The results of radical nephrectomy for renal cell carcinoma

Open mini-flank partial nephrectomy: an essential contemporary operation

Secondary to the widespread use of the modern imaging techniques of computed tomography, magnetic resonance imaging, and ultrasound, 70% of renal tumors today are detected incidentally with a median tumor size of less than 4 cm. Twenty years ago, all renal tumors, regardless of size were treated with radical nephrectomy (RN). Elective partial nephrectomy (PN) has emerged as the treatment of choice for small renal tumors. The basis of this paradigm shift is three major factors: (1) cancer specific survival is equivalent for T1 tumors (7 cm or less) whether treated by PN or RN; (2) approximately 45% of renal tumors have indolent or benign pathology; and (3) PN prevents or delays the onset of chronic kidney disease, a condition associated with increased cardiovascular morbidity and mortality. Although PN can be technically demanding and associated with potential complications of bleeding, infection, and urinary fistula, the patient derived benefits of this operation far outweigh the risks. We have developed a "mini-flank" open surgical approach that is highly effective and, coupled with rapid recovery postoperative care pathways associated with a 2-day length of hospital stay.

[Organ and kidney function preservation in renal cell carcinoma]

BACKGROUND

The organ-preserving partial nephrectomy has increasingly established itself in small unilateral renal tumours (<4 cm) with contralateral healthy kidney and counter gained in recent years in importance. There was found a significantly increased cardiovascular mortality rate and deteriorated quality of life, the more intact kidney tissue has been removed.

OBJECTIVES

In the present study, the influence of pre- and perioperative factors on direct postoperative course was examined, including 5-year survival rate and relapse behaviour after open organ-preserving partial nephrectomy in our own collective.

MATERIALS AND METHODS

In this retrospective study of 1657 patients were collected, who underwent surgery between 2007 and 2013 in the Department of Urology at the University Hospital Essen because of a renal tumour. 38 % of these operations (n = 636) were performed organ-preserving. In this trial there are factors identified that have an impact on need of blood transfusion and length of hospitalization in organ-preserving operation method.

RESULTS

No independent parameter can be determined for the need of blood transfusion. Tumour size and thus time of resection procedure does not affect the need of erythrocytes administration. In addition, the tumour size influences neither the postoperative serum-haemoglobin nor serum-creatinine. Increased patient age and female gender are identified as non-modifiable factors, which cause a longer hospitalisation. Postoperative pain therapy can be considered as a variable size, which does not affect the length of hospital stay. Modifiable factors that increase the overall length of stay, however, are the type of direct postoperative monitoring (ICU vs. anaesthetic recovery room) and the administration of blood transfusions.

CONCLUSIONS

There are constant factors, which can be associated with a longer residence time in the framework of an organ-preserving partial nephrectomy. Further there is shown evidence of the independence of the tumour size - in addition to proven good oncological results - of an extension of indication of organ-preserving nephrectomy of tumours > 4 cm.

Comparison of robotic and open partial nephrectomy: Single-surgeon matched cohort study

INTRODUCTION

We present comparative outcomes among matched patients who underwent robotic partial nephrectomy (RPN) or open partial nephrectomy (OPN) by a single surgeon at a single institution.

METHODS

We reviewed the medical records of 200 patients who underwent RPN (n = 100) or OPN (n = 100) between May 2003 and May 2013. The patients who underwent RPN were matched for age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) score, as well as tumour size, side and location. Perioperative outcomes were compared.

RESULTS

There was no significant difference between the 2 cohorts with respect to patient age, BMI, ASA score, preoperative glomerular filtration rate, tumour size and the R.E.N.A.L. nephrometry score. The mean operative time was longer in the RPN group, but there were no significant differences with respect to warm ischemic time and postoperative renal function. The length of hospitalization and use of postoperative analgesics (ketoprofen) were more favourable in the RPN cohort. There was no significant difference in the mean estimated blood loss, transfusion rate, or complications between the cohorts.

CONCLUSIONS

Considering the perioperative and postoperative parameters, RPN is a viable option as a nephron-sparing surgical procedure for small renal masses that yields outcomes comparable to those achieved with OPN. Despite matched cohort analysis among patients who underwent PN by a single surgeon, there may be inherent selection bias; therefore future prospective trials are needed.

Lymphatic drainage in renal cell carcinoma: back to the basics

Lymphatic drainage in renal cell carcinoma (RCC) is unpredictable, however, basic patterns can be observed in cadaveric and sentinel lymph node mapping studies in patients with RCC. The existence of peripheral lymphovenous communications at the level of the renal vein has been shown in mammals but remains unknown in humans. The sentinel lymph node biopsy technique can be safely applied to map lymphatic drainage patterns in patients with RCC. Further standardisation of sentinel node biopsy techniques is required to improve the clinical significance of mapping studies. Understanding lymphatic drainage in RCC may lead to an evidence-based consensus on the surgical management of retroperitoneal lymph nodes.

A generation of laparoscopic nephrectomy: stage-specific surgical and oncologic outcomes for laparoscopic nephrectomy in a single center

PURPOSE

To determine the stage-specific operative, postoperative and oncologic outcomes, for patients undergoing a laparoscopic radical nephrectomy (LRN) for renal cell carcinoma (RCC) in a single center and assess changes over a generation of practice.

PATIENTS AND METHODS

From December 1992 to July 2011, data were collected prospectively for 854 consecutive simple laparoscopic necphrectomies (LNs) and LRNs, 397 of which were LRNs for RCC. The first LRN was performed in December 1997. Stage-specific surgical and oncologic outcomes were assessed across the study period. Patients were then grouped into three equal consecutive cohorts. Case mix and surgical outcomes were compared to assess changes with departmental experience.

RESULTS

There were 206, 71, 118, and 2 patients across stages pT1, pT2, pT3, and pT4, respectively. Median operative time was significantly shorter for pT1 tumors (125, 150 and 150 min for pT1-3, P<0.021), while median estimated blood loss (EBL) was greater for pT3 tumors (50, 50, 100 mL, for pT1-3, P<0.001). Median follow-up time was 31, 30, and 18 months, respectively, across pT1-pT3. There was a significant difference in 5-year overall survival (82.4%, 68.4%, 58.9%), cancer-specific survival (99.5%, 83.6%, 66.5%) and progression free survival (86.5%, 66.3%, 47.5%) across these stage-specific subgroups. Over the three cohorts, there was an increase in LRN performed for locally advanced disease and cytoreduction. With greater surgical experience, there was improvement in median operative time and median EBL in localized disease over the three periods, but no significant changes for locally advanced disease.

CONCLUSION

This is the largest reported series of LRN in the United Kingdom. Departmental experience has resulted in improved surgical outcomes for localized RCC, with expansion of practice in more complex advanced disease. Laparoscopic nephrectomy is both operatively and oncologically safe in T1 and T2 disease, and although technically more demanding, it is also safe in selected T3 disease.

Surgical management of renal cell carcinoma

Surgical resection of renal cell carcinoma (RCC) is the benchmark for long-term cure of the disease. Although open or laparoscopic radical nephrectomy is considered the gold standard for stage T1b-T4 tumors, nephron-sparing surgery is the preferred operative modality for small renal masses demonstrating equivalent oncologic efficacy and improved renal function outcomes compared with complete nephrectomy. With the advance of minimally invasive surgery, nephron-sparing procedures can safely be conducted laparoscopically with or without robotic assistance. RCC with intravenous tumor thrombus presents a surgical challenge, but multidisciplinary surgical approaches can provide long-term benefit in these patients. The role of cytoreductive nephrectomy and metastasectomy in patients with metastatic RCC (mRCC) is controversial, but seems to be beneficial for patients in the era of targeted therapy.

Cancer-free survival and local tumor control after impendence-based radiofrequency ablation of biopsy-proven renal cell carcinomas with a minimum of 1-year follow-up

OBJECTIVES

There are numerous reports describing the use of radiofrequency ablation (RFA) to treat renal cell carcinoma. Many series, however, describe heterogeneous populations, lack histologic descriptions, use various RFA systems, and indicate tumor destruction by different ablation end points. This study examined the outcomes of computed tomography-guided, impedance-based RFA of biopsy-proven renal cell carcinoma clinically staged as T1a with a minimum of 1 year of postablation follow-up.

METHODS AND MATERIALS

This retrospective study identified all consecutive patients who had undergone renal RFA since May 2005 at our institution. Patients without biopsy-proven renal cell carcinoma (RCCa) were excluded. Of the patients who met these criteria, evaluation was limited to patients with a minimum of 12 months of follow-up. Data collected from the patients' electronic medical and radiologic records included demographic data, tumor-related data, procedural details, and clinical follow-up visits.

RESULTS

A total of 39 patients (46 lesions) met the inclusion criteria. The mean tumor diameter was 2.6 cm (range: 1.2-4.0 cm). The most common histologies were clear cell (n = 27) and papillary (n = 16) renal cancer. The lesion location was equally divided between upper pole (n = 16), middle pole (n = 16), and lower pole (n = 14). Overall, 83% of the tumors were exophytic. No residual or recurrent enhancing mass was identified in the ablation bed on post-RFA imaging during the mean follow-up period of 35.3 months (range: 12-83). All patients were treated in a single encounter and no lesion required a second ablation; technical success (absence of residual tumor) on the initial post-RFA imaging study was 46 of 46 (100%). Clinical success was achieved in 45 of 46 lesions (98%); residual, viable tumor was found in a pretransplant nephrectomy specimen on postprocedure day 127. The mean cancer-free survival was 36.2 months. Comparison of preablation and postablation renal function found no statistically significant change.

CONCLUSIONS

The consistent outcomes in our post-RFA imaging and clinical surveillance allow us to offer image-guided ablation to patients with T1a RCCa as a valid treatment option offering long-term cancer-free survival. Impedance-based RFA in a carefully selected patient population with T1a RCCa is a reliable treatment option, with disease-free survival rates that are comparable to partial nephrectomy.

[Open and minimally invasive partial nephrectomy. Management of complications]

Current guidelines increasingly recommend organ-preserving surgical procedures in the treatment of renal tumors. Both the open surgical and minimally invasive surgical techniques are well established. In the literature, various systems for the systematic evaluation of comorbidities and complications have been reported. Already while taking the patient's history and preoperative planning prior to partial nephrectomy, it is recommended that a detailed risk assessment be carried out regarding expected complications. Essentially the two critical factors - the comorbidities of the patient and anatomic complexity level of the tumor - should be evaluated in order to achieve the best possible selection of patients for a partial nephrectomy and the determination of the surgical method.

Survival advantage of partial over radical nephrectomy in patients presenting with localized renal cell carcinoma

Background

Partial nephrectomy (PN) preserves renal function and has become the standard approach for T1a renal cell carcinoma (RCC). However, there is still an ongoing debate as to which patients will actually derive greater benefit from partial than from radical nephrectomy (RN). The aim of this study was to retrospectively evaluate the impact of the type of surgery on overall survival (OS) in patients with localized RCC.

Methods

Renal surgery was performed in 4326 patients with localized RCC (pT ≤ 3a N/M0) at six German tertiary care centers from 1980 to 2010: RN in 2955 cases (68.3%), elective (ePN) in 1108 (25.6%), and imperative partial nephrectomy (iPN) in 263 (6.1%) cases. The median follow-up for all patients was 63 months. Kaplan-Meier and Cox regression analyses were carried out to identify prognosticators for OS.

Results

PN was performed significantly more often than RN in patients presenting with lower tumor stages, higher RCC differentiation, and non-clear cell histology. Accordingly, the calculated 5 (10)-year OS rates were 90.0 (74.6)% for ePN, 83.9 (57.5)% for iPN, and 81.2 (64.7)% for RN (p < 0.001). However, multivariate analysis including age, sex, tumor diameter and differentiation, histological subtype, and the year of surgery showed that ePN compared to RN still qualified as an independent factor for improved OS (HR 0.79, 95% CI 0.66-0.94, p = 0.008).

Conclusion

Even allowing for the weaknesses of this retrospective analysis, our multicenter study indicates that in patients with localized RCC, PN appears to be associated with better OS than RN irrespective of age or tumor size.

The role of lymphadenectomy in the management of renal cell carcinoma

The role of lymphadenectomy in the management of renal cell carcinoma has been established in staging but is less well defined as a therapeutic maneuver. Level one evidence suggests no survival benefit or increased complication rate with lymphadenectomy when performed concurrently with radical nephrectomy. However, several retrospective studies have identified a survival benefit when patients with increased risk of micrometastatic lymph node disease undergo lymphadenectomy. We perform a selective review of the literature and present the historical basis, risk assessment, use and development of nodal templates, and therapeutic benefits associated with the use of lymphadenectomy in the management of renal cell carcinoma.

Risk of chronic kidney disease after cancer nephrectomy

The incidence of early stage renal cell carcinoma (RCC) is increasing and observational studies have shown equivalent oncological outcomes of partial versus radical nephrectomy for stage I tumours. Population studies suggest that compared with radical nephrectomy, partial nephrectomy is associated with decreased mortality and a lower rate of postoperative decline in kidney function. However, rates of chronic kidney disease (CKD) in patients who have undergone nephrectomy might be higher than in the general population. The risks of new-onset or accelerated CKD and worsened survival after nephrectomy might be linked, as kidney insufficiency is a risk factor for cardiovascular disease and mortality. Nephron-sparing approaches have, therefore, been proposed as the standard of care for patients with type 1a tumours and as a viable option for those with type 1b tumours. However, prospective data on the incidence of de novo and accelerated CKD after cancer nephrectomy is lacking, and the only randomized trial to date was closed prematurely. Intrinsic abnormalities in non-neoplastic kidney parenchyma and comorbid conditions (including diabetes mellitus and hypertension) might increase the risks of CKD and RCC. More research is needed to better understand the risk of CKD post-nephrectomy, to develop and validate predictive scores for risk-stratification, and to optimize patient management.

Percutaneous radiofrequency ablation: minimally invasive therapy for renal tumors

Currently, up to 60% of renal tumors are detected incidentally by abdominal imaging. Most of these tumors are small and localized to the kidney. Owing to the shift to lower stage at diagnosis, radical nephrectomy has fallen out of favor and has been replaced by nephron-sparing surgery. Currently, partial nephrectomy is the treatment of choice for patients with small renal tumors. As the trend towards less invasive therapy continues, laparoscopic and percutaneous ablation techniques have gained popularity for the treatment of renal tumors in patients who are high-risk surgical candidates, or have a solitary kidney, limited renal function or multifocal disease. Percutaneous radiofrequency ablation is a safe, minimally invasive treatment option for those patients.

High-intensity focused ultrasound as a treatment option in renal cell carcinoma

Due to the widespread use of modern imaging modalities, small renal masses are discovered incidentally at increasing rates. Advances in minimally invasive technologies have changed the treatment options for renal cell carcinoma. High-intensity focused ultrasound aims to completely ablate renal tumors in a noninvasive manner. Experimental studies have demonstrated principle feasibility and safety of the technology. However, clinical studies on renal cell carcinoma are very limited and no substantial oncologic results are available to date. Major technical improvements are mandatory to enable high-intensity focused ultrasound as an effective treatment option for patients with small renal masses.

Significance of gene expression analysis of renal cell carcinoma

Renal cell carcinoma (RCC) describes a family of epithelial tumors arising from within the kidney. Each subtype of RCC presents a unique clinical picture with varied tumor biology, patient prognosis and response to treatment. Gene expression profiling offers the ability to analyze thousands of candidate genes in high-throughput arrays and has led to a greater knowledge of the molecular genetics of RCC. This powerful technology can identify RCC subtypes, recapitulating and refining the current histological classifications. Gene expression data also promise to advance current staging systems and improve prognostic information for patients and clinicians. Understanding the genetic signature of RCC tumors will allow for sophisticated application of systemic and targeted therapies, improving patient response and minimizing unnecessary exposure of patients to treatment toxicities. This article reviews the significance of gene expression analysis in the understanding of tumor biology and RCC treatment.

Pilot study comparing the two hemostatic agents in patients undergoing partial nephrectomy

Background

Recently studies have demonstrated improved outcomes in patients undergoing nephron-sparing surgery (NSS) for low stage renal tumors, thus NSS is widely accepted as the treatment option for these patients. With NSS, there is a risk of renal hemorrhage and thus haemostatic agents may be routinely applied to the cut surface of the kidney. Herein we compare two commercially available haemostatic agents applied intra-operatively to the cut surface of the kidney. Post-operative outcomes (oncologic and non-oncologic) are reported.

Methods

The medical records of 23 patients with suspicious renal mass documented on axial imaging and who underwent open NSS via a mini-subcostal incision were extensively reviewed. One of two haemostatic agents (Floseal^®, n = 11; Arista^®, n = 12) was intra-operatively applied to the cut surface of the kidney. Chi-square and T- student test was used to compare outcomes between the cohort of 11 patients who had Floseal^® and the 12 patients who had Arista^®.

Results

Median pre-operative size of renal mass was 4.3 cm (range 1.5-7.0 cm). Final pathology revealed 3 oncocytomas and 20 renal cell carcinoma (17 clear cell, 1 chromophobe and 2 papillary), pT1a = 14 and pT1b = 6. Mean intra-operative blood loss and hospital stay between the Floseal^®vs. Arista^® cohorts did not significantly differ (227 mL vs. 250 mL, p = 0.68 and 4.4 days vs. 4.5 days, p = 0.76, respectively). Intra-operative and post-operative complications were not different between the two cohorts. No recurrences have been documented with a mean follow-up of 18 months.

Conclusion

Along with meticulous surgical technique, the use of either haemostatic agent (Floseal^® or Arista^®) was not associated with high rate of intra-operative or post-operative haemorrhage. Thus either haemostatic agent may be successfully used during NSS.

Partial nephrectomy versus radical nephrectomy for non-metastatic pathological T3a renal cell carcinoma: a multi-institutional comparative analysis

OBJECTIVES

To compare the recurrence-free survival of partial nephrectomy and radical nephrectomy in patients with non-metastatic pathological T3a renal cell carcinoma.

METHODS

We reviewed the records of 3567 patients who had undergone a nephrectomy for renal cell carcinoma at five institutions in Korea from January 2000 to December 2010. The clinical data of 45 patients with pathological T3a renal cell carcinoma in the partial nephrectomy group were compared with 298 patients with pathological T3a renal cell carcinoma in the radical nephrectomy group. The effects of surgical methods on recurrence-free survival were assessed by a multivariate Cox proportional hazard analysis. All comparisons were repeated in subgroup analysis on 63 clinical T1a patients with tumors ≤4 cm.

RESULTS

During a median 43-month follow-up period, disease recurrence occurred in two patients (4.4%) in the partial nephrectomy group, and 94 patients (31.5%) in the radical nephrectomy group. The results from a multivariate model showed that radical nephrectomy was a significant predictor of recurrence. However, in subgroup analysis that included 63 clinical T1a pathological T3a patients, the recurrence-free survival rates were not significantly different between the two cohorts. The renal function was significantly better preserved in the partial nephrectomy cohort than in the radical nephrectomy cohort.

CONCLUSIONS

Partial nephrectomy provides similar recurrence-free survival outcomes compared with radical nephrectomy in patients with clinical T1a pathological T3a renal cell carcinoma. However, there seems to be a higher risk of recurrence for large pathological T3a tumors treated by radical nephrectomy compared with small tumors treated by partial nephrectomy. Thus, large tumors with the same pathological T3a renal cell carcinoma grade could have hidden aggressive features.

A population-based study of surgeon characteristics associated with the uptake of contemporary techniques in renal surgery

INTRODUCTION

We have witnessed the slow uptake of many contemporary techniques in the surgical management of renal tumours. We sought to evaluate surgeon-level characteristics associated with the uptake of laparoscopy, partial nephrectomy (PN) and adrenal-sparing approaches in surgically managing these tumours.

METHODS

Using the Ontario Cancer Registry, we identified surgeons treating renal cell carcinoma (RCC) in the province of Ontario, Canada between 2002 and 2004. We then classified individuals within this cohort as either high or low utilizers of laparoscopy, PN or adrenal-sparing approaches. Further variables analyzed included academic status, surgeon graduation year and surgical volume status. We then used univariable and multivariable logistic regression models to assess predictors of uptake.

RESULTS

We evaluated a total of 108 surgeons for their uptake of both laparoscopy and adrenal-sparing approaches and 94 surgeons for their uptake of PN. We identified 32 surgeons (30%) as high users of laparoscopy. Predictors of uptake of laparoscopy included graduation year after 1990 (odds ratio [OR] 4.81, confidence interval [CI] 1.57-14.8) and high-surgeon volume (OR 4.33, CI 1.60-10.4). We identified 41 surgeons (44%) as high users of PN. The only predictor of uptake of PN was academic status (OR 5.83, CI 1.96-17.3). We identified 69 surgeons (65%) as high users of adrenal-sparing approaches, but did not identify any significant predictors for uptake in this group.

DISCUSSION

We identify unique factors contributing to the uptake of distinct surgical techniques in the management of RCC. This information sheds lights on the underlying mechanisms and helps us understand how to further encourage the dissemination of these practices.

Multiple renal arteries with renal cell carcinoma: Preoperative evaluation using computed tomography angiography prior to laparoscopic nephrectomy

Objective

To investigate anatomical variations in the renal arteries of patients with renal cell carcinoma (RCC) using computed tomography angiography (CTA).

Methods

Patients diagnosed with RCC were evaluated using CTA prior to undergoing laparoscopic nephrectomy. Any anatomical variations of the renal arteries on the side affected by the RCC were recorded. The CTA results were compared with the observations made during surgery and those produced by conventional digital subtraction angiography.

Results

A total of 107 patients with RCC were enrolled in the study. Multiple renal arteries were found in 11 patients (10.3%). Accessory renal inferior polar arteries were the most common type of multiple renal arteries. Multiple renal arteries acting as the feeding arteries to the RCC were found in five patients (4.7%).

Conclusion

CTA can be used as part of the preoperative evaluation prior to laparoscopic nephrectomy to provide anatomical information about the presence of multiple renal arteries in the affected kidney of patients with RCC. This could help with planning the surgery and reducing surgical complications.

Is adrenalectomy necessary during unilateral nephrectomy for Wilms Tumor? A report from the Children's Oncology Group

PURPOSE

To determine whether performing adrenalectomy at the time of nephrectomy for unilateral Wilms tumor impacts clinical outcome.

METHODS

We reviewed information on all patients enrolled on National Wilms Tumor Study-4 and -5. Data were abstracted on patient demographics, tumor characteristics, surgical and pathologic status of the adrenal gland, and patient outcomes. The primary endpoints were intraoperative spill and five-year event-free survival (EFS) in patients who did or did not undergo adrenalectomy.

RESULTS

Of 3825 patients with complete evaluable data, the adrenal was left in situ in 2264 (57.9%) patients, and was removed completely in 1367 patients (36.7%) or partially in 194 patients (5.2%). Of the adrenal glands removed, 68 (4.4%) contained tumor. Adrenal involvement was more common in patients with stage 3 (9.8%) than stage 2 disease (1.9%; p < 0.0001). After controlling for stage and histopathology, five-year EFS was similar whether or not the adrenal gland was removed (p = 0.48), or involved with tumor (p = 0.81); however, intraoperative spill rates were higher in patients undergoing adrenalectomy (26.1% vs 15.5%, p < 0.0001), likely due to larger tumor size or technical factors. No patient had clinical evidence of adrenal insufficiency or tumor recurrence in the adrenal gland during follow-up (median 9.9 years).

CONCLUSIONS

Sparing the adrenal gland during nephrectomy for unilateral Wilms tumor was not associated with a higher incidence of intraoperative spill and was associated with a similar oncologic outcome, on a per-stage basis, with cases where the adrenal was removed. Thus, adrenalectomy should not be considered mandatory during radical nephrectomy for Wilms tumor.

Nephrectomy or nephron-sparing surgery - how to decide?

Aim of the study

Radical nephrectomy in the treatment of renal cell carcinoma (RCC) remains the gold standard, but nephron-sparing surgery (NSS) is still increasing in importance. The main goal of this study was to compare the diagnostic accuracy of ultrasound and multi-detector computed tomography in RCC staging and its influence on deciding about further patient treatment.

Material and methods

87 patients (age range 27–90 years; median 61.5) underwent ultrasound (US) scan and contrast-enhanced computed tomography (CE-CT) of the abdomen and pelvis. 28 patients were qualified for NSS. The remaining group of patients underwent nephrectomy.

Results

NSS was performed more frequently among patients with lesions in the lower pole of the kidney and there was no infiltration to the calyx and renal pelvis. Radical nephrectomy (RN) was pursued in cases with lesions in the central or upper pole. Lesion diameter in patients qualified for NSS was smaller than in patients qualified for radical nephrectomy.

Conclusions

Determining the relationship between tumour and adjacent structures is not a simple matter. According to our study, 50% of CT results differ from histopathology assessment. Tumour diameter determined in CT examination is larger than in ultrasound and histopathological measurements while US scanning tends to underestimate tumour size in relation to histopathological assessment.

Kidney function following partial or radical nephrectomy for renal cell carcinoma: a population-based study

OBJECTIVE

The aim of this retrospective study was to compare kidney function in a population-based cohort of renal cell carcinoma (RCC) patients after partial (PN) or radical nephrectomy (RN).

MATERIAL AND METHODS

Forty-four consecutive RCC patients who had undergone PN in Iceland between 2000 and 2010 were compared with 44 controls matched for tumour, node, metastasis (TNM) stage who had undergone RN during the same period. Estimated glomerular filtration rate (eGFR) and survival were calculated, and predictors of chronic kidney disease (CKD) were evaluated with multivariate analysis.

RESULTS

In 16 cases (36%), PN was performed for imperative reasons (single kidney, decreased kidney function or bilateral kidney tumours) but 28 patients had a normal contralateral kidney. The groups were similar regarding preoperative eGFR, median follow-up and TNM stage, but age and American Society of Anesthesiologists (ASA) score were significantly higher in the RN group. Six months after surgery, eGFR was significantly higher in the PN group. By multivariate analysis, RN contributed negatively to eGFR 6 months after surgery (-12.6 ml/1.73 m², p < 0.001) and increased the risk of new-onset CKD (odds ratio = 3.07, 95% confidence interval 1.03-9.79, p = 0.04), compared to PN. At median follow-up of 44 months, no patients in either group had a recurrence of RCC. The 5-year overall survival (Kaplan-Meier) was 100% and 65% in the PN and RN groups, respectively (log-rank test, p < 0.001).

CONCLUSION

eGFR was significantly lower after RN, and these patients were three times more likely to develop new-onset CKD. These findings suggest that PN successfully preserves kidney function compared to RN, with good oncological outcome and survival.

The survival benefit of lymph node dissection at the time of removal of kidney, prostate and urothelial carcinomas: what is the evidence?

INTRODUCTION

Lymph node dissection (LND) has been advocated by oncologic surgeons to completely eradicate cancer. However, evidence for that strategy is solely based on poor quality data. Some randomized studies done outside the field of urology failed to show any benefit to LND. Our objective was to evaluate whether LND at the time of removal of prostate, kidney and urothelial carcinomas results in a survival benefit.

METHODS

For that purpose, we performed a systematic literature review.

RESULTS

For kidney cancer, LND might be able to cure some patients with N+ disease. In N0 patients, although a randomized trial has been completed, the value of LND remains uncertain. LND at the time of radical prostatectomy can be useful in some patients with lymph node invasion. However, studies on the impact of LND in pN0 patients are retrospective and conflictive. Extended LND has been recommended when performing a radical cystectomy based on improved outcomes observed in retrospective studies. However, these studies are limited by selection biases and results of ongoing randomized trials will specify the template and the advantages of LND when removing a bladder cancer. Recent data of large series of radical nephro-ureterectomies for upper tract urothelial carcinomas are conflicting. Some found a benefit of LND in N0 patients while others did not.

CONCLUSION

The studies that support LND at the time of surgery for prostate, kidney and urothelial carcinomas have low level of evidence. This should encourage urologists to design and perform well-designed randomized trials to assess the potential survival impact of a commonly done procedure.

Patient and caregiver knowledge and utilization of partial versus radical nephrectomy: results of a national kidney foundation survey to assess educational needs of kidney cancer patients and caregivers

BACKGROUND

In response to requests from patients, caregivers, and physicians for information on kidney cancer, the National Kidney Foundation (NKF) conducted a survey to assess the educational needs of the kidney cancer community. Key areas of assessment were patient and caregiver knowledge of risk factors for chronic kidney disease (CKD), including kidney cancer and nephrectomy, and of kidney-sparing surgical options.

STUDY DESIGN

Survey to assess educational needs of patients with kidney cancer and caregivers.

SETTING & PARTICIPANTS

Respondents were invited through physician referrals and online sources and included 365 adult patients with kidney cancer and 52 caregivers.

PREDICTOR

Age, geographic region, and cancer stages 1-2 versus 3-4.

OUTCOMES & MEASUREMENTS

Survey responses were descriptively analyzed, with data compared and weighted to the population age and geographic characteristics of the general kidney cancer population.

RESULTS

83% of 181 early-stage patients, 92% of 123 late-stage patients, and 86% of 113 patients who did not know their stage received radical nephrectomy. Although 62% agreed that radical nephrectomy for cancer treatment is a risk factor for CKD, only 40% agreed that losing part or all of 1 kidney from injury or a disease other than cancer is a risk factor for CKD. 56% agreed that kidney cancer can be related to CKD.

LIMITATIONS

We did not have patient medical records to validate responses and we do not know the number of people who were invited to take the survey but declined.

CONCLUSIONS

There is a lack of patient awareness that kidney cancer and radical nephrectomy are risk factors for CKD. Only a minority of patients underwent partial nephrectomy or were given it as an option for their early-stage kidney cancer. This suggests a knowledge deficit among physicians, surgeons, patients, and caregivers alike that there is a bidirectional relationship between kidney cancer and CKD and that kidney-sparing surgery is preferable when feasible.

Oncological and renal medical importance of kidney-sparing surgery

In the past decade, the medical and oncological rationale for kidney-sparing surgical approaches for small renal masses has been clarified. Although radical nephrectomy is still necessary for many patients diagnosed with large renal tumours, accumulating evidence indicates that partial nephrectomy provides equivalent oncological outcomes while also preserving renal function and preventing the adverse cardiovascular effects of chronic kidney disease. Furthermore, approximately 45% of resected small renal tumours are benign or indolent, with limited--if any--metastatic potential. Patients who develop kidney cancer often have medical comorbidities that can affect kidney function, such as diabetes and hypertension, and histological examination of the non-tumour-bearing elements of the kidney demonstrate significant pathological changes in the vast majority of patients. For elderly patients or patients with comorbidities, active surveillance provides an alternative kidney-sparing approach, and is associated with extremely low rates of clinical disease progression and metastases. Despite these important advances in understanding, which support the use of partial nephrectomy for the treatment of small renal masses, the technique remains underused.

Fast access and early ligation of the renal pedicle significantly facilitates retroperitoneal laparoscopic radical nephrectomy procedures: modified laparoscopic radical nephrectomy

Background

The objective of this study was to develop a modified retroperitoneal laparoscopic nephrectomy and compare its results with the previous technique.

Methods

One hundred retroperitoneal laparoscopic nephrectomies were performed from February 2007 to October 2011. The previous technique was performed in 60 cases (Group 1). The modified technique (n = 40) included fast access to the renal pedicle according to several anatomic landmarks and early ligation of renal vessels (Group 2). The mean operation time, mean blood loss, duration of hospital stay conversion rate and complication rate were compared between the groups.

Results

No significant differences were detected regarding mean patient age, mean body mass index, and tumor size between the two groups (P >0.05). The mean operation time was 59.5 ± 20.0 and 39.5 ± 17.5 minutes, respectively, in Groups 1 and 2 (P <0.001). The mean intraoperative blood loss was 147 ± 35 and 100 ± 25 ml, respectively, in Groups 1 and 2 (P <0.001). No significant differences were detected regarding the conversion rate and the complication rate between the two groups (P >0.05).

Conclusions

Early ligature using fast access to the renal vessels during retroperitoneal laparoscopic radical nephrectomy contributed to less operation time and intraoperative blood loss compared with the previous technique. In addition, the modified technique permits the procedure to be performed following the principles of open radical nephrectomy.

[Small renal mass]

The frequent application of ultrasound and radiological imaging for non-urological indications in recent years has resulted in an increase in the diagnosis of small renal masses. The treatment options for patients with a small renal mass include active surveillance, surgery (both open and minimally invasive) as well as ablative techniques. As there is a risk for metastatic spread even in small renal masses surgical extirpation remains the treatment of choice in most patients. Ablative procedures, such as cryoablation and radiofrequency ablation are appropriate for old and multi-morbid patients who require active treatment of a small renal mass. Active surveillance is an alternative for high-risk patients. Meticulous patient selection by the urologist and patient preference will determine the choice of treatment option in the future.

Renal cell carcinoma : clinical features and management

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

Combined resection of a tumor and the inferior vena cava: report of two cases

Tumor resection and caval tumor thrombectomy, with or without cavotomy and inferior vena cava (IVC) replacement are sometimes performed in patients with renal cell carcinoma (RCC) extending into the IVC or liver tumors invading the IVC. Two such cases were treated. Case 1: a 68-year-old female was transferred with a diagnosis of right RCC with tumor thrombus extending into the IVC. A plication was performed to prevent extension into the right atrium before the nephrectomy and cavotomy with removal of the tumor thrombus was accomplished, because the IVC was almost completely obstructed and the hemodynamics were stable during cross-clamping of the IVC. Case 2: a 37-year-old female was transferred with a diagnosis of a giant metastatic liver tumor. A trisegmentectomy with resection of the invaded IVC and IVC replacement was performed while the abdominal aorta was cross-clamped to maintain the hemodynamics. Therefore, abdominal aortic cross-clamping was convenient to maintain the hemodynamics when the IVC replacement was performed during IVC cross-clamping.

Prognostic significance of perirenal infiltration in renal cell carcinoma (<7 cm)

PURPOSE

Pathologic stage is the most accurate prognostic factor of renal cell carcinoma. We evaluated whether perirenal fat infiltration is a significant factor in tumors 7 cm or less in size.

MATERIALS AND METHODS

We retrospectively reviewed the record of 164 cases of tumors 7 cm or less in size. We divided the patients into two groups according to the presence of perirenal fat infiltration (group A, pT1; group B, pT3a). We evaluated relationships, recurrence-free survival and disease-specific survival according to clinicopathologic parameters. Statistical differences were calculated by log-rank test.

RESULTS

A total 131 patients were included in group A, with a mean age of 55.8 years, average tumor size was 4.2 cm, and a mean follow-up period of 43 months. Group B included 33 patients, with a mean age of 55.9 years, an average tumor size of 4.1 cm, and a mean follow-up period of 38 months. There was no significant difference in disease-specific survival; however, recurrence-free survival showed significantly different between two groups (group A: 95.5%, group B: 84.4%).

CONCLUSION

In this study, perirenal fat infiltration proved to be an independent prognostic factor for predicting disease-free survival in patients with tumors of 7 cm or less in size. Therefore, as this study showed, the presence of perirenal fat infiltration requires stricter follow-up planning, even in small renal cell carcinoma.

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.

Laparoscopic partial nephrectomy: The McMaster University experience

INTRODUCTION

: Laparoscopic partial nephrectomy (LPN) remains one of the more challenging procedures in urology. Minimizing warm ischemia time (WIT) and bleeding requires efficient intracorporeal suturing. In addition, achieving negative surgical margins requires complete excision of the tumour. We report a large Canadian series of laparoscopic partial nephrectomy with intermediate follow-up.

METHODS

: Between September 2000 and August 2008, 152 consecutive laparoscopic partial nephrectomies were performed at our centre. Demographic, pathological and clinical data were collected through a retrospective review of the charts.

RESULTS

: The average tumour size was 2.68 cm (Range: 0.5-8.8. The vast majority of tumours were malignant (80%). All margins were negative, except for 2 patients who underwent an immediate re-resection. There were no local recurrences or distant metastasis during the follow-up period of 44.3 months. Most procedures required hilar clamping (93.4%) with a mean WIT of 34 minutes, with a clear trend for declining WIT with increasing experience. Five procedures were converted to laparoscopic radical nephrectomy, 10 converted to a hand-assisted procedure, and 1 was converted to an open partial nephrectomy. The average blood loss was 162 cc. Complications related to the procedure were classified according to the Clavien grading system. The average drop in the glomerular filtration rate was calculated by the Modification of Diet in Renal Disease (MDRD) Study equation between preoperative and 2.5 months postoperative was 8.6 mL/min/1.73 m(2).

CONCLUSIONS

: LPN is a challenging procedure that requires advanced laparoscopic skills. LPN is feasible with excellent oncological outcomes, and an acceptable complication profile. The short-term impact on overall renal function is minimal. The most common postoperative complication was pseudo-aneurysm requiring embolization, which reinforces the intra-operative need for meticulous and a quick suture-ligation of blood vessels during LPN.

Preoperative Erythrocyte Sedimentation Rate Independently Predicts Overall Survival in Localized Renal Cell Carcinoma following Radical Nephrectomy

Objectives. To determine the relationship between preoperative erythrocyte sedimentation rate (ESR) and overall survival in localized renal cell carcinoma (RCC) following nephrectomy. Methods. 167 patients undergoing nephrectomy for localized RCC had ESR levels measured preoperatively. Receiver Operating Characteristics curves were used to determine Area Under the Curve and relative sensitivity and specificity of preoperative ESR in predicting overall survival. Cut-offs for low (0.0–20.0 mm/hr), intermediate (20.1–50.0 mm/hr), and high risk (>50.0 mm/hr) groups were created. Kaplan-Meier analysis was conducted to assess the univariate impact of these ESR-based groups on overall survival. Univariate and multivariate Cox regression analysis was conducted to assess the potential of these groups to predict overall survival, adjusting for other patient and tumor characteristics. Results. Overall, 55.2% were low risk, while 27.0% and 17.8% were intermediate and high risk, respectively. Median (95% CI) survival was 44.1 (42.6–45.5) months, 35.5 (32.3–38.8) months, and 32.1 (25.5–38.6) months, respectively. After controlling for other patient and tumor characteristics, intermediate and high risk groups experienced a 4.5-fold (HR: 4.509, 95% CI: 0.735–27.649) and 18.5-fold (HR: 18.531, 95% CI: 2.117–162.228) increased risk of overall mortality, respectively. Conclusion. Preoperative ESR values represent a robust predictor of overall survival following nephrectomy in localized RCC.

Urolithiasis: the most risk for nephrectomy in nonrenal tumor patients

BACKGROUND AND PURPOSE

The existence of upper urinary tract calculus may cause complete loss of renal function, which eventually results in nephrectomy. Our purpose was to describe the prevalence and clinical characteristics of upper urinary tract calculus cases among a series of patients undergoing nephrectomy during a 10-year period.

PATIENTS AND METHODS

The data of 1059 patients undergoing nephrectomy between January 2001 and December 2010 in our center were reviewed. The prevalence and clinical characteristics of upper urinary tract calculi-derived nonfunctioning kidney were analyzed.

RESULTS

Among 1059 patients, 177 (16.7%) had nonfunctioning kidneys, which were second in number to renal tumor cases (801, 75.6%). Upper urinary tract calculi accounted for the greatest cause (101, 57.1%) in these nonfunctioning kidney cases. These patients were mainly screened by ultrasonography and the diagnosis confirmed by CT, intravenous urography, and nuclear renography. There were 44 (43.6%) patients with a single renal stone in the ureteropelvic junction, 36 (35.6%) with a single ureteral stone, and 21 (20.8%) with multiple unilateral renal and ureteral stones. The average size of the renal stones and ureteral stones were 15.6±8.8 mm (4-50 mm) and 13.4±4.0 mm (4-21mm) in diameter, respectively. Prevalence of urolithiasis derived nonfunctioning kidney had not changed significantly over 10 years and even showed a slight increase. Most of the stones were more than 10 mm in diameter. A nonfunctioning kidney was more likely to develop in females or patients with a low living standard.

CONCLUSIONS

Upper urinary tract calculus (>10 mm) and loss to follow-up are the greatest risk factors for a nonfunctioning kidney. A nonfunctioning kidney develops more easily in females or patients with a low living standard. A regular urinary system health examination is recommended. Routine follow-up of urolithiasis is also recommended for patients with a stone history to prevent renal dysfunction.

Integration of laparoscopic partial nephrectomy into an Australian public hospital: three-year follow-up of our initial 50 cases

OBJECTIVE

To examine the early outcomes and complications of integrating laparoscopic partial nephrectomy (LPN) into a public teaching hospital in Australia.

PATIENTS AND METHODS

An outcomes review from prospectively collected data on our initial 50 cases of LPN. The median follow-up was 36 months with a minimum follow-up of 2 years and a maximum of 5 years.

RESULTS

The mean patient age was 60 years, mean tumour size was 2.9 cm, and mean baseline creatinine concentration was 79 µmol/L. One patient had a solitary kidney, and one patient had bilateral tumours. The mean operative duration was 168 min, with a mean warm ischaemia time of 25 min. The median blood loss was 100 mL and the median (range) hospital stay was 4 (2-12) days. The complication rate was 6%, including two instances of secondary haemorrhage, and one port-site hernia. No patient required conversion to radical nephrectomy or experienced clinically significant deterioration in their renal function. There have been no local or systemic recurrences to date, with a maximum follow-up of 5 years.

CONCLUSIONS

LPN can be successfully integrated into the Australian public health care sector as standard of care for stage 1 renal masses requiring treatment. Due to the inherent risk of bleeding early in the learning curve, cases should be performed in the setting of adequate surgical and interventional radiographic support.