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

How not to miss or mischaracterize a renal cell carcinoma: protocols, pearls, and pitfalls

OBJECTIVE

MDCT protocol optimization for renal cell carcinoma requires attention to several data acquisition, reconstruction, and display parameters. Specifically, multiple acquisitions with varying coverage, careful timing of each contrast-enhanced phase, and use of 2D and 3D multiplanar displays are required. This article reviews these parameters, supplemented by experience-based pearls and pitfalls.

CONCLUSION

Proper data acquisition and utilization of postprocessing tools are essential to avoid missed diagnoses or misinterpretation when imaging renal cell carcinoma.

Laparoscopic and open partial nephrectomy: cost comparison with analysis of individual parameters

INTRODUCTION

Laparoscopic partial nephrectomy (LPN) is less morbid than open partial nephrectomy (OPN), but the high cost of new technologies used in LPN may make this a significantly more expensive procedure. In this study, the overall costs of OPN and LPN were compared using data extracted from the literature, and a series of sensitivity analyses were performed to determine the impact of individual cost components on overall cost.

MATERIALS AND METHODS

Data on operating room (OR) time, equipment use, and length of stay (LOS) were abstracted after a comprehensive literature review of LPN and OPN. Decision tree models were devised to estimate the cost of each treatment using the DATA program (TreeAge software 3.5). LPN model assumptions included one that used all reusable equipment, all disposable equipment, and a hand-assist model. One and two-way sensitivity analyses were performed to evaluate the effect of individual treatment variables on overall cost.

RESULTS

The literature yielded 12 OPN and 13 LPN articles, comprising a total of 574 and 949 patients, respectively. The weighted mean LOS were 5.7 and 2.9 days (<0.001); average tumor sizes were 3.2 cm and 2.5 cm (P = 0.016); and the weighted mean OR times were 184 and 187 minutes for OPN and LPN (P = 0.7), respectively. The LPN model using all disposable equipment is less costly than OPN by $431 ($8450 v $8019). The slight cost superiority of the laparoscopic approach was driven by shorter LOS. One-way sensitivity analyses showed that LPN is less costly if the OR time of LPN is less than 146 minutes; LOS after LPN is less than 4.6 days; or LPN OR supply costs are less than $1670. Two-way sensitivity analyses demonstrated the effects of modifying OR time, LOS, and surgical equipment on the cost-equivalence of LPN and OPN.

CONCLUSIONS

Laparoscopic partial nephrectomy can be cost equivalent to the open approach in managing small renal masses if the OR time, LOS, and equipment costs are closely monitored. The high cost of new technologies can be offset by shorter LOS and decrease in OR time.

Staging of renal cell carcinoma

As in other malignant tumors, prognosis in renal cell carcinoma (RCC) depends on tumor extent and metastasis at the time of primary diagnosis. Staging systems formalize the way in which the extent of RCC is being described and classified. Primary staging of RCC aims at evaluating surgical options. Since surgical excision, which is the mainstay of therapy in non-metastatic RCC, and, recently, minimally invasive ablation methods have evolved significantly over the last decades, staging systems continue to evolve along the way. The 40-year-old Robson classification has been replaced with the TNM classification of RCC, because the latter adapts more easily to changing patterns of diagnosis and therapy. Modern cross-sectional imaging methods, such as multidetector-row computed tomography (MDCT), and magnetic resonance imaging (MRI), perform highly in T-staging of local tumor extent and M-staging of distant metastasis. However, both MDCT and MRI perform poorly in N-staging of lymphadenopathy. At present, 18-F-desoxy-glucose positron emission tomography (FDG-PET) appears to be unreliable in the detection of RCC and its metastasis. This overview of current radiological and surgical literature attempts to describe how modern staging systems for RCC are organized, and which radiological and surgical developments currently influence the way in which primary staging and prognosis of RCC depend on one another.