Challenging situations in partial nephrectomy

Impact of tumor multiplicity on the prognosis of patients with primary renal cell carcinoma: a SEER database analysis

To compare clinical characteristics and survival outcomes of patients with multiple renal cell carcinoma versus single renal cell carcinoma. Develop a prognostic model for predicting prognosis in patients with multiple tumors and analyze prognostic factors. Patients with primary multiple renal cell carcinoma were selected from the Surveillance, Epidemiology, and End Results database (2004-2015). They were divided into single-tumor and multiple-tumor groups. Survival analysis was conducted using the Kaplan-Meier method and log-rank test. A Cox regression model was used to identify potential prognostic factors. A total of 19,489 renal cell carcinoma cases were included, with 947 in the multiple-tumor group and 18,542 in the single-tumor group. The multiple-tumor group had lower cancer-specific survival (P = 0.03, HR = 1.431). Cox regression identified risk factors for the multiple-tumor group including number of tumors, gender, combined summary stage, T stage, N stage, tumor size, and type of surgery. The predicted probabilities showed acceptable agreement with the actual observations at 3-, 5-, and 8-years area under the curve values in both the training and validation cohorts (0.831 vs. 0.605; 0.775 vs. 0.672; and 0.797 vs. 0.699, respectively). Compared with single renal cell carcinoma, multiple renal cell carcinoma is associated with decreased cancer-specific survival. Additionally, we identified several prognostic factors including the number of tumors, T stage, tumor size, and type of surgery. These findings offer valuable insights for selecting appropriate treatment strategies for patients diagnosed with multiple renal cell carcinomas.

Role and Utility of Mixed Reality Technology in Laparoscopic Partial Nephrectomy: Outcomes of a Prospective RCT Using an Indigenously Developed Software

Objective

To develop a software for mixed reality (MR) anatomical model creation and study its intraoperative clinical utility to facilitate laparoscopic partial nephrectomy.

Materials and Methods

After institutional review board approval, 47 patients were prospectively randomized for LPN into two groups: the control group (24 patients) underwent operation with an intraoperative ultrasound (US) control and the experimental group (23 patients) with smart glasses HoloLens 2 (Microsoft, Seattle, WA, USA). Our team has developed an open-source software package called “HLOIA,” utilization of which allowed to create and use during surgery the MR anatomical model of the kidney with its vascular pedicle and tumor. The study period extended from June 2020 to February 2021 where demographic, perioperative, and pathological data were collected for all qualifying patients. The objective was to assess the utility of a MR model during LPN and through a 5-point Likert scale questionnaire, completed by the surgeon, immediately after LPN. Patient characteristics were tested using the chi-square test for categorical variables and Student's t-test or Mann–Whitney test for continuous variables.

Results

Comparison of the variables between the groups revealed statistically significant differences only in the following parameters: the time for renal pedicle exposure and the time from the renal pedicle to the detection of tumor localization (p < 0.001), which were in favor of the experimental group. The surgeon's impression of the utility of the MR model by the proposed questionnaire demonstrated high scores in all statements.

Conclusions

Developed open-source software “HLOIA” allowed to create the mixed reality anatomical model by operating urologist which is when used with smart glasses has shown improvement in terms of time for renal pedicle exposure and time for renal tumor identification without compromising safety.

The Role of Intraoperative Ultrasonography Associated with Clampless Technique in Three-Dimensional Retroperitoneoscopic Laparoscopic Enucleation of Completely Endophytic Renal Tumors

Objectives: To evaluate perioperative and functional outcomes of clampless laparoscopic tumor enucleation for completely endophytic renal tumors with the guide of intraoperative ultrasonography. Methods: We analyzed patients with clinically completely endophytic tumors, renal tumors, who underwent clampless three-dimensional (3D) retroperitoneoscopic laparoscopic tumor enucleation between January 2012 and January 2021. Patients with exophytic tumors were excluded. Intraoperative ultrasonography was used to map out the mass in all surgeries. Results: Overall, 57 patients underwent clampless 3D retroperitoneoscopic laparoscopic tumor enucleation. Mean surgical time was 131 minutes, and mean estimated blood loss was 202 mL. Mean hospital stay was 4.7 days. Major and minor postoperative complications occurred, respectively, in 3 and 10 cases. Only a patient had a positive surgical margin. One-year renal function did not differ from baseline. Conclusion: Our study showed that clampless laparoscopic enucleation guided by laparoscopic ultrasonography ensured satisfactory outcomes for completely intrarenal tumors, with excellent renal function preservation 1 year after surgery.

Open transperitoneal partial nephrectomy in a horseshoe kidney

We report the case of a 50-year-old Tibetan man who presented to an outpatient urology clinic after abdominal ultrasound for poorly defined abdominal pain demonstrated horseshoe kidney (HK) with a right moiety ~3.7 cm mass further characterised using contrast-enhanced CT scan (CECT). This dedicated imaging confirmed HK with a heterogeneously enhancing right upper pole 3.1 cm×3.7 cm×2.7 cm mass. Due to suspicion for aberrant vasculature on CECT, renovascular angiography was performed, which revealed recruitment of a right paravertebral vessel alongside two right renal moiety arteries and multiple right renal moiety veins. Based on vascular complexity and the surgical exposure required for arterial clamping, open transperitoneal right partial nephrectomy was preferred to minimally invasive techniques. Postoperative course was complicated by ileus, which resolved with standard management. Pathologic analysis revealed complete resection of a 5.0 cm Fuhrman grade II clear cell renal cell carcinoma.

Laparoscopic nephron-sparing surgery for a tumor near the isthmus of a horseshoe kidney with a complicated blood supply

A horseshoe kidney is a congenital kidney malformation commonly associated with complications such as hydronephrosis, renal calculi, and infections of the renal pelvis. Renal cell carcinoma is extremely rare in a horseshoe kidney; once it occurs, however, it is intractable because of vascular abnormalities. This is especially true in laparoscopic nephron-sparing surgery, even for tumors of <4 cm in diameter. We herein report a case involving an asymptomatic 65-year-old man with an incidental finding of a 4-cm solid mass near the isthmus of a horseshoe kidney on B-mode ultrasonography. Preoperative computed tomography of the renal artery revealed six arterial vessels supplying the affected kidney. Laparoscopic partial nephrectomy was performed. The outcome of this case suggests that laparoscopic nephron-sparing surgery might be a successful treatment method for a horseshoe kidney but that preoperative vessel evaluation and experienced laparoscopic skills are needed.

Percutaneous thermoablation of small renal masses (T1a) in surgical candidate patients: oncologic outcomes

OBJECTIVE

To evaluate the local tumour progression-free survival (LTPFS), metastasis-free survival (MFS), cancer-specific survival (CSS) and overall survival (OS) of healthy surgical candidates who underwent percutaneous thermoablation (TA) as a first-line therapy for small renal masses (T1a).

METHODS

The institutional review board approved this bi-institutional retrospective study of 85 consecutive surgical candidates with 97 biopsy-proven malignant renal masses (T1a) treated with percutaneous TA from 2008 to 2016. The LTPFS, MFS, CSS and OS rates were calculated using the Kaplan-Meier method. Descriptive analysis was also performed.

RESULTS

The median tumour size was 2.3 cm (range, 0.7-3.9 cm). The minimal and mean follow-up periods were 24 and 56 months, respectively. Local recurrence was detected in four patients (4.7%) at 8.5, 13.8, 58.0 and 64.0 months of follow-up and retreated successfully with percutaneous TA. No patient developed metastatic renal cell carcinoma, and none died due to renal oncologic complications. One patient died of heart attack. The 5-year LTPFS, OS, MFS and CSS rates were 93.0%, 98.4%, 100% and 100%, respectively. Only two patients (2.3%) had major complications (Clavien-Dindo grade > II), including ureteropelvic junction stenosis and urinary obstruction due to ureteral blood clots.

CONCLUSIONS

Our study demonstrates that percutaneous TA is a feasible and effective first-line therapy for healthy surgical candidates with small renal masses (T1a). The 5-year LTPFS, OS, CSS and MFS rates were 93.0%, 98.4%, 100% and 100%, respectively, with a major complication rate of only 2.3%.

KEY POINTS

• Image-guided percutaneous thermoablation of small renal malignancies was effective in 95.3% of the healthy surgical candidates. • Major complications were detected in 2.3% of the patients. • The local tumour progression-free survival rate was 97.6% and 93.0% at 3 and 5 years, respectively.