Bilateral synchronous sporadic renal masses: intermediate functional and oncological outcomes at a single institution

The current evidence on surgical management for synchronous bilateral renal tumors: results from a scoping review

PURPOSE

Synchronous bilateral renal masses (SBRM) account for a low percentage of kidney tumors, and there is no current recommendation for their management. The objective was to review evidence regarding the best surgical approach for SBRM in terms of type and timing of surgery.

METHODS

A broad literature search was performed on 28th January 2023 using Scopus, PubMed, and EMBASE. Only English papers dealing with adults were included. Meeting abstracts were excluded.

RESULTS

Twenty-four papers were accepted and included. SBRM behave less aggressively than metachronous tumors, and partial nephrectomy (PN) is the preferred therapeutic option to preserve renal function. Open, laparoscopic, and robot-assisted approaches were found to be similar in oncological outcomes, though robot-assisted surgery resulted in lower comorbidities. Same-sitting PN was demonstrated to be a safe approach, particularly in the robotic-assisted one. Finally, the same-siting and staged NSS were similar in preserving renal function.

CONCLUSIONS

PN should be the desirable treatment for SBRM whenever feasible and if patients are fit, but surgeon expertise should also be taken into the account.

Evaluation of functional outcome of bilateral kidney tumors after sequential surgery

Background

There are limited data concerning patients treated with sequential bilateral kidney surgery. Current guidelines still lack an optimal surgical sequencing approach. We evaluated renal functional outcomes after sequential partial nephrectomy (PN) and radical nephrectomy (RN) in patients with bilateral renal cell carcinoma (RCC).

Methods

A propensity score matched cohort of 267 patients (synchronous bilateral RCCs, N = 44 [88 lesions]; metachronous bilateral, N = 45 [90 lesions]; unilateral, N = 178) from two tertiary institutions were retrospectively analyzed. Synchronous bilateral RCCs were defined as diagnosis concomitantly or within 3 months of former tumor. Renal functional outcomes were defined as estimated glomerular filtration rate (eGFR) changes and de novo chronic kidney disease (CKD, stage ≥3) after surgery. Renal functional outcomes and clinical factors predicting de novo CKD were assessed using descriptive statistics and Cox regression analysis.

Results

In subgroup of bilateral RCCs, patients underwent sequential PN (N = 48), PN followed by RN (N = 8), or RN followed by PN (N = 25). Final postoperative estimated glomerular filtration rates (eGFRs) were 79.4, 41.4, and 61.2 ml/minute/1.73 m2, respectively (p = 0.003). There were significant differences in eGFR decline from baseline and de novo chronic kidney disease (CKD stage ≥ III) among groups, with PN followed by RN group showing the worst functional outcomes (all p <  0.05). Moreover, sequential PN subgroup in bilateral RCC showed significantly higher rate of de novo CKD than unilateral RCC group (13.8% vs. 6.9%, p = 0.016). On multivariate analysis, hypertension (p = 0.010) and surgery sequence (PN followed by RN, p <  0.001) were significant predictors of de novo CKD.

Conclusions

The surgery sequence should be prudently determined in bilateral renal tumors. PN followed by RN showed a negative impact on renal functional preservation. Nephron-sparing surgery should be considered for all amenable bilateral RCCs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08324-3.

Multiple and Bilateral Sporadic Renal Cell Carcinomas: A Surgical Challenge

Sporadic, synchronous, bilateral, or unilateral Renal Cell Carcinomas constitute a rare clinical entity. We report the case of a 68-year-old male patient who presented in our department due to incidentally discovered multiple, bilateral renal tumors. Magnetic Resonance Imaging demonstrated cT1b renal tumors at the lower pole of each kidney and a cT1a renal tumor at the upper pole of the right kidney. The patient underwent transperitoneal, laparoscopic left partial nephrectomy with renal artery occlusion, histology revealed high-grade, pT1b, clear-cell renal cell carcinoma; however we observed decline of patient's estimated glomerular filtration rate postoperatively. Forty days postoperatively, he underwent open partial nephrectomy for the right sided tumors with manual compression of the renal parenchyma and no use of ischemia. Histology revealed high-grade, pT1a, clear-cell renal cell carcinoma at the upper pole of the right kidney and low-grade, pT1b, clear-cell renal cell carcinoma at the lower pole of the right kidney. There was no additional decline in the serum creatinine value postoperatively. The patient avoided permanent or temporary dialysis and 6 months postoperatively he demonstrated no recurrence on imaging and his renal function remained stable.

Surgical strategy of bilateral synchronous sporadic renal cell carcinoma-experience of a Chinese university hospital

Background

The objective of this study is to investigate the optimal therapeutic protocol for BSSRCC.

Methods

A total of 32 BSSRCC patients, including 28 males and 4 females, were enrolled the study from January 2004 to May 2016. The diagnoses were defined by the measurements of CT, ultrasound, and MRI. Patients with hereditary syndrome were excluded. The management of surgical manner, operation staging, and sequence were scheduled in accordance with the tumor’s location and size (based on Zhongshan score, ZS score), as well as the performance status of the patients. Among them, 8 cases were conducted with bilateral surgical procedure simultaneously and 24 cases were implemented with staged operations. NSS on the one side with contralateral RN, and NSS on both sides were performed in 17 and 15 patients separately.

Results

Thirty cases were conducted 56 operations in total. The average operation time was 260 ± 52 min in simultaneous operations and 162 ± 40 min in staged operations. The length of hospital stay in average was 11.5 ± 1.8 and 7.5 ± 1.4 days, respectively. Twenty-eight cases were followed up by 6–138 months. The level of creatinine was elevated in 5 cases without hemodialysis conducted.

Conclusions

The location and size of the carcinomas, and the performance status of patients should be considered in determination of an appropriate surgical approach. Both renal function preservation and tumor eradication were similarly critical, whereas the latter is of more importance. ZS score may be helpful in the dilemma. Longer follow-up period and more patient enrolment are required.

Bilateral renal cancers: oncological and functional outcomes

PURPOSE

The authors assessed the characteristics of bilateral renal cancers.

METHODS

From January 1995 to January 2015, 65 patients underwent surgery for bilateral renal cancers. Thirty-four of the patients had 36 synchronous tumors, while the remaining 29 had metachronous tumors. The mean age of the patients was 60 ± 11 years. There were 22 females and 43 males. In all cases, bilateral partial nephrectomies or unilateral nephrectomy and contralateral nephron-sparing surgery were performed.

RESULTS

The mean sizes of the synchronous tumors were 5.0 ± 2.7 and 4.7 ± 3.0 cm at the first and the second operations, respectively. The average diameters of the metachronous carcinomas were 6.6 ± 3.0 and 3.1 ± 1.6 cm at the initial and the second surgeries, respectively. Histologic concordance was 91.1 % in the synchronous and 96.5 % in the metachronous tumors. The mean postoperative creatinine levels increased by 116 %, while the GFR decreased by 44.8 % in synchronous tumors at the second operation. The mean postoperative creatinine levels increased by 42 %, while the GFR decreased by 30.4 % in metachronous carcinomas at the second operation. The mean follow-up time was 4.8 ± 3.7 years. During this period, distant metastases occurred in two patients with synchronous tumors and in six cases with metachronous tumors. Local recurrences were detected in one case of synchronous tumor and in four patients with metachronous carcinomas. The 5-year overall and tumor-specific survivals were 53 and 80 %, respectively.

CONCLUSIONS

In patients with bilateral renal carcinomas, the histologic concordance was 93.6 %. The bilateral partial nephrectomies or unilateral nephrectomy and contralateral resection provided acceptable oncological and functional outcomes.