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Dong BN, Song J, Yang WL, Zhan H, Luan T, Wang JS. Comparison of Outcomes Between Partial and Radical Laparoscopic Nephrectomy for Localized Renal Tumors Larger Than Four Centimeters: A Systematic Review and Meta-Analysis. World J Oncol 2024; 15:625-639. [PMID: 38993256 PMCID: PMC11236382 DOI: 10.14740/wjon1866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 05/25/2024] [Indexed: 07/13/2024] Open
Abstract
Background Earlier studies have juxtaposed different laparoscopic methods for treating renal tumors; however, extensive evidence with a particular focus on large kidney tumors remains lacking. The objective of this meta-analysis was to assess the perioperative outcomes, kidney performance, and cancer-related results of laparoscopic partial nephrectomy (LPN) versus laparoscopic radical nephrectomy (LRN) for treating extensive, localized, non-metastatic kidney tumors (cT1b-cT2N0M0). Methods We systematically searched multiple databases from database inception until December 2023 for relevant studies. Selected data were analyzed with the Cochrane Collaboration's Review Manager 5.4 software using a random-effects model. Outcomes were expressed as odds ratios and weighted mean differences with 95% confidence intervals, considering a P value of < 0.05 as significant. Results Data from nine studies encompassing 1,303 patients (529 LPN, 774 LRN) revealed that LPN was associated with lengthier surgeries and increased blood loss compared to LRN. While LPN exhibited higher postoperative complication rates, the disparity did not reach statistical significance. LPN led to improved postoperative renal function, manifesting as a reduced estimated glomerular filtration rate (eGFR) decline and fewer incidents of new chronic kidney disease cases. Both groups demonstrated comparable tumor recurrence and overall mortality rates, but LPN exhibited significantly lower cancer-specific mortality rates. Conclusions LPN, despite longer operative times and greater intraoperative blood loss, was found to be superior to LRN in preserving postoperative renal function. Oncologically, LPN and LRN have comparable overall mortality rates, but LPN showed a significant advantage in terms of lower cancer-specific mortality rates.
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Affiliation(s)
- Bao Nan Dong
- Urology Surgery Department, The Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Jie Song
- Urology Surgery Department, The Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Wen Li Yang
- Urology Surgery Department, The Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Hui Zhan
- Urology Surgery Department, The Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Ting Luan
- Urology Surgery Department, The Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Jian Song Wang
- Urology Surgery Department, The Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
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Lin Z, Yang W, Zhang W, Jiang C, Chu J, Yang J, Yuan X. Recognizing pathology of renal tumor from macroscopic cross-section image by deep learning. Biomed Eng Online 2023; 22:3. [PMID: 36670469 PMCID: PMC9854121 DOI: 10.1186/s12938-023-01064-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 01/09/2023] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES This study aims to develop and evaluate the deep learning-based classification model for recognizing the pathology of renal tumor from macroscopic cross-section image. METHODS A total of 467 pathology-confirmed patients who received radical nephrectomy or partial nephrectomy were retrospectively enrolled. The experiment of distinguishing malignant and benign renal tumor are conducted followed by performing the multi-subtypes classification models for recognizing four subtypes of benign tumor and four subtypes of malignant tumors, respectively. The classification models used the same backbone networks which are based on the convolutional neural network (CNN), including EfficientNet-B4, ResNet-18, and VGG-16. The performance of the classification models was evaluated by area under the receiver operating characteristic curve (AUC), sensitivity, specificity, and accuracy. Besides, we performed the quantitative comparison among these CNN models. RESULTS For the model to differentiate the malignant tumor from the benign tumor, three CNN models all obtained relatively satisfactory performance and the highest AUC was achieved by the ResNet-18 model (AUC = 0.9226). There is not statistically significance between EfficientNet-B4 and ResNet-18 architectures and both of them are significantly statistically better than the VGG-16 model. The micro-averaged AUC, macro-averaged sensitivity, macro-averaged specificity, and micro-averaged accuracy for the VGG-16 model to distinguish the malignant tumor subtypes achieved 0.9398, 0.5774, 0.8660, and 0.7917, respectively. The performance of the EfficientNet-B4 is not better than that of VGG-16 in terms of micro-averaged AUC except for other metrics. For the models to recognize the benign tumor subtypes, the EfficientNet-B4 ranked the best performance, but had no significantly statistical difference with other two models with respect to micro-averaged AUC. CONCLUSIONS The classification results were relatively satisfactory, which showed the potential for clinical application when analyzing the renal tumor macroscopic cross-section images. Automatically distinguishing the malignant tumor from benign tumor and identifying the subtypes pathology of renal tumor could make the patient-management process more efficient.
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Affiliation(s)
- Zefang Lin
- grid.258164.c0000 0004 1790 3548Zhuhai Interventional Medical Center, Zhuhai Precision Medical Center, Zhuhai People’s Hospital, Zhuhai Hospital Affiliated with Jinan University, Jinan University, Zhuhai, China
| | - Weihong Yang
- grid.258164.c0000 0004 1790 3548Department of Medical Equipment Engineering, Zhuhai People’s Hospital, Zhuhai Hospital Affiliated with Jinan University, Jinan University, Zhuhai, China
| | - Wenqiang Zhang
- grid.258164.c0000 0004 1790 3548Department of Urology, Zhuhai People’s Hospital, Zhuhai Hospital Affiliated with Jinan University, Jinan University, Zhuhai, China
| | - Chao Jiang
- Nursing Department, Guizhou Aerospace Hospital, Zunyi, China
| | - Jing Chu
- grid.258164.c0000 0004 1790 3548Department of Urology, Zhuhai People’s Hospital, Zhuhai Hospital Affiliated with Jinan University, Jinan University, Zhuhai, China
| | - Jing Yang
- grid.258164.c0000 0004 1790 3548Department of Pathology, Zhuhai People’s Hospital, Zhuhai Hospital Affiliated with Jinan University, Jinan University, Zhuhai, China
| | - Xiaoxu Yuan
- grid.258164.c0000 0004 1790 3548Department of Urology, Zhuhai People’s Hospital, Zhuhai Hospital Affiliated with Jinan University, Jinan University, Zhuhai, China
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Bai R, Gao L, Wang J, Jiang Q. Positive surgical margins may not affect the survival of patients with renal cell carcinoma after partial nephrectomy: A meta-analysis based on 39 studies. Front Oncol 2022; 12:945166. [PMID: 36033492 PMCID: PMC9399599 DOI: 10.3389/fonc.2022.945166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 07/22/2022] [Indexed: 11/13/2022] Open
Abstract
Background So far, whether positive surgical margin(PSM) has adverse effects on the prognosis of patients is still controversial, so we designed this study to systematically evaluate the effect of PSM on the prognosis of patients with renal cell carcinoma (RCC) after partial nephrectomy (PN). Methods On the basis of three electronic databases (PubMed, Embase and the Cochrane Library) up to May 2022, all case-control studies (CCSs) comparing the effects of PSM and negative surgical margin (NSM) after PN on the oncological results of RCC patients were included. Two evaluators independently conducted a systematic literature search and extracted the data we needed. The methodological quality of all studies was evaluated by the modified Newcastle-Ottawa scale. The odds ratio (OR) was used to describe the results for dichotomous variables, and the meta-analysis was conducted using Cochrane Review Manager 5.2 and Stata 14.2. Results A total of 39 studies involving 21461 patients were included in our meta-analysis. The pooled results showed that the rates of tumor recurrence (OR 3.93, 95% CI 2.95-5.24; p < 0.00001) and metastasis (OR 4.63, 95% CI 3.11-6.88; p < 0.00001) in the PSM group were significantly higher than those in the NSM group. However, there were no significant differences in the rates of all-cause death (OR 1.35, 95% CI 0.92-1.99; p = 0.13) or cancer-specific death (OR 0.99, 95% CI 0.51-1.94; p = 0.99) between the two groups. In addition, subgroup analyses were carried out according to different average follow-ups, which revealed similar results. Conclusion Insignificant differences in survival between the PSM and NSM groups were observed, although significant differences in recurrence and metastasis in the PSM group were reported. Our study supported that close monitoring might be another effective choice for patients with PSM after PN. Considering the possible limitations, we recommended cautious interpretation of our results.
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Affiliation(s)
- Renran Bai
- Department of Nephrology, Qianjiang Central Hospital, Chongqing, China
| | - Liang Gao
- Department of Urology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jiawu Wang
- Department of Urology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qing Jiang
- Department of Urology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Yun JK, Kim SH, Kim WB, Kim HK, Lee SW. Simultaneous robot-assisted approach in a super-elderly patient with urothelial carcinoma and synchronous contralateral renal cell carcinoma: A case report. World J Clin Cases 2022; 10:7153-7162. [PMID: 36051108 PMCID: PMC9297406 DOI: 10.12998/wjcc.v10.i20.7153] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 04/04/2022] [Accepted: 05/22/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND It is rare for urothelial and renal cell carcinomas to coexist in the same patient, and even rarer for them to be detected simultaneously. Because of this rarity, a standard treatment has not been established and studies about overall survival are scarce. Therefore, physicians must modify treatments according to the individual’s situation and the stage of each disease. In recent years, with advances in the instruments and techniques, minimal invasive robotic surgeries have become available for advanced-stage or high-risk patients.
CASE SUMMARY An 85-year-old woman with a medical history of hypertension and hyperlipidemia visited our institution. She had visited her local hospital complaining of intermittent, painless, gross hematuria that had started 3 mo earlier. On computed tomography, a right renal mass and left proximal ureteral mass with hydronephrosis were found simultaneously. We decided to perform robot-assisted surgery on both sides during one operation. Considering renal function and kidney loading, right partial nephrectomy was performed first, followed by left nephroureterectomy with bladder cuff excision. At the 6-mo follow-up, no specific symptoms were reported and dialysis was not considered. There were no unusual findings in the imaging study, and regular follow-up and imaging studies are scheduled.
CONCLUSION This case report assessed the feasibility of simultaneous minimal invasive robotic surgery as an alternative to conventional open or laparoscopic surgery.
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Affiliation(s)
- Ji Kang Yun
- Department of Urology, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon 14584, South Korea
| | - Si Hyun Kim
- Department of Urology, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan 31151, South Korea
| | - Woong Bin Kim
- Department of Urology, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon 14584, South Korea
| | - Hee Kyung Kim
- Department of Pathology, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon 14584, South Korea
| | - Sang Wook Lee
- Department of Urology, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon 14584, South Korea
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Outcome of laparoscopic nephron sparing surgery using a Satinsky clamp for hilar control: a trusted tool (SKIMS experience). Curr Urol 2021; 15:172-175. [PMID: 34552458 PMCID: PMC8451325 DOI: 10.1097/cu9.0000000000000022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 03/09/2020] [Indexed: 01/10/2023] Open
Abstract
Background Nephron sparing surgery is a well-established surgical procedure for patients with small/bilateral renal masses. During the procedure, hilar control can be achieved by using bulldog clamps individually on the renal vessels, the renal artery alone without clamping the vein, or a laparoscopic Satinsky clamp for en bloc hilar clamping. In our series, we described the outcome of laparoscopic nephron sparing surgery using a Satinsky clamp for hilar control. Materials and methods All eligible cases with confirmed diagnosis of a renal mass were advised of nephron sparing surgery. The short-term outcomes were evaluated by warm ischemia time (using a Satinsky clamp especially when CT renal angiography was not available), average blood loss, and length of postoperative hospital stay. The oncological outcome was evaluated by noting the surgical margins of histopathological specimen, local recurrence, and distant metastasis. Results Of 30 cases 20 were male. The mean age was 54.25 years. On preoperative evaluation, 24 cases were T1a stage and the rest were 6 T1b stage. Four tumors were located in the upper pole, 4 in the posterior midpole, and 22 in the lower pole. Twenty-six patients had a low complexity score on RENAL scoring (ie, 4-6) and 4 patients a medium complexity score (ie, 7-9). Three patients were converted to open partial nephrectomy because of technical difficulty in intracorporeal suturing and difficulty in achieving hemostasis. Among these 3 patients, 2 patients had posterior base tumors and 1 had a lower polar tumor. Average blood loss was 350 ml, warm ischemia time was 28.46 minutes, and postoperative stay was 4.55 days. Of 30 specimens for histopathology, 23 (76%) were clear cell renal cell carcinoma (RCC), 4 (13%) were papillary RCC, 1 (3.3%) was chromophobe RCC, whereas 2 (6.6%) were benign (oncocytoma). Margins were free of tumors in all the patients with no recurrence in 2 years of follow-up. Conclusion Laparoscopic partial nephrectomy by using a Satinsky clamp as a tool for en bloc hilar clamping in the proper axis at the hilum takes care of multiple vessels irrespective of size and number, particularly when renal angiography is not available. This technique of en bloc hilar clamping is quite useful especially in developing countries where robotic facilities are not available. The Satinsky clamp decreases blood loss and intraoperative time.
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Abstract
Surgical resection of renal cell carcinoma plays a large role in the overall management of the disease. The gold standard for surgical management historically has been open or laparoscopic radical nephrectomy, however, evidence of equivalent oncologic efficacy with improved clinical outcomes has driven the use of nephron-sparing surgeries, especially for smaller and localized renal tumors. A role for surgery remains in metastatic RCC as well, but controversy exists as to which patients may benefit most from surgical intervention in addition to other systemic targeted therapies. This article focuses specifically on renal cell carcinoma, transitional cell carcinoma is not described here.
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Carvalho JAM, Nunes P, Tavares-da-Silva E, Parada B, Jarimba R, Moreira P, Retroz E, Caetano R, Sousa V, Cipriano A, Figueiredo A. Impact of Positive Surgical Margins After Partial Nephrectomy. EUR UROL SUPPL 2020; 21:41-46. [PMID: 34337467 PMCID: PMC8317835 DOI: 10.1016/j.euros.2020.08.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2020] [Indexed: 01/27/2023] Open
Abstract
Background The impact of positive surgical margins (PSMs) after partial nephrectomy (PN) is controversial. Objective To evaluate the risk factors for a PSM and its impact on overall survival. Design, setting, and participants This is a retrospective study of 388 patients were submitted to PN between November 2005 and December 2016 in a single centre. Two groups were created: PSM and negative surgical margin (NSM) after PN. A p value of <0.05 was considered significant. Outcome measurements and statistical analysis Relationships with outcome were assessed using univariable and multivariable tests and log-rank analysis. Results and limitations The PSM rate was 3.8% (N = 16). The mean age at the time of surgery (PSM group: 64.1 ± 11.3 vs NSM group: 61.8 ± 12.8 yr, p = 0.5) and the mean radiological tumour size (4.0 ± 1.5 vs 3.4 ± 1.8 cm, p = 0.2) were similar. Lesion location (p = 0.3), surgical approach (p = 0.4), warm ischaemia time (p = 0.9), and surgery time (p = 0.06) had no association with PSM. However, higher surgeon experience was associated with a lower PSM incidence (2.6% if ≥30 PNs vs 9.6% if <30 PNs; p = 0.02). Higher operative blood loss (p = 0.02), higher-risk tumours (p = 0.03), and larger pathological size (p = 0.05) were associated with an increase in PSM. In the PSM group, recurrence rate (18.7% vs 4.2%, p = 0.007) and secondary total nephrectomy rate (25% vs 4.4%, p < 0.001) were higher. However, overall survival was similar. Multivariate analysis revealed that high-risk tumour (p = 0.05) and low experience (p = 0.03) could predict a PSM. Limitations include retrospective design and reduced follow-up time. Conclusions PSMs were mainly associated with high-risk pathological tumour (p = 0.05) and low-volume surgeon experience. Recurrence rate and need for total nephrectomy were higher in that group, but no impact on survival was noticed. Patient summary The impact of positive surgical margins (PSMs) after partial nephrectomy is a matter of debate. In this study, we found that PSMs were mainly associated with aggressive disease and low surgeon experience.
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Affiliation(s)
- João André Mendes Carvalho
- Department of Urology and Renal Transplantation, Coimbra University Hospital Center, Coimbra, Portugal.,Faculty of Medicine, Coimbra University, Coimbra, Portugal
| | - Pedro Nunes
- Department of Urology and Renal Transplantation, Coimbra University Hospital Center, Coimbra, Portugal.,Faculty of Medicine, Coimbra University, Coimbra, Portugal
| | - Edgar Tavares-da-Silva
- Department of Urology and Renal Transplantation, Coimbra University Hospital Center, Coimbra, Portugal.,Faculty of Medicine, Coimbra University, Coimbra, Portugal
| | - Belmiro Parada
- Department of Urology and Renal Transplantation, Coimbra University Hospital Center, Coimbra, Portugal.,Faculty of Medicine, Coimbra University, Coimbra, Portugal
| | - Roberto Jarimba
- Department of Urology and Renal Transplantation, Coimbra University Hospital Center, Coimbra, Portugal
| | - Pedro Moreira
- Department of Urology and Renal Transplantation, Coimbra University Hospital Center, Coimbra, Portugal
| | - Edson Retroz
- Department of Urology and Renal Transplantation, Coimbra University Hospital Center, Coimbra, Portugal
| | - Rui Caetano
- Department of Pathology, Coimbra University Hospital Center, Coimbra, Portugal
| | - Vítor Sousa
- Faculty of Medicine, Coimbra University, Coimbra, Portugal.,Department of Pathology, Coimbra University Hospital Center, Coimbra, Portugal
| | - Augusta Cipriano
- Faculty of Medicine, Coimbra University, Coimbra, Portugal.,Department of Pathology, Coimbra University Hospital Center, Coimbra, Portugal
| | - Arnaldo Figueiredo
- Department of Urology and Renal Transplantation, Coimbra University Hospital Center, Coimbra, Portugal.,Faculty of Medicine, Coimbra University, Coimbra, Portugal
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Ryan ST, Patel DN, Ghali F, Patel SH, Sarkar R, Yim K, Eldefrawy A, Cotta BH, Bradshaw AW, Meagher MF, Hamilton ZA, Murphy JD, Derweesh IH. Impact of positive surgical margins on survival after partial nephrectomy in localized kidney cancer: analysis of the National Cancer Database. Minerva Urol Nephrol 2020; 73:233-244. [PMID: 32748614 DOI: 10.23736/s2724-6051.20.03728-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND The impact of positive surgical margins (PSM) on outcomes in partial nephrectomy (PN) is controversial. We investigated impact of PSM for patients undergoing PN on overall survival (OS) in different stages of renal cell carcinoma (RCC). METHODS Retrospective analysis of patients from the US National Cancer Database who underwent PN for cT1a-cT2b N0M0 RCC between 2004-13. Patients were stratified by pathological stage (pT1a, pT1b, pT2a, pT2b, and pT3a [upstaged]) and analyzed by margin status. Cox Regression multivariable analysis (MVA) was performed to investigate associations of PSM and covariates on all-cause mortality (ACM). Kaplan-Meier analysis (KMA) of OS was performed for PSM versus negative margin (NSM) by pathological stage. Sub-analysis of Charlson Comorbidity Index 0 (CCI=0) subgroup was conducted to reduce bias from comorbidities. RESULTS We analyzed 42,113 PN (pT1a: 33,341 [79.2%]; pT1a, pT1b: 6689 [15.9%]; pT2a: 757 [1.8%]; pT2b: 165 [0.4%]; and pT3a: upstaged 1161 [2.8%]). PSM occurred in 6.7% (2823) (pT1a: 6.5%, pT1b: 6.3%, pT2a: 5.9%, pT2b: 6.1%, pT3a: 14.1%, P<0.001). On MVA, PSM was associated with 31% increase in ACM (HR 1.31, P<0.001), which persisted in CCI=0 sub-analysis (HR: 1.25, P<0.001). KMA revealed negative impact of PSM vs. NSM on 5-year OS: pT1 (87.3% vs. 90.9%, P<0.001), pT2 (86.7% vs. 82.5%, P=0.48), and upstaged pT3a (69% vs. 84.2%, P<0.001). CONCLUSIONS PSM after PN was independently associated with across-the-board decrement in OS, which worsened in pT3a disease and persisted in sub-analysis of patients with CCI=0. PSM should prompt more aggressive surveillance or definitive resection strategies.
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Affiliation(s)
- Stephen T Ryan
- Department of Urology, University of California San Diego School of Medicine, La Jolla, CA, USA
| | - Devin N Patel
- Department of Urology, University of California San Diego School of Medicine, La Jolla, CA, USA
| | - Fady Ghali
- Department of Urology, University of California San Diego School of Medicine, La Jolla, CA, USA
| | - Sunil H Patel
- Department of Urology, University of California San Diego School of Medicine, La Jolla, CA, USA
| | - Reith Sarkar
- Department of Radiation Medicine, University of California San Diego School of Medicine, La Jolla, CA, USA
| | - Kendrick Yim
- Department of Urology, University of California San Diego School of Medicine, La Jolla, CA, USA
| | - Ahmed Eldefrawy
- Department of Urology, University of California San Diego School of Medicine, La Jolla, CA, USA
| | - Brittney H Cotta
- Department of Urology, University of California San Diego School of Medicine, La Jolla, CA, USA
| | - Aaron W Bradshaw
- Department of Urology, University of California San Diego School of Medicine, La Jolla, CA, USA
| | - Margaret F Meagher
- Department of Urology, University of California San Diego School of Medicine, La Jolla, CA, USA
| | - Zachary A Hamilton
- Department of Urology, University of California San Diego School of Medicine, La Jolla, CA, USA
| | - James D Murphy
- Department of Radiation Medicine, University of California San Diego School of Medicine, La Jolla, CA, USA
| | - Ithaar H Derweesh
- Department of Urology, University of California San Diego School of Medicine, La Jolla, CA, USA -
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Castilho TML, Lemos GC, Cha JD, Colombo JR, Claros OR, Lemos MB, Carneiro A. Transition from open partial nephrectomy directly to robotic surgery: experience of a single surgeon to achieve "TRIFECTA". Int Braz J Urol 2020; 46:814-821. [PMID: 32648421 PMCID: PMC7822359 DOI: 10.1590/s1677-5538.ibju.2019.0101] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 08/20/2019] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Recent data suggest that robotic platform has become the most accessible minimal invasive surgery even for surgeons without previous training in laparoscopy. Laparoscopic partial nephrectomy (LPN) is a well-stablished procedure, however, with high level of complexity and long learning curve that limit its use. OBJECTIVE To describe safety, efficiency and learning curve of a single surgeon without previous experience in LPN to reach "TRIFECTA" at robot-assisted partial nephrectomy (RAPN). PATIENTS AND METHODS This is a retrospective study, with prospective data collection of 101 patients submitted to RAPN by a single surgeon. In order to analyze the learning curve, sample was chronologically divided in two phases: first phase: P1: 50 first patients, second phase: P2: 51 subsequent patients. TRIFECTA was defined as: ischemia time lower than 25 minutes, negative surgical margin and absence of severe complications (Clavien >2). RESULTS Mean age of patients was 54 years (SD=11.85), median tumor size was 32mm (SD=17) and surgery was performed with zero ischemia time in 33.6% of patients (29.8% at P1 and 40.9% at P2). Demographic data of patients were similar between both groups, except tumor size (P1=27.5mm vs. P2=35.3mm; p=0.02) and body mass index (BMI) (P1=26.6kg/m2 vs. P2=29kg/m2; p=0.03). Rate of bleeding, surgical time, presence of positive margin and peri-operatory surgical complications were similar in both phases. TRIFECTA was higher in P2 in relation to P1 (P1: 58% vs. P2: 87.8%; p=0.002) and median time of hot ischemia was significantly lower at P2 (P1: 17.3 vs. P2: 11.7; p=0.02). At multivariate analysis independent factors related to TRIFECTA included: chronological phase (OR 10.74; 95% IC: 1.63-70.53; p=0.013) and tumor size (OR 0.95; 95% IC: 0.91-0.99; p=0.024). CONCLUSION RAPN seems to be safe and efficient with good functional and oncological results (TRIFECTA) since the beginning. Experience improvement was related to treatment of larger tumors, higher proportion of patients with zero ischemia and higher rate of TRIFECTA.
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Affiliation(s)
| | | | | | | | | | | | - Arie Carneiro
- Hospital Israelita Albert Einstein, São Paulo, SP, Brasil
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Fernández-Concha Schwalb J, Pérez Reggeti J, López Costea M, Bonet Puntí X, Ramos Reina H, Vigués Julia F. Positive margins after partial nephrectomy in renal cell carcinoma: Oncological outcomes of conservative management after long-term follow-up. Actas Urol Esp 2019; 43:414-418. [PMID: 31171378 DOI: 10.1016/j.acuro.2019.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 02/09/2019] [Accepted: 03/04/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Partial nephrectomy (PN) is the standard treatment for small and localized kidney tumours (cT1). One of the controversial aspects regarding this technique is the management of affected/positive resection margins. We present the long-term oncological results in patients with PSM after PN managed conservatively. MATERIAL AND METHODS There were 207 PN performed in our centre between 1990 and 2011. 17 patients presented PSM. 2 patients were excluded from the study due to completion nephrectomy afterwards. Follow-up was was done with abdominal contrast-enhanced computed tomography every 6 months for the first 2 years and subsequently, once a year. Cancer-specific survival and disease-free survival were calculated with the Kaplan-Meier method. RESULTS The median age was 62 years (RIQ: 55-71) and the mean tumour size was 34.8 (10-77) mm. Histopathological results were: 6 (40%) clear cell RCC, 4 (26.7%) papillary, 3 (20%) chromophobe and 2 (13.3%) oncocytic. The pathologic stages were: 11 (73.3%) pT1a, 1 (6.7%) pT1b and 3 (20%) pT3a. The median follow-up was 84 months (IQR 72-120). 2 patients had metastatic recurrence and this was the cause of death. The first one had recurrence at 112 months and the second one at 59. 5-year CSS and RFS were 87.5% and 93.3% respectively. CONCLUSIONS In our experience, patients with PSM after PN can be managed conservatively with satisfactory long-term oncological outcomes.
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Hao B, Peng X, Bi B, Yu M, Sang C, Chen Z. Preoperative serum high-density lipoprotein cholesterol as a predictor of poor survival in patients with clear cell renal cell cancer. Int J Biol Markers 2019; 34:168-175. [PMID: 30912469 DOI: 10.1177/1724600819831404] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Purpose: Numerous studies have suggested that dyslipidemia is closely related to various cancers and the high-density lipoprotein cholesterol (HDL-C) levels are associated with the outcome of cancer patients. However, the predictive value of HDL-C in patients with renal cell carcinoma remains unclear. Our study aims to explore the relationship between the levels of serum HDL-C and the prognosis of renal cell carcinoma. Methods: A total of 308 patients diagnosed with clear cell renal cell carcinoma (CCRCC) who received surgical treatment were retrospectively enrolled in our study. The necessary clinical data of each enrolled patient were collected and the Kaplan–Meier method and the Cox proportional hazards regression model were used to calculate the overall survival and cancer-specific survival. Results: Kaplan–Meier and univariate analysis showed that a lower preoperative serum HDL-C level was a risk factor of CCRCC patients. Multivariate analyses demonstrated that a higher serum HDL-C level was closely associated with better overall survival (hazard ratio = 0.32; 95% confidence interval (0.13, 0.78); P=0.013) and cancer-specific survival (hazard ratio =0.42; 95% confidence interval (0.15, 0.99); P=0.048). Conclusion: Our findings suggest that an increased serum level of HDL-C might predict better overall survival and cancer-specific survival in patients with CCRCC.
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Affiliation(s)
- Bo Hao
- Department of Cardiothoracic Surgery, the Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Xufeng Peng
- Department of Urology, Children’s Hospital of Shanghai, Shanghai Jiao Tong University, Shanghai, China
| | - Baochen Bi
- Department of Cardiothoracic Surgery, the Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Miaomei Yu
- Comprehensive Laboratory, the Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Chen Sang
- Department of Cardiothoracic Surgery, the Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Zhen Chen
- Department of Urology, the Third Affiliated Hospital of Soochow University, Changzhou, China
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12
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Marchiñena PG, Tirapegui S, Gonzalez IT, Jurado A, Gueglio G. Positive surgical margins are predictors of local recurrence in conservative kidney surgery for pT1 tumors. Int Braz J Urol 2018; 44:475-482. [PMID: 29368873 PMCID: PMC5996790 DOI: 10.1590/s1677-5538.ibju.2017.0039] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 10/30/2018] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES The clinical significance of positive surgical margin (PSM) after a Nephron Sparing Surgery (NSS) is controversial. The aim of this study is to evaluate the association between PSM and the risk of disease recurrence in patients with pT1 kidney tumors who underwent NSS. MATERIALS AND METHODS Retrospective cohort study. A total of 314 patients submitted to a NSS due to stage pT1 renal tumor between January 2010 and June 2015 were included. Recurrence-free survival was estimated. The Cox model was used to adjust the tumor size, histological grade, pathological stage, age, surgical margins and type of approach. RESULTS Overall PSM was 6.3% (n=22). Recurrence was evidenced in 9.1% (n=2) of patients with PSM and 3.5% (n=10) for the group of negative surgical margin (NSM). The estimated local recurrence-free survival rate at 3 years was 96.4% (95% CI 91.9 to 100) for the NSM group and 87.8% (95% CI 71.9 to 100) for PSM group (p=0.02) with no difference in metastasis-free survival. The PSM and pathological high grade (Fuhrman grade III or IV) were independent predictors of local recurrence in the multivariate analysis (HR 12.9, 95%CI 1.8-94, p=0.011 / HR 38.3, 95%CI 3.1-467, p=0.004 respectively). Fuhrman grade proved to be predictor of distant recurrence (HR 8.1, 95%CI 1.6-39.7, p=0.011). CONCLUSIONS The PSM in pT1 renal tumors showed to have higher risk of local recurrence and thus, worse oncological prognosis.
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Affiliation(s)
| | - Sebastián Tirapegui
- Department of Urology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - Alberto Jurado
- Department of Urology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Guillermo Gueglio
- Department of Urology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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13
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Wang M, Tulman DB, Sholl AB, Mandava SH, Maddox MM, Lee BR, Brown JQ. Partial nephrectomy margin imaging using structured illumination microscopy. JOURNAL OF BIOPHOTONICS 2018; 11:10.1002/jbio.201600328. [PMID: 28834287 PMCID: PMC5821599 DOI: 10.1002/jbio.201600328] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 05/19/2017] [Accepted: 08/17/2017] [Indexed: 06/07/2023]
Abstract
Partial nephrectomy (PN) is the recommended procedure over radical nephrectomy (RN) for patients with renal masses less than 4 cm in diameter (Stage T1a). Patients with less than 4 cm renal masses can also be treated with PN, but have a higher risk for positive surgical margins (PSM). PSM, when present, are indicative of poor clinical outcomes. The current gold-standard histopathology method is not well-suited for the identification of PSM intraoperatively due to processing time and destructive nature. Here, video-rate structured illumination microscopy (VR-SIM) was investigated as a potential tool for PSM detection during PN. A clinical image atlas assembled from ex vivo renal biopsies provided diagnostically useful images of benign and malignant kidney, similar to permanent histopathology. VR-SIM was then used to image entire parenchymal margins of tumor resection covering up to >1800× more margin surface area than standard histology. Aided by the image atlas, the study pathologist correctly classified all parenchymal margins as negative for PSM with VR-SIM, compared to standard postoperative pathology. The ability to evaluate large surgical margins in a short time frame with VR-SIM may allow it to be used intraoperatively as a "safety net" for PSM detection, allowing more patients to undergo PN over RN.
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Affiliation(s)
- Mei Wang
- Department of Biomedical Engineering, Tulane University, New Orleans, LA 70118
| | - David B. Tulman
- Bioinnovation Program, Tulane University, New Orleans, LA 70118
| | - Andrew B. Sholl
- Department of Pathology and Laboratory Medicine, Tulane University School of Medicine, New Orleans, LA 70112
| | - Sree H. Mandava
- Department of Urology, Tulane University School of Medicine, New Orleans, LA 70112
| | - Michael M. Maddox
- Department of Urology, Tulane University School of Medicine, New Orleans, LA 70112
| | - Benjamin R. Lee
- Division of Urology, University of Arizona College of Medicine, Tucson, AZ 85724
| | - J. Quincy Brown
- Department of Biomedical Engineering, Tulane University, New Orleans, LA 70118
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14
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Chen VS, Abouassaly R, Gonzalez CM, Kutikov A, Smaldone MC, Meropol NJ, Psutka SP, Williams SB, O’Malley R, Sedlacek HM, Kim SP. Association of race and margin status among patients undergoing robotic partial nephrectomy for T1 renal cell carcinoma: Results from a population-based cohort. Urol Oncol 2017; 35:662.e17-662.e21. [DOI: 10.1016/j.urolonc.2017.07.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 05/23/2017] [Accepted: 07/10/2017] [Indexed: 12/17/2022]
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15
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Wang B, Gong H, Ma X, Li H, Yan Y, Cai W, Shi L, Li X, Zhang X. Retroperitoneal Laparoscopic Nephrotomy Along the Brodel Line and Tumor Enucleation for Complete Intraparenchymal Renal Tumors: A Single Institution Experience. J Endourol 2017; 31:1044-1048. [PMID: 28747133 DOI: 10.1089/end.2017.0236] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- Baojun Wang
- State Key Laboratory of Kidney Diseases, Department of Urology Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Huijie Gong
- Department of Urology, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Xin Ma
- State Key Laboratory of Kidney Diseases, Department of Urology Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Hongzhao Li
- State Key Laboratory of Kidney Diseases, Department of Urology Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Yongji Yan
- Department of Urology, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Wei Cai
- State Key Laboratory of Kidney Diseases, Department of Urology Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Lixin Shi
- State Key Laboratory of Kidney Diseases, Department of Urology Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Xintao Li
- State Key Laboratory of Kidney Diseases, Department of Urology Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Xu Zhang
- State Key Laboratory of Kidney Diseases, Department of Urology Chinese PLA General Hospital/PLA Medical School, Beijing, China
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16
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Ng AM, Shah PH, Kavoussi LR. Laparoscopic Partial Nephrectomy: A Narrative Review and Comparison with Open and Robotic Partial Nephrectomy. J Endourol 2017; 31:976-984. [PMID: 28937805 DOI: 10.1089/end.2017.0063] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION Kidney cancer ranks among the top 10 most prevalent cancers in Western society, ∼90% of which are renal cell carcinomas. There has been a paradigm shift in the management of small renal masses with strong emphasis now placed on nephron-sparing surgery and increased utilization of laparoscopic approaches to partial nephrectomy. In this review, the current state of laparoscopic partial nephrectomy (LPN) is discussed. EVIDENCE ACQUISITION The PubMed database was queried using the MeSH terms "laparoscopy" and "nephrectomy," as well as the search term "partial." A search was performed filtering for "clinical trial," "review," "humans", and "English." EVIDENCE SYNTHESIS Articles that discussed intraoperative techniques, functional and oncologic outcomes, and a comparison between robot-assisted partial nephrectomy and LPN were synthesized. CONCLUSION LPN reduces ischemia time, affords equivalent functional outcomes, oncologic outcomes, and equivalent complication rates compared with open partial nephrectomy. Future advances in laparoscopic technique and advancements in robotic technology offer potential to improve surgical and patient outcomes.
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Affiliation(s)
- Andrew M Ng
- Arthur Smith Institute of Urology , New Hyde Park, New York
| | - Paras H Shah
- Arthur Smith Institute of Urology , New Hyde Park, New York
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Al-Qudah HS, Rodriguez AR, Sexton WJ. Laparoscopic Management of Kidney Cancer: Updated Review. Cancer Control 2017; 14:218-30. [PMID: 17615527 DOI: 10.1177/107327480701400304] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Laparoscopy has emerged as the preferred option for the surgical management of kidney cancer. Although many reports have been published regarding the operative outcome of renal cell carcinoma (RCC) and upper-tract transitional cell carcinoma (TCCA) treated laparoscopically, few review the oncologic outcome of these pathologies treated with laparoscopic techniques. METHODS We review the literature regarding the laparoscopic approaches, the complications related to laparoscopic surgery, and the long-term oncologic results of laparoscopic radical nephrectomy, partial nephrectomy, and nephroureterectomy. RESULTS Laparoscopic radical nephrectomy has become the new standard of care for most patients with suspected RCCs that are not amenable to nephron-sparing procedures. Laparoscopic techniques for managing RCC and TCCA are safe, follow well-established guidelines for surgical dissection, and meet or exceed perioperative convalescence and oncologic outcomes compared to traditional open procedures. The surgical techniques and the long-term outcome data for laparoscopic partial nephrectomy continue to mature. CONCLUSIONS Laparoscopy is a minimally invasive option available to most patients with kidney cancer. The immediate benefits of laparoscopy are well established and include less estimated blood loss, decreased pain, shorter perioperative convalescence, and improved cosmesis. Long-term oncologic outcomes of patients treated laparoscopically for kidney tumors resemble those of the open surgical approach.
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Affiliation(s)
- Hosam S Al-Qudah
- Genitourinary Oncology Program, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
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18
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Bansal RK, Tanguay S, Finelli A, Rendon R, Moore RB, Breau RH, Lacombe L, Black PC, Kawakami J, Drachenberg D, Pautler S, Saarela O, Liu Z, Jewett MAS, Kapoor A. Positive surgical margins during partial nephrectomy for renal cell carcinoma: Results from Canadian Kidney Cancer information system (CKCis) collaborative. Can Urol Assoc J 2017; 11:182-187. [PMID: 28652876 DOI: 10.5489/cuaj.4264] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION We sought to determine the incidence, risk factors, and prognosis for patients with positive surgical margin (PSM) during partial nephrectomy (PN) for renal cell carcinoma (RCC). METHODS From the Canadian Kidney Cancer information system (CKCis) database, a historical cohort of PN patients with PSM were identified and compared to negative surgical margin (NSM). Risk factors for PSM were examined through multivariable logistic regression. Kaplan-Meier curves were used to compare progression-free survival. RESULTS Of 1103 patients, 972 (88.1%), 71 (6.4%), and 60 (5.4%) had NSM, PSM, and unknown status, respectively. Median patient age and tumour size were 61 years and 3.0 cm for both groups. From multivariable analysis, pathological stage ≥T3 (odds ratio [OR] 2.51; 95% confidence interval [CI] 1.13-5.60) and Fuhrman grade 4 (OR 5.35; 95% CI 1.11-25.72) were associated with PSM, whereas age, operative technique, and tumour size were not. Forty-nine (5.0%) patients from the NSM cohort and seven (9.9%) from the PSM cohort had a local/systemic progression of disease (adjusted hazard ratio [HR] 1.4; 95% CI 0.6-3.6). There were three (0.3%) cancer-related deaths in the NSM group and none in the PSM group. After median followup of 19 (interquartile range [IQR] 5-42) and 15 (IQR 7-30) months, 855 (91.4%) and 61 (89.7%) patients were alive in the NSM and PSM groups, respectively. CONCLUSIONS PSM occurred in 6.4% of PNs performed for RCC in this pan-Canadian cohort. Higher stage and grade are associated with a higher risk of positive margin. The small association between a PSM and progression suggests that complete nephrectomy is not necessary in patients with a PSM. The main study limitations are lack of nephrometry score and possible reporting bias.
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Affiliation(s)
| | - Simon Tanguay
- Division of Urology, McGill University, Montreal, QC
| | - Antonio Finelli
- Division of Urology, Departments of Surgery and Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, ON
| | - Ricardo Rendon
- Department of Urology, Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, NS
| | - Ronald B Moore
- Division of Urology, University of Alberta, Edmonton, AB
| | | | | | - Peter C Black
- Department of Urology, University of British Columbia, Vancouver, BC
| | - Jun Kawakami
- Southern Alberta Institute of Urology, University of Calgary, Calgary, AB
| | - Darrel Drachenberg
- Section of Urology, Department of Surgery, University of Manitoba, Winnipeg, MB
| | - Stephen Pautler
- Divisions of Urology and Surgical Oncology, Departments of Surgery and Oncology, Western University, London, ON
| | - Olli Saarela
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON
| | | | - Michael A S Jewett
- Division of Urology, Departments of Surgery and Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, ON
| | - Anil Kapoor
- Division of Urology, McMaster University, Hamilton, ON; Canada
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Mouracade P, Kara O, Maurice MJ, Dagenais J, Malkoc E, Nelson RJ, Kaouk JH. Patterns and Predictors of Recurrence after Partial Nephrectomy for Kidney Tumors. J Urol 2016; 197:1403-1409. [PMID: 27993666 DOI: 10.1016/j.juro.2016.12.046] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2016] [Indexed: 01/20/2023]
Abstract
PURPOSE We sought to identify patterns and predictors of recurrence in patients with clinically localized renal cell carcinoma managed by partial nephrectomy. MATERIALS AND METHODS We performed a retrospective study of 830 consecutive cases of partial nephrectomy done between 2007 and 2015 for clinically localized renal cell carcinoma at a single institution. Patient demographics and pathological characteristics were correlated with recurrence patterns (overall, local and distant) and overall survival using Kaplan-Meier and Cox regression analyses. Differences in the recurrence patterns were evaluated. RESULTS Median patient age was 61 years and median tumor size was 3.1 cm. Overall, 11.6% of tumors were stage pT3, 39.3% were high grade, 2.9% had lymphovascular invasion and 7.1% had positive margins. Higher grade, higher stage, positive surgical margins and increased R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of deepest tumor portion to collecting system or sinus, anterior/posterior and location relative to polar line) score were associated with shorter disease-free survival on Kaplan-Meier analysis. On multivariable regression pT (p <0.01), grade (p <0.01) and R.E.N.A.L. score (p = 0.03) remained independent predictors of disease-free survival. Predictors of metastasis were pT stage (HR 4.5) and grade (HR 3.9, both p <0.01), while R.E.N.A.L. score (HR 3.2, p = 0.03) was the single predictor of local recurrence. Five-year disease-free and overall survival probabilities were 91% and 94%, respectively. Local recurrence manifested and developed earlier than metastasis (median 13 vs 22 months, p <0.01). CONCLUSIONS High pT stage, high grade and high R.E.N.A.L. score increase the risk of disease recurrence after partial nephrectomy. The pT stage and grade are predictors of metastasis, while R.E.N.A.L. score predicts local recurrence. Because relapse features and risk factors differ between the 2 recurrence patterns, they should be studied separately in the future.
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Affiliation(s)
- Pascal Mouracade
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Onder Kara
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Matthew J Maurice
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Julien Dagenais
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ercan Malkoc
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ryan J Nelson
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jihad H Kaouk
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio.
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20
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Maurice MJ, Zhu H, Kim SP, Abouassaly R. Reexamining the Association Between Positive Surgical Margins and Survival After Partial Nephrectomy in a Large American Cohort. J Endourol 2016; 30:698-703. [DOI: 10.1089/end.2016.0031] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Matthew J. Maurice
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Hui Zhu
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
- Division of Urology, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio
| | - Simon P. Kim
- Urology Institute, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Robert Abouassaly
- Urology Institute, University Hospitals Case Medical Center, Cleveland, Ohio
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21
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Laguna MP. Re: Partial vs Radical Nephrectomy for T1 Renal Tumours: An Analysis from the British Association of Urological Surgeons Nephrectomy Audit. J Urol 2016; 195:1377-1379. [PMID: 27186720 DOI: 10.1016/j.juro.2016.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2016] [Indexed: 10/22/2022]
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22
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Kang HW, Lee SK, Kim WT, Yun SJ, Lee SC, Kim WJ, Hwang EC, Kang SH, Hong SH, Chung J, Kwon TG, Kim HH, Kwak C, Byun SS, Kim YJ. Surgical margin does not influence recurrence rate in pT1 clear cell renal cell carcinoma after partial nephrectomy: A multicenter study. J Surg Oncol 2016; 114:70-4. [PMID: 27074886 DOI: 10.1002/jso.24259] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 03/26/2016] [Indexed: 02/05/2023]
Abstract
PURPOSE To assess the risk factors of positive surgical margins (PSM) and the influence of margin status on recurrence in pT1 clear cell renal cell carcinoma (RCC) following partial nephrectomy (PN). MATERIALS AND METHODS Patients (1,831) with pathologically confirmed stage T1 clear cell RCC were retrospectively analyzed following PN at eight institutions in Korea between 1999 and 2011. Demographics, operative data, pathological margin status, and site of recurrence were analyzed. RESULTS Resection margins were positive in 31 patients (1.7% of the cohort) on final pathology. None of the clinicopathological parameters were significantly related to the marginal status (all P > 0.05). During a median follow-up of 32.5 months, local recurrences were observed in 0.4% of negative surgical margins. There was no local recurrence in any of the cases with PSM. Distant recurrences developed in 1.7% of negative surgical margins and 3.2% of PSM. There were no significant differences in recurrence-free survival by margin status (P = 0.566). CONCLUSIONS Our multi-institutional data suggest that marginal status does not influence tumor recurrence risk in pT1 clear cell RCC after PN. Careful surveillance seems to be a sufficient strategy in this clinical scenario. J. Surg. Oncol. 2016;114:70-74. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Ho Won Kang
- Department of Urology, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Sang Keun Lee
- Department of Urology, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Won Tae Kim
- Department of Urology, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Seok Joong Yun
- Department of Urology, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Sang-Cheol Lee
- Department of Urology, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Wun-Jae Kim
- Department of Urology, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Eu Chang Hwang
- Department of Urology, Chonnam National University Hwasun Hospital, Jeonnam, Korea
| | - Seok Ho Kang
- Department of Urology, Korea University School of Medicine, Seoul, Korea
| | - Sung-Hoo Hong
- Department of Urology, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jinsoo Chung
- Department of Urology, National Cancer Center, Goyang, Korea
| | - Tae Gyun Kwon
- Department of Urology, Kyungpook National University College of Medicine, Daegu, Korea
| | - Hyeon Hoe Kim
- Department of Urology, Seoul National University College of Medicine, Seoul, Korea
| | - Cheol Kwak
- Department of Urology, Seoul National University College of Medicine, Seoul, Korea
| | - Seok-Soo Byun
- Department of Urology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Yong-June Kim
- Department of Urology, Chungbuk National University College of Medicine, Cheongju, Korea
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Alemozaffar M, Filson CP, Master VA. The importance of surgical margins in renal cell and urothelial carcinomas. J Surg Oncol 2016; 113:316-22. [DOI: 10.1002/jso.24121] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 11/20/2015] [Indexed: 11/11/2022]
Affiliation(s)
| | - Christopher P. Filson
- Department of Urology; Emory University; Atlanta Georgia
- Atlanta Veterans Affairs Medical Center; Decatur Georgia
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24
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Guo S, He X, Chen Q, Yang G, Yao K, Dong P, Ye Y, Chen D, Zhang Z, Qin Z, Liu Z, Li Z, Xue Y, Zhang M, Liu R, Zhou F, Han H. The Effect of Preoperative Apolipoprotein A-I on the Prognosis of Surgical Renal Cell Carcinoma: A Retrospective Large Sample Study. Medicine (Baltimore) 2016; 95:e3147. [PMID: 27015197 PMCID: PMC4998392 DOI: 10.1097/md.0000000000003147] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
The prognostic value of serum lipid-profile in renal cell cancer (RCC) remains unknown. The purpose of the study is to explore the association between the serum lipid-profile and RCC patients.The levels of preoperative serum lipid-profile (including cholesterol, triglycerides, high-density lipoprotein-cholesterol [HDL-C], low-density lipoprotein-cholesterol [LDL-C], apolipoprotein A-I [ApoA-I], and apolipoprotein B [ApoB]) were retrospectively performed in 786 patients with RCC. The cutoff values of the lipids were determined by the receiver-operating characteristic (ROC) curve analysis. Univariate and multivariate Cox regression analyses were performed to investigate the prognostic value of serum lipids in RCC.Combined ROC analysis and univariate and multivariate Cox regression analyses, for overall survival (OS), revealed patients with low ApoA-I (<1.04) had significantly lower OS than the high ApoA-I (≥1.04) group (multivariate Cox regression analyses, hazard ratio [HR], 0.57; P = 0.003). Not only in the whole RCC cohort but also in the subgroups stratified according to the pT1-2 (P = 0.002), pN0 (P < 0.001), and pM0 (P = 0.001) status, respectively. Moreover, in the 755 patients with nonmetastasis, the low ApoA-I group was also associated with shortened disease-free survival (DFS) time compared to the high ApoA-I group (multivariate Cox regression analyses, HR, 0.65; P = 0.033). However, the other lipids were not independent prognostic factors for surgical RCC.An elevated level of preoperative ApoA-I was demonstrated to be related with better survival in patients with surgical RCC. Measuring the preoperative ApoA-I might be a simple way for finding the poor prognostic patients who should enrolled in further clinical trials and management.
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Affiliation(s)
- Shengjie Guo
- From the Department of Urology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou (SG, KY, PD, YY, DC, ZZ, ZQ, ZL, ZL, FZ, HH); Department of Medical Oncology, the Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai (XH, GY); Xinhua College of Sun Yat-Sen University (QC); Medicine School of Sun Yat-Sen University, Guangzhou, China (YX, MZ); and Department of Biochemistry and Molecular Medicine, University of California Davis, Sacramento, CA, USA (RL)
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Shah PH, Moreira DM, Okhunov Z, Patel VR, Chopra S, Razmaria AA, Alom M, George AK, Yaskiv O, Schwartz MJ, Desai M, Vira MA, Richstone L, Landman J, Shalhav AL, Gill I, Kavoussi LR. Positive Surgical Margins Increase Risk of Recurrence after Partial Nephrectomy for High Risk Renal Tumors. J Urol 2016; 196:327-34. [PMID: 26907508 DOI: 10.1016/j.juro.2016.02.075] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2016] [Indexed: 02/07/2023]
Abstract
PURPOSE The clinical significance of a positive surgical margin after partial nephrectomy remains controversial. The association between positive margin and risk of disease recurrence in patients with clinically localized renal neoplasms undergoing partial nephrectomy was evaluated. MATERIALS AND METHODS A retrospective multi-institutional review of 1,240 patients undergoing partial nephrectomy for clinically localized renal cell carcinoma between 2006 and 2013 was performed. Recurrence-free survival was estimated using the Kaplan-Meier method and evaluated as a function of positive surgical margin with the log rank test and Cox models adjusting for tumor size, grade, histology, pathological stage, focality and laterality. The relationship between positive margin and risk of relapse was evaluated independently for pathological high risk (pT2-3a or Fuhrman grades III-IV) and low risk (pT1 and Fuhrman grades I-II) groups. RESULTS A positive surgical margin was encountered in 97 (7.8%) patients. Recurrence developed in 69 (5.6%) patients during a median followup of 33 months, including 37 (10.3%) with high risk disease (eg pT2-pT3a or Fuhrman grade III-IV). A positive margin was associated with an increased risk of relapse on multivariable analysis (HR 2.08, 95% CI 1.09-3.97, p=0.03) but not with site of recurrence. In a stratified analysis based on pathological features, a positive surgical margin was significantly associated with a higher risk of recurrence in cases considered high risk (HR 7.48, 95% CI 2.75-20.34, p <0.001) but not low risk (HR 0.62, 95% CI 0.08-4.75, p=0.647). CONCLUSIONS Positive surgical margins after partial nephrectomy increase the risk of disease recurrence, primarily in patients with adverse pathological features.
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Affiliation(s)
- Paras H Shah
- Department of Urology, Smith Institute for Urology, North Shore LIJ, New Hyde Park, New York.
| | | | - Zhamshid Okhunov
- Department of Urology, University of California, Irvine, California
| | - Vinay R Patel
- Department of Urology, Smith Institute for Urology, North Shore LIJ, New Hyde Park, New York
| | - Sameer Chopra
- USC Institute of Urology, University of Southern California, Los Angeles, California
| | - Aria A Razmaria
- Department of Urology, University of Chicago, Chicago, Illinois
| | - Manaf Alom
- Department of Urology, Smith Institute for Urology, North Shore LIJ, New Hyde Park, New York
| | - Arvin K George
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Oksana Yaskiv
- Department of Urology, Smith Institute for Urology, North Shore LIJ, New Hyde Park, New York
| | - Michael J Schwartz
- Department of Urology, Smith Institute for Urology, North Shore LIJ, New Hyde Park, New York
| | - Mihir Desai
- USC Institute of Urology, University of Southern California, Los Angeles, California
| | - Manish A Vira
- Department of Urology, Smith Institute for Urology, North Shore LIJ, New Hyde Park, New York
| | - Lee Richstone
- Department of Urology, Smith Institute for Urology, North Shore LIJ, New Hyde Park, New York
| | - Jaime Landman
- Department of Urology, University of California, Irvine, California
| | - Arieh L Shalhav
- Department of Urology, University of Chicago, Chicago, Illinois
| | - Inderbir Gill
- USC Institute of Urology, University of Southern California, Los Angeles, California
| | - Louis R Kavoussi
- Department of Urology, Smith Institute for Urology, North Shore LIJ, New Hyde Park, New York
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Tabayoyong W, Abouassaly R, Kiechle JE, Cherullo EE, Meropol NJ, Shah ND, Dong S, Thompson RH, Smaldone MC, Zhu H, Ialacci S, Kim SP. Variation in Surgical Margin Status by Surgical Approach among Patients Undergoing Partial Nephrectomy for Small Renal Masses. J Urol 2015; 194:1548-53. [DOI: 10.1016/j.juro.2015.06.076] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2015] [Indexed: 01/20/2023]
Affiliation(s)
- William Tabayoyong
- Urology Institute, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Robert Abouassaly
- Urology Institute, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio
- Center for Health Care Quality and Outcomes, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio
- Case Comprehensive Cancer Center, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, Ohio
| | - Jonathan E. Kiechle
- Urology Institute, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Edward E. Cherullo
- Urology Institute, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio
- Center for Health Care Quality and Outcomes, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Neal J. Meropol
- Division of Hematology and Oncology, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio
- Case Comprehensive Cancer Center, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, Ohio
| | - Nilay D. Shah
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota
| | - Shan Dong
- Urology Institute, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio
| | | | - Marc C. Smaldone
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Hui Zhu
- Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio
- Department of Urology, Cleveland Clinic, Cleveland, Ohio
| | - Sarah Ialacci
- Urology Institute, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio
- Center for Health Care Quality and Outcomes, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Simon P. Kim
- Urology Institute, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio
- Center for Health Care Quality and Outcomes, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio
- Case Comprehensive Cancer Center, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, Ohio
- Department of Internal Medicine, Cancer Outcomes and Public Policy Effectiveness Research Center, Yale University, New Haven, Connecticut
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Self-assessment of surgical technique leads to reduction of positive surgical margins in partial nephrectomy. J Robot Surg 2015; 9:45-50. [PMID: 26530970 DOI: 10.1007/s11701-014-0485-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Accepted: 08/04/2014] [Indexed: 10/24/2022]
Abstract
The background of the study was to examine potential causes for a positive surgical margin (PSM) and develop strategies to improve surgical outcomes. A retrospective review of consecutive partial nephrectomy cases for renal cell carcinoma was performed. We divided the patients into 2 groups. The first group consisted of the first 67 renal tumors in 65 patients that underwent our early surgical technique. The second group consisted of the next 45 renal tumors in 39 patients that underwent the revised surgical technique which included wider resections and robotically controlled ultrasound. Our primary outcome was margin status and secondary outcome was disease recurrence. Univariate and multivariate analyses were performed to determine factors that resulted in a PSM. Positive margins were detected in 19 out of 67 (28 %) renal tumors in the early technique group compared to 1 out of 45 (2 %) positive margins in the revised technique group (p < 0.001). On multivariate analysis, only technique modification (OR 0.04, p = 0.003) and larger tumor size (OR 0.41, p = 0.01) were significant predictors of a lower rate of PSM. Smaller tumors were more common in robotic assisted partial nephrectomies which had a higher rate of PSM on univariate analysis (OR 3.51, p = 0.04). Only one patient with a PSM experienced a systemic disease recurrence. In our experience, self-assessment and technique modification resulted in a dramatic PSM improvement. Smaller tumors were associated with PSM. It is important for all surgeons to periodically look at their own surgical outcomes and modify their surgical technique accordingly.
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Khemees TA, Lam ET, Joehlin-Price AS, Mortazavi A, Phillips GS, Shabsigh A, Sharp DS, Zynger DL. Does the Renal Parenchyma Adjacent to the Tumor Contribute to Kidney Function? A Critical Analysis of Glomerular Viability in Partial Nephrectomy Specimens. Urology 2015; 87:114-9. [PMID: 26505834 DOI: 10.1016/j.urology.2015.10.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 10/08/2015] [Accepted: 10/15/2015] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To evaluate the viability of glomeruli in the peritumor parenchyma of partial nephrectomy specimens removed for renal cell carcinoma (RCC) and relate it to kidney function, to better understand the contribution of peritumor parenchyma to renal function. MATERIALS AND METHODS A retrospective analysis of 53 partial nephrectomies containing RCC was performed. Glomeruli within 0.25-cm increments from the tumor were quantified and histologically assessed for viability. Tumor size, minimum and maximum margin size, and pre- and postoperative estimated glomerular filtration rate (eGFR) were obtained. RESULTS Glomerular viability positively correlated with distance from tumor with mean viable glomeruli in successive 0.25-cm increments of 0-0.25 cm, 58%; 0.25-0.5 cm, 80%; 0.5-0.75 cm, 90%; and 0.75-1.0 cm, 92%. Glomerular viability near the tumor did not correlate with preoperative eGFR, whereas decreased viability further from the tumor did correlate with worse preoperative eGFR. Tumor size showed a nonstatistically significant positive trend with minimum (median 0.15 cm) and maximum margin (median 0.7 cm) sizes. Percent change of glomerular filtration rate did not correlate with margin size (P = .190). CONCLUSION Renal parenchyma immediately adjacent to RCC contains fewer viable glomeruli compared with the parenchyma further from the tumor. Based on this information, attempts to preserve all non-neoplastic renal parenchyma via a surgical margin approaching zero may not necessarily result in clinically relevant differences in the amount of viable glomeruli remaining or the renal function preserved.
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Affiliation(s)
- Tariq A Khemees
- Department of Urology, The Ohio State University, Columbus, OH.
| | - Elaine T Lam
- Deparment of Internal Medicine, Division of Medical Oncology, The Ohio State University, Columbus, OH; Department of Internal Medicine, Division of Medical Oncology, University of Colorado Cancer Center, Aurora, CO
| | | | - Amir Mortazavi
- Deparment of Internal Medicine, Division of Medical Oncology, The Ohio State University, Columbus, OH
| | - Gary S Phillips
- Center for Biostatistics, The Ohio State University, Columbus, OH
| | - Ahmad Shabsigh
- Department of Urology, The Ohio State University, Columbus, OH
| | - David S Sharp
- Department of Urology, The Ohio State University, Columbus, OH
| | - Debra L Zynger
- Department of Pathology, The Ohio State University, Columbus, OH
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Hadjipavlou M, Khan F, Fowler S, Joyce A, Keeley FX, Sriprasad S. Partial vs radical nephrectomy for T1 renal tumours: an analysis from the British Association of Urological Surgeons Nephrectomy Audit. BJU Int 2015; 117:62-71. [DOI: 10.1111/bju.13114] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
| | - Fahd Khan
- Department of Urology; Darent Valley Hospital; Dartford Kent UK
| | - Sarah Fowler
- British Association of Urological Surgeons; London UK
| | - Adrian Joyce
- Department of Urology; St James's University Hospital; Leeds UK
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Abstract
PURPOSE OF REVIEW Despite the controversy surrounding the benefits of nephron-sparing surgery, multiple absolute indications for nephron-sparing surgery still exist, including the classic indications of hereditary and bilateral kidney tumors. RECENT FINDINGS Multiple genetic mutations have been identified which lead to hereditary kidney cancer conditions. These are briefly reviewed because the surgical management of hereditary kidney tumors depends on the genetic and histologic subtypes involved. Clear understanding of these hereditary conditions is crucial for proper surgical management of these tumors. SUMMARY Complex partial nephrectomy for multiple renal tumors, or multiplex partial nephrectomy, requires not only exceptional surgical skills but expertise of numerous nonsurgical methodologies, such as hands-on intraoperative ultrasonography and interpretation of multiple imaging modalities. In addition, multidisciplinary management is crucial for optimal outcomes in patient care. This review evaluates the most advanced surgical techniques and perioperative management required to successfully care for these challenging cases.
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Gordetsky J, Gorin MA, Canner J, Ball MW, Pierorazio PM, Allaf ME, Epstein JI. Frozen section during partial nephrectomy: does it predict positive margins? BJU Int 2015; 116:868-72. [DOI: 10.1111/bju.13011] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Jennifer Gordetsky
- Departments of Pathology and Urology; The University of Alabama; Birmingham AL USA
| | - Michael A. Gorin
- Department of Urology; The Johns Hopkins Hospital; Baltimore MD USA
| | - Joe Canner
- Department of Surgery; Center for Surgical Trials and Outcomes Research; The Johns Hopkins Hospital; Baltimore MD USA
| | - Mark W. Ball
- Department of Urology; The Johns Hopkins Hospital; Baltimore MD USA
| | | | - Mohamad E. Allaf
- Department of Urology; The Johns Hopkins Hospital; Baltimore MD USA
| | - Jonathan I. Epstein
- Department of Urology; The Johns Hopkins Hospital; Baltimore MD USA
- Department of Pathology; The Johns Hopkins Hospital; Baltimore MD USA
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Azhar RA, de Castro Abreu AL, Broxham E, Sherrod A, Ma Y, Cai J, Gill TS, Desai M, Gill IS. Histological analysis of the kidney tumor-parenchyma interface. J Urol 2014; 193:415-22. [PMID: 25111913 DOI: 10.1016/j.juro.2014.08.010] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE During enucleative partial nephrectomy excision is performed adjacent to the tumor edge. To better determine the oncologic propriety of enucleative partial nephrectomy we histologically examined the tumor-parenchyma interface. MATERIALS AND METHODS Archived hematoxylin and eosin stained slides of 124 nephrectomy specimens were rereviewed. We evaluated representative sections of tumor abutting the renal parenchyma and overlying pseudocapsule/perirenal fat were selected at 4 mm(2) sectors apportioned 1, 2, 3 and 4 mm, respectively, from the tumor edge. RESULTS Median tumor size was 3.5 cm. Of the tumors 111 were malignant (90%) and 119 (96%) had a pseudocapsule with a median thickness of 0.6 mm. Of malignant and benign tumors 82% and 31%, respectively, had an intrarenal pseudocapsule (p < 0.001). Pseudocapsule invasion was noted in 45% of cancers and 15% of benign tumors (p < 0.04). Of pT1a cancers 36% showed intrarenal pseudocapsule invasion. No patient had positive surgical margins. Intrarenal pseudocapsule invasion correlated with clear cell renal cell carcinoma histology but not with cancer size, grade, necrosis or margin width. Inflammation, nephrosclerosis, glomerulosclerosis and arteriosclerosis decreased with increasing distance from the tumor edge. At 1 mm changes were moderate to severe in 38%, 32%, 20% and 17% of tumors while at 5 mm changes were mild in 2.5%, 0.8%, 0.8% and 4%, respectively (p <0.001). Mean arteriolar diameter decreased with tumor proximity (p < 0.0001). CONCLUSIONS Most renal cancers have an intrarenal pseudocapsule. Partial nephrectomy excision adjacent to the tumor edge appears to be histologically safe. Because 18% of cancers lacked a discernible intrarenal pseudocapsule and 25% of pT1a cancers showed intrarenal pseudocapsule invasion, extreme care is needed to avoid positive margins during enucleative partial nephrectomy.
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Affiliation(s)
- Raed A Azhar
- Institute of Urology, Catherine and Joseph Aresty Department of Urology and Department of Pathology (EB, AS, YM), Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Andre Luis de Castro Abreu
- Institute of Urology, Catherine and Joseph Aresty Department of Urology and Department of Pathology (EB, AS, YM), Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Eric Broxham
- Institute of Urology, Catherine and Joseph Aresty Department of Urology and Department of Pathology (EB, AS, YM), Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Andy Sherrod
- Institute of Urology, Catherine and Joseph Aresty Department of Urology and Department of Pathology (EB, AS, YM), Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Yanling Ma
- Institute of Urology, Catherine and Joseph Aresty Department of Urology and Department of Pathology (EB, AS, YM), Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Jie Cai
- Institute of Urology, Catherine and Joseph Aresty Department of Urology and Department of Pathology (EB, AS, YM), Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Tania S Gill
- Institute of Urology, Catherine and Joseph Aresty Department of Urology and Department of Pathology (EB, AS, YM), Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Mihir Desai
- Institute of Urology, Catherine and Joseph Aresty Department of Urology and Department of Pathology (EB, AS, YM), Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Inderbir S Gill
- Institute of Urology, Catherine and Joseph Aresty Department of Urology and Department of Pathology (EB, AS, YM), Keck School of Medicine, University of Southern California, Los Angeles, California.
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Steinestel J, Steffens S, Steinestel K, Schrader AJ. Positive surgical margins in nephron-sparing surgery: risk factors and therapeutic consequences. World J Surg Oncol 2014; 12:252. [PMID: 25103683 PMCID: PMC4249770 DOI: 10.1186/1477-7819-12-252] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Accepted: 07/20/2014] [Indexed: 01/21/2023] Open
Abstract
The increased use of nephron-sparing surgery to treat localized renal cell carcinoma (RCC) lends weight to the question of the value of microscopically positive surgical margins (PSM) in cases with a tumor bed macroscopically free of residual tumor. The aim of this article is to highlight the data available on risk factors for PSM, their clinical relevance, and possible therapeutic consequences. For this purpose, publications on the incidence and relevance of PSM after partial nephrectomy from the last 15 years were examined and evaluated. We summarize that PSM are generally rare, regardless of the surgical procedure, and are seen more often in connection with an imperative indication for nephron-sparing surgery as well as a central tumor location. Most studies describe that PSM lead to a moderate increase in the rate of local relapses, but no study has thus far been able to demonstrate an association with shorter tumor-specific overall survival. Intraoperative frozen section analysis had no positive influence on the risk of definite PSM in most trials. Therefore, we conclude that PSM should definitely be avoided. However, in cases with a macroscopically tumor-free intraoperative resection bed, they should lead to close surveillance of the affected kidney and not to immediate (re)intervention.
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Affiliation(s)
- Julie Steinestel
- />Department of Urology, Münster University Medical Center, Albert-Schweitzer-Campus 1, Building A1, 48149 Münster, Germany
| | - Sandra Steffens
- />Department of Urology, Hannover University Medical School, Carl-Neubergstr. 1, 30625 Hannover, Germany
| | - Konrad Steinestel
- />Department of Pathology, Bundeswehrkrankenhaus Ulm, Oberer Eselsberg 40, 89081 Ulm, Germany
| | - Andres Jan Schrader
- />Department of Urology, Münster University Medical Center, Albert-Schweitzer-Campus 1, Building A1, 48149 Münster, Germany
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[Positive surgical margins in nephron sparing surgery for renal cell carcinoma]. Urologia 2014; 81:30-9. [PMID: 24803357 DOI: 10.5301/uro.5000067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2014] [Indexed: 01/20/2023]
Abstract
Nephron sparing surgery (NSS) with a minimal tumor-free margin is considered the cornerstone in the contemporary management of renal cell carcinoma (RCC) stage T1. The aim of this study is to review incidence, predictive risk factors, clinical significance and oncologic outcomes of positive surgical margins (PSM) in NSS. English articles published before March 2014 have been searched in Medline Databank.PSM are present in 0-7% of patients in all surgical approaches considered. Some predictive factors,such as tumor size, localization, and histology have been identified in the past. Other topics concerning surgical technique and approach are discussed.The majority of patients with PSM do not experience disease recurrence and PSM impact on overall survival and cancer-specific survival seems to be irrelevant. These results lead to more conservative clinical strategies. However, an active surveillance is mandatory for all patients with PSM and especially for those with high risk disease. Generalization of these results is limited by the low level of evidence of available studies. Further efforts are necessary to avoid PSM intraoperatively and to provide prospective information in order to standardize the postoperative management.
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Barbier E, Theveniaud PE, Claudon M, Eschwege P, Hubert J. [Eight years of experience in robot-assisted partial nephrectomy: oncological and functional outcomes]. Prog Urol 2014; 24:185-90. [PMID: 24560208 DOI: 10.1016/j.purol.2013.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2013] [Revised: 09/15/2013] [Accepted: 09/20/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Partial nephrectomy (PN) is currently the reference treatment for renal tumors of less than 4 cm in size (T1a). Laparoscopic PN is difficult to perform, with the main consequence being an increase in warm ischemia time and morbidity. In facilitating the surgical procedure, robotics combines the benefits of minimally invasive and conservative surgery. We report here 8 years of experience with 110 robot-assisted partial nephrectomies (RAPN). The objective of this study was to analyze the oncological and functional outcomes. PATIENTS AND METHODS Between March 2005 and September 2012, 110 patients underwent RAPN. The epidemiological and surgical data and the oncological and functional outcomes were retrospectively collected and analyzed. RESULTS Seventy-six men and 34 women underwent surgery. The mean age was 59.6 ± 14.2 years. Mean operative time was 141.3 ± 36.1 minutes with a warm ischemia time of 21.2 ± 8.8 minutes. Mean hospital stay was 5.3 ± 2.2 days. Mean tumor size was 27.4 ± 9.8mm with 82.7% malignant tumors, of which 62.7% were clear cell carcinomas. Surgical margins were healthy in 100% of cases. After a mean follow-up of 28.7 ± 18.5 months, no recurrence was noted. On a functional level, there was no short-term or medium-term impairment of renal function. The frequency of postoperative complications was estimated as 12% including 7% of surgical complications (3 arterial pseudoaneurysms, 4 episodes of bleeding from the cut surface and 1 conversion to laparotomy). CONCLUSION Robotics brought surgeon dexterity, meticulousness and precision. These qualities are essential in conservative renal surgery and made RAPN a safe and effective technique that gives good short and medium-term oncological and functional results.
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Affiliation(s)
- E Barbier
- Service d'urologie, CHU de Nancy, 1, rue du Morvan, 54500 Vandœuvre-les-Nancy, France.
| | - P-E Theveniaud
- Service d'urologie, groupe hospitalier Paris-Saint-Joseph, 185, rue Raymond-Losserand, 75014 Paris, France
| | - M Claudon
- Service de radiologie, CHU de Nancy, rue du Morvan, 54500 Vandœuvre-les-Nancy, France
| | - P Eschwege
- Service d'urologie, CHU de Nancy, 1, rue du Morvan, 54500 Vandœuvre-les-Nancy, France
| | - J Hubert
- Service d'urologie, CHU de Nancy, 1, rue du Morvan, 54500 Vandœuvre-les-Nancy, France
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Shapiro EY, Scarberry K, Patel T, Bergman A, Ahn JJ, Sahi N, RoyChoudhury A, Deutch I, McKiernan JM, Benson MC, Badani KK. Comparison of robot-assisted and open retropubic radical prostatectomy for risk of biochemical progression in men with positive surgical margins. J Endourol 2013; 28:208-13. [PMID: 24044423 DOI: 10.1089/end.2013.0393] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Robot-assisted radical prostatectomy (RARP) is a minimally invasive alternative to open retropubic radical prostatectomy (RP), and is reported to offer equivalent oncologic outcomes while reducing perioperative morbidity. However, the technique of extirpation can differ based on the usage of thermal energy and coagulation during RARP, which may alter the risk of finding a positive surgical margin (PSM) as cautery may destroy residual cancer cells. We sought to evaluate whether the method of surgery (RP vs RARP) affects the rate of biochemical recurrence (BCR) in patients with PSMs. MATERIALS & METHODS The Columbia University Urologic Oncology Database was reviewed to identify patients who underwent RP and RARP from 2000 to 2010 and had a PSM on final pathology. BCR was defined as a postoperative prostate-specific antigen (PSA) ≥0.2 ng/mL. The Kaplan-Meier analysis was utilized to calculate BCR rates based on the method of surgery. Cox regression analysis was performed to determine if the method of surgery was associated with BCR. RESULTS We identified 3267 patients who underwent prostatectomy, of which 910 (28%) had a PSM. Of those with a PSM, 337 patients had available follow-up data, including 229 who underwent RP (68%) and 108 who underwent RARP (32%). At a mean follow-up time of 37 months for the RP group, 103 (46%) patients demonstrated BCR; at a mean follow-up time of 44 months for the RARP group, 62 (57%) patients had a BCR (p=0.140). Two-year BCR-free rates for RP vs RARP were 65% and 49%, respectively (log-rank p<0.001). However, after controlling for age, PSA, grade, and year of surgery, the surgical method was not significantly associated with increased risk of BCR (HR 1.25; p=0.29). CONCLUSION Our results confirm the noninferiority of RARP to RP with regard to patients with PSMs. As such, all patients with a PSM at RP are at high risk for BCR and should be followed in the same manner regardless of the surgical approach.
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Affiliation(s)
- Edan Y Shapiro
- 1 Department of Urology, Columbia University Medical Center , New York, New York
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Khalifeh A, Kaouk JH, Bhayani S, Rogers C, Stifelman M, Tanagho YS, Kumar R, Gorin MA, Sivarajan G, Samarasekera D, Allaf ME. Positive Surgical Margins in Robot-Assisted Partial Nephrectomy: A Multi-Institutional Analysis of Oncologic Outcomes (Leave No Tumor Behind). J Urol 2013; 190:1674-9. [DOI: 10.1016/j.juro.2013.05.110] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2013] [Indexed: 02/01/2023]
Affiliation(s)
- Ali Khalifeh
- Center for Laparoscopic and Robotic Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jihad H. Kaouk
- Center for Laparoscopic and Robotic Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sam Bhayani
- Division of Urologic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Craig Rogers
- Vattikuti Urology Institute, Henry Ford Hospital, Detroit, Michigan
| | - Michael Stifelman
- Department of Urology, New York University, Langone Medical Center, New York, New York
| | - Youssef S. Tanagho
- Division of Urologic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Ramesh Kumar
- Vattikuti Urology Institute, Henry Ford Hospital, Detroit, Michigan
| | - Michael A. Gorin
- James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Ganesh Sivarajan
- Department of Urology, New York University, Langone Medical Center, New York, New York
| | - Dinesh Samarasekera
- Center for Laparoscopic and Robotic Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Mohamad E. Allaf
- James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, Maryland
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Tanaka K, Shigemura K, Furukawa J, Ishimura T, Muramaki M, Miyake H, Fujisawa M. Comparison of the Transperitoneal and Retroperitoneal Approach in Robot-Assisted Partial Nephrectomy in an Initial Case Series in Japan. J Endourol 2013; 27:1384-8. [PMID: 24044768 DOI: 10.1089/end.2012.0641] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- Kazushi Tanaka
- Division of Urology, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Katsumi Shigemura
- Division of Urology, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Junya Furukawa
- Division of Urology, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takeshi Ishimura
- Division of Urology, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Mototsugu Muramaki
- Division of Urology, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hideaki Miyake
- Division of Urology, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Masato Fujisawa
- Division of Urology, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan
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Ani I, Finelli A, Alibhai SM, Timilshina N, Fleshner N, Abouassaly R. Prevalence and impact on survival of positive surgical margins in partial nephrectomy for renal cell carcinoma: a population-based study. BJU Int 2013; 111:E300-5. [DOI: 10.1111/j.1464-410x.2012.11675.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Ifeanyi Ani
- Urology Institute; University Hospitals of Cleveland Case Medical Center; Cleveland; OH; USA
| | - Antonio Finelli
- Urological Oncology and Health Policy; Management and Evaluation Departments; Princess Margaret Hospital; University of Toronto; Toronto; ON; Canada
| | - Shabbir M.H. Alibhai
- Urological Oncology and Health Policy; Management and Evaluation Departments; Princess Margaret Hospital; University of Toronto; Toronto; ON; Canada
| | - Narhari Timilshina
- Urological Oncology and Health Policy; Management and Evaluation Departments; Princess Margaret Hospital; University of Toronto; Toronto; ON; Canada
| | - Neil Fleshner
- Urological Oncology and Health Policy; Management and Evaluation Departments; Princess Margaret Hospital; University of Toronto; Toronto; ON; Canada
| | - Robert Abouassaly
- Urology Institute; University Hospitals of Cleveland Case Medical Center; Cleveland; OH; USA
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Tiu A, Kim KH, Shin TY, Han WK, Han SW, Rha KH. Feasibility of robotic laparoendoscopic single-site partial nephrectomy for renal tumors >4 cm. Eur Urol 2012; 63:941-6. [PMID: 23219087 DOI: 10.1016/j.eururo.2012.11.031] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Accepted: 11/13/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Laparoendoscopic single-site (LESS) urologic procedures have gained significant interest worldwide in an attempt to further reduce morbidity and minimize scarring associated with conventional laparoscopic surgery. The robotic technology has overcome some of the limitations of manual single-incision surgery relating to lack of triangulation, instrument collision, and surgical exposure. There are no data on robotic LESS partial nephrectomy (PN) for renal tumors >4 cm. OBJECTIVES To evaluate the feasibility of robotic LESS PN for renal tumors >4 cm. DESIGN, SETTING, AND PARTICIPANTS Data from 67 consecutive patients who underwent robotic LESS PN were collected between May 2009 to January 2011. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Patients were stratified into two groups: 20 patients with renal tumors >4 cm (group 1) and 47 patients with renal tumors ≤ 4 cm (group 2). Perioperative data were recorded and comparisons between the two groups were analyzed using the Mann-Whitney U test for continuous variables and Fisher exact test for categorical variables. RESULTS AND LIMITATIONS No statistically significant differences were found between the two groups in demographic information, operative complications, pathologic characteristics, mean decline in estimated glomerular filtration rate, estimated blood loss, operative times, conversion rate, or positive surgical margins. However, group 1 had a higher mean nephrometry score (p<0.01), longer warm ischemia time (p = 0.007), and longer length of stay (p = 0.046). Its retrospective design and being conducted at a single center were the main limitations of this study. CONCLUSIONS This study demonstrated the feasibility and safety of robotic LESS PN for tumors >4 cm. Patients with tumors >4 cm had a statistically significant, higher mean nephrometry score, longer warm ischemia time, and longer length of stay, but there was no increased risk of adverse outcomes. A long-term study is needed to confirm the durable renal preservation and oncologic outcomes for patients with larger tumor burden.
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Affiliation(s)
- Albert Tiu
- Department of Urology, University of Miami Miller School of Medicine, Miami, FL, USA
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Kim EH, Tanagho YS, Sandhu GS, Bhayani SB, Figenshau RS. Off-Clamp Robot-Assisted Partial Nephrectomy for Complex Renal Tumors. J Endourol 2012; 26:1177-82. [DOI: 10.1089/end.2012.0353] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- Eric H. Kim
- Division of Urology, Washington University School of Medicine, St. Louis, Missouri
| | - Youssef S. Tanagho
- Division of Urology, Washington University School of Medicine, St. Louis, Missouri
| | - Gurdarshan S. Sandhu
- Division of Urology, Washington University School of Medicine, St. Louis, Missouri
| | - Sam B. Bhayani
- Division of Urology, Washington University School of Medicine, St. Louis, Missouri
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Jack GS, Lua M, Chan Y, Bolton DM. Integration of laparoscopic partial nephrectomy into an Australian public hospital: three-year follow-up of our initial 50 cases. BJU Int 2012; 109 Suppl 3:35-9. [PMID: 22458491 DOI: 10.1111/j.1464-410x.2012.11043.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Gregory S Jack
- Division of Urology, Austin Health, Heidelberg, Victoria, Australia.
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Kroeze SGC, van Melick HHE, Nijkamp MW, Kruse FK, Kruijssen LWJ, van Diest PJ, Bosch JLHR, Jans JJM. Incomplete thermal ablation stimulates proliferation of residual renal carcinoma cells in a translational murine model. BJU Int 2012; 110:E281-6. [PMID: 22612555 DOI: 10.1111/j.1464-410x.2012.11261.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
UNLABELLED What's known on the subject? and What does the study add? Thermal ablation influences the local tissue microenvironment. Several studies have reported that residual tumour cells may exhibit a more aggressive phenotype. This study shows that incomplete CA and RFA cause an increased proliferation and decreased apptosis of residual renal tumour cells. This may be caused by stimulatory factors such as hypoxia, HSPs and inflammatory cells. OBJECTIVE To compare the effect of incomplete thermal ablation vs partial nephrectomy (PN) on growth stimulation and cellular survival in renal tumours. MATERIALS AND METHODS Renca renal tumours were transplanted under the renal capsule of mice (four to six mice/group) after which incomplete radiofrequency ablation (RFA), cryoablation (CA) or PN was performed. At several time points after treatment, presence of cell proliferation, apoptosis, hypoxic areas, inflammatory factors and the heat-shock proteins (HSPs) 70 and 90 were evaluated using immunohistochemistry. RESULTS At 2 h after thermal ablation residual tumour cells showed increased proliferation. This hyperproliferation was significantly stronger after RFA than CA (P < 0.05) and not present after PN. Residual cells showed increased apoptosis after 2 h and decreased apoptosis from 2 days after thermal ablation. Apoptotic cells were significantly less evident at 3 days after RFA (P < 0.001). Hypoxic areas and HSPs were increasingly present from 2 h up to 7 days after thermal ablation (P < 0.001). Inflammatory cells infiltrated mainly the necrotic areas after thermal ablation, and their abundance peaked at 1 week after ablation (P < 0.05). The increased cell growth was preceded by hypoxia and presence of HSPs. CONCLUSIONS CA and RFA result in an increased proliferation and decreased apoptosis of residual renal tumour cells. This hyperproliferation may be caused by stimulatory factors, e.g. hypoxia, HSPs and inflammatory cells, and could facilitate recurrences of renal tumours after thermal ablation. This study highlights the importance of achieving complete tumour destruction.
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Affiliation(s)
- Stephanie G C Kroeze
- Department of Urology, University Medical Center Utrecht, Utrecht, The Netherlands
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Krane LS, Manny TB, Hemal AK. Is near infrared fluorescence imaging using indocyanine green dye useful in robotic partial nephrectomy: a prospective comparative study of 94 patients. Urology 2012; 80:110-6. [PMID: 22607949 DOI: 10.1016/j.urology.2012.01.076] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Revised: 01/30/2012] [Accepted: 01/31/2012] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To compare a consecutive prospective cohort of patients who underwent robotic partial nephrectomy (RPN) with near infrared fluorescence (NIRF) imaging with indocyanine green dye (ICG) with a previous consecutive patient cohort. METHODS A total of 47 consecutive patients with renal masses suspicious for malignancy undergoing RPN were given 5-7.5 mg of ICG before hilar clamping or tumor excision. This cohort of patients was compared with 47 immediate previous consecutive patients who had undergone RPN without NIRF real-time imaging using ICG. The intraoperative, perioperative, and postoperative parameters were collected in an institutional review board-approved prospective database. RESULTS The preoperative demographics and tumor complexity according to the nephrometry or preoperative aspects and dimensions used for an anatomic (PADUA) scores were similar. The mean warm ischemia time was significantly decreased in the ICG group (15 vs 17 minutes, P = .01). The median hospital stay was 2 days in both groups. No significant difference was seen in the positive margin rate (ICG, 6% vs control, 8.5%; P = .69) or observed Clavien grade III-IV complications in these 2 cohorts (ICG, 4% vs control, 15%; P = .07). No adverse events were associated with ICG dye administration. Differential ICG uptake was observed with selective clamping or in patients with cystic tumors, hypofluorescent tumors with exophytic components, and angiomyelolipomas, but these benefits could not be quantified. NIRF-ICG was transiently helpful to identify the vascular anatomy and not helpful at all for endophytic tumors. CONCLUSION RPN using NIRF-ICG can be performed safely and effectively. A decreased warm ischemia time in the ICG cohort was observed without specific measured advantages. Differential ICG uptake by different tumors did not lead to significant differences in the positive margin rate.
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Affiliation(s)
- L Spencer Krane
- Department of Urology, Wake Forest University, Winston-Salem, North Carolina 27157-1094, USA
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Pietzak EJ, Guzzo TJ. Advancements in laparoscopic partial nephrectomy: expanding the feasibility of nephron-sparing. Adv Urol 2012; 2012:148952. [PMID: 22645606 PMCID: PMC3357511 DOI: 10.1155/2012/148952] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2011] [Accepted: 02/25/2012] [Indexed: 01/06/2023] Open
Abstract
Partial nephrectomy (PN) offers equivalent oncologic outcomes to radical nephrectomy (RN) but has greater preservation of renal function and less risk of chronic kidney disease and cardiovascular disease. Laparoscopic PN remains underutilized likely because it is a technically challenging operation with higher rates of perioperative complications compared to open PN and laparoscopic RN. A review of the latest PN literature demonstrates that recent advancements in laparoscopic approaches, imaging modalities, ischemic mitigating strategies, renorrhaphy techniques, and hemostatic agents will likely allow greater utilization of LPN and expand its usage to increasingly more complex tumors.
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Affiliation(s)
- Eugene J. Pietzak
- Division of Urology, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Thomas J. Guzzo
- Division of Urology, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA
- Perelman Center for Advanced Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
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Abstract
Partial nephrectomy has become the most frequently used surgical procedure in the treatment of renal cell cancer. The current role of laparoscopy for this indication has to be defined.The technique of laparoscopic partial nephrectomy has undergone a continuous development to become mature. Once the learning curve of the individual surgeon has been overcome the results are comparable to those of open surgery. This is true for ischemia time, complication rate and oncologic outcome. In addition there is the advantage of the minimally invasive approach in laparoscopy sparing a painful flank incision. Laparoscopic partial nephrectomy is not yet a standard of care but yields excellent results in the hands of experts. There are no conclusive studies comparing standard and da Vinci®-assisted laparoscopy. No clear advantages become obvious, but the costs of the robot are substantial.
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Affiliation(s)
- G Janetschek
- Universitätsklinik für Urologie und Andrologie, Paracelsus Medizinische Privatuniversität Salzburg, Müllner Hauptstraße 48, A-5020 Salzburg, Österreich.
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Marszalek M, Carini M, Chlosta P, Jeschke K, Kirkali Z, Knüchel R, Madersbacher S, Patard JJ, Van Poppel H. Positive surgical margins after nephron-sparing surgery. Eur Urol 2011; 61:757-63. [PMID: 22136987 DOI: 10.1016/j.eururo.2011.11.028] [Citation(s) in RCA: 164] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2011] [Accepted: 11/15/2011] [Indexed: 02/07/2023]
Abstract
CONTEXT Little is known on the natural history of positive surgical margins (PSMs) in partial nephrectomy (PN). Accumulating data suggest that secondary nephrectomy might not be necessary in all patients with PSMs after PN. OBJECTIVE Provide an overview on incidence and risk factors for PSMs after partial nephrectomy and on the rate of local and distant disease recurrence related to PSMs. We also provide recommendations on how to avoid and how to treat PSMs after PN. EVIDENCE ACQUISITION A nonsystematic literature research was based on Medline, Scopus, and Web of Science queries on these keywords: nephron-sparing surgery, partial nephrectomy/ies, and margin. Only human studies (original research) published in English were included. EVIDENCE SYNTHESIS PSMs are present in 0-7% of patients after open PN, in 0.7-4% after laparoscopic PN, and in 3.9-5.7% after robot-assisted PN. The thickness of healthy parenchyma surrounding the tumour is irrelevant as long as complete tumour removal is achieved. The coincidence of a highly malignant tumour and PSM increases the risk of local recurrence. Intermediate follow-up data indicate that the vast majority of patients with PSMs will not experience local or distant tumour recurrence. Frozen-section analysis for evaluation of resection margins during PN is of minor clinical significance, as the surgeon's gross assessment of macroscopically negative margins provides reliable results. CONCLUSIONS PSMs in PN are rare. As indicated by intermediate follow-up data, the majority of patients with PSMs after PN remain without disease recurrence, and a surveillance strategy seems preferable to surgical reintervention.
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Affiliation(s)
- Martin Marszalek
- Department of Urology and Andrology, Donauspital, Vienna, Austria.
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Han JS, Huang WC. Impact of Kidney Cancer Surgery on Oncologic and Kidney Functional Outcomes. Am J Kidney Dis 2011; 58:846-54. [DOI: 10.1053/j.ajkd.2011.07.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2011] [Accepted: 07/18/2011] [Indexed: 11/11/2022]
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Shuch B, Linehan WM, Bratslavsky G. Repeat partial nephrectomy: surgical, functional and oncological outcomes. Curr Opin Urol 2011; 21:368-75. [PMID: 21788903 PMCID: PMC3173810 DOI: 10.1097/mou.0b013e32834964ea] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE OF REVIEW The greater utilization of partial nephrectomy and ablative procedures has increased the incidence of patients presenting with local renal recurrence. The choice to either perform a partial or radical nephrectomy in these situations can be a challenging decision. RECENT FINDINGS Repeat and salvage partial nephrectomy, while challenging and potentially associated with increased complications, offers patients the ability to maintain excellent renal functional outcomes and promising oncologic outcomes at intermediate follow-up. SUMMARY Surgeons should be familiar with the surgical complications and the functional and oncologic outcomes of reoperative nephron-sparing surgery (NSS). Recent data and outcome analysis support utilization of these procedures in patients presenting with either local recurrence or de-novo lesions in the ipsilateral kidney.
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Affiliation(s)
| | | | - Gennady Bratslavsky
- Correspondence: Gennady Bratslavsky, M.D., Senior Staff, Urologic Oncology Branch, National Cancer Institute National Institutes of Health, 10 Center Drive MSC 1107, Building 10, CRC, Room 2W-5942, Bethesda, Maryland 20892-1107, , Tel: (301) 496-6353, Fax:(301) 480-5626
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