Partial nephrectomy after previous radio frequency ablation: the National Cancer Institute experience

Salvage stereotactic ablative body radiotherapy after thermal ablation of primary kidney cancer

OBJECTIVE

To evaluate the effectiveness and safety of salvage stereotactic ablative body radiotherapy (SABR) for recurrent renal cell carcinoma (RCC) after thermal ablation (TA).

MATERIALS AND METHODS

This study was a multi-institutional retrospective analysis of patients with recurrent RCC following TA who received SABR between 2016 and 2020. The primary study outcome was freedom from local failure, evaluated radiographically based on Response Evaluation Criteria in Solid Tumours (RECIST) v1.1. Distant failure, cancer-specific survival (CSS), overall survival (OS), treatment-related toxicity and renal function changes following SABR were the secondary outcomes. The Kaplan-Meier method was used to estimate freedom from local and distant failure, CSS and OS.

RESULTS

Seventeen patients with 18 biopsy-confirmed RCCs were included, with a median (interquartile range [IQR]) age at time of SABR of 75.2 (72.6-68.7) years, a median (IQR) tumour size of 3.5 (1.9-4.1) cm and follow-up (reverse Kaplan-Meier method) of 3.36 (95% confidence interval [CI] 1.6-4.1) years. Six of the 17 patients had a solitary kidney. Five patients had failed repeat TA prior to SABR. The median (IQR) time from TA procedure to SABR was 3.03 (1.5-5.1) years. No patient experienced local progression, with a local control rate of 100%. Four patients, two with baseline metastatic disease, experienced distant progression. The distant progression-free survival, CSS and OS at 3 years were 72.1% (95% CI 51.9%-100%), 92.3% (95% CI 78.9%-100%) and 82.1% (95% CI 62.1%-100%), respectively. The median (IQR) glomerular filtration rate before SABR was 58 (40-71) mL/min, and at last follow-up, it was 48 (33-57) mL/min. No patient experienced grade 3+ toxicity or went on to develop end-stage renal disease.

CONCLUSION

The results showed that SABR appears to be an effective and safe salvage strategy in patients with recurrent RCC following TA.

Ablative Treatments for Small Renal Masses and Management of Recurrences: A Comprehensive Review

This review focuses on ablative techniques for small renal masses (SRMs), including radiofrequency ablation (RFA), cryoablation (CA), microwave ablation (MWA), and irreversible electroporation (IRE), and discusses recurrence management. Through an extensive literature review, we outline the procedures, outcomes, and follow-up strategies associated with each ablative method. The review provides a detailed examination of these techniques-RFA, CA, MWA, and IRE-elucidating their respective outcomes. Recurrence rates vary among them, with RFA and CA showing comparable rates, MWA demonstrating favorable short-term results, and IRE exhibiting promise in experimental stages. For managing recurrences, various strategies are considered, including active surveillance, re-ablation, or salvage surgery. Surveillance is preferred post-RFA and post-CA, due to slow SRM growth, while re-ablation, particularly with RFA and CA, is deemed feasible without additional complications. Salvage surgery emerges as a viable option for larger or resistant tumors. While ablative techniques offer short-term results comparable to surgery, further research is essential to understand their long-term effects fully. Decisions concerning recurrence management should consider individual and tumor-specific factors. Imaging, notably contrast-enhanced ultrasounds, plays a pivotal role in assessing treatment success, emphasizing the necessity of a multidisciplinary approach for optimal outcomes. The lack of randomized trials highlights the need for further research.

Operative and oncological outcomes of salvage robotic radical and partial nephrectomy: a multicenter experience

We aim to describe the perioperative and oncological outcomes for salvage robotic partial nephrectomy (sRPN) and salvage robotic radical nephrectomy (sRRN). Using a prospectively maintained multi-institutional database, we compared baseline clinical characteristics and perioperative and postoperative outcomes, including pathological stage, tumor histology, operative time, ischemia time, estimated blood loss (EBL), length of stay (LOS), postoperative complication rate, recurrence rate, and mortality. We identified a total of 58 patients who had undergone robotic salvage surgery for a recurrent renal mass, of which 22 (38%) had sRRN and 36 (62%) had sRPN. Ischemia time for sRPN was 14 min. The median EBL was 100 mL in both groups (p = 0.581). One intraoperative complication occurred during sRRN, while three occurred during sRPN cases (p = 1.000). The median LOS was 2 days for sRRN and 1 day for sRPN (p = 0.039). Postoperatively, one major complication occurred after sRRN and two after sRPN (p = 1.000). The recurrence reported after sRRN was 5% and 3% after sRPN. Among the patients who underwent sRRN, the two most prevalent stages were pT1a (27%) and pT3a (27%). Similarly, the two most prevalent stages in sRPN patients were pT1a (69%) and pT3a (6%). sRRN and sRPN have similar operative and perioperative outcomes. sRPN is a safe and feasible procedure when performed by experienced surgeons. Future studies on large cohorts are essential to better characterize the importance and benefit of salvage partial nephrectomies.

Feasibility of salvage robotic partial nephrectomy after ablative treatment failure (UroCCR-62 study)

BACKGROUND

Ablative therapies (AT) are increasingly being offered to patients with kidney tumors. In cases of failure or local relapse, salvage surgery may be required. Such procedures often require an open approach, are difficult and have received little attention in the literature. We aim to evaluate the feasibility of salvage robot-assisted partial nephrectomy (sRAPN) after AT.

METHODS

We conducted a monocentric retrospective study of all patients who benefited from sRAPN. Clinical data were collected prospectively after written consent in the French UroCCR database.

RESULTS

Between 2013 and 2020, 724 RAPN were performed in our center; of these, 11 patients underwent salvage RAPN and four (36.4%) had an imperative indication for a solitary kidney. The median patient age was 54 (49-72) years, median preoperative glomerular filtration rate (GFR) was 65.5 (42.9-88.4) mL/min/1.73 m², and median tumor diameter was 34 (16-38) mm. Extensive perinephric fibrosis was present in 90.9% of cases. Postoperative complications occurred in 36.4% of patients, including major complications in 18.2%. The median GFR at three months (56.8 [45.9-63.9] mL/min/1.73 m²) and at last follow-up (52.1 [45.85-68.3] mL/min/1.73 m²) were not significantly different to the preoperative GFR (P=0.51 and P=0.65, respectively). During follow-up (median 12 months), three patients (all with Von Hippel Lindau disease) developed a recurrence, but none were on the sRAPN site.

CONCLUSIONS

Our series of sRAPN following AT failure confirms that such surgery is feasible with good functional and oncological results. However, these surgeries remain difficult, are associated with significant complication rate and should be performed in expert centers.

Tailoring Chemoimmunostimulant Bioscaffolds for Inhibiting Tumor Growth and Metastasis after Incomplete Microwave Ablation

Microwave ablation has attracted the most attention as a locoregional therapeutic method for solid neoplasms. However, the high incidence of incomplete ablation that could promote the rapid cancer progression still remains a challenge in clinic. Herein, we found that the high invasiveness of residual tumor following incomplete microwave ablation (iMWA) is mainly due to the myeloid cell-mediated immunosuppression. Accordingly, we develop a biohydrogel scaffold-enabled chemoimmunotherapeutic strategy by targeting myeloid cells with a phosphoinositide 3-kinase γ (PI3Kγ) inhibitor (IPI549) to synergize with immunostimulatory chemotherapy (Oxaliplatin, OX) for post-ablative cancer therapy. With several tumor mouse models, we reveal that OX&IPI549@Gel-based localized chemoimmunotherapy can substantially suppress the growth of tumor post-iMWA, simultaneously evoke robust systemic anticancer immunity to inhibit metastatic spread, and offer strong long-term immunological memory functions against tumor rechallenge. Besides, this work proposes a potential opportunity for precision medicine by utilizing a mechanism-based rationale to the adoption of our pre-existing arsenal of anticancer immunotherapeutic schedule.

Salvage Robot-assisted Renal Surgery for Local Recurrence After Surgical Resection or Renal Mass Ablation: Classification, Techniques, and Clinical Outcomes

BACKGROUND

Salvage treatment for local recurrence after prior partial nephrectomy (PN) or local tumor ablation (LTA) for kidney cancer is, as of yet, poorly investigated.

OBJECTIVE

To classify the treatments and standardize the nomenclature of salvage robot-assisted renal surgery, to describe the surgical technique for each scenario, and to investigate complications, renal function, and oncologic outcomes.

DESIGN, SETTING, AND PARTICIPANTS

Sixty-seven patients underwent salvage robot-assisted renal surgery from October 2010 to December 2020 at nine tertiary referral centers.

SURGICAL PROCEDURE

Salvage robot-assisted renal surgery classified according to treatment type as salvage robot-assisted partial or radical nephrectomy (sRAPN or sRARN) and according to previous primary treatment (PN or LTA).

MEASUREMENTS

Postoperative complications, renal function, and oncologic outcomes were assessed.

RESULTS AND LIMITATIONS

A total of 32 and 35 patients underwent salvage robotic surgery following PN and LTA, respectively. After prior PN, two patients underwent sRAPN, while ten underwent sRARN for a metachronous recurrence in the same kidney. No intra- or perioperative complication occurred. For local recurrence in the resection bed, six patients underwent sRAPN, while 14 underwent sRARN. For sRAPN, the intraoperative complication rate was 33%; there was no postoperative complication. For sRARN, there was no intraoperative complication and the postoperative complication rate was 7%. At 3 yr, the local recurrence-free rates were 64% and 82% for sRAPN and sRARN, respectively, while the 3-yr metastasis-free rates were 80% and 79%, respectively. At 33 mo, the median estimated glomerular filtration rates (eGFRs) were 57 and 45 ml/min/1.73 m² for sRAPN and sRARN, respectively. After prior LTA, 35 patients underwent sRAPN and no patient underwent sRARN. There was no intraoperative complication; the overall postoperative complications rate was 20%. No local recurrence occurred. The 3-yr metastasis-free rate was 90%. At 43 mo, the median eGFR was 38 ml/min/1.73 m². The main limitations are the relatively small population and the noncomparative design of the study.

CONCLUSIONS

Salvage robot-assisted surgery has a safe complication profile in the hands of experienced surgeons at high-volume institutions, but the risk of local recurrence in this setting is non-negligible.

PATIENT SUMMARY

Patients with local recurrence after partial nephrectomy or local tumor ablation should be aware that further treatment with robot-assisted surgery is not associated with a worrisome complication profile, but also that they are at risk of further recurrence.

[Ablative therapy of small renal masses]

Renal cell cancer is nowadays predominantly diagnosed in early stages due to the widespread use of sectional imaging for unrelated symptoms. Small renal masses (<4 cm) feature a largely indolent biology with a very low risk for metastasis or even a benign biology in up to 30% of the cases. Consequently, there is a need for less invasive therapeutic alternatives to nephron-sparing surgery. Meanwhile, there is a broad portfolio of local ablation techniques to treat small renal tumors. These include the extensively studied radiofrequency ablation and cryoablation techniques as well as newer modalities like microwave ablation and irreversible electroporation as more experimental techniques. Tumor ablation can be performed percutaneously under image guidance or laparoscopically. In particular, the percutaneous approach is a less invasive alternative to nephron-sparing surgery with lower risk for complications. Comparative studies and meta-analyses report a higher risk for local recurrence after renal tumor ablation compared to surgery. However, long-term oncological results after treatment of small renal masses are promising and do not seem to differ from partial nephrectomy. The possibility for salvage therapy in case of recurrence also accounts for this finding. Especially old patients with an increased risk of surgical and anesthesiological complications as well as patients with recurrent and multiple hereditary renal cell carcinomas may benefit from tumor ablation. Tumor biopsy prior to intervention is associated with very low morbidity rates and is oncologically safe. It can help to assess the biology of the renal mass and prevent therapy of benign lesions.

Systematic Review of the Management of Local Kidney Cancer Relapse

CONTEXT

Management of locally recurrent renal cancer is complex.

OBJECTIVE

In this systematic review we analyse the available literature on the management of local renal cancer recurrence.

EVIDENCE ACQUISITION

A systematic search (PubMed, Web of Science, CINAHL, Clinical Trials, and Scopus) of English literature from 2000 to 2017 was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.

EVIDENCE SYNTHESIS

The search identified 1838 articles. Of those, 36 were included in the evidence synthesis. The majority of the studies identified were retrospective and not controlled. Local recurrence after thermal ablation (TA) may be managed with repeat TA. Alternatively, salvage nephrectomy is possible. However, a higher rate of complications should be expected than after primary nephrectomy. Salvage nephrectomy and TA represent treatment options for local recurrence after partial nephrectomy. Local retroperitoneal recurrence after radical nephrectomy is ideally treated with surgical resection, for which minimally invasive approaches might be applicable to select patients. For large recurrences, addition of intraoperative radiation may improve local control. Local tumour destruction appears to be more beneficial than systemic therapy alone for local recurrences.

CONCLUSIONS

Management of local renal cancer relapse varies according to the clinical course and prior treatments. The available data are mainly limited to noncontrolled retrospective series. After nephron-sparing treatment, TA represents an effective treatment with low morbidity. For local recurrence after radical nephrectomy, the low-level evidence available suggests superiority of surgical excision relative to systemic therapy or best supportive care. As a consequence, surgery should be prioritised when feasible and applicable.

PATIENT SUMMARY

In renal cell cancer, the occurrence and management of local recurrence depend on the initial treatment. This cancer is a disease with a highly variable clinical course. After initial organ-sparing treatment, thermal ablation offers good cancer control and low rates of complications. For recurrence after radical nephrectomy, surgical excision seems to provide the best long-term cancer control and it is superior to medical therapy alone.

Focal ablation therapy for renal cancer in the era of active surveillance and minimally invasive partial nephrectomy

Partial nephrectomy is the optimal surgical approach in the management of small renal masses (SRMs). Focal ablation therapy has an established role in the modern management of SRMs, especially in elderly patients and those with comorbidities. Percutaneous ablation avoids general anaesthesia and laparoscopic ablation can avoid excessive dissection; hence, these techniques can be suitable for patients who are not ideal surgical candidates. Several ablation modalities exist, of which radiofrequency ablation and cryoablation are most widely applied and for which safety and oncological efficacy approach equivalency to partial nephrectomy. Data supporting efficacy and safety of ablation techniques continue to mature, but they originate in institutional case series that are confounded by cohort heterogeneity, selection bias, and lack of long-term follow-up periods. Image guidance and surveillance protocols after ablation vary and no consensus has been established. The importance of SRM biopsy, its optimal timing, the type of biopsy used, and its role in treatment selection continue to be debated. As safety data for active surveillance and experience with minimally invasive partial nephrectomy are expanding, the role of focal ablation therapy in the treatment of patients with SRMs requires continued evaluation.

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.

Sixth BHD Symposium and First International Upstate Kidney Cancer Symposium: latest scientific and clinical discoveries

The Sixth BHD Symposium and First International Upstate Kidney Cancer Symposium concluded in September 2015, in Syracuse, NY, USA. The program highlighted recent findings in a variety of areas, including drug development, therapeutics and surgical management of patients with BHD and multi-focal renal tumors, as well as multidisciplinary approaches for patients with localized, locally advanced and metastatic renal cell carcinoma.

Molecular genetics and clinical features of Birt-Hogg-Dubé syndrome

Birt-Hogg-Dubé (BHD) syndrome is an inherited renal cancer syndrome in which affected individuals are at risk of developing benign cutaneous fibrofolliculomas, bilateral pulmonary cysts and spontaneous pneumothoraces, and kidney tumours. Bilateral multifocal renal tumours that develop in BHD syndrome are most frequently hybrid oncocytic tumours and chromophobe renal carcinoma, but can present with other histologies. Germline mutations in the FLCN gene on chromosome 17 are responsible for BHD syndrome--BHD-associated renal tumours display inactivation of the wild-type FLCN allele by somatic mutation or chromosomal loss, confirming that FLCN is a tumour suppressor gene that fits the classic two-hit model. FLCN interacts with two novel proteins, FNIP1 and FNIP2, and with AMPK, a negative regulator of mTOR. Studies with FLCN-deficient cell and animal models support a role for FLCN in modulating the AKT-mTOR pathway. Emerging evidence links FLCN with a number of other molecular pathways and cellular processes important for cell homeostasis that are frequently deregulated in cancer, including regulation of TFE3 and/or TFEB transcriptional activity, amino-acid-dependent mTOR activation through Rag GTPases, TGFβ signalling, PGC1α-driven mitochondrial biogenesis, and autophagy. Currently, surgical intervention is the only therapy available for BHD-associated renal tumours, but improved understanding of the FLCN pathway will hopefully lead to the development of effective forms of targeted systemic therapy for this disease.

Outlining the limits of partial nephrectomy

Amongst nephron-sparing modalities, partial nephrectomy (PN) is the standard of care in the treatment of renal cell carcinoma (RCC). Despite the increasing utilization of PN, particularly propagated by robot-assisted, minimally invasive approaches for small renal masses (SRMs), the limits of PN appear to be also evolving. In this review, we sought to address the tumour stage beyond which PN may be oncologically perilous. While the evidence supports PN in the treatment of tumours < pT2a, PN may have a role in advanced or metastatic RCC. Other scenarios wherein PN has limited utility are also explored, including anatomical or surgical factors that dictate the difficulty of the case, such as prior renal surgery. Lastly, we discuss the emerging role of molecular biomarkers, specifically epigenetics, to aid in the risk stratification of SRMs and to select tumours optimally suited for PN.

Oncological and functional outcomes of salvage renal surgery following failed primary intervention for renal cell carcinoma

PURPOSE

To assess the oncologic and functional outcomes of salvage renal surgery following failed primary intervention for RCC.

MATERIALS AND METHODS

We performed a retrospective review of patients who underwent surgery for suspected RCC during 2004-2012. We identified 839 patients, 13 of whom required salvage renal surgery. Demographic data was collected for all patients. Intraoperative and postoperative data included ischemic duration, blood loss and perioperative complications. Preoperative and postoperative assessments included abdominal CT or magnetic resonance imaging, chest CT and routine laboratory work. Estimated glomerular filtration rate (eGFR) was calculated according to the Modification of Diet in Renal Disease equation.

RESULTS

The majority (85%) of the patients were male, with an average age of 64 years. Ten patients underwent salvage partial nephrectomy while 3 underwent salvage radical nephrectomy. Cryotherapy was the predominant primary failed treatment modality, with 31% of patients undergoing primary open surgery. Pre-operatively, three patients were projected to require permanent post-operative dialysis. In the remaining 10 patients, mean pre- and postoperative serum creatinine and eGFR levels were 1.35 mg/dL and 53.8 mL/min/1.73 m2 compared to 1.43 mg/dL and 46.6 mL/min/1.73 m2, respectively. Mean warm ischemia time in 10 patients was 17.4 min and for all patients, the mean blood loss was 647 mL. The predominant pathological stage was pT1a (8/13; 62%). Negative surgical margins were achieved in all cases. The mean follow-up was 32.9 months (3.5-88 months).

CONCLUSION

While salvage renal surgery can be challenging, it is feasible and has adequate surgical, functional and oncological outcomes.

Open mini-flank partial nephrectomy: an essential contemporary operation

Secondary to the widespread use of the modern imaging techniques of computed tomography, magnetic resonance imaging, and ultrasound, 70% of renal tumors today are detected incidentally with a median tumor size of less than 4 cm. Twenty years ago, all renal tumors, regardless of size were treated with radical nephrectomy (RN). Elective partial nephrectomy (PN) has emerged as the treatment of choice for small renal tumors. The basis of this paradigm shift is three major factors: (1) cancer specific survival is equivalent for T1 tumors (7 cm or less) whether treated by PN or RN; (2) approximately 45% of renal tumors have indolent or benign pathology; and (3) PN prevents or delays the onset of chronic kidney disease, a condition associated with increased cardiovascular morbidity and mortality. Although PN can be technically demanding and associated with potential complications of bleeding, infection, and urinary fistula, the patient derived benefits of this operation far outweigh the risks. We have developed a "mini-flank" open surgical approach that is highly effective and, coupled with rapid recovery postoperative care pathways associated with a 2-day length of hospital stay.

Diagnosis and management of BHD-associated kidney cancer

In addition to the associated cutaneous and pulmonary manifestations, individuals with the Birt-Hogg-Dubé (BHD) syndrome have an increased risk of developing kidney cancer, which is often bilateral and multifocal. The risk of developing a renal tumor in this population does not decrease with age and therefore warrants a lifelong screening approach. We recommend abdominal imaging every 36 months in individuals without renal lesions at initial screening. Once renal tumors are identified, they should be followed with interval imaging studies until the largest tumor reaches 3 cm in maximal diameter, at which point nephron-sparing surgery should be ideally pursued. While the histology of renal tumors can vary in the BHD syndrome, most tumors possess a relatively indolent natural history and do not require adjuvant therapy if resected when localized to the kidney. With this approach, the vast majority of patients will achieve a curative oncologic outcome and avoid the medical sequelae of chronic renal insufficiency that could otherwise result from total nephrectomy.

Hereditary renal cell carcinoma: genetics, clinical features, and surgical considerations

OBJECTIVES

Hereditary renal cancer syndromes have been described and have illuminated novel methods to treat sporadic renal cell carcinoma. In this work, we aimed to review the genetic basis, molecular pathology and clinical manifestations of hereditary syndromes, as well as outline principles of surgical management and use of targeted therapy.

METHODS

We performed a comprehensive review of selected peer-reviewed publications regarding hereditary renal cancer syndromes, their genetic basis, and recommendations for surgical management.

RESULTS

The major syndromes contributing to hereditary renal cell carcinoma are discussed along with relevant literature guiding their management. The evolving surgical and molecular treatments are discussed.

CONCLUSIONS

Identification of genetic basis of hereditary carcinomas provides opportunity for targeted therapy of metastatic sporadic renal cell carcinoma. Appropriate and timely surgical management of hereditary renal cancers decreases the possibility of development of metastatic disease, and allows for preservation of renal function despite the need for repeat surgical interventions.

The contemporary role of ablative treatment approaches in the management of renal cell carcinoma (RCC): focus on radiofrequency ablation (RFA), high-intensity focused ultrasound (HIFU), and cryoablation

INTRODUCTION

Currently, most of renal tumors are small, low grade, with a slow growth rate, a low metastatic potential, and with up to 30 % of these tumors being benign on the final pathology. Moreover, they are often diagnosed in elderly patients with preexisting medical comorbidities in whom the underlying medical conditions may pose a greater risk of death than the small renal mass. Concerns regarding overdiagnosis and overtreatment of patients with indolent small renal tumors have led to an increasing interest in minimally invasive, ablative as an alternative to extirpative interventions for selected patients.

OBJECTIVE

To provide an overview about the state of the art in radiofrequency ablation (RFA), high-intensity focused ultrasound, and cryoablation in the clinical management of renal cell carcinoma.

METHODS

A PubMed wide the literature search of was conducted.

RESULTS

International consensus panels recommend ablative techniques in patients who are unfit for surgery, who are not considered candidates for or elect against elective surveillance, and who have small renal masses. The most often used techniques are cryoablation and RFA. These ablative techniques offer potentially curative outcomes while conferring several advantages over extirpative surgery, including improved patient procedural tolerance, faster recovery, preservation of renal function, and reduction in the risk of intraoperative and postsurgical complications. While it is likely that outcomes associated with ablative modalities will improve with further advances in technology, their application will expand to more elective indications as longer-term efficacy data become available.

CONCLUSION

Ablative techniques pose a valid treatment option in selected patients.

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.

Outcomes of patients with surgically treated bilateral renal masses and a minimum of 10 years of followup

PURPOSE

Nephron sparing surgery has been advocated for patients with bilateral renal masses but long-term functional and oncological outcomes are lacking. We report the outcomes of patients with bilateral renal masses and a minimum 10-year followup.

MATERIALS AND METHODS

Patients with bilateral renal masses evaluated at our institution who were treated with initial surgery at least 10 years ago and underwent interventions on each renal unit were included in the analysis. Collected data included demographics, hereditary diagnosis, number of renal interventions, renal function and mortality status. Overall and renal cell carcinoma specific survival was assessed. Comparisons were made of renal function and overall survival between groups with 2 renal units and a surgically solitary kidney.

RESULTS

A total of 128 patients met study inclusion criteria. Median followup in our cohort was 16 years (mean 17, range 10 to 49). The median number of surgical interventions was 3 (range 2 to 10). Of the patients 87 (68%) required repeat interventions on the ipsilateral renal unit at last followup with a median of 6.2 years (range 0.7 to 21) between interventions. Overall and renal cell cancer specific survival was 88% and 97%, respectively. Six patients (4.7%) ultimately underwent bilateral nephrectomy. Although renal function was better preserved in patients with 2 kidneys (70 vs 53 ml/minute/1.73 m(2), p = 0.0002), there was no difference in overall survival between those with bilateral kidneys or a surgically solitary kidney.

CONCLUSIONS

At a minimum 10-year followup after initial surgery, nephron sparing surgery allowed for excellent oncological and functional outcomes. Despite the need for repeat surgical interventions, nephron sparing surgery enabled dialysis to be avoided in more than 95% of patients.

Economic burden of repeat renal surgery on solitary kidney--do the ends justify the means? A cost analysis

PURPOSE

Despite the high morbidity of repeat renal surgery in patients with multifocal recurrent renal carcinoma, in most patients adequate renal function is preserved to obviate the need for dialysis. To our knowledge the economic burden of repeat renal surgery has not been evaluated. We provide a cost analysis for patients requiring repeat renal surgery on a solitary kidney.

MATERIALS AND METHODS

We reviewed the charts of patients treated at the National Cancer Institute who required repeat renal surgery from 1989 to 2010. Functional, oncological and surgical outcomes were evaluated and the costs of repeat renal surgery were calculated. We then compared costs in a cohort of 33 patients who underwent repeat renal surgery on a solitary kidney and in a hypothetical patient cohort treated with uncomplicated nephrectomy, fistula placement and dialysis. All costs were calculated based on Medicare reimbursement rates derived from CPT codes. Cost analysis was performed.

RESULTS

Despite a high 45% complication rate, 87% of patients maintained renal function that was adequate to avoid dialysis and 96% remained metastasis free at an average followup of 3.12 years (range 0.3 to 16.4). Compared to the hypothetical dialysis cohort, the financial benefit of repeat renal surgery was reached at 0.68 years.

CONCLUSIONS

Repeat renal surgery is a viable alternative for patients with multifocal renal cell carcinoma requiring multiple surgical interventions, especially when left with a solitary kidney. Despite the high complication rate, renal function is preserved in most patients and they have an excellent oncological outcome. The financial benefit of repeat renal surgery is reached at less than 1 year.

The contemporary role of renal mass biopsy in the management of small renal tumors

The selective use of percutaneous biopsy for diagnosis in renal masses is a relatively uncommon approach when compared to the management of other solid neoplasms. With recent advancements in imaging techniques and their widespread use, the incidental discovery of asymptomatic, small renal masses (SRM) is on the rise and a substantial percentage of these SRM are benign. Recent advances in diagnostics have significantly improved accuracy rates of renal mass biopsy (RMB), making it a potentially powerful tool in the management of SRM. In this review, we will discuss the current management of SRM, problems with the traditional view of RMB, improvements in the diagnostic power of RMB, cost-effectiveness of RMB, and risks associated with RMB. RMB may offer important information enabling treating clinicians to better risk-stratify patients and ultimately provide a more personalized treatment approach for SRM.

Comparison of safety, renal function outcomes and efficacy of laparoscopic and percutaneous radio frequency ablation of renal masses

PURPOSE

With the increased incidence of low stage renal cancers, thermal ablation technology has emerged as a viable treatment option. Current AUA (American Urological Association) guidelines include thermal ablation as a treatment modality for select individuals. We compared the laparoscopic and percutaneous approach for the radio frequency ablation of renal tumors under the guidance of urological surgeons.

MATERIALS AND METHODS

We reviewed our radio frequency ablation database of patients with renal masses undergoing laparoscopic or computerized tomography guided percutaneous radio frequency ablation with simultaneous peripheral fiberoptic thermometry from November 2001 to January 2011 at a single tertiary care center. Data were collected on patient demographics, and surgical and clinicopathological outcomes stratified by approach.

RESULTS

A total of 298 patients with 316 renal tumors underwent laparoscopic (122 tumors) or computerized tomography guided (194 tumors) radio frequency ablation. There were no statistically significant differences between the laparoscopic and computerized tomography guided radio frequency ablation groups with respect to patient demographics, complication rates and renal functional outcomes (p>0.05). The 3-year Kaplan-Meier estimation of radiographic recurrence-free probability was 95% for computerized tomography guided radio frequency ablation and 94% for laparoscopic radio frequency ablation (p=0.84). Subanalysis of the 212 (67%) renal cell carcinoma tumors showed a 3-year Kaplan-Meier estimation of oncologic recurrence-free probability (post-ablation biopsy proven viable tumor) of 94% for computerized tomography guided radio frequency ablation and 100% for laparoscopic radio frequency ablation (p=0.16). Median followup was 21 months for laparoscopic radio frequency ablation) and 19 months for computerized tomography guided radio frequency ablation.

CONCLUSIONS

Laparoscopic and computerized tomography guided radio frequency ablation appear safe and effective with statistically equivalent rates of complications and recurrence.

Percutaneous ablation in the kidney

Percutaneous ablation in the kidney is now performed as a standard therapeutic nephron-sparing option in patients who are poor candidates for resection. Its increasing use has been largely prompted by the rising incidental detection of renal cell carcinomas with cross-sectional imaging and the need to preserve renal function in patients with comorbid conditions, multiple renal cell carcinomas, and/or heritable renal cancer syndromes. Clinical studies to date indicate that radiofrequency ablation and cryoablation are effective therapies with acceptable short- to intermediate-term outcomes and with a low risk in the appropriate setting, with attention to pre-, peri-, and postprocedural detail. The results following percutaneous radiofrequency ablation and cryoablation in the treatment of renal cell carcinoma are reviewed in this article, including those of several larger scale studies of ablation of T1a tumors. Clinical and technical considerations unique to ablation in the kidney are presented, and potential complications are discussed.

Repeat partial nephrectomy: surgical, functional and oncological outcomes

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.

Probe ablation as salvage therapy for renal tumors in von Hippel-Lindau patients: the Cleveland Clinic experience with 3 years follow-up

BACKGROUND

To evaluate the efficacy and safety of probe ablative therapy as salvage treatment for renal tumor in von Hippel-Lindau (VHL) patients after previous partial nephrectomy (PN).

METHODS

Medical records of VHL patients undergoing probe ablative treatment for renal tumors from March 2003 to January 2010 at our institution were retrospectively analyzed.

RESULTS

Fourteen VHL patients who were submitted to salvage probe ablative therapy were included in the analysis. Twelve patients (85%) had a solitary kidney. Overall, 33 tumors were ablated by either percutaneous cryoablation (P-Cryo) (n of procedures = 13), radiofrequency ablation (RFA) (n = 14), and laparoscopic cryoablation (L-Cryo) (n = 3). Average maximal renal tumor diameter was 2.6 ± 1 cm. Average ablation time was 18.3 ± 2.1 minutes for P-Cryo, 36.7 ± 17 minutes for RFA, and 17.3 ± 4 minutes for L-Cryo. All procedures were successfully completed without transfusions and intraoperative complications. No early postoperative complications were recorded. Postoperative decline in renal function was minimal and not clinically significant. With a mean follow-up of 37.6 months (range 12-82), 4 patients had a suspicious recurrence on computed tomography/magnetic resonance imaging (CT/MRI) scan and in 3 of them a re-ablation was performed. Actuarial overall and cancer-specific survivals were 92% and 100%, respectively.

CONCLUSIONS

Probe ablative therapy seems to represent a suitable treatment option for VHL patients with a previous history of PN as it offers a repeatable operation, with a high technical success rate and causing minor changes in renal function.

Initial experience using microwave ablation therapy for renal tumor treatment: 18-month follow-up

OBJECTIVES

To assess efficacy and morbidity of microwave ablation (MWA) for small renal tumors in an initial cohort of patients. MWA is a recently introduced thermal needle ablation treatment modality with theoretical advantages compared with radiofrequency ablation, such as greater intratumoral temperatures, lack of a grounding pad, and superior convection profile. However, experience has been limited in the human kidney.

METHODS

Ten patients with a single, solid-enhancing renal tumor from June 2008 to November 2008 received laparoscopic or computed tomography-guided percutaneous MWA at a tertiary referral center with ≥14 months of follow-up. MWA was performed using the Valleylab Evident, 915-MHz MWA system at 45 W with intraoperative biopsy before ablation, and peripheral fiberoptic thermometry to determine the treatment endpoints. The patients were followed up with contrast-enhanced computed tomography at 1 month, 6 months to 1 year, and annually to monitor for tumor recurrence.

RESULTS

The follow-up duration for the 6 male and 4 female patients (mean tumor size 3.65 cm, range 2.0-5.5; mean age 69.8 years) was 17.9 months. The recurrence rate, defined by persistent enhancement, was 38% (3 of 8). The intraoperative and postoperative complication rate was 20% and 40%, respectively.

CONCLUSIONS

MWA resulted in poor oncologic outcomes with a significant complication rate at an intermediate level of follow-up. However, MWA has promising theoretical advantages and should not be discarded. Additional studies should be considered to better understand the microwave-tissue interaction and treatment endpoints for different size renal masses before widespread use.

Feasibility and outcomes of partial nephrectomy for resection of at least 20 tumors in a single renal unit

PURPOSE

Patients with hereditary renal cancer are at increased risk for recurrent bilateral multifocal tumors and may require aggressive nephron sparing surgery to prevent renal replacement therapy. We evaluated feasibility and outcomes in patients who underwent partial nephrectomy with removal of at least 20 tumors in a single renal unit at 1 setting.

MATERIALS AND METHODS

We retrospectively reviewed the records of 30 patients who underwent a total of 34 partial nephrectomies with removal of at least 20 tumors at our institution from 1993 to 2008. Operative reports and hospital records were reviewed for perioperative data, and renal functional and oncologic outcomes. We compared preoperative and postoperative renal function with the 2-tailed t test.

RESULTS

There were no deaths and only 1 renal unit was lost. A median of 26.5 tumors was removed. Median estimated blood loss was 3,500 ml and median operative time was 9 hours. Perioperative complications developed in greater than 50% of cases. There was a statistically significant decrease in the estimated glomerular filtration rate at 3 months (67 vs 59 ml/minute/1.73 m(2), p < 0.001). Only 1 patient had metastatic disease. Eight of the 34 operated kidneys required subsequent intervention during the median followup of 52 months (range 4 to 187).

CONCLUSIONS

Aggressive partial nephrectomy to resect multiple tumors is technically feasible. There was a significant decrease in postoperative renal function but more than 80% of preoperative renal function was preserved in this cohort except in 1 patient. Also, oncologic outcomes were encouraging at intermediate term followup.

Percutaneous vs surgical cryoablation of the small renal mass: is efficacy compromised?

OBJECTIVE

• To review and analyse the cumulative literature to compare surgical and percutaneous cryoablation of small renal masses (SRMs).

METHODS

• A MEDLINE search was performed (1966 to February 2010) of the published literature in which cryoablation was used as therapy for localized renal masses. • Residual disease was defined as persistent enhancement on the first post-ablation imaging study, while recurrent disease was defined as enhancement after an initially negative postoperative imaging study, consistent with the consensus definition by the Working Group on Image-Guided Tumor Ablation. • Data were collated and analysed using the two-sample Mann-Whitney test and random-effects Poisson regression, where appropriate.

RESULTS

• In all, 42 studies, representing 1447 lesions treated by surgical (n= 28) or percutaneous (n= 14) cryoablation were pooled and analysed. • No significant differences were detected between approaches regarding patient age (median 67 vs 66 years, P= 0.55), tumour size (median 2.6 vs 2.7 cm, P= 0.24),or duration of follow-up (median 14.9 vs 13.3 months, P= 0.40). • Differences in rates of unknown pathology also failed to reach statistical significance (14 vs 21%, P= 0.76). The difference in the rate of residual tumour was not statistically different (0.033 vs 0.046, P= 0.25), nor was the rate of recurrent tumour (0.008 vs 0.009, P= 0.44). • The reported rate of metastases was negligible in both groups, precluding statistical analysis.

CONCLUSIONS

• Cryoablation has shown acceptable short-term oncological results as a viable strategy for SRMs. • Analysis of the cumulative literature to date shows that surgical and percutaneous cryoablation have similar oncological outcomes.

Long-term management of bilateral, multifocal, recurrent renal carcinoma

Patients with bilateral multifocal renal cell carcinoma are at increased risk of developing locally recurrent or de novo tumors after nephron-sparing procedures. When dealing with recurrent renal masses the options are limited to observation, total nephrectomy, ablation, or repeat surgical intervention. The main reason for recurrence after nephron-sparing surgery is likely to be the presence of multifocal disease, which is identified in 4.3-25.0% of radical nephrectomy specimen. Bilateral renal involvement is seen in almost 90% of cases of multifocal renal carcinoma, and conversely the majority of patients with bilateral disease will have multifocal tumors. Many patients who are treated for multifocal disease, therefore, require subsequent surgical interventions. The outcome data for repeat renal interventions demonstrate reasonable functional and oncologic outcomes despite higher rates of perioperative complications. Our own results support the use of reoperative renal surgery rather than total nephrectomy and renal replacement therapy.

The changing face of renal-cell carcinoma

The present decade can be credited with the improved understanding of renal-cell carcinoma (RCC), its local and systemic management, and various controversies from diagnosis to types of various available interventions. The old paradigms and dogmas are no longer accepted as "the best way" without evidence, and many "old" principles are cautiously questioned. These notions have resulted in new knowledge, questions, arguments, and treatment options. This article will describe the "changing face of RCC" over the past several years and will briefly summarize the major changes and issues in the field of renal oncology. The discussed topics include improved molecular understanding of RCC, management of small renal masses, the safety and accuracy of renal mass biopsy, the emerging role of molecular imaging, the importance of maximal renal preservation, and the evolving role of laparoscopy, robotics, and ablation.

Repeat partial nephrectomy on the solitary kidney: surgical, functional and oncological outcomes

PURPOSE

We examined outcomes in patients with recurrent or de novo renal lesions treated with repeat partial nephrectomy on a solitary kidney.

MATERIALS AND METHODS

We reviewed the records of patients who underwent nephron sparing surgery at the National Cancer Institute from 1989 to 2008. Patients were included in analysis if they underwent repeat partial nephrectomy on a solitary kidney. Perioperative, functional and oncological outcomes were assessed. Functional outcomes were evaluated using the Modification of Diet in Renal Disease equation for the estimated glomerular filtration rate. Oncological efficacy was examined by the need for subsequent repeat renal surgery and the development of metastatic disease.

RESULTS

A total of 25 patients were included in the analysis. A median of 4 tumors were resected. Median estimated blood loss was 2,400 ml and median operative time was 8.5 hours. Perioperative complications occurred in 52% of patients, including 1 death and the loss of 3 renal units. There was a decrease in the estimated glomerular filtration rate at followup visit 1 within 3 months after surgery but at 1-year followup the difference was not significant (p <0.01 and 0.12, respectively). Surgical intervention was recommended in 8 patients (38%) for recurrent or de novo tumors at a median of 36 months. The average metastasis-free survival rate in the cohort was 95% at 57 months (median 50, range 3 to 196).

CONCLUSIONS

Repeat partial nephrectomy in patients with solitary kidney is a high risk alternative. The complication rate is high and there is a modest decrease in renal function but most patients remain free of dialysis with acceptable oncological outcomes at intermediate followup.