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Kolanukuduru KP, Dovey Z, Tillu N, Venkatesh A, Kotb A, Buscarini M, Zaytoun O. Preoperative Computed Tomography Imaging Accurately Identifies Adrenal Gland Involvement In Patients With Renal Masses. Urology 2024:S0090-4295(24)00657-5. [PMID: 39173932 DOI: 10.1016/j.urology.2024.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 06/18/2024] [Accepted: 08/07/2024] [Indexed: 08/24/2024]
Abstract
OBJECTIVE To determine the frequency of adrenal gland involvement (AGI) in patients with renal cell carcinoma (RCC) and assess the ability of preoperative computed tomography (CT) imaging to predict AGI prior to radical nephrectomy (RN). METHODS We retrospectively identified 90 patients who underwent RN with concomitant ipsilateral adrenalectomy (CIA) between 2019 and 2021 at our institution. We reviewed the preoperative CT findings and final pathology reports to assess AGI and determine the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of preoperative CT imaging. RESULTS Five patients (5.5%) had AGI on pathological analysis. On preoperative CT, 8 patients had CT findings suspicious of AGI. All 5 patients with pathological AGI were identified preoperatively yielding a sensitivity of 100%. Pathological analysis in all patients who did not demonstrate AGI on imaging showed no adrenal invasion, yielding a negative predictive value of 100%. High-grade tumors were significantly associated with AGI (84.4% vs 33.6%, P = .02). Patients with AGI had larger tumor size when compared with those without AGI on final pathology (10 cm vs 6.89 cm, P = .07). CONCLUSION The overall incidence of AGI in patients with RCC is low. Preoperative CT can accurately identify those with AGI and can thus prevent unnecessary CIA during RN.
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Affiliation(s)
| | - Zachary Dovey
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Neeraja Tillu
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Arjun Venkatesh
- School of Medicine, St. George's University, St. George, Grenada
| | - Ahmed Kotb
- Department of Urology, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
| | - Maurizio Buscarini
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Osama Zaytoun
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Urology, Faculty of Medicine, University of Alexandria, Egypt
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Sudarević B, Pavoković D, Slobođanac E. HISTOPATHOLOGIC FEATURES OF KIDNEY TUMORS AND COMPARISON OF PATIENTS TREATED WITH RADICAL AND PARTIAL NEPHRECTOMY AT OSIJEK UNIVERSITY HOSPITAL CENTER FROM 2017 UNTIL THE END OF 2021. Acta Clin Croat 2023; 62:84-94. [PMID: 38966018 PMCID: PMC11221236 DOI: 10.20471/acc.2023.62.s2.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2024] Open
Abstract
The objective of this study was to present results of kidney tumor treatment at Osijek University Hospital Center over a 5-year period and to compare the outcomes between patients treated with radical nephrectomy (RN) and partial nephrectomy (PN). From November 2016 until the end of 2021, there were 280 consecutive PNs and RNs included in this cross-sectional study. Exclusion criteria were nephrectomies due to non-oncologic reasons and transitional cell carcinoma. There were 229 RNs and 51 PNs, median age of all patients was 62.5 (range 34-84) years. In the RN group, there were 197 renal cell carcinomas (RCC), predominantly clear-cell subtype, while among others there were 8 multilocular cystic renal neoplasms of low malignant potential (MCRNLMP) and 6 oncocytomas and angiomyolipomas each. There were 44 RCCs, 4 oncocytomas, 1 MCRNLMP and 2 cysts removed with PN; median R.E.N.A.L. score was 5. RN group had greater tumor diameters and higher tumor grade, higher postoperative creatinine levels and complications of higher grade. There was no difference in median hospital stay (6 days) and follow-up (20 months). With regard to oncologic safety, preservation of kidney function and lower overall morbidity, PN should be preferred to RN whenever oncologically safe and technically feasible.
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Affiliation(s)
- Bojan Sudarević
- Department of Urology, Osijek University Hospital Center, Osijek, Croatia
- Department of Surgery, Urology, Orthopedics, and Physical and Rehabilitation Medicine, Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
| | - Deni Pavoković
- Department of Urology, Osijek University Hospital Center, Osijek, Croatia
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
| | - Eva Slobođanac
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
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Lavi A, Breau RH, Mallick R, Kapoor A, Finelli A, So A, Pouliot F, Tanguay S, Lavallée LT, Rendon R, Fairey A, Drachenberg DE, Lattouf JB, Maloni R, Power NE. Adrenalectomy During Radical Nephrectomy- Incidence and Oncologic Outcomes From the Canadian Kidney Cancer Information System (CKCis) -A Modern Era, Nationwide, Multicenter Cohort. Urology 2021; 157:168-173. [PMID: 34129893 DOI: 10.1016/j.urology.2021.05.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 04/20/2021] [Accepted: 05/28/2021] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To characterize proportion of patients receiving adrenalectomy, adrenal involvement prevalence and oncologic outcomes of routine adrenalectomy in contemporary practice. Ipsilateral adrenalectomy was once standard during radical nephrectomy. However, benefit of routine adrenalectomy has been questioned because adrenal involvement of renal cell carcinoma (RCC) is low. METHODS All patients receiving radical nephrectomy in the Canadian Kidney Cancer information system, a collaborative prospective cohort populated by 14 major Canadian centers, between January 2011 to February 2020 were included. Patients were excluded if they had non-RCC histology, multiple tumors, contralateral tumors, metastatic disease or previous history of RCC. Patient demographic, clinical, and surgical information were summarized and compared. Cox-proportional hazards was used for multivariable analysis. RESULTS During study period, 2759 patients received radical nephrectomy, of these, 831(30.1%) had concomitant adrenalectomy. Pathological adrenal involvement was identified in 102 (3.7%overall; 12.3%of adrenalectomy). Median follow-up was 21.6months (Interquartile range 7.0-46.5). Patients with adrenalectomy had higher venous tumor thrombus (30.3% vs 9.6%; P <.0001), higher T stage (71.1% vs 43.4% pT3/4; P <.0001), lymph node metastases (17.6% vs 10.7%; P = .0035), Fuhrman grades (71.4% of Fuhrman grades 3/4 vs 56.2%; P <.0001) and increased proportion of clear cell histology (79.3% vs 74.5%; P = .0074) compared to the no adrenalectomy group. Adrenalectomy patients had higher risk of recurrence (HR 1.23; 95% CI 1.04-1.47; P = .019) and no difference in survival (HR 1.09, 95% CI 0.86-1.38, P = .48). CONCLUSION Adrenalectomy is not associated with better oncological outcome of recurrence/survival. Adrenalectomy should be reserved for patients with radiographic adrenal involvement and/or intra-operative adrenal involvement.
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Affiliation(s)
- Arnon Lavi
- Urology Division, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Rodney H Breau
- The Division of Urology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ontario, Canada
| | - Ranjeeta Mallick
- School of Epidemiology and Public Health, University of Ottawa, Ontario, Canada
| | - Anil Kapoor
- McMaster Institute of Urology, at St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Antonio Finelli
- Division of Urologic Oncology, Princess Margaret Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Alan So
- Department of Urologic Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Frédéric Pouliot
- Department of Surgery, Division of Urology, Université Laval, Quebec City, Quebec, Canada
| | - Simon Tanguay
- Department of Urology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Luke T Lavallée
- The Division of Urology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ontario, Canada
| | - Ricardo Rendon
- Department of Urology, QEII Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia; Canada
| | - Adrian Fairey
- Division of Urology, University of Alberta, Edmonton, Alberta, Canada
| | | | - Jean-Baptiste Lattouf
- Division of Urology, University of Montreal Hospital Centre (CHUM), Montreal, Quebec, Canada
| | - Ranjena Maloni
- Division of Urologic Oncology, Princess Margaret Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Nicholas E Power
- Urology Division, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
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Nason GJ, Aslam A, Giri SK. Predictive Ability of Preoperative CT Scan in Determining Whether the Adrenal Gland is Spared at Radical Nephrectomy. Curr Urol 2016; 9:143-147. [PMID: 27867332 DOI: 10.1159/000442869] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 02/09/2016] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The aim of this study was to assess whether preoperative multiple detector computed tomography (MDCT) accurately predicts adrenal involvement for patients undergoing non-adrenal sparing radical nephrectomy for renal cell carcinoma. METHODS AND MATERIALS A retrospective observational study based on a composite patient population of two university teaching hospitals who underwent radical nephrectomy. Sensitivity, specificity, overall accuracy, positive and negative predictive values and likelihood ratios were calculated from radiological reports. RESULTS Total 579 patients underwent radical nephrectomy, of which 199 (34.4%) patients underwent a non-adrenal sparing radical nephrectomy, in which 128 (64.3%) were male and 118 (59.3%) were left side tumors. Mean tumor size was 8.2 cm (range 1.4-20cm). MDCT was found to have a sensitivity of 100% and specificity of 95.2% for identifying adrenal invasion. Total 179 patients (89.9%) had a radiographically normal ipsilateral adrenal gland, of which none were found to have adrenal involvement. Therefore, the negative predictive value of preoperative cross-sectional imaging for identification of adrenal involvement was 100%. CONCLUSION Cross- sectional MDCT imaging accurately predicts adrenal involvement and the decision to remove or spare the adrenal gland should be made preoperative planning regardless of tumour size or location at the time of multi-disciplinary discussion unless there is intraoperative evidence of adrenal invasion.
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Affiliation(s)
- Gregory J Nason
- Department of Urology, University Hospital Limerick, Limerick, Ireland
| | - Asadullah Aslam
- Department of Urology, University Hospital Limerick, Limerick, Ireland
| | - Subhasis K Giri
- Department of Urology, University Hospital Limerick, Limerick, Ireland
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Weight CJ, Mulders PF, Pantuck AJ, Thompson RH. The Role of Adrenalectomy in Renal Cancer. Eur Urol Focus 2015; 1:251-257. [PMID: 28723393 DOI: 10.1016/j.euf.2015.09.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 08/25/2015] [Accepted: 09/08/2015] [Indexed: 11/19/2022]
Abstract
CONTEXT Since the 1960s, routine ipsilateral adrenalectomy (IA) has been considered an integral step in the removal of renal tumors as a part of a radical nephrectomy. However, recent data from the past decade have narrowed the indications for adrenalectomy and called into question the need for adrenalectomy at all in the treatment of renal cell carcinoma (RCC). OBJECTIVE We sought to identify the role of adrenalectomy in the treatment of RCC. Specifically, we wanted to answer the following questions: What is the incidence of ipsilateral adrenal involvement by cancer? How reliable is preoperative imaging? What is the rate of ipsilateral and contralateral metachronous recurrence? And finally, what are the potential noncancer sequelae from unnecessary removal of the adrenal gland? EVIDENCE ACQUISITION A systematic literature search of Embase, PubMed, Cochrane, and Ovid Medline was performed to identify studies evaluating the role of adrenalectomy during RCC surgery. Only articles published in English from the years 2000-2015 were included. Case reports, articles about primary adrenal tumors, letters to the editor, and surgical technique papers were excluded. EVIDENCE SYNTHESIS We found little evidence to suggest that routine IA is associated with a higher risk of short-term surgical or medical complications. We did not find evidence that IA is associated with improved cancer control. Tomographic preoperative imaging of the adrenal gland demonstrating no cancer involvement is rarely wrong (<1% of the time), and the few adrenal lesions missed on imaging can often be identified intraoperatively. Some evidence indicates that IA may be associated with worse long-term survival. Adrenalectomy rates have been decreasing in recent years, reflecting a changing practice pattern. CONCLUSIONS IA at the time of kidney surgery for a renal mass should be performed only if radiographic or intraoperative evidence indicates adrenal gland involvement. PATIENT SUMMARY We sought to define the role of adrenalectomy in patients with kidney cancer. Although there are not high-quality studies to answer this question definitively, we conclude that the adrenal gland should be spared unless there is clinical evidence of adrenal involvement.
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Affiliation(s)
| | - Peter F Mulders
- Radbount University, Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Allan J Pantuck
- University of California at Los Angles, Los Angeles, CA, USA
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Gabr AH, Steinberg Z, Eggener SE, Stuart Wolf J. Indications for adrenalectomy during radical nephrectomy for renal cancer. Arab J Urol 2015; 12:304-8. [PMID: 26019967 PMCID: PMC4434884 DOI: 10.1016/j.aju.2014.09.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Revised: 08/03/2014] [Accepted: 09/24/2014] [Indexed: 11/26/2022] Open
Abstract
Objectives To determine if the selection criteria for ipsilateral adrenalectomy during laparoscopic radical nephrectomy (RN) can be further restricted, with the goal of sparing more patients unnecessary adrenalectomy while preserving the removal of adrenal glands containing malignancy, as recent evidence suggests that adrenalectomy in association with RN for renal cancer can be limited to patients with abnormalities on adrenal imaging or large upper-pole renal tumours. Patients and methods The cohort consisted of two data sets, each from one institution, i.e., a training set and a validation set. All patients underwent RN for radiographically localised disease. Removal of the adrenal gland was based on the surgeon’s preference, related to the presence of a suspect adrenal lesion on preoperative imaging, suspicion for involvement of the adrenal gland intraoperatively, location of the tumour, size of the tumour and local tumour stage. Results Of 159 patients in the training cohort, three (2%) had metastatic renal cancer in the ipsilateral adrenal gland. All three patients had tumours of >7 cm and either an abnormal radiographic appearance of the adrenal gland or suspect intraoperative findings. In the validation cohort of 74 patients, seven (10%) had adrenal metastasis, of which one had a tumour of <7 cm and the indication for adrenalectomy was the high intraoperative suspicion. Conclusion We recommend performing ipsilateral adrenalectomy in association with RN for renal cancer when there is either abnormal radiographic appearance of the adrenal gland or suspect intraoperative findings, with no regard for primary tumour size.
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Affiliation(s)
- Ahmed H Gabr
- Department of Urology, Minia University, Egypt ; Department of Urology, Salman Bin Abdulaziz University, Saudi Arabia
| | - Zoe Steinberg
- Section of Urology, University of Chicago, Chicago, USA
| | | | - J Stuart Wolf
- Department of Urology, University of Michigan, Michigan, USA
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Blakely S, Bratslavsky G, Zaytoun O, Daugherty M, Landas SK, Shapiro O. Preoperative cross-sectional imaging allows for avoidance of unnecessary adrenalectomy during RCC surgery. Urol Oncol 2014; 33:22.e23-22.e27. [PMID: 25304287 DOI: 10.1016/j.urolonc.2014.08.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Revised: 08/27/2014] [Accepted: 08/29/2014] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To assess the frequency of adrenal involvement and the reliability of preoperative imaging to predict adrenal involvement in patients treated for cortical renal masses at a single institution. METHODS Using a retrospective pathology database, we identified 117 consecutive patients who underwent radical nephrectomy and concomitant ipsilateral adrenalectomy at our institution over the course of 2 decades. Patient demographics, tumor characteristics, and radiographic results were obtained for analysis. RESULTS Of 117 patients, only 6 (5.1%) were identified as having adrenal involvement. The average age of the patient was 58.3 years, and the average tumor size was 7.13 cm. The mean tumor size in patients without adrenal involvement was 6.79 cm, whereas in those with adrenal involvement, it was 9.62 cm (P = 0.057). Of 6 patients with adrenal involvement, 5 had imaging studies available for review, and all 5 demonstrated suspicion for adrenal involvement preoperatively. Among 111 patients without adrenal involvement, 53 (47.7%) had imaging available for review, with only 3 (5.7%) demonstrating suspicion for adrenal involvement. The negative predictive value was 100%, whereas the sensitivity and specificity were 100% and 94.3%, respectively. CONCLUSIONS Ipsilateral adrenal involvement in renal cell carcinoma is uncommon and reliably predicted by preoperative cross-sectional imaging. Among all adrenalectomies in this series, nearly 95% were performed unnecessarily. With careful review, preoperative imaging can help avoid unnecessary adrenalectomy during radical nephrectomy in patients with renal cortical tumors.
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Affiliation(s)
- Stephen Blakely
- Department of Urology, SUNY Upstate Medical University, Syracuse, NY
| | | | - Osama Zaytoun
- Department of Urology, SUNY Upstate Medical University, Syracuse, NY
| | - Mickey Daugherty
- Department of Urology, SUNY Upstate Medical University, Syracuse, NY
| | - Steve K Landas
- Department of Pathology, SUNY Upstate Medical University, Syracuse, NY
| | - Oleg Shapiro
- Department of Urology, SUNY Upstate Medical University, Syracuse, NY
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Bhatt JR, Finelli A. Landmarks in the diagnosis and treatment of renal cell carcinoma. Nat Rev Urol 2014; 11:517-25. [PMID: 25112856 DOI: 10.1038/nrurol.2014.194] [Citation(s) in RCA: 159] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The most common renal cancer is renal cell carcinoma (RCC), which arises from the renal parenchyma. The global incidence of RCC has increased over the past two decades by 2% per year. RCC is the most lethal of the common urological cancers: despite diagnostic advances, 20-30% of patients present with metastatic disease. A clearer understanding of the genetic basis of RCC has led to immune-based and targeted treatments for this chemoresistant cancer. Despite promising results in advanced disease, overall response rates and durable complete responses are rare. Surgery remains the main treatment modality, especially for organ-confined disease, with a selective role in advanced and metastatic disease. Smaller tumours are increasingly managed with biopsy, minimally invasive interventions and surveillance. The future promises multimodal, integrated and personalized care, with further understanding of the disease leading to new treatment options.
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Affiliation(s)
- Jaimin R Bhatt
- Princess Margaret Cancer Centre, University of Toronto, Division of Urology, 610 University Avenue 3-130, Toronto, ON M5G 2M9, Canada
| | - Antonio Finelli
- Princess Margaret Cancer Centre, University of Toronto, Division of Urology, 610 University Avenue 3-130, Toronto, ON M5G 2M9, Canada
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Laguna MP. Re: Systematic Review of Adrenalectomy and Lymph Node Dissection in Locally Advanced Renal Cell Carcinoma. J Urol 2014; 191:1728-9. [DOI: 10.1016/j.juro.2014.03.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Buethe DD, Spiess PE. Current management considerations for the incidentally detected small renal mass. Cancer Control 2014; 20:211-21. [PMID: 23811705 DOI: 10.1177/107327481302000309] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Nephron-sparing treatments remain underutilized for the management of small renal masses despite a rise in incidentally detected renal cell carcinoma and a downward stage migration. METHODS Historical publications representative of currently accepted paradigms were reviewed, and the results of a contemporary scientific literature search conducted in PubMed focusing on studies involving humans, published in English, and inclusive of clinical trials, meta-analyses, randomized controlled trials, and practice guidelines are included. Results from contemporary retrospective trials augment the data when level I or II evidence is absent. RESULTS Phase III clinical trial results substantiate the long-held tenet that partial nephrectomy is equivalent to radical nephrectomy with respect to safety and oncologic efficacy. Further, minimally invasive techniques using laparoscopy and robotic assistance to achieve partial nephrectomy appear equally effective to traditional open techniques. Although no prospective randomized studies are available, large retrospective studies support the notion that active surveillance and thermal ablative techniques are viable options for carefully selected patients. CONCLUSIONS The management of small renal masses encompasses a host of therapeutic options, all of which must be considered and discussed with the individual patient.
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Affiliation(s)
- David D Buethe
- Genitourinary Oncology Program, Moffitt Cancer Center, Tampa, FL 33612, USA
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Yap SA, Alibhai SM, Abouassaly R, Timilshina N, Margel D, Finelli A. Ipsilateral adrenalectomy at the time of radical nephrectomy impacts overall survival. BJU Int 2012; 111:E54-8. [DOI: 10.1111/j.1464-410x.2012.11435.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Vourganti S, Shuch B, Bratslavsky G. Surgical management of large renal tumors. Expert Rev Anticancer Ther 2011; 11:1889-900. [PMID: 22117156 DOI: 10.1586/era.11.129] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
The surgical management of patients with renal cell carcinoma has undergone many changes. With equivalent oncologic outcomes and appreciation of the importance of renal functional preservation, the utilization of nephron-sparing partial nephrectomy has increased in recent years. Nevertheless, tumors of larger size continue to be preferentially treated with radical nephrectomy. Here, we present evidence that improvements in techniques and durability of oncologic outcomes has justified the use of nephron sparing to accomplish renal functional preservation even in patients with large renal tumors. In addition, surgical technical considerations when managing such tumors are discussed. Finally, we discuss cytoreductive surgery and the evolving role of systemic targeted therapies in the management of advanced metastatic disease.
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Affiliation(s)
- Srinivas Vourganti
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, 10 Center Drive, Bethesda, MD 20892-1107, USA
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