Initial experience with robot assisted partial nephrectomy for multiple renal masses

What factors may affect the effect of ICI-combined therapy in patients with metastatic renal cell carcinoma? A meta-analysis

OBJECTIVE

The prognostic factors of ICI-including combined therapy in patients with metastatic renal cell carcinoma were analyzed by systematic review.

METHOD

We searched Web of Science, Cochrane, PubMed, CNKI, Wanfang and other databases for randomized controlled trials and clinical trials of combination therapy including ICIs in the treatment of metastatic renal cell carcinoma. The search time was from the establishment of the database to September 2023. Data were extracted and evaluated with RevMan 5.4 software.

RESULTS

Six studies were included, including 4723 patients. The results showed that ① in terms of progression-free survival, the factors of age < 65 years old, male sex, Canada and Western Europe, nephrectomy, different IMDC class, number of organs with metastases and PD-L1 expression ≥ 1% significantly prolonged PFS in patients with metastatic cancer treated by combination therapy including ICIs; ② in terms of overall survival rate, the factors of age < 65 years old, female sex, nephrectomy, different IMDC class and PD-L1 expression ≥ 1% significantly prolonged the OS of patients with metastatic cancer treated by combination therapy including ICIs.

CONCLUSIONS

Age, sex, region, nephrectomy, different IMDC class, number of organs with metastases and PD-L1 expression are independent factors influencing the efficacy of combination therapy including ICIs in the treatment of metastatic renal cell carcinoma. Systematic evaluation of baseline indicators of patients with metastatic renal cell carcinoma to predict clinical benefits can effectively improve the benefit rate of patients.

A systematic review of robot-assisted partial nephrectomy outcomes for advanced indications: Large tumors (cT2-T3), solitary kidney, completely endophytic, hilar, recurrent, and multiple renal tumors

Objective

Robot-assisted partial nephrectomy (RAPN) has become widely used for treatment of renal cell carcinoma and it is expanding in the field of complex renal masses. The aim of this systematic review was to analyze outcomes of RAPN for completely endophytic renal masses, large tumors (cT2-T3), renal cell carcinoma in solitary kidney, recurrent tumors, completely endophytic and hilar masses, and simultaneous and multiple tumors.

Methods

A comprehensive search in the PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials databases was performed in December 2022 for English language papers. The primary endpoint was to evaluate the role of RAPN in the setting of each category of complex renal masses considered. The secondary endpoint was to evaluate the surgical and functional outcomes.

Results

After screening 1250 records, 43 full-text manuscripts were selected, comprising over 8500 patients. Twelve and thirteen studies reported data for endophytic and hilar renal masses, respectively. Five and three studies reported outcomes for cT2-T3 and solitary kidney patients, respectively. Four studies focused on redo-RAPN for recurrent tumors. Two studies investigated simultaneous bilateral renal masses and five reports focused on multiple tumor excision in ipsilateral kidney.

Conclusion

Over the past decade, evidence supporting the use of RAPN for the most challenging nephron-sparing surgery indications has continuously grown. Although limitations remain including study design and lack of detailed long-term functional and oncological outcomes, the adoption of RAPN for the included advanced indications is associated with favorable surgical outcomes with good preservation of renal function without compromising the oncological result. Certainly, a higher likelihood of complication might be expected when facing extremely challenging cases. However, none of these indications should be considered per se an exclusion criterion for performing RAPN. Ultimately, a risk-adapted approach should be employed.

How far has robot-assisted partial nephrectomy reached?

Nephron-sparing surgery is the standard treatment for small renal mass (SRM). Nephron-sparing surgery has evolved from an open to a minimally invasive technique. Robot-assisted partial nephrectomy (RAPN) is the latest technique in this field and is reported to be safe and feasible, showing oncologically and functionally superior or compatible results compared with open and laparoscopic partial nephrectomy for SRM. This is not limited to only SRM but also applies to large and complex renal masses and other challenging situations. RAPN showed good oncological and functional outcomes for ≥clinical T2 renal tumors, complex renal masses (PADUA score ≥10, RENAL score ≥10), hilar renal tumors, and multiple renal tumors. In addition, the outcomes of RAPN in these challenging cases were not inferior to those in conventional cases. RAPN could also be applied to a number of challenging cases in which the open technique was considered first. RAPN showed good results in patients with a solitary kidney, horseshoe kidney, and in repeat surgeries. Furthermore, RAPN could be safely performed on obese, elderly, and pediatric patients. Finally, this review evaluates efficiency and utility of RAPN based on the results of challenging cases of renal masses and to project the future of RAPN.

Comparison between minimally invasive partial nephrectomy and open partial nephrectomy for complex renal tumors: a systematic review and meta-analysis

BACKGROUND

The present study aimed to conduct a pooled analysis to compare the efficacy and safety of minimally invasive partial nephrectomy (MIPN) with open partial nephrectomy (OPN) in patients with complex renal tumors (defined as PADUA or RENAL score ≥7).

METHODS

The present study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, Supplemental Digital Content 1, http://links.lww.com/JS9/A394 . We conducted a systematic search of the PubMed, Embase, Web of Science, and Cochrane Library databases until October 2022. MIPN and OPN-controlled trials for complex renal tumors were included. The primary outcomes were perioperative results, complications, renal function, and oncologic outcomes.

RESULTS

A total of 2405 patients were included in 13 studies. MIPN outperformed OPN in terms of hospital stay [weighted mean difference (WMD) -1.84 days, 95% CI -2.35 to -1.33; P <0.00001], blood loss (WMD -52.42 ml, 95% CI -71.43 to -33.41; P <0.00001), transfusion rates [odds ratio (OR) 0.34, 95% CI 0.17-0.67; P =0.002], major complications (OR 0.59, 95% CI 0.40-0.86; P =0.007) and overall complications (OR 0.43, 95% CI 0.31-0.59; P <0.0001), while operative time, warm ischemia time, conversion to radical nephrectomy rates, estimated glomerular decline, positive surgical margins, local recurrence, overall survival, recurrence-free survival, and cancer-specific survival were not significantly different.

CONCLUSIONS

The present study demonstrated that MIPN was associated with a shorter length of hospital stay, less blood loss, and fewer complications in treating complex renal tumors. MIPN may be considered a better treatment for patients with complex tumors when technically feasible.

Cytoreductive Nephrectomy and Metastatic Renal Cell Carcinoma: State of the Art and Future Perspectives

In the past decades, several treatments have been proposed for the management of metastatic renal cell carcinoma (mRCC). Among these, cytoreductive nephrectomy (CN) represents a controversial and open issue in the era of targeted therapy and novel immunotherapy with immune checkpoint inhibitors. Two important studies, CARMENA and SURTIME, analyzed therapy with sunitinib with or without CN, and immediate CN followed by sunitinib versus a deferred CN after three cycles of sunitinib, respectively. CARMENA showed the non-inferiority of sunitinib alone versus sunitinib plus CN, whereas SURTIME showed no difference in progression-free survival (PFS), but a better median OS among patients with deferred CN. Therefore, more prospective clinical trials and appropriate patient identification are necessary to support CN in this new scenario. This review provides a snapshot of the current evidence for CN in mRCC, discusses the management strategies, and offers perspectives on the direction of future research.

Tumorigenesis Mechanisms Found in Hereditary Renal Cell Carcinoma: A Review

Renal cell carcinoma is a heterogenous cancer composed of an increasing number of unique subtypes each with their own cellular and tumor behavior. The study of hereditary renal cell carcinoma, which composes just 5% of all types of tumor cases, has allowed for the elucidation of subtype-specific tumorigenesis mechanisms that can also be applied to their sporadic counterparts. This review will focus on the major forms of hereditary renal cell carcinoma and the genetic alterations contributing to their tumorigenesis, including von Hippel Lindau syndrome, Hereditary Papillary Renal Cell Carcinoma, Succinate Dehydrogenase-Deficient Renal Cell Carcinoma, Hereditary Leiomyomatosis and Renal Cell Carcinoma, BRCA Associated Protein 1 Tumor Predisposition Syndrome, Tuberous Sclerosis, Birt-Hogg-Dubé Syndrome and Translocation RCC. The mechanisms for tumorigenesis described in this review are beginning to be exploited via the utilization of novel targets to treat renal cell carcinoma in a subtype-specific fashion.

Robot-assisted partial nephrectomy for moderate to highly complex renal masses. A systematic review and meta-analysis

Introduction

Multiple studies have been published recently assessing feasibility of robot-assisted partial nephrectomy (RAPN) for moderate to highly complex renal masses. Some studies have even compared partial nephrectomy (PN) performed through various modalities such as open PN (OPN) versus RAPN and laparoscopic PN (LPN) versus OPN. The primary aim of this review was to analyze perioperative outcomes such as warm ischemia time (WIT), duration of surgery, estimated blood loss (EBL), complications, blood transfusion, length of stay, and margin status following RAPN for complex renal masses. Another objective was to compare perioperative outcomes following various surgical modalities, i.e., OPN, LPN, or RAPN.

Methods

Literature search was conducted to identify studies reporting perioperative outcomes following RAPN for moderate (Radius, Endophytic/Exophytic, Nearness, Anterior/posterior location [RENAL] score 7-9 or Preoperative Aspects of Dimension used for anatomic classification [PADUA] score 8-9) to high complexity renal masses (RENAL or PADUA score ≥ 10). Meta-analysis of robotic versus OPN and robotic versus LPN was also performed. Study protocol was registered with PROPSERO (CRD42019121259).

Results

In this review, 22 studies including 2,659 patients were included. Mean duration of surgery, WIT, and EBL was 132.5-250.8 min, 15.5-30 min, and 100-321 ml, respectively. From pooled analysis, positive surgical margin, need for blood transfusion, minor and major complications were seen in 3.9%, 5.2%, 19.3%, and 6.3% of the patients. No significant difference was noted between RAPN and LPN for any of the perioperative outcomes. Compared to OPN, RAPN had significantly lower EBL, complications rate, and need for transfusion.

Conclusions

RAPN for moderate to high complexity renal masses is associated with acceptable perioperative outcomes. LPN and RAPN were equal in terms of perioperative outcomes for complex masses whereas, OPN had significantly higher blood loss, complications rate, and need for transfusion as compared to RAPN.

Surgical Insights for the Management of Variant Histology in Renal Cell Carcinoma

Purpose:

To review the current literature regarding variant (non-clear) histology of renal cell carcinoma (RCC) and the clinical management of these renal tumors.

Material and Methods:

A PubMed database search was performed in May 2020 focusing on variant RCC, its diagnosis and associated syndromes, tumor characteristics, and options for management.

Results:

A broad range of pathological, clinical and diagnostic characteristics amongst non-ccRCC variants were found to have an impact on the overall management of these tumors. The imaging modalities, frequency of surveillance, and timing for intervention were found to be dependent on the type of genetic alterations, type of histology, and tumor growth rates. The timing and type of surgery as well as the systemic therapy are tailored to the specific tumor type and patient.

Conclusion:

The findings of this review suggest that clinical management should be considered and adjusted for patients with non-ccRCC histological variants based on tumor subtype and genetic alterations.

Robotic-assisted partial nephrectomy with sequential clamping of segmental renal arteries for multiple ipsilateral renal tumors: initial outcomes

Background

To assess the technical feasibility and outcomes of robotic-assisted partial nephrectomy (RPN) with sequential segmental renal artery (SRA) clamping for multiple ipsilateral renal tumors (MIRTs).

Methods

From April 2016 to February 2018, consecutive eleven cases successfully underwent RPN with sequential SRA clamping under the guidance of dual-source computed tomography (DSCT).

Results

Ten cases had two lesions and two cases had three at the ipsilateral kidneys. The mean size and the mean R.E.N.A.L score for the dominant lesion of single case were 3.3 cm and 5.7, respectively. Twenty-two lesions (84.6%) had one target SRA and four (15.4%) had two target SRAs. Satisfactory ischemic areas were achieved by sequentially clamping two (81.8%) or three (18.2%) target SRAs with mean clamping time of 18.8 (15.0–27.0) min for single lesion, and the mean of total clamping time for single case was 37.5 (32.0–52.0) min. Only the complications of grade 1–2 were found and no positive surgical margin was discovered. The mean follow-up time was 5.4 months and no local recurrence or metastasis was found. The mean postoperative eGFR was 71.2 ml/minute/1.73m² that was only an insignificant reduction (9.3%) compared with the preoperative baseline.

Conclusion

This novel nephron-sparing technique, RPN with sequential SRA clamping, represents a good alternative for selected patients with MIRTs. With the guidance of DSCT and skilled robotic experience, this technique is feasible and can maximize renal function preservation. Large-scale multicenter clinical studies are still needed to further prove these initial outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12894-019-0451-y) contains supplementary material, which is available to authorized users.

Trifecta Outcomes in Multifocal Tumors: A Comparison Between Robotic and Open Partial Nephrectomy

OBJECTIVES

To report a comparative analysis of outcomes in patients who underwent multiple excisions for unilateral synchronous multifocal renal tumors using both open and robotic approaches.

METHODS

We retrospectively reviewed 110 patients who underwent robotic and open partial nephrectomy and had multiple tumor excisions in an ipsilateral kidney. "Trifecta" was defined as negative surgical margins, no urologic complications, and a glomerular filtration rate (GFR) preservation of ≥90% at last follow-up. Inverse probability of treatment weighting (IPTW) was applied to equilibrate treatment groups, minimize selection bias, and optimize inference on the basis of each patient's clinicodemographic characteristics.

RESULTS

Sixty-eight robotic and 42 open patient approaches had sufficient data for IPTW. After weighting, there were no statistical differences in baseline characteristics between the two groups. On adjusted analyses, robotic partial nephrectomy achieved equivalent rates of trifecta to open surgery (16.3% vs 16.5%, p = 0.99), which persisted on subgroup analyses of patients with two (20.1% vs 23.7%, p = 0.82) or more than two tumors (6.8% vs 7.4%, p = 0.95). There were no differences between robotic and open cohorts for negative margin rates, absence of complications, or GFR ≥90%. The robotic cohort had a shorter mean length of stay (3.4 vs 4.9 days, p < 0.001).

CONCLUSIONS

Surgical resection remains the mainstay for patients with unilateral, synchronous, and multifocal renal tumors. Our analysis found that both open and robotic approaches to partial nephrectomy are equally likely to achieve the "trifecta" outcome in an equilibrated high-risk group of patients. The robotic approach for these complex patients may be safe and feasible for a carefully selected group of patients.

Renal functional outcomes after robotic multiplex partial nephrectomy: the National Cancer Institute experience with robotic partial nephrectomy for 3 or more tumors in a single kidney

OBJECTIVE

To identify renal function outcomes after robotic multiplex partial nephrectomy (RMxPNx), we reviewed our institutional database at the National Institutes of Health, National Cancer Institute. To our knowledge, we present the largest series of RMxPNx renal function outcomes to date. Robotic partial nephrectomy has been employed for oncologic control and to prevent dialysis dependence in hereditary multifocal renal cell carcinoma conditions. We have termed robotic surgery on a single kidney with three or more lesions a RMxPNx.

MATERIALS AND METHODS

We evaluated patients from a prospectively maintained database at a single institution (NIH/NCI) that underwent RMxPNx from 2007 to 2013. Demographic and operative data were compiled with statistical analysis with T test performed to determine renal function outcomes.

RESULTS

A total of 54 patients underwent RMxPNx. Mean number of tumors removed was 8.63 (range 3-52). Mean preoperative creatinine and eGFR were 1.02 ± 0.26 mg/dL and 85.4 ± 21.5 mL/min, respectively. Postoperatively, creatinine increased from baseline by 0.45 mg/dL (p < 0.001). Similarly, a mean decrease in eGFR by 24.6 mL/min was observed (p < 0.001). At 3-month follow-up, the creatinine increase from baseline was 0.05 mg/dL (p = 0.10) and mean decrease in eGFR was 3.01 mL/min (p = 0.21). When stratifying based on preoperative CKD stages I-III, similar results were observed.

CONCLUSION

Robotic multiplex partial nephrectomy is a safe and feasible approach to patients with multifocal renal masses. These complex surgeries have a demonstrated learning curve, but this minimally invasive approach for nephron-sparing surgery allows patients to preserve renal function where they would otherwise require open surgery or a radical nephrectomy.

Repeat Robotic Partial Nephrectomy: Characteristics, Complications, and Renal Functional Outcomes

INTRODUCTION

Multifocal and hereditary kidney cancers often require repeated ipsilateral nephron sparing procedures with higher blood loss and complication rates compared to first time renal surgery. Consequently, many surgeons avoid minimally invasive techniques in the setting. We present the characteristics, complications, and short-term renal functional outcomes of patients who underwent a repeat robotic partial nephrectomy (rRPNx).

MATERIALS AND METHODS

A database was retrospectively reviewed to identify patients who underwent robotic partial nephrectomies between January 2007 and December 2013. Selection criteria for the rRPNx cohort included patients who had undergone at least two ipsilateral renal surgeries, with the second procedure being an rRPNx. All other patients comprised the initial robotic partial nephrectomy (iRPNx) group.

RESULTS

One hundred twenty-four patients who underwent robotic partial nephrectomy during the study period were identified. rRPNx constituted 26 (21%) of the total cases. Age of the rRPNx cohort was similar (p = 0.56), but number of tumors resected was two-fold greater in the rRPNx group (p = 0.44). Neither surgery time nor renal clamp time was significantly longer in either group (p = 0.18 and p = 0.65, respectively). Importantly, estimated blood loss (EBL) was significantly larger than in the iRPNx group (p = 0.01). Both groups had similar intravenous pain medication administration durations (p = 0.32), but postsurgical length of stay was greater for the rRPNx patients (p = 0.011). There were no significant differences in clavian complication rates (p = 0.17-0.39), with the exception of urine leak which occurred more frequently in the rRPNx group (p = 0.01). There was no difference in percent change in serum creatinine or estimated glomerular filtration rate (p = 0.89 and p = 0.67, respectively).

CONCLUSIONS

rRPNx is safe and feasible in select patients. EBL, postoperative lengths of stay, and urine leak were the only factors significantly associated with rRPNx compared to iRPNx. Patient 3-month follow-up revealed excellent and comparable outcomes between the two groups.

Standardized Reporting of Microscopic Renal Tumor Margins: Introduction of the Renal Tumor Capsule Invasion Scoring System

PURPOSE

Renal tumor enucleation allows for maximal parenchymal preservation. Identifying pseudocapsule integrity is critically important in nephron sparing surgery by enucleation. Tumor invasion into and through the capsule may have clinical implications, although it is not routinely commented on in standard pathological reporting. We describe a system to standardize the varying degrees of pseudocapsule invasion and identify predictors of invasion.

MATERIALS AND METHODS

We performed a multicenter retrospective review between 2002 and 2014 at Indiana University Hospital and Loyola University Medical Center. A total of 327 tumors were evaluated following removal via radical nephrectomy, standard margin partial nephrectomy or enucleation partial nephrectomy. Pathologists scored tumors using our i-Cap (invasion of pseudocapsule) scoring system. Multivariate analysis was done to determine predictors of higher score tumors.

RESULTS

Tumor characteristics were similar among surgical resection groups. Enucleated tumors tended to have thinner pseudocapsule rims but not higher i-Cap scores. Rates of complete capsular invasion, scored as i-Cap 3, were similar among the surgical techniques, comprising 22% of the overall cohort. Papillary histology along with increasing tumor grade was predictive of an i-Cap 3 score.

CONCLUSIONS

A capsule invasion scoring system is useful to classify renal cell carcinoma pseudocapsule integrity. i-Cap scores appear to be independent of surgical technique. Complete capsular invasion is most common in papillary and high grade tumors. Further work is warranted regarding the relevance of capsular invasion depth as it relates to the oncologic outcome for local recurrence and disease specific survival.

Is surgeon intuition equivalent to models of operative complexity in determining the surgical approach for nephron sparing surgery?

Introduction:

The choice of approach for partial nephrectomy often depends on surgical complexity. We aimed to determine if surgeon intuition was equivalent to markers of operative complexity, such as RENAL nephrometry and Mayo adhesive probability (MAP) score, in determining the surgical approach for partial nephrectomy (PN).

Materials and Methods:

We retrospectively identified 119 masses removed for suspected renal cell carcinoma from January 2012 to September 2014 by a single surgeon who intuitively chose treatment with one of three surgical approaches: Open PN (OPN), robotic-assisted transperitoneal PN (RATPN), or robotic-assisted retroperitoneal PN (RARPN). Clinicodemographic characteristics, pathological features, and postoperative outcomes were compared for each approach. Logistic regression was performed to identify independent predictors of open surgical resection, our primary endpoint.

Results:

Fifty-four tumors (45%) were resected via OPN, 40 (34%) via RATPN, and 25 (21%) via RARPN. OPN was performed in patients with more comorbidities (P = 0.02), lower baseline renal function (P < 0.01), more solitary kidneys (P < 0.01), and more multifocal disease (P < 0.01). Patients undergoing OPN had higher median nephrometry scores compared to RATPN and RARPN patients (8 vs. 7 vs. 7, respectively; P = 0.03), but MAP scores were no different among all three groups (P = 0.36). On multivariate analysis, higher nephrometry scores (odds ratio: 1.41, 95% confidence interval: 1.10-1.81; P = 0.007) were independently associated with open surgical resection. Nephrometry score was predictive of OPN (area under curve = 0.64, P = 0.01) with a score of 6.5 having the highest sensitivity and specificity (76% and 42%, respectively).

Conclusions:

RENAL nephrometry score was associated with surgical approach intuitively chosen by an experienced surgeon, but the presence of adherent perinephric fat did not correlate with decision-making.

Postoperative elevation in creatine kinase and its impact on renal function in patients undergoing complex partial nephrectomy

OBJECTIVE

To identify the risk factors associated with development of postoperative elevation of creatine kinase (CK) and study its effect on renal function in patients who underwent complex multifocal partial nephrectomy (PN).

METHODS

Patients who underwent PN at National Cancer Institute between January 2007 and December 2012 were included in the study. Elevated serum CK was defined as >2000 U/L. Kidney function was assessed using serum creatinine and estimated glomerular filtration rate (eGFR). Changes were reported as percent change from preoperative values and compared using the Wilcoxon test. Regression analysis was performed to identify the predictors of elevation in CK and decline in eGFR.

RESULTS

From 407 total cases, 207 had adequate CK data for analysis. Median number of tumors removed was 3 (1-70). Median peak CK was 1458 (82-36,788). Forty-two percent developed CK elevation >2000 U/L. Factors associated with postoperative elevation of CK > 2000 were young age (p = 0.009), high BMI (p = 0.003) and operating room time (p < 0.001). Although CK > 2000 was associated with significantly greater decline in eGFR (37.4 vs. 20.3 %, p < 0.001) in immediate postoperative period, this change largely resolved to a much less clinically relevant (9.2 vs 3.3 %, p = 0.040) change after 3 months. On multivariate analysis, postoperative elevation in CK was not found to be an independent factor determining renal function at 3 months.

CONCLUSION

In our cohort, a significant proportion of patients developed CK elevations >2000 U/L. While patients with elevated CK had more decline in eGFR in immediate postoperative period, postoperative elevations of CK did not appear to impact overall long-term renal function in patients undergoing PN.

Comparison of robot-assisted and laparoscopic partial nephrectomy for complex renal tumours with a RENAL nephrometry score ≥7: peri-operative and oncological outcomes

OBJECTIVE

To evaluate the peri-operative, functional and oncological outcomes of robot-assisted partial nephrectomy (RAPN) and laparoscopic partial nephrectomy (LPN) for moderately or highly complex tumours (defined as RENAL nephrometry score ≥7).

PATIENTS AND METHODS

We retrospectively analysed the medical charts of 216 patients with complex tumours who underwent LPN (n = 135) or RAPN (n = 81) between 2008 and 2014. Peri-operative data, pathological variables, complications, functional and oncological outcomes were reviewed.

RESULTS

Demographic characteristics were similar in the two groups. LPN was associated with a longer operating time (149.6 vs 135.6 min; P = 0.017) and greater estimated blood loss (220.8 vs 196.5 mL; P = 0.013). RAPN was associated with a higher direct cost. There were no differences in warm ischaemia time, transfusion rate, conversion rate, hospital stay, operative complications and estimated glomerular filtration rate change at 6 months after surgery. The mean follow-ups for LPN and RAPN were 31.4 and 16.5 months, respectively. The 3-year recurrence-free survival rate was 95.2% for LPN and 97.1% for RAPN (P = 0.71).

CONCLUSION

In patients with complex tumours, RAPN and LPN provided acceptable and similar results in terms of peri-operative, functional and oncological outcomes. RAPN was superior to LPN in terms of estimated blood loss and operating time, and LPN was the more cost-effective approach. Both surgery techniques remain viable options in the management of complex tumours with RENAL scores ≥7.

Nephron-sparing surgery for multifocal and hereditary renal tumors

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.

Robotic nephron-sparing surgery for renal tumors: Current status

There have been a number of advances in robotic partial nephrectomy (RPN) for renal masses. We reviewed these advances with emphasis on the evolution of technique and outcomes as well as the expanding indications for RPN. Literature in the English language was reviewed using the National Library of Medicine database. Relevant articles were extracted, and their citations were utilized to broaden our search. The identified articles were reviewed and summarized with a focus on novel developments. RPN is an evolving procedure and is an emerging viable alternative to laparoscopic partial nephrectomy and open partial nephrectomy with favorable outcomes. The contemporary techniques used for RPN demonstrate excellent perioperative outcomes. The short-term oncologic outcomes are comparable to those of laparoscopic and open surgical approaches. Further studies are needed to assess long-term oncologic control.

Do we need to clamp the renal hilum liberally during the initial phase of the learning curve of robot-assisted nephron-sparing surgery?

Objective. We aimed to compare the results of our initial robot-assisted nephron-sparing surgeries (RANSS) performed with or without hilar clamping. Material and Method. Charts of the initial RANSSs (n = 44), which were performed by a single surgeon, were retrospectively reviewed. R.E.N.A.L. nephrometry system, modified Clavien classification, and M.D.R.D. equation were used to record tumoral complexity, complications, and estimated glomerular filtration rate (eGFR), respectively. Outcomes of the clamped (group 1, n = 14) versus off-clamp (group 2, n = 30) RANSSs were compared. Results. The difference between the two groups was insignificant regarding mean patient age, mean tumor size, and mean R.E.N.A.L. nephrometry score. Mean operative time, mean estimated blood loss amount, and mean length of hospitalization were similar between groups. A total of 4 patients in each group suffered 11 Clavien grade ≥2 complications early postoperatively. Open conversion rates were similar. The difference between the 2 groups in terms of the mean postoperative change in eGFR was insignificant. We did not encounter any local recurrence after a mean follow-up of 18.9 months. Conclusions. Creating warm-ischemic conditions during RANSS should not be a liberal decision, even in the initial phases of the learning curve for a highly experienced open surgeon.

Feasibility and outcomes of laparoscopic renal intervention after prior open ipsilateral retroperitoneal surgery

BACKGROUND AND PURPOSE

Treating patients with renal-cell carcinoma (RCC) after previous retroperitoneal surgery (renal or adrenal) is technically challenging. We present our initial experience with laparoscopic renal interventions (LRI) after previous open retroperitoneal surgery in patients needing ipsilateral renal intervention. We report on feasibility, functional and oncologic outcomes of LRI after previous open retroperitoneal surgery.

PATIENTS AND METHODS

We reviewed records of patients undergoing attempted laparoscopic or robot-assisted renal intervention after at least one previous open ipsilateral retroperitoneal surgery. We identified 34 patients who underwent 39 staged attempted LRI after 48 previous open ipsilateral renal or adrenal surgeries. The LRI included 20 minimally invasive partial nephrectomies (MIPN), 11 laparoscopic radiofrequency ablations (LRFA), and 8 laparoscopic nephrectomies (LTN). Demographic, perioperative, renal functional, and oncologic outcome data were collected. Statistical analyses were performed to identify risks for conversion to open surgery.

RESULTS

No attempted nephron-sparing procedure resulted in kidney loss. Overall conversion rate of the cohort was 28% and was highest in the MIPN group (40%). On univariate analysis, only multiple tumors that were treated significantly increased chances of open conversion (P<0.01). Subset analysis demonstrated similar rates of blood loss, operative times, and conversion rates in patients undergoing partial nephrectomy having previous open partial nephrectomy compared with previous open adrenal surgery only. There was no significant difference in preservation of renal function between MIPN and LRFA, with more than 85% of preoperative renal function preserved. Mean follow-up of 11.9 months (range 1-97.5 mos) metastasis-free survival and overall survival was 94.1% and 97%, respectively.

CONCLUSIONS

LRI after previous open ipsilateral retroperitoneal surgery is feasible. Repeated partial nephrectomy has the highest conversion risks among the laparoscopic renal interventions and appears to be independent of previous renal or adrenal procedure. Attempting repeated LRI for multiple tumors is a significant risk factor for open conversion. Renal functional and oncologic outcomes are encouraging at early follow-up.

Partial nephrectomy--contemporary indications, techniques and outcomes

Increased detection of the small renal mass over the last two decades has led to greater utilization of partial nephrectomy techniques. Appreciation of the negative impact of chronic renal impairment has resulted in partial nephrectomy surpassing radical nephrectomy as the preferred treatment for technically feasible lesions. Indeed the management of localized renal tumours has become focused on techniques that maximally preserve nephron quantity and quality, and therefore maximize renal function after surgery. Postoperative renal function is determined primarily by three factors: preoperative renal function, volume of renal mass preserved and surgical renal ischaemia. Minimization of surgical ischaemia is achieved by early unclamping and unclamped (zero ischaemia) techniques. In addition, laparoscopic and robotic approaches to nephron-sparing surgery have significantly reduced the morbidity of the partial nephrectomy procedure compared with the traditional open approach. The contemporary techniques used for partial nephrectomy demonstrate excellent renal functional and oncological outcomes and minimize perioperative complications.

Robot-assisted laparoscopic partial nephrectomy for tumors greater than 4 cm and high nephrometry score: feasibility, renal functional, and oncological outcomes with minimum 1 year follow-up

OBJECTIVES

Minimally invasive robotic assistance is being increasingly utilized to treat larger complex renal masses. We report on the technical feasibility and renal functional and oncologic outcomes with minimum 1 year follow-up of robot-assisted laparoscopic partial nephrectomy (RALPN) for tumors greater than 4 cm.

MATERIALS AND METHODS

The urologic oncology database was queried to identify patients treated with RALPN for tumors greater than 4 cm and a minimum follow-up of 12 months. We identified 19 RALPN on 17 patients treated between June 2007 and July 2009. Two patients underwent staged bilateral RALPN. Demographic, operative, and pathologic data were collected. Renal function was assessed by serum creatinine levels, estimated glomerular filtration rate, and nuclear renal scans assessed at baseline, 3, and 12 months postoperatively. All tumors were assigned R.E.N.A.L. nephrometry scores (http://www.nephrometry.com).

RESULTS

The median nephrometry score for the largest tumor from each kidney was 9 (range 6-11) while the median size was 5 cm (range 4.1-15). Three of 19 cases (16%) required intraoperative conversion to open partial nephrectomy. No renal units were lost. There were no statistically significant differences between preoperative and postoperative creatinine and eGFR. A statistically significant decline of ipsilateral renal scan function (49% vs. 46.5%, P = 0.006) was observed at 3 months and at 12 mo postoperatively (49% vs. 45.5%, P = 0.014). None of the patients had evidence of recurrence or metastatic disease at a median follow-up of 22 months (range 12-36).

CONCLUSIONS

RALPN is feasible for renal tumors greater than 4 cm with moderate or high nephrometry scores. Although there was a modest decline in renal function of the operated unit, RALPN may afford the ability resect challenging tumors requiring complex renal reconstruction. The renal functional and oncologic outcomes are promising at a median follow-up of 22 months, but longer follow-up is required.

Argument in favor of performing partial nephrectomy for tumors greater than 7 cm: the metastatic prescription has already been written

The acceptance of partial nephrectomy over the past few decades has been gradual with initial utilization of nephron sparing approach for tumors up to 4 cm and more recently up to 7 cm. The arbitrary cutoff values used in the historic recommendations are based on the oncologic outcomes documenting the increase in metastatic potential of renal lesions that is strongly associated with increase in tumor size. Despite these observations, radical nephrectomy has not been found to be protective from development of metastatic disease, and oncologic outcomes of partial nephrectomy for tumors matched for size or stage have not been inferior to radical nephrectomy. The present manuscript argues for avoidance of specific size cutoffs as patients with larger masses may benefit from maximal preservation of nephrons. These are the very patients at higher risk for metastatic disease, who may benefit from preserved renal function to allow for future additional therapies or adjuvant trials.

Robotic partial nephrectomy: The new horizon

Background

There has been an exponential growth in the reporting of series of robotic partial nephrectomy (RPN). We review the technique of RPN and the outcomes from large single-centre series of RPN.

Methods

We searched databases to identify original articles related to RPN. For the technical aspects, we describe our technique and provide a general review of previous work. For outcomes, we reviewed previous reports using more rigid criteria, including only single-institution studies with at least 50 patients undergoing RPN.

Results

We found seven retrospective studies that met our criteria, with a total of 701 patients. Mean tumour size was 2.8 cm, with an average R.E.N.A.L. score (Radius, tumour size as maximum diameter; Exophytic/endophytic properties of the tumour, Nearness of tumour deepest portion to the collecting system or sinus, Anterior, a/posterior, p, descriptor, and the Location relative to the polar line) of 6.8. The mean warm ischaemia time was 21 min and mean operative duration was 196 min. The mean estimated blood loss was 182 mL, with a 7.4% transfusion rate. The conversion rate was 1.7% and the postoperative complication rate was 14%. The mean length of stay was 3.6 days. There were positive surgical margins in 1.7% of patients. The mean decrease in renal function was 5.4% and the mean follow-up was 8.4 months.

Conclusions

RPN is feasible and safe for different levels of complexity of renal tumours. Perioperative outcomes are comparable to those found with more established techniques. Future studies should compare different approaches and prioritise prospective and randomised designs.

Familial renal cancer: molecular genetics and surgical management

Familial renal cancer (FRC) is a heterogeneous disorder comprised of a variety of subtypes. Each subtype is known to have unique histologic features, genetic alterations, and response to therapy. Through the study of families affected by hereditary forms of kidney cancer, insights into the genetic basis of this disease have been identified. This has resulted in the elucidation of a number of kidney cancer gene pathways. Study of these pathways has led to the development of novel targeted molecular treatments for patients affected by systemic disease. As a result, the treatments for families affected by von Hippel-Lindau (VHL), hereditary papillary renal carcinoma (HPRC), hereditary leiomyomatosis renal cell carcinoma (HLRCC), and Birt-Hogg-Dubé (BHD) are rapidly changing. We review the genetics and contemporary surgical management of familial forms of kidney cancer.

Current status of partial nephrectomy for renal mass

The standard treatment for a small mass has shifted from radical nephrectomy to partial nephrectomy. The benefits of partial nephrectomy, including preserving renal function, prolonging overall survival, preventing postoperative chronic kidney disease, and reducing cardiovascular events, have been discussed in many studies. With the accumulation of surgeons' experience and simplification of the operative procedures, the warm ischemic time has become shorter despite the indication of tumor size becoming larger. With the help of intraoperative ultrasound, partial nephrectomy can be performed for an endophytic renal mass. Recently, laparoscopic partial nephrectomy has become well indicated for most renal tumors in many centers with advanced laparoscopic expertise. Open partial nephrectomy remains indicated for complex tumors. With technical innovation, robotic partial nephrectomy shows at least comparable perioperative outcomes with a benefit for challenging cases. Laparoendoscopic single-site partial nephrectomy has recently been tried in limited indications and seems to be feasible.

Impact of genetics on the diagnosis and treatment of renal cancer

Kidney cancer is a heterogeneous disease comprised of a number of histologic subtypes, each associated with unique genetic mutations, clinical features, and sensitivity to treatment. By examining families affected with the hereditary kidney cancer syndromes von Hippel-Lindau, hereditary papillary renal cell carcinoma, hereditary leiomyomatosis and renal cell carcinoma, and Birt-Hogg-Dubé, researchers have been able to identify the genes responsible for these syndromes. This work has revealed that kidney cancer is fundamentally a metabolic disorder, and as such, novel targeted therapies specific to their molecular biology have been developed and employed in both the hereditary and sporadic forms of renal cell carcinoma.

Laparoscopic partial nephrectomy for multiple tumours: feasibility and analysis of peri-operative outcomes

OBJECTIVE

• To describe our experience with laparoscopic partial nephrectomy (LPN) for multiple kidney tumours and compare the outcomes with LPN performed for single masses.

PATIENTS AND METHODS

• Retrospective analysis of medical records of patients undergoing LPN at our institution between 2005 and 2009 was performed. • The cohort was divided in two groups based on tumour focality: group 1, LPN for a single tumour (n= 99) and group 2, LPN for multiple ipsilateral tumours (n= 12). • The groups were compared with regards to demographic and peri-operative variables.

RESULTS

• Demographic variables were not different between the groups. Median dominant tumour size was 3.1 cm (interquartile range [IQR] 2.4-4.0) and 4.0 cm (2.3-5.9) in groups 1 and 2, respectively. • Median secondary tumour size in group 2 was 1.0 cm (1.0-1.8). • Operative times were longer in group 2 compared with group 1 (220 vs 160 min, P= 0.009). • Warm ischaemia times (WIT) (23 vs 22 min) and estimated blood loss (EBL) (100 vs 85 mL) were similar.

CONCLUSIONS

• LPN is a viable option for the treatment of multiple ipsilateral renal tumours. • Peri-operative outcomes are similar to standard LPN with the exception of longer operative time. • In experienced hands, the advantages of minimally invasive surgery may be extended to select patients with ipsilateral multifocal renal tumours.

Robot-assisted laparoscopic partial adrenalectomy: initial experience

OBJECTIVES

To evaluate the feasibility of performing robot-assisted laparoscopic partial adrenalectomy (RALPA) in patients seen at the National Cancer Institute and report the results of our initial experience.

METHODS

We reviewed the records of patients with adrenal masses who underwent attempted RALPA from July of 2008 until January of 2010. Demographic, perioperative, and pathologic data were collected. The functional and early oncological outcomes were examined by the need for steroid replacement and development of recurrent disease, respectively.

RESULTS

Ten patients underwent a total of 13 attempted RALPAs for removal of 19 adrenal tumors. There was one open conversion with successful completion of partial adrenalectomy. Of the patients, 80% had a known hereditary syndrome predisposing them to adrenal tumors. One patient had bilateral multifocal adrenal masses with unknown germ line genetic alteration and 1 patient had a sporadic adrenal mass. Of the 19 tumors removed, 17 were pheochromocytoma and 2 were adrenal-cortical hyperplasia. Two patients underwent partial adrenalectomy on a solitary adrenal gland, with one subsequently requiring steroid replacement postoperatively. On postoperative imaging, all but one operated adrenal gland demonstrated contrast enhancement. No patient developed local recurrence at a median follow-up of 16.2 months (range, 2-29).

CONCLUSIONS

RALPA appears safe and feasible in our early experience. Only 1 patient in our series required steroid replacement. Local recurrence rates are low but will require longer follow-up.

Recent updates in renal cell carcinoma

PURPOSE OF REVIEW

The review will examine the recent advances in our understanding of the genetic and molecular events that shape this cancer, and overview the emerging targeted therapies that have altered the landscape for renal cell carcinoma (RCC) patients.

RECENT FINDINGS

The incidence of RCC continues to rise, making it the 7th and 8th most common cancer among men and women in the US, respectively. Von Hippel-Lindau (VHL) gene loss is an important factor in the development of clear cell RCC, however: loss of VHL can result in tumors which express both HIF1 and HIF2, or HIF2 alone, correlating with distinct pathway activities. Invasive tumors demonstrating loss of VHL consistently demonstrate additional genetic changes, which appear to be essential for tumor progression. Targeted therapies have demonstrated improvements in overall survival. New ways to radiographically measure the tumor response to these treatments may provide additional information about a drug's activity in an individual patient. Vascular endothelial growth factor receptor tyrosine kinase inhibitors are still being investigated in the adjuvant setting.

SUMMARY

The field of RCC biology continues to rapidly change. As new targeted strategies to control this cancer evolve, so do both the clinical strategies, and the strategies to measure response and predict outcome.

Robot-assisted surgery: applications in urology

The past decade has seen a dramatic shift in the surgical management of certain urologic conditions with the advent of a robotic surgical platform. In fact, the surgical management of prostate cancer has seen the most dramatic shift, with the majority of cases now being performed robotically. Technical refinements over the years have led to improved outcomes regarding oncologic and functional results. Recently, robotic surgery has also been utilized for the surgical management of bladder cancer, renal cancer, and other benign conditions. As further experience is gained and longer-term outcomes are realized, robotic surgery will likely play an increasing role in the surgical management of many urologic conditions.

Molecular diagnosis and therapy of kidney cancer

Kidney cancer is not a single disease; it is made up of a number of cancers that occur in the kidney, each having a different histology, following a different clinical course, responding differently to therapy, and caused by a different gene. Study of the genes underlying kidney cancer has revealed that it is fundamentally a metabolic disorder. Understanding the genetic basis of cancer of the kidney has significant implications for diagnosis and management of this disease. VHL is the gene for clear cell kidney cancer. The VHL protein forms a complex that targets the hypoxia-inducible factors for ubiquitin-mediated degradation. Knowledge of this pathway provided the foundation for the development of novel therapeutic approaches now approved for treatment of this disease. MET is the gene for the hereditary form of type 1 papillary renal carcinoma and is mutated in a subset of sporadic type 1 papillary kidney cancers. Clinical trials are currently ongoing with agents targeting the tyrosine kinase domain of MET in sporadic and hereditary forms of papillary kidney cancer. BHD is the gene for the hereditary type of chromophobe kidney cancer. It is thought to be involved in energy and/or nutrient sensing through the AMPK and mTOR signaling pathways. Hereditary leiomyomatosis renal cell carcinoma, a hereditary form of type 2 papillary renal carcinoma, is caused by inactivation of a Krebs cycle enzyme due to mutation. Knowledge of these kidney cancer gene pathways has enabled new approaches in the management of this disease and has provided the foundation for the development of targeted therapeutics.