Conservative surgery for renal cell carcinoma: a single-center experience with 100 patients

Trends in renal cancer surgery and patient provider characteristics associated with partial nephrectomy in the United States

OBJECTIVE

Many renal tumors are amenable to either partial or total nephrectomy, but little is known about the relative frequency that these procedures are performed in the United States. We describe recent temporal trends in surgery for renal neoplasm and identified factors associated with partial nephrectomy.

METHODS

Data from the 1998 through 2002 National Inpatient Sample was analyzed to identify adult patients discharged after renal cancer surgery. The frequency of partial and total nephrectomy in the United States was estimated, and multivariate regression was used to examine patient and provider factors associated with partial nephrectomy.

RESULTS

The number of nephrectomies performed for tumor in the United States increased yearly, with an estimated 23,375 total nephrectomies and 4272 partial nephrectomies performed in 2002. The ratio of partial nephrectomies to total nephrectomies also increased (P < 0.001), with partial nephrectomy representing 15.5% of all nephrectomies in 2002. In the multivariate analysis, patient and provider factors significantly associated with undergoing partial nephrectomy included female sex (odds ratio [OR] = 0.86, 95% confidence interval [CI] 0.79-0.94), age (OR = 0.38, 95% CI 0.30-0.49 comparing age older than 79 to younger than 40 years), teaching hospital status (OR = 1.54, 95% CI 1.34-1.76), annual hospital nephrectomy volume (OR = 1.96, 95% CI 1.62-2.39 comparing highest to lowest quartiles), annual surgeon nephrectomy volume (OR = 2.60, 95% CI 2.12-3.20 comparing highest to lowest quartiles), and private insurance/health maintenance organization coverage (OR = 1.25, 95% CI 1.11-1.40 compared to Medicare).

CONCLUSIONS

The total number of nephrectomies and the proportion of partial nephrectomies performed in the United States increased yearly from 1998 to 2002. Male sex, hospital teaching status, higher hospital and surgeon volume, and insurance status are associated with receiving partial nephrectomy.

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.

The therapeutic value of adrenalectomy in case of solitary metastatic spread originating from primary renal cell cancer

INTRODUCTION

Solitary adrenal metastases occur in about 1.2-10% of renal cell cancer patients. Since the vast majority of intraadrenal lesions can be detected preoperatively, we and others have recently recommended to renounce a routine adrenalectomy during surgery of renal cell cancer. However, the impact of adrenalectomy on the patients' clinical prognosis in case of a solitary metastatic lesion within the adrenal gland remains an issue of controversial discussion. Whereas some authors suggest adrenalectomy as a potentially curative treatment option in these cases, others compare its clinical value with that of a mere lymphadenectomy.

PATIENTS AND METHOD

Between 1981 and 2000, 648 patients (440 males and 208 females) underwent nephrectomy in combination with adrenalectomy in our clinic for the diagnosis of renal cell cancer. The median age at first diagnosis was 59 (range 33-84) and 60 (range 20-85) years for male and female patients, respectively. The median postoperative follow - up was 2.4 years (0.2-18 years). According to the TNM - classification system (2003) tumor stages were classified as follows: T1, 228 pat. (37%); T2, 70 pat. (11%); T3, 287 pat. (46%); T4, 37 pat. (6%). In total, 339 patients revealed regional lymph node or distant metastases at the time of the surgical treatment. Although metastases of the adrenal gland were diagnosed in 48 patients, solitary intraadrenal metastases without further systemic spread were observed in only 13 cases. Several patients' and tumor characteristics (age, tumor stage and size, the presence of regional lymph node metastases, the presence of metastatic lesions at different organ sites as well as the detection of solitary intraadrenal metastases) were correlated with the patients' overall survival by univariate and multivariate statistical analysis (logistic Cox regression analysis).

RESULTS

The median long - term survival was 4.8 years for the entire cohort of patients investigated. The median long - term survival was 13.8 years and 11.7 years for patients with no evidence of metastatic spread as well as for patients with a solitary intraadrenal metastatic lesion, respectively. Accordingly, the long - term survival rates at 5 and 10 years after surgery were 66%/50% and 51%/51% for patients with no evidence of metastatic spread or isolated intraadrenal metastases. This difference was not statistically significant. In contrast, for patients revealing lymph node or distant metastases at other organ sites, the median long - term survival was significantly decreased (lymph node metastases: 0.7 years; distant metastases: 1.2 years).

DISCUSSION

For patients with a solitary intraadrenal metastatic lesion, adrenalectomy is a potentially curative treatment option. The observation that the long - term survival of the latter patients is comparable to that of patients with organ - confined disease might suggest the establishment of a separate TNM - category for patients revealing a solitary metastasis within the adrenal gland and no hint at further systemic metastatic spread.

Effects of perfusion on radiofrequency ablation in swine kidneys

PURPOSE

To evaluate the effect of vascular occlusion on the size of radiofrequency (RF) ablation lesions and to evaluate embolization as an occlusion method.

MATERIALS AND METHODS

The kidneys of six swine were surgically exposed. Fifteen RF ablation lesions were created in nine kidneys by using a 2-cm-tip single-needle ablation probe in varying conditions: Seven lesions were created with normal blood flow and eight were created with blood flow obstructed by means of vascular clamping (n = 5) or renal artery embolization (n = 3). The temperature, applied voltage, current, and impedance were recorded during RF ablation. Tissue-cooling curves acquired for 2 minutes immediately after the ablation were compared by using regression analysis. Lesions were bisected, and their maximum diameters were measured and compared by using analysis of variance.

RESULTS

The mean diameter of ablation lesions created when blood flow was obstructed was 60% greater than that of lesions created when blood flow was normal (1.38 cm +/- 0.05 [standard error of mean] vs 0.86 cm +/- 0.07, P <.001). The two methods of flow obstruction yielded lesions of similar mean sizes: 1.40 cm +/- 0.06 with vascular clamping and 1.33 cm +/- 0.07 with embolization. The temperature at the probe tip when lesions were ablated with normal blood flow decreased more rapidly than did the temperature when lesions were ablated after flow obstruction (P <.001), but no significant differences in tissue-cooling curves between the two flow obstruction methods were observed.

CONCLUSION

Obstruction of renal blood flow before and during RF ablation resulted in larger thermal lesions with potentially less variation in size compared with the lesions created with normal nonobstructed blood flow. Selective arterial embolization of the kidney vessels may be a useful adjunct to RF ablation of kidney tumors.

Prognostic Value of Multifocality on Progression and Survival in Localized Renal Cell Carcinoma

OBJECTIVE

Incidence of multifocality in Renal Cell Carcinoma (RCC) is estimated at between 5 and 25%. Multifocality has been largely studied because of the growing interest in conservative surgery which is a risk of local recurrence. The aim of this study is to evaluate the relationship between multifocality and other prognostic parameters and whether it is an independent prognostic factor.

MATERIAL AND METHODS

From 1980 to 1990, 255 patients (median age: 60.9 years) were treated by radical nephrectomy for pT1 to pT3b N0M0 RCC. The median follow-up time was 183 months. Multifocality was defined as the existence of at least one other tumoral localization, macroscopically and microscopically diagnosed as renal cell carcinoma, in the same kidney. Studied parameters were: age, sex, side, size, stage, Fuhrman's grade, capsular invasion, renal vein involvement and microvascular invasion. Survival was assessed with Kaplan-Meier and Cox models.

RESULTS

37 cases of multifocal RCC were diagnosed (14.5%). There was only a significant correlation with stage (p=0.002) and with capsular invasion (p=0.002). No other factor was correlated with multifocality. It had no influence on the risk of metastatic progression, overall or specific survival.

CONCLUSION

There is a significant correlation between capsular invasion and multifocality that has to be considered before proposing conservative surgery for a localized RCC. Multifocality has no influence on survival or metastatic progression in case of radical nephrectomy.

Primary care update on kidney and bladder cancer: a urologic perspective

The past decade has witnessed many substantive changes in the approach to the diagnosis and treatment of both kidney and bladder cancer. In part, this is based on changes in the understanding of their carcinogenesis and pathogenesis, an appreciation of new concepts in their classification, and the incorporation of new technologies that have emerged. This article reviews advances and updates changes that have been made in the understanding of and approaches to these malignancies from the perspective of their urologic assessment and management while in the context of primary care issues.

The role of partial nephrectomy for renal cell carcinoma in contemporary practice

Partial nephrectomy has proved to be a safe and effective treatment modality, even for patients with normal contralateral kidneys. The indications for elective partial nephrectomy continue to evolve as contemporary series demonstrate low morbidity approaching that of radical nephrectomy. Furthermore, patients who undergo partial nephrectomy have a significantly decreased risk of future renal insufficiency. As such, a rationale exists for expanding indications in an era of excellent technical outcomes and increased patient longevity. Characterization of newer diagnostic (three-dimensional imaging) and treatment (laparoscopic partial nephrectomy, cryosurgery) modalities will allow continued evolution of nephron-sparing techniques.

Long-term follow-up of bilateral sporadic renal tumors

OBJECTIVES

To assess the clinical characteristics, pathology, and long-term follow-up of patients with bilateral nonfamilial renal tumors (BNFRTs).

METHODS

Patients with BNFRTs and unilateral tumors were identified from a prospective surgery database. The Mann-Whitney U test, Cox proportional hazards regression analysis, and the log-rank test were used to compare groups.

RESULTS

From a database of 1082 patients with nonmetastatic renal tumors, 46 were identified with BNFRTs (4.25%). Thirty-three had synchronous tumors and 13 had asynchronous tumors. The median patient age of BNFRT patients was 61 years. Of the 92 renal tumors in these 46 patients, 42% were managed with radical nephrectomy (RN) and 58% with partial nephrectomy (PN); 7 underwent bilateral PN. The tumors were conventional clear cell carcinoma in 66% (n = 61), papillary carcinoma in 14% (n = 13), and the remaining 20% were of varied histologic origin. A 76.2% concordance was noted between the histologic subtypes of the two renal tumors in each patient. Median follow-up was 74 months. Thirty-three patients (72%) were disease-free and 7 patients had recurrence (2 local, 5 metastatic). Compared with patients having unilateral disease, BNFRT patients had an equivalent disease-free survival (DFS) (bilateral: 3-year DFS 90%, 5-year DFS 83%; unilateral: 3-year DFS 92%, 5-year DFS 82% [P = 0.449]). No difference in DFS was observed between synchronous and asynchronous tumors.

CONCLUSIONS

BNFRTs were present in 4.25% of patients with sporadic renal tumors. Conventional clear cell histology was the most common histologic subtype; concordance among tumors was found to be 76%. DFS rates comparable to those of unilateral tumors can be obtained by using combinations of PN and RN.

The evolving role of partial nephrectomy in the management of renal cell carcinoma

The surgical management of renal cell carcinoma has undergone critical review over the past decade. Initially treated with radical nephrectomy, renal cell carcinoma is now approached with nephron-sparing surgical techniques. Improved imaging modalities have substantially increased the number of incidental renal tumors detected, and with the increasing number of incidentally detected kidney tumors, a size and stage migration has occurred in renal cell carcinoma. Early studies showed that disease-free survival rates were similar between cancers treated with radical and partial nephrectomy. The standard now is to offer partial nephrectomy as a surgical option to all patients with renal lesions measuring 4.0 cm or smaller in the setting of a normal contralateral kidney. More recent issues regarding partial nephrectomy concern complication rates and management, renal cell carcinoma multifocality, margin status and distance to normal renal parenchyma, cost analysis, and the development of laparoscopic techniques that duplicate open partial nephrectomy. The purpose of this review is to outline and analyze these more recent concerns regarding partial nephrectomy.

The effect of bilaterality, pathological features and surgical outcome in nonhereditary renal cell carcinoma

PURPOSE

We evaluated the differences in cancer specific, distant metastasis-free and local recurrence-free survival in patients with sporadic subtype concordant bilateral synchronous renal cell carcinoma and those with unilateral renal cell carcinoma, controlling for the covariates of subtype, stage, tumor size, grade and necrosis. We also analyzed early surgical complications and long-term renal function in patients who underwent staged surgery and those who underwent a single operation for bilateral synchronous renal cell carcinoma.

MATERIALS AND METHODS

We retrospectively evaluated 44 patients with sporadic subtype concordant bilateral synchronous renal cell carcinoma treated at our institution between 1970 and 1998. There were 32 patients with bilateral synchronous clear cell renal cell carcinoma and 12 with bilateral synchronous papillary renal cell carcinoma. These patients were compared with 1,714 with sporadic unilateral clear cell renal cell carcinoma and 322 with sporadic unilateral papillary renal cell carcinoma treated with partial or radical nephrectomy during that period. Outcomes were estimated using the Kaplan-Meier method and Cox proportional hazard models were used to test associations with outcome.

RESULTS

Clinicopathological features were similar for patients with bilateral synchronous and unilateral renal cell carcinoma except for the incidence of multifocality, which was 28% and 33% for bilateral synchronous clear cell and papillary renal cell carcinoma compared with 2% and 7% for unilateral clear cell and papillary renal cell carcinoma, respectively. Cancer specific survival and distant metastasis-free survival in patients with bilateral synchronous disease was similar to that in those with unilateral disease when controlling for subtype, stage, tumor size, grade and tumor necrosis. However, patients with bilateral synchronous clear cell renal cell carcinoma were more likely to experience local recurrence even after controlling for these covariates. The majority of patients (84%) with bilateral synchronous disease underwent bilateral surgery at a single operation. The incidence of early surgical complications was low, in that only 2 patients had urinary extravasation, 3 had acute renal failure and 1 was ultimately rendered anephric and required hemodialysis.

CONCLUSIONS

The incidence of multifocality was greater in patients with bilateral synchronous renal cell carcinoma than in those with unilateral renal cell carcinoma. There were no statistically significant differences in cancer specific and distant metastasis-free survival in patients with bilateral synchronous renal cell carcinoma and unilateral renal cell carcinoma of the same histological subtype. These results suggest that subtype concordant bilateral renal cell carcinoma is a result of multiple de novo primary events rather than primary renal cell carcinoma with contralateral renal metastasis. A surgical approach is appropriate for bilateral synchronous renal cell carcinoma and most cases can be approached at a single surgical procedure with acceptable morbidity.

[Long-term outcome of conservative surgery for kidney cancer: survival, blood pressure, and renal function]

PURPOSE

Nephron-sparing surgery (NSS) for renal cell carcinoma (RCC) remains controversial for elective indications (low stage RCC in the presence of a normal contralateral kidney). In this single center study survival rate and, as novel aspects, the frequency of postoperative arterial hypertension and renal function parameters were investigated to evaluate safety and efficacy of NSS.

PATIENTS AND METHODS

The complete data of 248 patients operated nephron-sparing for RCC between 1975 and 1995 were evaluated. One hundred and seventy-five patients were treated for elective indication (95% with tumor stage T1 or T2), 73 patients for mandatory indication (bilateral tumors, solitary kidney, renal insufficiency). The mean follow-up was 75 months (maximum 23 years).

RESULTS

Mean tumor-size was lower under elective (3.8 cm) than under mandatory (4.7 cm) indication. Overall tumor-specific survival after 5 years for both indications was 88%. Comparing preoperative vs. follow-up values, arterial blood pressure and serum-creatinine values remained unchanged for both indications. The incidence of postoperative proteinuria (19% imperative, 11% elective indication) was strongly related to hypertension.

CONCLUSIONS

NSS for RCC under elective indication achieves patient survival comparable to the results of radical nephrectomy. The presented data do not indicate significant longterm complications such as arterial hypertension, proteinuria or deterioration of renal function as a result of glomerulosclerosis or hyperfiltration. This gives further argument for the concept of NSS in RCC as an alternative to radical nephrectomy in the presence of a healthy contralateral kidney.

[Role of partial nephrectomy in the treatment of kidney cancer]

Incidental finding of small renal carcinoma by radiologic exams (ultrasound, computed tomography, MRI) performed for non urological purposes raises therapeutic and management problems (therapeutic abstinence and surveillance, partial or radical nephrectomy). Radical nephrectomy is recognized as a curative treatment for renal cell carcinoma. However, partial nephrectomy was suggested for renal cell carcinoma of solitary functional kidney or bilateral tumors in order to avoid dialysis or renal transplantation. The debate remains open for the small renal carcinomas with a normal controlateral kidney. Is partial nephrectomy an adequate treatment or rather perform radical nephrectomy? The present study was performed to analyse the published literature on the subject.

The need for routine adrenalectomy during surgical treatment for renal cell cancer: the Hannover experience

OBJECTIVES

To further clarify the need for routine adrenalectomy during the surgical treatment of renal cell cancer, as in the absence of clinically overt metastatic disease, tumorous lesions within the adrenal gland are found in only 2-10% of patients, with most being over-treated by adrenalectomy.

PATIENTS AND METHODS

The medical records of 819 patients undergoing adrenalectomy combined with nephrectomy, irrespective of the local extension of the primary tumour or the clinical stage at first diagnosis, were reviewed to determine the reliability of currently available imaging methods in predicting adrenal gland metastases. Several patient and tumour characteristics were correlated with the presence of intra-adrenal metastases, and their possible independent prognostic value was determined by a multivariate logistic regression model.

RESULTS

There was metastatic spread into the adrenal gland in 27 of 819 (3.3%) patients. In only three of eight patients in whom the adrenal was identified as the only metastatic site were preoperative abdominal computed tomography scans interpreted as false-negative. On multivariate statistical analysis only the presence of distant metastases, vascular invasion within the primary tumour and multifocal growth of renal cell cancer within the tumour-bearing kidney were identified as independent predictors of the presence of intra-adrenal metastases.

CONCLUSIONS

None of the patient or tumour characteristics evaluated reliably predicted the likelihood of adrenal metastases in patients with no evidence of disseminated metastatic spread. However, previously published data indicate that the frequency of metachronous metastases within the contralateral kidney (1.8-3.8%) is significantly higher than the risk of a preoperatively undetected isolated intra-adrenal metastatic lesion when currently available imaging modalities are applied. Therefore, routine adrenalectomy should not be recommended if the preoperative radiological examinations are normal.

Minimally invasive ablative approaches in the treatment of renal cell carcinoma

Ablative techniques for the treatment of renal cell carcinoma (RCC) are an extension of nephron-sparing surgery and include cryoablation, radiofrequency ablation (RFA), and high-intensity focused ultrasound (HIFU). Although experimental, these are evolving treatment modalities. The widespread use of computed tomography scans, ultrasound, and magnetic resonance imaging caused an increase in the diagnosis rate of small renal masses amenable to nephron-sparing surgery. The same imaging modalities permit interactive monitoring both during the delivery of ablative measures and at postoperative follow-up. Cryosurgery is the most studied of the ablative approaches, and clinical studies have demonstrated promising short-term results and a remarkable safety profile. Long-term studies, however, are needed in order to determine the appropriate selection criteria and to confirm a response as durable as that for partial and radical nephrectomy. More data are needed to evaluate the efficacy of RFA. Currently, preclinical results with HIFU do not justify its use for treating RCC in humans.

Renal arteriovenous fistula developing after tumor enucleation using a microwave tissue coagulator

With the increase in detection of incidental renal cell carcinoma, nephron-sparing surgery for small renal cell carcinomas is now recognized as one of the surgical options. We report a case of renal arteriovenous fistula developing after non-ischemic tumor enucleation of a small renal cell carcinoma using a microwave tissue coagulator. A 50-year-old Japanese man presented with right flank pain and gross hematuria. The patient had undergone non-ischemic tumor enucleation for right renal cell carcinoma, 2 cm in diameter, 1 month previously. Doppler ultrasound revealed the formation of an arteriovenous fistula at the enucleated portion. Transcatheter super-selective occlusion of the feeding artery was successfully performed with two metallic coils. The patient has been followed up with no sign of recanalization of the fistula. In this case, the tumor was located close to the renal hilus with thick arterial branches around the tumor. Additional microwave coagulations against arterial bleeding from the cutting surface might have been the cause of the fistula formation of this case. Non-ischemic tumor enucleation using a microwave tissue coagulator is a relatively easy and secure nephron-sparing surgical procedure. Excessive coagulation, however, should be avoided, since it might be the cause of unexpected postoperative vascular complications.

Incidence and outcome of patients with adrenal metastases of renal cell cancer

OBJECTIVES

To evaluate the outcome of patients with adrenal metastasis in renal tumors to establish the oncologic necessity of adrenalectomy in these patients. Radical nephrectomy for renal cell cancer includes simultaneous ipsilateral adrenalectomy. Recent reports suggest that adrenal involvement in renal cell cancer is rare and can be predicted by computed tomography or distinct algorithms.

METHODS

In a retrospective analysis of 866 consecutive patients who underwent nephrectomy and adrenalectomy, we established the rate of adrenal metastasis and obtained follow-up information to evaluate disease outcome.

RESULTS

We calculated an adrenal metastasis rate of 3.1% (n = 27); of these 27 patients, only 6 (0.7% of all patients) presented with a solitary adrenal metastasis. Kaplan-Meier analysis demonstrated that patients with solitary adrenal and multiple metastases have a poor outcome. The median survival of patients with localized renal cancer was 43.9 months compared with 21.3 months for patients with a solitary adrenal metastasis and 11.0 months for patients with multiple metastases.

CONCLUSIONS

Ipsilateral, solitary, and synchronous metastases in renal cell cancer are rare and patients have a poor outcome despite surgical resection. Therefore, simultaneous adrenalectomy can be omitted during radical nephrectomy if the preoperative examinations or algorithms used do not predict adrenal metastasis in the patient with renal cell cancer.

Renal anatomy. Endourologic considerations

The general anatomy of the kidney as applied to minimally invasive surgery is described. The kidney morphometry, the spatial planes, and the perirenal coverings are presented. The kidney's relationship with the diaphragm, ribs, pleura, liver, spleen, and colon is described in importance of intrarenal access. The intrarenal anatomy is also described, based on a large series of three-dimensional endocasts. The anatomic relationships of the intrarenal vessels (arteries and veins) with the kidney collecting system are presented and discussed with respect to intrarenal access by puncture, for endopyelotomy and for nephron-sparing operations.

Comparison of complications after radical and partial nephrectomy: results from the National Veterans Administration Surgical Quality Improvement Program

OBJECTIVE

To determine whether radical nephrectomy causes less morbidity, less mortality and is associated with a shorter hospital stay than is partial nephrectomy.

PATIENTS AND METHODS

A total of 1885 nephrectomies (1373 radical and 512 partial) conducted between 1991 and 1998 in the Department of Veterans Affairs (VA) National Surgical Quality Improvement Program were evaluated. Using multivariate analyses, outcomes were risk-adjusted based on 45 preoperative variables to compare mortality and morbidity rates.

RESULTS

The unadjusted 30-day mortality was 2.0% for radical and 1.6% for partial nephrectomy (P = 0.58). Risk-adjusting the two groups did not result in a statistically significant difference in mortality. The 30-day overall morbidity rate was 15% for radical and 16.2% for partial nephrectomy (P = 0.52); risk-adjusted morbidity rates were not statistically different. There were no statistically significant differences in the rates of postoperative progressive renal failure, acute renal failure, urinary tract infection, prolonged ileus, transfusion requirement, deep wound infection, or extended length of stay.

CONCLUSIONS

Partial nephrectomy carried out in the VA program has low morbidity and mortality rates, comparable with the complication rates after radical nephrectomy.

Management and extended outcome of patients with synchronous bilateral solid renal neoplasms in the absence of von Hippel-Lindau disease

OBJECTIVE

To gain information regarding long-term follow-up in patients with synchronous bilateral solid renal neoplasms in whom renal-preserving surgery is imperative.

PATIENTS AND METHODS

We examined our surgical experience and the survival outcome, as evaluated by Kaplan-Meier and log-rank analysis, of 94 patients (64 men and 30 women) who presented to the Mayo Clinic in Rochester, Minn, from 1973 to 1998 with bilateral synchronous solid renal neoplasms in the absence of von Hippel-Lindau disease. Follow-up of these patients ranged from 1 to 25 years, with a mean of 5.86 years and a median of 4.18 years. Tumors were staged according to the TNM classification. Pathologic staging and grading were usually performed on the kidney with the most extensive cancer. The Cox proportional hazards model was used to assess the relationship of grade (1-4), tumor size, and enucleation as opposed to extended (1 cm) partial nephrectomy on overall, cancer-specific, local recurrence-free, and metastasis-free survival.

RESULTS

Seventy-one patients (76%) had bilateral synchronous renal cell carcinoma, and 14 patients (15%) had a unilateral renal cell carcinoma with a contralateral benign solid neoplasm. Nine patients (10%) had bilateral benign solid lesions. Sixty-six patients (70%) underwent a single procedure, whereas 28 (30%) underwent staged surgical procedures. Fifty-one patients (54%) are alive, and 43 (46%) have died. Twenty patients (21%) died of metastatic disease, and 5 (5%) had a local recurrence. Cancer-specific survival of the 85 patients with at least 1 renal cell carcinoma still under observation was 81% (+/- 4.9% SE) and 59% (+/- 8.1% SE) at 5 and 10 years, respectively, and survival to local recurrence was 96% (+/- 2.6% SE) at 5 years and 93% (+/- 3.7% SE) at 10 years with 14 patients still under observation. Grade 3 was a statistically significant factor for metastasis (P < .001). A significant difference in metastasis-free survival and cancer-specific survival was noted dependent on pathologic T stage (P < .001 and P = .02, respectively), with patients with local pT3 disease having a higher rate of metastasis and cancer-specific death. Multivariate analysis revealed that tumor grade was associated with metastasis-free survival (P = .002) and tumor size with cancer-specific survival (P = .04). There was no statistical significance on survival outcome end points according to procedure performed, i.e., enucleation vs extended partial nephrectomy.

CONCLUSION

Long-term results of renal-preserving procedures for a series of patients with bilateral solid renal neoplasms indicate that grade, stage, and tumor size are significant predictors of outcome. Mean follow-up of over 5 years supports nephron-sparing techniques in selected patients because local recurrence was infrequent compared with distant metastasis.

Embryology, anatomy, and surgical applications of the kidney and ureter

This article discusses the embryology and anatomy of the kidney and ureter. Surgical approaches, such as the lumbar and thoracoabdominal, are provided. Operations for kidney (i.e., radical nephrectomy, nephroureterectomy, and partial nephrectomy) and ureteric tumors also are discussed.

Adenocarcinoma of the kidney: nephron-sparing surgical approach vs. radical nephrectomy

BACKGROUND AND OBJECTIVES

Radical nephrectomy has been the traditional surgical treatment for renal cell carcinoma in patients with a normally functioning contralateral kidney. The necessity for a less aggressive surgical approach has emerged in cases in which there is a need to preserve renal function.

METHODS

We retrospectively evaluated the records of 41 patients with localized, symptomless small renal masses (<5 cm) treated with nephron-sparing surgery (group A) and 48 patients matched for age, tumor location, size, and stage who were treated with radical nephrectomy (group B).

RESULTS

The 5-year cancer-specific survival rates were 97.5% and 98. 4% for the treated patients of groups A an B, respectively. No statistical association was found between cancer-specific survival and surgical approach, tumor stage, tumor location, or recurrence. The size of the primary tumor did not seem to influence the cause-specific survival. Local recurrence was observed in 3 patients (7.3%) who underwent partial nephrectomy. In our series, the overall incidence of multifocality was 10.4%.

CONCLUSIONS

We propose segmental renal resection for unifocal small adenocarcinoma of the kidney in preference to radical surgery as it is corroborated by the presented data.

Current Status of Partial Nephrectomy in the Management of Kidney Cancer

BACKGROUND: The technique of partial nephrectomy for managing renal cancers is well recognized, but guidelines regarding indications for its use are not generally accepted. METHODS: The authors review the indications for partial nephrectomy in various clinical situations, and they include their own experience to clarify the utility of the technique. RESULTS: Intraoperative renal ultrasound and helical computed tomography can assist the surgeon in technical decisions. Partial nephrectomy is considered when nephrectomy would render the patient anephric and dependent on dialysis. CONCLUSIONS: The technical and operative advances in partial nephrectomy make the approach increasingly attractive for patients with kidney cancer in a variety of clinical circumstances.

Complex renal reconstruction

This article provides a complete review of current renal reconstructive techniques. The techniques described include partial nephrectomy, intrasinusal surgery, anatrophic nephrolithotomy, nonvascular bench procedures with autotransplantation, and allograft partial nephrectomy in renal transplantation. A detailed discussion on renovascular and collecting system anatomy and current indications for these procedures is presented.

Management of renal cell carcinoma in von Hippel-Lindau disease

BACKGROUND

An evaluation of nephron-sparing surgery (NSS) or radical nephrectomy (RN) for treating renal cell carcinoma (RCC) in patients with von Hippel-Lindau disease (VHL) was carried out.

METHODS

Between 1976 and 1997, 10 patients with RCC from four VHL families, of whom seven were from one family, were studied by clinical and histopathological examination. Before 1991, three patients were treated using RN, and thereafter five patients were treated using NSS. Two patients were not operated on.

RESULTS

RCCs in our patients showed a slow growth rate (on average 0.3 cm year-1), and asymptomatic patients presented with tumours of low-grade malignancy. In all patients, tumours were surrounded by a fibrous pseudocapsule. In 5 out of 17 tumours, pseudocapsular invasion was observed, and three of these five tumours broke through the pseudocapsule. To date, these patients have not shown a less favourable outcome than those without pseudocapsular involvement by tumour growth. Multicentricity of RCC was relatively low (4.6 lesions per kidney). In two of the three RN patients, only a single satellite lesion, in the direct vicinity of a RCC, was found in one kidney. Six tumours (1.8-5.5 cm) were enucleated by NSS. During a mean follow-up of 30 months, renal function in these patients was well preserved.

CONCLUSIONS

In our patients, RCCs grew slowly, were of low grade, had a dense fibrous pseudocapsule and were thus good candidates for NSS.

Partial nephrectomy: alternative treatment for selected patients with renal cell carcinoma

OBJECTIVES

To analyze the experience and the results of partial nephrectomy in a single institution over the last 10 years in order to optimize patient selection and minimize morbidity.

METHODS

This is a retrospective chart review of 64 patients (mean age 56.6 years, range 18 to 88; 43 men, 21 women) who underwent 66 partial nephrectomies at the Brigham and Women's Hospital between 1987 and 1997. Preoperatively, 62% of the patients had no symptoms, whereas 38% had pain and/or hematuria. The indications were elective in 23 patients, solitary kidney in 28 (14 with bilateral asynchronous tumor), bilateral synchronous tumor in 7, von Hippel-Lindau disease with normal contralateral kidney in 3, lymphoma in 3, and other indications in 2 patients. Surgery was performed for solid or indeterminate renal mass suspected of being renal cell carcinoma in 58 patients.

RESULTS

The most common final pathologic diagnosis was renal cell carcinoma in 47 procedures. One or more complications occurred after 18 procedures (15 with solitary kidney and 3 in patients with normal contralateral kidney) or 27% of the patients. The most common complication was an increased creatinine level (two times the baseline), occurring in 10 procedures (15.1%). Transfusion was necessary in 37 of 66 procedures (56%), and the mean blood loss was 836 cc (range 100 to 3200). Regarding renal function, 85% of the patients had a minimal increase in creatinine of less than 0.5 mg/dL after surgery (all patients with a normal contralateral kidney are in this group); 3 patients required either temporary (n = 1) or permanent (n = 2) dialysis. Other complications are also described. The mean length of stay among 65 patients was 6.5 days (range 3 to 14). The differences between length of stay, blood loss, and tumor size were statistically significant between the solitary kidney group and the elective indications group (P < 0.001).

CONCLUSIONS

Nephron sparing surgery is feasible and relatively safe in patients with a normal contralateral kidney. Awareness of potential complications should aid in the selection of appropriate patients for this procedure.

La chirurgia conservativa renale nell'anziano: Kidney preserving surgery in the elderly

Conservative renal surgery has recently been extended to elderly patients who have decreased renal function and reduced survival rates in the case of dialytic treatment. Furthermore, age is no longer a limiting factor despite the increased anethesiological risk. Fifteen cases of renal neoplasm in patients over 70, who had undergone conservative surgery, were reviewed: 14 are alive and disease-free after 14-135 months and 1 died from unrelated causes. It is concluded that conservative renal surgery has a role even in the elderly.