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

Efficacy and safety of nephron-sparing surgery

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

Trends in renal tumor surgery delivery within the United States

BACKGROUND

Most small renal tumors are amenable to partial nephrectomy (PN). Studies have documented the association of radical nephrectomy (RN) with an increased risk of comorbid conditions, such as chronic kidney disease. Despite evidence of equivalent oncologic outcomes, PN remains under used within the United States. In this study, the authors identified the most recent trends in kidney surgery for small renal tumors and determined which factors were associated with the use of PN versus RN within the United States.

METHODS

A population-based patient cohort was analyzed using the Surveillance, Epidemiology and End Results cancer registry (SEER 1999-2006). The authors identified 18,330 patients ages 40 to 90 years who underwent surgery for kidney tumors <or=4 cm in the United States between 1999 and 2006.

RESULTS

In total, 11,870 patients (65%) underwent RN, and 6460 patients (35%) underwent PN. The ratio of PN to RN increased yearly (P < .001), representing 45% of kidney surgeries in 2006 for small tumors. There were significant differences in the cohort of patients who underwent PN versus RN, including age, sex, tumor location, marital status, year of treatment, and tumor size. When adjusting for these variables, being a man, age <or=70 years, urban residence, smaller tumor size, and more recent treatment year were predictors of PN.

CONCLUSIONS

Although the total numbers of PN procedures increased in the United States between 1999 and 2006, there remains a significant under use of PN, particularly among women, the elderly, and those living in rural locations. Further investigation will be required to determine the reasons for these disparities, and strategies to optimize access to PN need to be developed.

Impact of the learning curve on perioperative outcomes in patients who underwent robotic partial nephrectomy for parenchymal renal tumours

BACKGROUND

Robot-assisted partial nephrectomy (RAPN) is an emerging, minimally invasive technique to treat patients with small renal masses.

OBJECTIVE

To evaluate the impact of the learning curve on perioperative outcomes such as operative times and warm ischaemia times (WIT), blood loss, overall complications, and renal function impairment in patients who underwent RAPN.

DESIGN, SETTING, AND PARTICIPANTS

We collected prospectively the clinical and pathologic records of 62 consecutive patients who underwent RAPN between September 2006 and November 2009 for renal tumours at a nonacademic teaching institution by a single surgeon with extensive prior robotic experience.

INTERVENTIONS

The surgeon used transperitoneal RAPN with excision of an adequate rim of healthy peritumour renal parenchyma.

MEASUREMENTS

Perioperative parameters, pathologic outcome, and short-term outcomes for renal function were recorded. The effects of the learning curve on the previous reported perioperative and functional outcomes was studied.

RESULTS AND LIMITATIONS

The mean pathologic tumour size was 2.8 +/-1.3 cm. A pelvicaliceal repair was needed in 33 cases (53%). The mean console time was 91 +/-33 min (range: 52-180), with a mean WIT of 20 +/- 7 min (range: 9-40). Warm ischaemia (<20 min) and console times were optimised after the first 30 (p<0.001) and 20 cases (p<0.001), respectively. Pathologic results yielded a positive surgical margin (PSM) rate of 2%. Mean creatinine level changed from a baseline value of 1.02 +/- 0.38 mg/dl to 1.1 +/- 0.7 mg/dl 3 mo after surgery. Estimated glomerular filtration rate changed from a baseline value of 81.17 +/- 29 to 80.5 +/- 29 (millilitres per minute per 1.73 m(2)) 3 mo postoperatively.

CONCLUSIONS

RAPN is a viable option for nephron-sparing surgery in patients with renal carcinoma. Specifically, in the hands of a surgeon with extensive robotic experience, RAPN requires a short learning curve to reach WIT < 20 min, console times < 100 min, limited blood loss, and acceptable overall complication rates.

Complications after radical and partial nephrectomy as a function of age

PURPOSE

Partial nephrectomy may be underused compared with radical nephrectomy in elderly patients due to concerns about higher complication rates. We determined if the association of age and perioperative outcomes differed between nephrectomy types.

MATERIALS AND METHODS

We identified patients who underwent radical or partial nephrectomy between January 2000 and October 2008. Using multivariable methods we determined whether the relationship between age and risk of postoperative complications, estimated blood loss or operative time differed by nephrectomy type.

RESULTS

Of 1,712 patients 651 (38%) underwent radical nephrectomy and 1,061 (62%) underwent partial nephrectomy. Patients treated with partial nephrectomy had higher complication rates than those who underwent radical nephrectomy (20% vs 14%). In a multivariable model age was significantly associated with a small increase in risk of complications (OR for 10-year age increase 1.17, 95% CI 1.04-1.32, p = 0.009). When including an interaction term between age and procedure type, the interaction term was not significant (p = 0.09), indicating there was no evidence the risk of complications associated with partial vs radical nephrectomy increased with advancing age. There was no evidence that age was significantly associated with estimated blood loss or operative time.

CONCLUSIONS

We found no evidence that elderly patients experience a proportionally higher complication rate, longer operative times or higher estimated blood loss from partial nephrectomy than do younger patients. Given the advantages of renal function preservation we should expand the use of nephron sparing treatment to renal tumors in elderly patients.

Localized renal cell carcinoma management: an update

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

[Open partial nephrectomy. Experience at the 12 de Octubre University Hospital]

INTRODUCTION

Radical nephrectomy has traditionally been considered as the standard treatment for renal tumors. Nephron-sparing surgery was introduced two decades ago. Its excellent oncological and functional results have led to widespread use of this procedure. This procedure was first performed at our institution in 1991. Our experience with open partial nephrectomy is reported.

MATERIALS AND METHODS

Our series of 83 open partial nephrectomies performed from 1991 to date for oncological purposes is analyzed. The demographic, intraoperative, postoperative, oncological, and functional results are reported. A survival analysis and renal function evaluation is also provided.

RESULTS

Thirty-four of the 83 open partial nephrectomies (42%) were non-elective. Mean tumor size was 36 mm (12-120). Fifty-two percent of tumors were exophytic and 38% endophytic. The most relevant intraoperative variables included a median surgery time of 160 min, an ischemia time of 15 min, a blood loss of 500 mL, and a 9-day hospital stay. Twenty-four percent of patients experienced complications, of which fistula was the most common, occurring in 6 patients (8.8%). The pathological study revealed clear renal cell carcinoma in 57% of patients and benign tumors in 25%. Stage at diagnosis was pT1A in 61% of patients, pT1B in 27%, pT2 in 3%, and pT3 in 9%. Grade 2 of Furham classification was most common (40%). Positive surgical margins were seen in 4% of patients. Cancer-specific survival rates were 94% at 5 years and 85% at 10 years. A slight increase was seen in median creatinine levels when preoperative and postoperative values were compared: 0.04, 0.11, 0.08, and 0.03 at 6, 12, 24, and 36 months respectively. A minimum, statistically significant increase was found in mean creatinine levels 6, 12, 24, and 36 months after surgery as compared to preoperative values.

CONCLUSIONS

Open partial nephrectomy is a feasible procedure routinely used in our standard practice. Its oncological results are satisfactory and consistent with those reported in the literature. The procedure also has a low complication rate and an excellent functional outcome, and is therefore the procedure of choice for a wide spectrum of patients when performed by experienced surgeons.

Surveillance as an option for the treatment of small renal masses

OBJECTIVES. To review the natural history and biological potential of small renal masses in order to evaluate surveillance as a treatment option. METHODS. Literature search of Medline and additional references from non-Medline-indexed publications concerning surveillance of small renal masses. RESULTS. The natural history and biological potential of small renal masses can still not be unambiguously predicted at present. There seems to be no clear correlation between tumour size and presence of benign histology. The majority of small renal masses grow and the majority are cancer, but one cannot safely assume that a lack of growth on serial CT scans is the confirmation of absence of malignancy. Needle core biopsies could be used to help in decision making. They show a high accuracy for histopathological tumour type but are less accurate in evaluating Fuhrman grade. CONCLUSIONS. At present, surveillance of small renal masses should only be considered in elderly and/or infirm patients with competing health risks, in those with a limited life expectancy, and in those for whom minimal invasive treatment or surgery is not an option. In all other patients, active surveillance should only be considered in the context of a study protocol. Long-term, prospective studies are needed to provide a more accurate assessment of the natural history and metastastic potential of small renal masses.

The contemporary role of surgery in kidney cancer

The diagnosis and treatment of renal cell carcinoma (RCC) has been the subject of major changes since the late 1980s. Initially, surgery was the only treatment available, but more recently, systemic therapies have been developed, and their introduction has modified some of the surgical indications for rcc. In addition, refinements in surgical technique and the introduction of minimally invasive approaches have revolutionized patient care and bear the promise of even more improvements to come. This paper provides an up-to-date overview of recent developments in the surgical treatment of RCC.

A population-based comparison of survival after nephrectomy vs nonsurgical management for small renal masses

OBJECTIVE

To examine population-based rates of cancer-specific and other-cause mortality after either non-surgical management (NSM) or nephrectomy, in patients with small renal masses, as several reports from selected institutions support the applicability of surveillance in patients with small renal masses, but there are no population-based studies confirming the general applicability of this therapy.

PATIENTS AND METHODS

Of 43 143 patients with renal cell carcinoma identified in the 1988-2004 Surveillance, Epidemiology and End Results database, 10 291 had localized small renal masses (<or=4 cm) and were offered NSM (433, 4.2%) or nephrectomy (9858, 95.8%). Univariable matched and multivariable unmatched competing-risks regression models were used in the analyses.

RESULTS

Cumulative incidence plots based on unmatched data, where the effect of other-cause mortality was controlled for, showed a 5.2%, 6.5% and 9.4% survival benefit for nephrectomy vs NSM at 1, 2 and 5 years after nephrectomy or diagnosis, respectively. The same magnitude of the benefit (4.5%, 5.6% and 8.0%) persisted in analyses matched for age, tumour size and year of diagnosis or of nephrectomy. Finally, in multivariable analyses, treatment type, age, tumour size and year of diagnosis or of nephrectomy were independent predictors.

CONCLUSION

Relative to nephrectomy, NSM appears to undermine the overall and cancer-specific survival of patients with small renal masses by as much as 9.4%, at 5 years.

Thirty-day mortality after nephrectomy: clinical implications for informed consent

BACKGROUND

The existing literature suggests that the surgical mortality (SM) observed with nephrectomy for localised disease varies from 0.6% to 3.6%.

OBJECTIVE

To examine age- and stage-specific 30-d mortality (TDM) rates after partial or radical nephrectomy.

DESIGN, SETTING, AND PARTICIPANTS

We relied on 24535 assessable patients from the National Cancer Institute (NCI) Surveillance, Epidemiology, and End Results (SEER) database.

MEASUREMENTS

In 12283 patients, logistic regression models were used to develop a tool for pretreatment prediction of the probability of TDM according to individual patient and tumour characteristics. External validation was performed on 12252 patients.

RESULTS AND LIMITATIONS

In the entire cohort of 24535 patients, 219 deaths occurred during the initial 30 d after nephrectomy (0.9% TDM rate). TDM increased with age (≤49 yr: 0.5% vs 50-59 yr: 0.7% vs 60-69 yr: 0.9% vs 70-79 yr: 1.2% vs ≥80 yr: 2.0%; χ(2) trend p<0.001) and stage (0.3% for T1-2N0M0 vs 1.3% for T3-4N0-2M0 vs 4.2% for T1-4N0-2M1; χ2 trend p=<0.001). TDM decreased in more recent years (1988-1993: 1.3% vs 1994-1998: 0.9% vs 1999-2002: 0.7% vs 2003-2004: 0.6%; χ2 trend p<0.001) and was lower after partial versus radical nephrectomy (RN) (0.4% vs 0.9%; p=0.008). Only age (p<0.001) and stage (p<0.001) achieved independent predictor status. The look-up table that relied on the regression coefficients of age and stage reached 79.4% accuracy in the external validation cohort.

CONCLUSIONS

Age and stage are the foremost determinants of TDM after nephrectomy. Our model provides individual probabilities of TDM after nephrectomy, and its use should be highly encouraged during informed consent prior to planned nephrectomy.

Stage-specific effect of nodal metastases on survival in patients with non-metastatic renal cell carcinoma

OBJECTIVE

To quantify the survival disadvantage related to the presence of exclusive nodal metastases (eNM) in patients with otherwise non-metastatic (M0) renal cell carcinoma (RCC).

PATIENTS AND METHODS

Data were retrieved from 12 institutional databases and yielded 3507 patients with T1-3N1-2M0 RCC treated with partial or radical nephrectomy. Cox regression analyses relied on T stage, Fuhrman grade and presence of eNM. Data were analysed using univariable, multivariable and stratified analyses.

RESULTS

Overall 165 (4.7%) patients had eNM; of 2023 patients of stage T1, 23 (1.1%) had eNM, vs 20 of 448 (4.5%) for T2 and 122 of 993 (12.3%) for T3. In univariable analyses the presence of eNM increased the rate of cancer specific mortality (CSM) by 7.1 times. After adjusting for T stage and Fuhrman grade, in all patients eNM increased the rate of CSM by 3.2 times. In stratified analyses adjusted for Fuhrman grade, the increase in CSM related to the presence of eNM was 28.9, 4.3 and 2.5 times (all P < 0.001) for stages T1, T2 and T3, respectively.

CONCLUSIONS

From the prognostic perspective, staging lymphadenectomy appears of most value in patients with T1-2 RCC, but the low prevalence of eNM questions the practical applicability of nodal staging in those patients. Conversely, in patients with T3 RCC, the prevalence and the prognostic impact of eNM might make a staging lymphadenectomy worthwhile.

Open partial nephrectomy in the management of small renal masses

Introduction. Most of the kidney masses are being detected incidentally with smaller size due to widespread use of imaging modalities leading to increased RCC incidence worldwide with an earlier stage. This article reviews the role of open partial nephrectomy (PN) in the management of small renal masses. Material and Methods. Review of the English literature using MEDLINE has been performed between 1963–2008 on small renal masses, partial nephrectomy, kidney cancer, nephron sparing surgery (NSS), radical nephrectomy, laparoscopy, and surgical management. Special emphasis was given on the indications of NSS, oncological outcomes and comparison with open and laparoscopic PN. Results. Overall 68 articles including 31 review papers, 35 human clinical papers, 1 book chapter, and 1 animal research study were selected for the purpose of this article and were reviewed by the authors. Conclusions. Currently, open NSS still remains as the gold standard surgical treatment modality in patients with small renal masses.

Surveillance for the management of small renal masses

Surveillance is a new management option for small renal masses (SRMs) in aged and infirm patients with short-life expectancy. The current literature on surveillance of SRM contains mostly small, retrospective studies with limited data. Imaging alone is inadequate for suggesting the aggressive potential of SRM for both diagnosis and followup. Current data suggest that a computed tomography (CT) or magnetic resonance imaging (MRI) every 3 months in the 1st year, every 6 months in the next 2 years, and every year thereafter, is appropriate for observation. The authors rather believe in active surveillance with mandatory initial and followup renal tumor biopsies than classical observation. Since not all SRMs are harmless, selection criteria for active surveillance need to be improved. In addition, there is need for larger studies in order to better outline oncological outcome and followup protocols.

Renal and cardiovascular morbidity after partial or radical nephrectomy

BACKGROUND

To clarify the benefits of nephron-sparing surgery among patients with early-stage kidney cancer, the authors compared the frequency of renal and cardiovascular morbidity after partial or radical nephrectomy.

METHODS

This retrospective cohort study was based on linked Surveillance, Epidemiology, and End Results-Medicare data. The authors identified 10,886 patients who underwent partial or radical nephrectomy between 1991 and 2002. Medical claims were examined for the occurrence of adverse renal and/or cardiovascular outcomes, and multivariate survival models were fit to estimate the association between type of surgery and each clinical outcome, using propensity scores to balance the treatment cohorts with respect to measured patient and disease characteristics. To control for secular trends in the indications for partial nephrectomy, separate analyses were performed based on treatment era (1991-1999 or 2000-2002).

RESULTS

During the study interval, 10,123 patients (93%) and 763 patients (7%) underwent radical or partial nephrectomy, respectively. During 2000 to 2002, patients who underwent partial nephrectomy experienced fewer adverse renal outcomes (16.4% vs 21.8%; adjusted hazard ratio, 0.74; 95% confidence interval, 0.58-0.94), including a trend toward less frequent receipt of dialysis services, dialysis access surgery, or renal transplantation. The likelihood of adverse cardiovascular outcomes did not differ by treatment.

CONCLUSIONS

Among contemporary patients, partial nephrectomy was associated with less clinically apparent renal morbidity than radical nephrectomy. This finding motivates expanded use of partial nephrectomy among patients with early-stage kidney cancer. Given the potential for selection bias and residual confounding in this observational cohort, additional prospective studies will be necessary to validate the current findings.

Changing concepts in the surgery of renal cell carcinoma

INTRODUCTION

Herein, current developments in open and minimally invasive renal surgery are presented.

MATERIALS AND METHODS

This also includes considerations on the appropriate indication for the two surgical procedures in small renal tumours, locally advanced disease (>pT2), complicated renal tumours as well as cytoreductive surgical situations. In small renal tumours, similar survival rates have been described for laparoscopic radical and partial nephrectomy. However, even experienced high volume laparoscopic centres report a high learning curve, increased complications and initial technical problems to achieve parenchymal haemostasis and renal ischaemia during nephron-sparing surgery. Surgical management of large (>T2) or complicated tumours is feasible, but long-term oncological outcome is not yet available.

CONCLUSION

Promising new developments such as natural orifice translumenal endoscopic surgery (NOTES) might add to our surgical armamentarium for minimally invasive surgery.

Oncological efficacy and safety of nephron-sparing surgery for selected patients with locally advanced renal cell carcinoma

OBJECTIVE

To evaluate perioperative complication rates, recurrence-free and cancer-specific survival (CSS) in a large group of matched patients who had nephron-sparing surgery (NSS) or radical nephrectomy (RN) for pT2-T3bN0M0 renal cell carcinoma (RCC).

PATIENTS AND METHODS

With approval from the institutional review board, the institutional nephrectomy database of 3470 patients treated at the authors' institution from 1990 to 2006 was searched for patients who had NSS or RN for unilateral, sporadic, pathological T2-T3bN0M0 RCC. Patients with non-metastatic, node-negative RCC and a follow-up of >/=6 months were included in the analysis.

RESULTS

In all, 601 patients treated with RN (567) or NSS (34) for pT2-T3bN0M0 RCC and a mean (median, range) follow-up of 43.4 (31.8, 6.1-172.6) and 62.1 (37.5, 7.0-192.0) months, respectively, met the study inclusion criteria. Disease recurred in four of 34 (12%) patients treated with NSS and in 164/567 (28.9%) managed with RN at a median of 24.2 and 13.2 months, respectively. There were no local recurrences among patients treated with NSS. On multivariate Cox proportional-hazards regression analysis, when adjusted for the effects of stage, grade, size and tumour histology, procedure type (NSS vs RN) was not an independent predictor of disease recurrence or RCC-specific death. Patients treated with NSS had a higher procedure-related complication rate, but similar estimated intraoperative blood loss, transfusion rate, equal duration of surgical procedure and hospital stay compared with patients managed with RN.

CONCLUSION

In highly selected patients with locally advanced RCC, NSS is safe and provides oncological outcomes equivalent to patients managed with RN.

Is Surveillance an Option for the Treatment of Small Renal Masses?

OBJECTIVES

To review the natural history and biological potential of small renal masses in order to evaluate whether surveillance is an option for treatment of small renal masses.

METHODS

Literature search of MEDLINE and additional references from non-MEDLINE-indexed publications concerning surveillance of small renal masses.

RESULTS

Because approximately 26-33% of observed small renal masses do not show radiographic growth, it has been suggested that a brief period of active surveillance may be feasible for selected renal masses, with treatment limited to tumours showing growth. Even though tumour growth might be absent or slow, a proportion of these tumours will express significant malignant behaviour. The biological behaviour of a tumour cannot be unambiguously predicted at present. Surveillance of small renal masses should only be considered in elderly and/or infirm patients with competing health risks, in those with limited life expectancy, and in those for whom surgery is not an option. In all other patients, active surveillance can be considered in the context of a study protocol only. In the majority of the patients, nephron-sparing surgery remains the gold standard treatment.

CONCLUSIONS

Surveillance should only be considered as an alternative to surgery for the treatment of small renal masses in selected patients. It should always be combined with close follow-up imaging and should be allowed only when the patient and the urologist accept the calculated risk. Long-term, prospective studies are needed to provide a more accurate assessment of the natural history and metastastic potential of small renal masses.

Laparoscopic partial nephrectomy: how far have we gone?

PURPOSE OF REVIEW

Several technical modifications of laparoscopic partial nephrectomy have resulted in a reduction of complications and warm ischemia time. The most recent results are reviewed with a focus on oncologic outcome and postoperative renal function.

RECENT FINDINGS

The indications for laparoscopic partial nephrectomy are the same as for open surgery. All tumors up to 4 cm should be included and selected tumors up to 7 cm may be considered as well. In experienced hands, the complication rate is considerably low. Oncologic outcome is comparable with open partial nephrectomy and 5-year survival data have been published recently. Long warm ischemia time may be of some concern. The published functional results are excellent. Cost should not be the main argument in favor of a method. Laparoscopic partial nephrectomy, however, combines advantages for the patient with lower cost as shown by two studies.

SUMMARY

Laparoscopic partial nephrectomy duplicates the principles of open surgery and has been standardized to a great extent. It is technically difficult and is being performed by a small number of centers only; however, the interest of the urologists and patient demand is growing quickly. At the present time, laparoscopic partial nephrectomy cannot be considered a standard of care, but excellent results have been reported when performed by experienced laparoscopists.