis in renal cell carcinoma: A recommendation for adjustment of the TNM staging system

OBJECTIVES

To study the incidence of adrenal metastasis in patients with renal cell carcinoma (RCC) of all stages, its correlation with clinicopathological variables and its impact on survival. Furthermore, the need for adrenalectomy as part of the routine radical nephrectomy was assessed.

MATERIAL AND METHODS

The medical records of 321 patients with RCC of all stages who were operated on with the aim of performing adrenalectomy combined with radical nephrectomy between 1982 and 2000 were reviewed. The accuracy of the available preoperative radiological examinations was evaluated and any adrenal involvement was compared with other clinical and histopathological findings.

RESULTS

Ipsilateral adrenal tumour involvement was detected in 17/321 patients (5.3%). In four of these patients, the adrenal gland was the only preoperatively found metastatic site. Factors predicting the presence of ipsilateral adrenal metastases were male gender, tumour size, vein invasion, renal capsule and perirenal fat invasion. Tumour location within the kidney and tumour side had no predictive value for the presence of adrenal metastasis. The presence of ipsilateral adrenal involvement was a significant adverse prognostic variable, indicating a short survival time (p<0.001).

CONCLUSIONS

Ipsilateral adrenal metastasis is a highly adverse prognostic factor. In the TNM staging system, adrenal gland involvement should be staged as M1a. Ipsilateral adrenalectomy in conjunction with radical nephrectomy should be performed if an adrenal lesion cannot be cleared of suspicion after preoperative radiological imaging, as in locally advanced tumours. The adrenal gland can be left in situ if the ipsilateral adrenal gland is assessed as normal at the preoperative investigation and perioperatively by the surgeon.

Nephron-sparing surgery and percutaneous biopsies in renal-cell carcinoma: a global impression among endourologists

BACKGROUND AND PURPOSE

On the one hand, nephron-sparing surgery (NSS) in small renal tumors is a safe and effective alternative to radical nephrectomy. On the other hand, the role of preoperative percutaneous needle biopsies (PNB) remains controversial. The purpose of this study was to evaluate the global current use of NSS in the treatment of renal-cell carcinoma (RCC) and the use of PNB among endourologists.

MATERIALS AND METHODS

One thousand questionnaires were distributed during the 23rd World Congress of Endourology and SWL. Six questions regarding NSS and two questions regarding PNB were presented. Two hundred twenty-two questionnaires were returned.

RESULTS

Of the respondents, 86.6% perform NSS for small renal tumors, whereas 13.4% perform only radical nephrectomies; 7.5% will consider NSS only in patients with a solitary kidney, and 0.5% will never consider NSS. The techniques for NSS, in descending order of preference, are partial nephrectomy, enucleation, cryoablation, radiofrequency ablation, and high-intensity focused ultrasound. The mean and maximum diameter of the tumor in patients with a normal contralateral kidney for which the urologists perform NSS is 4.0 cm. For a centrally located tumor, NSS is an option for 27.2% of the respondents. Regarding PNB in patients with suspicion of RCC, 55.9% of respondents never obtain renal biopsies in the preoperative assessment and 41.8% obtain them only in rare cases. The majority (90%) prefer histologic over cytologic biopsies.

CONCLUSIONS

Nephron-sparing surgery is evolving to a global worldwide standard treatment for small renal tumors. Percutaneous needle biopsy remains a highly debated procedure.

Laparoscopic versus open partial nephrectomy for the treatment of pathological T1N0M0 renal cell carcinoma: a 5-year survival rate

PURPOSE

We retrospectively compared the oncological adequacy of laparoscopic partial nephrectomy to that of open partial nephrectomy in the treatment of patients with pathological stage T1N0M0 renal cell carcinoma.

MATERIALS AND METHODS

A total of 143 patients with stage T1N0M0 renal tumors confirmed by pathological examination of the surgical specimen underwent partial nephrectomy between January 1996 and June 2004 with a followup of at least 1.5 years. Of these patients 85 were treated laparoscopically and the remaining 58 underwent open surgery. Medical and operative records were retrospectively reviewed with emphasis on tumor recurrence and survival. Statistical analysis was performed using Kaplan-Meier analysis.

RESULTS

The mean followup for the laparoscopy group was 40.4 +/- 18.0 months. A total of 83 patients survived. Of these patients 2 patients experienced disease recurrence within 18 to 46.2 months, 1 patient died of cancer metastasis to brain within 29.7 months and 1 died of an unrelated cause. Seeding of the port sites did not develop in any of the patients. The 5-year disease-free and actuarial survival rates for this group were 91.4%, and 93.8%, respectively. The 58 patients who underwent open surgery had a mean followup of 49.68 +/- 28.84 months. A total of 53 patients survived without any disease recurrence, 1 survived with recurrence within 8 months, 1 survived with metastasis within 49 months and 3 died of unrelated causes. The 5-year disease-free and patient survival rates for this group were 97.6% and 95.8%, respectively. Kaplan-Meier disease-free survival and patient survival analysis revealed no significant differences between the laparoscopic and open partial nephrectomy groups.

CONCLUSIONS

Laparoscopic partial nephrectomy is an alternative technique with mid-range oncological results comparable to open partial nephrectomy in patients with localized pathological stage T1N0M0 renal cell carcinoma.

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.

Controlled Study of Inline Radiofrequency Coagulation-Assisted Partial Nephrectomy in Sheep

BACKGROUND

Primary or secondary tumors of kidney often are managed by partial nephrectomy. Intraoperative blood loss can be significant. Laparoscopic partial nephrectomy may be even more challenging. We developed the Inline radiofrequency coagulation (ILRFA) probe for liver surgery. It uses radiofrequency energy to make a linear coagulative plane and considerably reduces bleeding during parenchymal transection. In this stud,y we tested the efficiency of ILRFA in ovine kidney.

METHOD

Seven sheep were used in this study. Under general anesthetic, a laparotomy was performed in each sheep. The first two sheep were used as pilot experiments. Five partial nephrectomies were made in the remaining five sheep using ILRFA. As a control, a matching partial nephrectomy was made in each sheep using diathermy and sutures. Blood loss was measured by determining the difference in the weights of dry sponges and blood stained sponges after resection. A paired t test was used to compare the bleeding between the control and the ILRFA technique.

RESULTS

The mean blood loss using ILRFA was 33.14 g (SD 17) and 123.43 g (SD 72) in the control group. The bleeding was significantly reduced in the ILRFA group, with a P value of 0.0056. The time taken for applying the ILRFA was 3-4 min.

CONCLUSION

We have achieved partial nephrectomy in ovine kidney using radiofrequency energy with significantly reduced blood loss.

Impact of resection margin status after nephron-sparing surgery for renal cell carcinoma

OBJECTIVE

To evaluate whether the negative-margin width after nephron-sparing surgery for renal cell carcinoma (RCC) is associated with tumour recurrence.

PATIENTS AND METHODS

In all, 121 patients had nephron-sparing surgery for non-metastatic RCC for elective (85 cases) and imperative (36 cases) indications. Intraoperative frozen sections were routinely obtained and revealed negative margins in all patients. The tumour size and the shortest distance of normal parenchyma around the tumour were assessed.

RESULTS

After a mean (range) follow-up of 49.3 (12-113) months, six patients had disease progression (three with local recurrence, two of whom also had distant metastases and pure metastatic disease in three). The mean (range) width of the negative margins was 0.56 (0.1-2.3) cm. The width of the resection margin did not correlate with disease progression, while tumour size was a strong predictor of progression (P < 0.02). The mean tumour size was 5.1 cm in patients with progression and 3.1 cm in patients who remained recurrence-free.

CONCLUSIONS

Our data suggest that the width of the resection margin, unlike tumour size, does not influence the risk of tumour recurrence.

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.

Routine frozen-section biopsy from the surgical bed should be performed during nephron-sparing surgery for renal cell carcinoma

OBJECTIVE

It has been reported in recent studies that nephron-sparing surgery (NSS) is as effective as radical nephrectomy (RN) for pT1a and pT1b renal cell carcinoma (RCC). In order to decrease the rate of tumor recurrence, resection of a small amount of normal parenchyma surrounding the tumor is widely recommended. Although a 0.5-1.5-cm wide resection margin is recommended no agreement has been reached concerning the thickness of the surgical margin. In this study we tried to determine whether routine frozen-section biopsy from the surgical bed is mandatory during NSS for RCC.

MATERIAL AND METHODS

The study involved 19 renal units of 18 patients who underwent partial nephrectomy for solid renal tumors (<7 cm) at different centers in Ankara. Hypothermic ischemia was instituted after placing the kidney in an intestinal bag full of ice slush and cross-clamping the renal artery. In all cases an approximately 1-cm margin of normal tissue was removed with the tumor. Then, intraoperatively, at least three frozen-section biopsies were taken from the surgical bed to determine the surgical margin. If the biopsy was positive, RN was performed.

RESULTS

All patients were staged as pT1a or pT1b according to the 2002 TNM classification. The average tumor size was 3.8 cm. In three cases we performed RN due to positive surgical margins. Surgical margins were negative in 16 tumors, with a mean negative margin size of 5 mm (range 2-11 mm). One patient died of a non-cancer-related cause. The mean distance to the renal capsule was 7 mm (range 1-11 mm). Seventeen patients were followed up for 18 months with no local or systemic recurrence.

CONCLUSION

In some cases an approximately 1-cm margin is not sufficient to ensure a negative margin and frozen-section biopsies must be taken from the tumor bed, even if it seems normal macroscopically.

Nephron-sparing surgery for renal tumours using selective renal parenchymal clamping

OBJECTIVE

To describe a technical modification that facilitates nephron-sparing surgery (NSS) for renal tumours, without clamping the renal pedicle or promoting renal surface hypothermia.

PATIENTS AND METHODS

Seventeen patients with renal tumours had NSS using the selective renal-parenchymal clamping technique. In 11 patients the tumour was polar and in six it was central. The mean (range) size of the tumours was 3.6 (2-6) cm. The technique was performed using one or two large Satinsky vascular clamps. Time was not limited as there was no clamping of the renal pedicle, or renal hypothermia.

RESULTS

The mean (range) operative duration was 190 (120-300) min. Only one patient needed a blood transfusion. There were no complications in 13 patients after NSS. The mean (range) hospital stay was 5 (3-12) days. The pathological examination detected malignant tumours in 13 patients, and a microscopic examination showed adequate surgical margins in all. The mean (range) follow-up was 24.5 (4-60) months. No patients required haemodialysis immediately after surgery or later.

CONCLUSIONS

Selective renal parenchymal clamping is a simple and efficient technical manoeuvre that facilitates NSS without dissection or clamping of the renal pedicle. Time is not limited as the ischaemia is limited to the tissue surrounding the tumour. The operative duration and blood loss are acceptable and the complications similar to those with the conventional technique. The size and position of the tumour could be limiting factors to this technique.

Water jet assisted laparoscopic partial nephrectomy without hilar clamping in the calf model

PURPOSE

Hemostasis represents a primary challenge during laparoscopic partial nephrectomy (LPN). We typically clamp the renal artery/vein en bloc and perform LPN expeditiously under warm ischemia conditions. We evaluated Helix Hydro-jet assisted LPN without renal hilar vascular control in the survival calf model.

MATERIALS AND METHODS

Staged bilateral LPN using the Hydro-jet was performed without renal hilar vessel control in 10 survival calves (20 kidneys). Parenchymal hydrodissection was performed with a high velocity, ultracoherent saline stream at 450 psi through a small nozzle with integrated suction at the tip. The denuded intrarenal parenchymal blood vessels were precisely coagulated with a BIClamp bipolar instrument and transected. Followup involved biochemical, radiological and histopathological evaluation at designated sacrifice intervals of 1 and 2 weeks, and 1, 2 and 3 months, respectively.

RESULTS

All LPNs were completed successfully without open conversion. Of 20 LPNs 18 (90%) were performed without hilar clamping. Pelvicaliceal suture repair was necessary in 5 of 10 chronic kidneys (50%). Mean Hydro-jet(R) partial nephrectomy time was 63 minutes (range 13 to 150), mean estimated blood loss was 174 cc (range 20 to 750) and mean volume of normal saline used for hydro-dissection was 260 cc (mean 50 to 1,250). No animal had a urinary leak. Histological sections from the acute specimen revealed a thin (1 mm) layer of adherent coagulum at the amputation site with minimal thermal artifact. At 2 weeks a layer of adherent fibro-inflammatory pseudomembrane with giant cell reaction was seen.

CONCLUSIONS

In this more stringent and robust survival calf model Hydro-jet assisted LPN can be performed without hilar vessel control, thus, completely avoiding warm ischemia. This approach has the potential to decrease the level of technical difficulty inherent in LPN.

EVALUATION OF MICROPOROUS POLYSACCHARIDE HEMOSPHERES AS A NOVEL HEMOSTATIC AGENT IN OPEN PARTIAL NEPHRECTOMY: FAVORABLE EXPERIMENTAL RESULTS IN THE PORCINE MODEL

PURPOSE

Microporous polysaccharide hemospheres (MPH, Medafor, Minneapolis, Minneapolis) are a novel hemostatic agent made from purified plant starch. MPH activates the clotting cascade and hyperconcentrates platelets and coagulation proteins, while enhancing a hemostatic plug. We evaluated the hemostatic efficacy of MPH compared with standard surgical technique in a porcine open partial nephrectomy model.

MATERIALS AND METHODS

Standardized lower pole partial nephrectomy was consecutively performed in each kidney of 12 female pigs. Each pig was randomized to 2 groups, namely treatment with MPH application or control with the conventional surgical technique (oxidized cellulose with bolster sutures). The right kidney was harvested 1 half-hour after hemostasis was achieved and the left kidney was harvested after 7 days.

RESULTS

Mean animal and resected renal tissue weight were comparable. Ischemic and hemostasis times were significantly decreased in the MPH treated group (2.67 and 4.67 minutes, respectively) vs the control group (8.33 and 7.75 minutes, respectively) (each p = 0.004). Blood loss was equivocal (0.88 gm in the treatment group vs 2.09 gm in the control group, p = 0.07). No hemostatic complications were noted in either group. No evidence of residual foreign material was found in the MPH group at 1 week.

CONCLUSIONS

MPH provided rapid, effective and durable hemostasis in the porcine open partial nephrectomy model. Additional experimental and clinical evaluation is warranted to define the role of MPH assisted partial nephrectomy in humans.

Selective intra-arterial 3-dimensional computed tomography angiography for preoperative evaluation of nephron-sparing surgery

OBJECTIVE

To evaluate selective intra-arterial 3-dimensional computed tomography (3D-CT) angiography as a tool for the preoperative evaluation of nephron-sparing surgery (NSS).

METHODS

Twenty-three patients with renal cell carcinoma indicating NSS underwent selective intrarenal 3D-CT angiography. The time-lapse dual-phase technique was used for simultaneous vascular and urographic visualization. The 3D images were created by the shaded volume-rendering method. The CT attenuation of target structures was measured for quantitative evaluation. The 3D images were visually evaluated for the renal artery, vein, and collecting system using a grading system. Results were statistically analyzed.

RESULTS

The 3D-CT angiography depicted the intrarenal branches of the renal artery and vein and the whole collecting system in most patients. Visualization of the renal artery was significantly correlated to its CT attenuation. Visualization of the renal vein was correlated to its CT attenuation adjusted by the surrounding renal parenchyma.

CONCLUSION

Selective intra-arterial 3D-CT angiography allows the detailed visualization of intrarenal structures.

Long-Term Results of Nephron Sparing Surgery for Localized Renal Cell Carcinoma

Several unrandomized studies from the current literature confirm that in selected patients with localized renal cell carcinoma (RCC), nephron sparing surgery (NSS) shows to be as effective as radical surgery. In this regard, we evaluated the data from patients treated by using such a conservative approach with a long-term follow-up.

Materials and Methods.

We considered 28 patients (19 M, 9 F; median age 54 years) with unilateral, localized, small (< 4 cm) RCC, submitted to NSS from 1988 to 1994. Only 3 of them (10%) were symptomatic at presentation. Oncological follow-up had been conducted with visits every 4 months for the first two years, every six for another three years and then annually.

Results.

All the patients were clinical stage T1aN0M0 (UICC TNM 2002). Grading was: 10 G1, 10 G2, 8 G3. Mean tumor diameter was 3.2 cm. After a long-term follow-up (mean 10 years, range 8–14), none present local relapse, disease specific survival is 93% and overall survival is 86%. Based on biochemistry, 82% of the remaining patients still have a normal renal function.

Conclusions.

Given the excellent long-term results and the recognized benefits of elective NSS, this approach should be preferentially adopted in a selected population of patients with small (<4 cm), unilateral, RCC.

Ketorolac: Safe and Effective Analgesia for the Management of Renal Cortical Tumors With Partial Nephrectomy

PURPOSE

Ketorolac has demonstrated advantages as a supplement to opioid based analgesia in several surgical settings, including donor nephrectomy. To our knowledge there has been no published data to date on the use of ketorolac in patients undergoing partial nephrectomy. We compared analgesia with ketorolac and opioids to analgesia with opioids alone with regard to pain control, postoperative recovery and effects on renal function in patients with renal cortical tumors surgically managed by partial nephrectomy.

MATERIALS AND METHODS

Records for 154 patients treated with partial nephrectomy for renal cortical tumors were retrospectively analyzed. Clinicopathological variables examined were age, gender, medication use, comorbidity profile, operation side, estimated blood loss, hospital stay, operative duration, American Society of Anesthesiologists class, histopathology results, perioperative transfusion status, ischemia type (warm vs cold vs none), duration of renal artery cross clamping, tumor size and intraparenchymal location, pathological stage and perioperative complications. Postoperative duration to the initiation of solid diet, discontinuation of patient controlled analgesia and overall pain control were assessed. Serum creatinine was measured during the preoperative period, and at 1, 3 or greater and 30 or greater days postoperatively.

RESULTS

Patients who received ketorolac demonstrated superior postoperative recovery with an earlier return to solid diet and earlier discontinuation of patient controlled analgesia. Treatment groups were similar with respect to changes in serum creatinine, blood loss, transfusion rates and complication rates. Ketorolac was not associated with an increased risk of acute renal failure.

CONCLUSIONS

Ketorolac is a safe and effective supplement to opioid based analgesia for pain control after partial nephrectomy.

Reassessment of the 1997 TNM classification system for renal cell carcinoma

BACKGROUND

The 1997 TNM staging classification for renal cell carcinoma (RCC) defined Stage I tumors as organ-confined tumors measuring up to 7 cm in size. The authors evaluated the validity of this cutoff size by assessing the survival of patients with Stage I RCC according to a series of alternative size cutoff values. In addition, the authors determined how these size cutoffs affected the risk of having nonorgan-confined tumors, regional lymph node involvement, and metastatic disease.

METHODS

A database containing the records of 1324 patients with RCC who underwent open radical nephrectomy between 1960 and 1991 was evaluated. Patients with Stage I disease were stratified by size cutoffs ranging from 2.5 to 7.0 cm in 0.5-cm increments. Five-year disease-specific survival (DSS) rates were estimated using the Kaplan-Meier method. The log-rank test was used to compare survival curves. The survival of patients with tumors smaller than a specified size cutoff was compared with the survival of patients with tumors larger than that cutoff and the most discriminating cutoff was identified. The same size cutoffs were used to compare the incidence of local nonorgan-confined, lymph node-positive, and metastatic disease for all patients with tumors 7.0 cm or smaller.

RESULTS

Of 544 evaluable patients, 351 patients had tumors 7.0 cm or smaller and 233 of these patients had 1997 Stage I (T1N0M0) disease. When patients with 1997 Stage I tumors were separated using the various size cutoffs, survivals were most different using a 5.0-cm cutoff. The 5-year DSS rates for patients with Stage I tumors 5 cm or smaller versus those with tumors measuring 5.1-7 cm were 94.6% versus 79.2% (P = 0.003). Furthermore, the survival of patients with Stage I RCC lesions measuring 5.1-7.0 cm was the same as for patients with 1997 Stage II (T2N0M0) RCC. The difference in probability of having local nonorgan-confined disease was also greatest with a 5.0 cm cutoff value. Nonorgan- confined disease was reported to be present in 16.2% of the patients with tumors smaller than 5.0 cm compared with 36.8% of the patients with tumors measuring 5.1-7.0 cm in size. The difference in the probabilities of having lymph node-positive or metastatic disease did not change significantly using any of the cutoffs, although the probability of both of these increased with increasing tumor size.

CONCLUSIONS

Survival and disease recurrence analysis in a large group of patients with RCC who underwent radical nephrectomy showed that the 1997 TNM cutoff of 7.0 cm used to separate Stage I from Stage II disease was too high. A size-related survival difference was found among patients with organ-confined 1997 Stage I disease and a 5.0-cm cutoff best stratified this difference. This finding was in general agreement with the changes made in the 6th edition of the American Joint Committee on Cancer cancer staging manual. Patients with tumors measuring between 5.1 cm and 7.0 cm were found to have the same survival as patients with Stage II disease. Thus, subclassification of T1 into T1a and T1b, as in the 6th edition of the AJCC cancer staging manual, may not be optimal. The 5-cm cutoff also best stratified the risk of developing nonorgan-confined disease. This finding may have an impact on nephron-sparing surgery in selected patients. The findings of the current study, as well as those of others, supported an upper size cutoff of 4-5 cm for patients with Stage I RCC.