Low Rate of Cancer Events After Partial Nephrectomy for Renal Cell Carcinoma: Clinicopathologic Analysis of 1994 Cases with Emphasis on Definition of "Recurrence"

Initial Experience with Hybrid Partial Nephrectomy with Ultrasound-guided Balloon Catheter Occlusion of the Renal Artery for Recurrent Renal Tumors

Repeat partial nephrectomy (PN) is an effective treatment in improving the prognosis for patients with recurrent renal cancer after initial PN. However, salvage PN (sPN) is inevitably associated with a higher rate of complications, largely because of intraperitoneal adhesions and fibrosis. Here we describe three initial cases for which recurrent renal tumors were treated with a novel minimally invasive approach, namely Ultrasound-guided Renal Artery Balloon catheter Occluded Hybrid Partial Nephrectomy (UBo-HPN).With laparoscopic ultrasound (LUS) guiding a Fogarty catheter to occlude the arterial blood supply, dissection of the renal hilum and most of the abdominal cavity can be avoided. UBo-HPN was successfully performed in three patients. One case of postoperative fever (Clavien-Dindo grade II) occurred, with no other complications. The mean operative time was 106 min, with a mean warm ischemia time of 21 min. UBo-HPN may be considered a safe and effective alternative for sPN, with a minimally invasive surgical footprint and better surgical outcomes.

Effectiveness of Thermal Ablation for Renal Cell Carcinoma after Prior Partial Nephrectomy

Background

Repeat partial nephrectomy (PN) for tumors recurring in the ipsilateral kidney is associated with surgical complexity and a higher rate of complications.

Objective

To evaluate the local oncologic efficacy of thermal ablation (TA) for renal cell carcinoma (RCC) in the ipsilateral kidney following PN.

Design setting participation

We included patients who underwent ablation for renal tumors in the ipsilateral kidney after PN between January 2005 and December 2019. Demographics, tumor size, procedural details, complications, pathology, local oncologic outcomes, and survival outcomes are described.

Outcome measurements and statistical analysis

The procedural, pathologic, and oncologic outcomes are described. Survival rates were estimated using the Kaplan-Meier method.

Results and limitations

A total of 66 patients (46 male and 20 female) with a median age of 62 yr (interquartile range [IQR] 52-69) met our inclusion criteria. In these patients, 74 TA procedures were performed for 86 lesions (median tumor size 1.9 cm, IQR 1.6-2.5). Radiofrequency ablation and cryoablation accounted for 60 (81%) and 14 (19%) procedures, respectively. Three patients (3.7%) had Clavien-Dindo grade III complications. Of 65 lesion biopsies, 62 (95.5%) were diagnostic. The most common subtype was clear cell RCC (n = 37). The median imaging follow-up duration was 60 mo (IQR 43-88). Recurrence in the ablation zone occurred for four lesions (4.6%) at a median of 6.9 mo (IQR 6.4-10.7). The rates of overall, recurrence-free, and disease-free survival were 93.1%, 94.4%, and 65.6% at 5 yr, and 71.6%, 94.4%, and 60.1% at 10 yr, respectively. Limitations include the retrospective design and the lack of a control group.

Conclusions

TA is effective for the treatment of RCC in the ipsilateral kidney following PN.

Patient summary

Heat treatment to remove tumor tissue is an effective option for small kidney masses recurring after partial kidney removal for cancer. Long-term follow-up data revealed that this treatment resulted in low recurrence and complication rates.

Redo Partial Nephrectomy for Local Recurrence After Previous Nephron-sparing Surgery. Surgical Insights and Oncologic Results from a High-volume Robotic Center

Background

The role of redo partial nephrectomy (PN) for recurrent renal cell carcinoma (RCC) is still overlooked.

Objective

To report our experience of salvage PN for local recurrence after previous nephron-sparing surgery (NSS).

Design setting and participants

We prospectively gathered data from patients treated with robotic redo PN for locally recurrent RCC after previous NSS from January 2017 to January 2023. The type of surgical resection technique was assigned to the pathologic specimen according to the surface-intermediate-base (SIB) score.

Surgical procedure

Redo PN was performed by using the Si Da Vinci robotic platform.

Measurements

Operative time, warm ischemia time, and intra- and postoperative complications were recorded. The severity of postoperative complications and tumor stage were evaluated.

Results and limitations

Overall, 26 patients entered the study. The median clinical diameter was 3.5 (interquartile range [IQR] 2.2-4.9) cm and the median Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) score was 8 (IQR 7-9). In 14 (53.8%) cases, recurrence was at the level of previous tumor resection bed. The median operative time was 177 (IQR 148-200) min, and hilar clamping was performed in 14 (53.8%) cases with a median warm ischemia time of 16 (14.5-22) min. Pure enucleation (SIB score 0-1), hybrid enucleation (SIB score 2), and pure enucleoresection (SIB score 3) were recorded in 13 (50%), eight (30.8%), and five (19.2%) cases, respectively. The totality of recurrent RCC far from previous tumor resection bed received a SIB score of 0-1, while in 57.1% and 35.8% of recurrent RCC on previous tumor resection a hybrid enucleation and a pure enucleoresection were performed, respectively. At a median follow-up of 37 (IQR 16-45) mo, five (19%) patients experienced disease recurrence, being local and systemic in three (11.5%) and two (7.7%) patients, respectively.

Conclusions

Our study highlights the feasibility and safety of redo PN for the treatment of locally recurrent RCCs after NSS, either on previous tumor resection bed or elsewhere in the kidney.

Patient summary

Robotic redo partial nephrectomy is a challenging procedure. The surgeon needs to tailor the surgical strategy and tumor resection technique case by case, given the heterogeneity of clinical scenarios and the need to achieve maximal functional preservation while ensuring oncologic efficacy.

Resection Techniques During Robotic Partial Nephrectomy: A Systematic Review

Context

The resection technique used to excise tumor during robotic partial nephrectomy (RPN) is of paramount importance in achieving optimal clinical outcomes.

Objective

To provide an overview of the different resection techniques used during RPN, and a pooled analysis of comparative studies.

Evidence acquisition

The systematic review was conducted according to established principles (PROSPERO: CRD42022371640) on November 7, 2022. A population (P: adult patients undergoing RPN), intervention (I: enucleation), comparator (C: enucleoresection or wedge resection), outcome (O: outcome measurements of interest), and study design (S) framework was prespecified to assess study eligibility. Studies reporting a detailed description of resection techniques and/or evaluating the impact of resection technique on outcomes of surgery were included.

Evidence synthesis

Resection techniques used during RPN can be broadly classified as resection (non-anatomic) or enucleation (anatomic). A standardized definition for these is lacking. Out of 20 studies retrieved, nine compared "standard" resection versus enucleation. A pooled analysis did not reveal significant differences in terms of operative time, ischemia time, blood loss, transfusions, or positive margins. Significant differences favoring enucleation were found for clamping management (odds ratio [OR] for renal artery clamping 3.51, 95% confidence interval [CI] 1.13-10.88; p = 0.03), overall complications (OR for occurrence 0.55, 95% CI 0.34-0.87; p = 0.01) major complications (OR for occurrence 0.39, 95% CI 0.19-0.79; p = 0.009), length of stay (weighted mean difference [WMD] -0.72 d, 95% CI -0.99 to -0.45; p < 0.001), and decrease in estimated glomerular filtration rate (WMD -2.64 ml/min, 95% CI -5.15 to -0.12; p = 0.04).

Conclusions

There is heterogeneity in the reporting of resection techniques used during RPN. The urological community must improve the quality of reporting and research produced accordingly. Positive margins are not specifically related to the resection technique. Focusing on studies comparing standard resection versus enucleation, advantages with tumor enucleation in terms of avoidance of artery clamping, overall/major complications, length of stay, and renal function were found. These data should be considered when planning the RPN resection strategy.

Patient summary

We reviewed studies on robotic surgery for partial kidney removal using different techniques to cut away the kidney tumor. We found that a technique called "enucleation" was associated with similar cancer control outcomes in comparison to the standard technique and had fewer complications, better kidney function after surgery, and a shorter hospital stay.

Markers of local kidney cancer recurrence: A surgeon's mistake or a pattern? Review

The influence of various morphological, anatomical, genetic and other factors on the local recurrence-free survival of patients who have undergone different renal cell cancer (RCC) treatment is still a rather complex, ambiguous and controversial issue for practicing oncourologists. This review evaluates the effect of several factors on both recurrence-free survival and local recurrence-free survival. The review includes articles, clinical cases, literature reviews, and meta-analyses highlighting the analysis of independent and interrelated predisposing factors for developing local recurrence of RCC from 1984 to 2020. The PubMed, Web of Science, and Scopus databases were searched in English, Spanish, and German. A review of the literature showed the role of the following indices in the local recurrence RCC: microvascular invasion (p = 0.001), tumor necrosis (p = 0.0001), high malignancy (Fuhrman III or IV) (HR = 38.3, 95% CI 3.1-467, p = 0.004) as histological factors, tumor size as an anatomical factor. Thus, the authors state that every centimeter of the tumor increases the risk of local recurrence (p < 0.05). A group from the Mayo Clinic showed the equivalence of different treatment methods in local RCC recurrence. Thus, in the group of patients with cT1a stage kidney cancer, the 5-year local recurrence-free survival rates were 97.7% (96.7-98.6), 95.9% (92.3-99.6), and 95.9% (92.3-99.6) for renal resection, RFA, and cryoablation, respectively. Surgical margin status is the most studied and controversial marker of local renal cell carcinoma recurrence. Researchers found a direct effect of PSM on the risk of local RCC recurrence (p < 0.01). The personalized approach with the search and evaluation of predisposing factors for the local recurrence, as well as further selection of the most optimal treatment, will allow oncourologists to improve both the effectiveness of primary treatment and the recurrence-free survival of patients.

Current strategies to diagnose and manage of positive surgical margins and local recurrence after partial nephrectomy

Objective

No standard strategy for diagnosis and management of positive surgical margin (PSM) and local recurrence after partial nephrectomy (PN) are reported in literature. This review aims to provide an overview of the current strategies and further perspectives on this patient setting.

Methods

A non-systematic review of the literature was completed. The research included the most updated articles (about the last 10 years).

Results

Techniques for diagnosing PSMs during PN include intraoperative frozen section, imprinting cytology, and other specific tools. No clear evidence is reported about these methods. Regarding PSM management, active surveillance with a combination of imaging and laboratory evaluation is the first option line followed by surgery. Regarding local recurrence management, surgery is the primary curative approach when possible but it may be technically difficult due to anatomy resultant from previous PN. In this scenario, thermal ablation (TA) may have the potential to circumvent these limitations representing a less invasive alternative. Salvage surgery represents a valid option; six studies analyzed the outcomes of nephrectomy on local recurrence after PN with three of these focused on robotic approach. Overall, complication rates of salvage surgery are higher compared to TA but ablation presents a higher recurrence rate up to 25% of cases that can often be managed with repeat ablation.

Conclusion

Controversy still exists surrounding the best strategy for management and diagnosis of patients with PSMs or local recurrence after PN. Active surveillance is likely to be the optimal first-line management option for most patients with PSMs. Ablation and salvage surgery both represent valid options in patients with local recurrence after PN. Conversely, salvage PN and radical nephrectomy have fewer recurrences but are associated with a higher complication rate compared to TA. In this scenario, robotic surgery plays an important role in improving salvage PN and radical nephrectomy outcomes.