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Li L, Wu H, Hu S, Yu Y, Chen Z, Wang P, Zhou L, Li R, Yao L, Yue S. Clear cell renal cell carcinoma detection by multimodal photoacoustic tomography. PHOTOACOUSTICS 2021; 21:100221. [PMID: 33251109 PMCID: PMC7683266 DOI: 10.1016/j.pacs.2020.100221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 09/22/2020] [Accepted: 11/03/2020] [Indexed: 06/12/2023]
Abstract
There is a need for accurate and rapid detection of renal cancer in clinic. Here, we integrated photoacoustic tomography (PAT) with ultrasound imaging in a single system, which achieved tissue imaging depth about 3 mm and imaging speed about 3.5 cm2/min. We used the wavelength at 1197 nm to map lipid distribution in normal renal tissues and clear cell renal cell carcinoma (ccRCC) tissues collected from 19 patients undergone nephrectomy. Our results indicated that the photoacoustic signal from lipids was significantly higher in ccRCC tissues than that in normal tissues. Moreover, based on the quantification of lipid area ratio, we were able to differentiate normal and ccRCC with 100 % sensitivity, 80 % specificity, and area under receiver operating characteristic curve of 0.95. Our findings demonstrate that multimodal PAT can differentiate normal and ccRCC by integrating the morphologic information from ultrasound and lipid amount information from vibrational PAT.
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Affiliation(s)
- Lin Li
- Institute of Medical Photonics, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing 100083, China
| | - Hanbo Wu
- Institute of Medical Photonics, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing 100083, China
| | - Shuai Hu
- Department of Urology, Peking University First Hospital, Beijing 100034, China
| | - Yanfei Yu
- Department of Urology, Peking University First Hospital, Beijing 100034, China
| | - Zhicong Chen
- Department of Urology, Peking University First Hospital, Beijing 100034, China
| | - Pu Wang
- Institute of Medical Photonics, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing 100083, China
- Vibronix Inc., West Lafayette, IN, USA
| | - Liqun Zhou
- Department of Urology, Peking University First Hospital, Beijing 100034, China
| | - Rui Li
- Vibronix Inc., West Lafayette, IN, USA
| | - Lin Yao
- Department of Urology, Peking University First Hospital, Beijing 100034, China
| | - Shuhua Yue
- Institute of Medical Photonics, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing 100083, China
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2
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Bozzini G, Seveso M, Otero JR, Osmolorskij B, Garcia Cruz E, Margreiter M, Verze P, Besana U, Buizza C. Is there a clinical role for frozen section analysis during partial nephrectomy? A multicenter experience over 10 years. MINERVA UROL NEFROL 2019; 72:332-338. [PMID: 31833332 DOI: 10.23736/s0393-2249.19.03110-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Frozen section analysis (FSA) is frequently performed during partial nephrectomy (PN). We investigate the utility of intraoperative FSA by evaluating its impact on final surgical margin (SM) status. METHODS Between January 1995 and December 2005, a series of patients who were treated with open PN for renal cell carcinoma was prospectively analyzed. During PN, each patient underwent a FSA on renal parenchyma distal margin. If FSA was positive for infiltration a deeper excision was performed till obtaining a negative FSA. SM outcome of the FSA was compared with the final pathology report. Recurrence-free survival (RFS) and cost analysis on the FSA performed were analyzed. RESULTS A total number of 373 patients were enrolled. FSA was performed in all the patients considered for PN. Fifteen patients had a conversion to radical nephrectomy. Positive SMs at the definitive pathological outcome were found in 36 patients (9.6%). FSA was positive in eight patients (2.1%). In that eight cases after a deeper excision the definitive pathological outcome on SM was still positive in two cases. FSA revealed just 14.3% of the positive SM. Patients with positive SM had a worse follow up considering RFS (P<0.05). Kaplan-Meier analysis revealed that FSA did not considerably contribute to prevent recurrence (P=0.35). 1438 euros was the mean cost of performing a FSA during PN. CONCLUSIONS FSA during PN does not reduce the risk of positive SMs. The use of FSA has also a higher cost related to the procedure.
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Affiliation(s)
- Giorgio Bozzini
- Department of Urology, ASST Valle Olona, Busto Arsizio, Varese, Italy -
| | - Mauro Seveso
- Department of Urology, ASST Valle Olona, Busto Arsizio, Varese, Italy
| | | | | | | | | | - Paolo Verze
- Department of Urology, Vienna General Hospital, Vienna, Austria
| | - Umberto Besana
- Department of Urology, ASST Valle Olona, Busto Arsizio, Varese, Italy
| | - Carlo Buizza
- Department of Urology, ASST Valle Olona, Busto Arsizio, Varese, Italy
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3
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Abdel Raheem A, Chang KD, Alenzi MJ, Lum TG, Ham WS, Han WK, Chung BH, Choi YD, Rha KH. Robot-Assisted Partial Nephrectomy for Totally Endophytic Renal Tumors: Step by Step Standardized Surgical Technique and Long-Term Outcomes with a Median 59-Month Follow-Up. J Laparoendosc Adv Surg Tech A 2019; 29:1-11. [DOI: 10.1089/lap.2018.0124] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- Ali Abdel Raheem
- Department of Urology and Urological Science Institute, Yonsei University College of Medicine, Seoul, South Korea
- Department of Urology, Tanta University Medical School, Tanta, Egypt
| | - Ki Don Chang
- Department of Urology and Urological Science Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Mohammed Jayed Alenzi
- Department of Urology and Urological Science Institute, Yonsei University College of Medicine, Seoul, South Korea
- Department of Urology, Aljouf University, Sakaka, Saudi Arabia
| | - Trenton G. Lum
- Department of Urology and Urological Science Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Won Sik Ham
- Department of Urology and Urological Science Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Woong Kyu Han
- Department of Urology and Urological Science Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Byung Ha Chung
- Department of Urology and Urological Science Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Young Deuk Choi
- Department of Urology and Urological Science Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Koon Ho Rha
- Department of Urology and Urological Science Institute, Yonsei University College of Medicine, Seoul, South Korea
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4
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Dagenais J, Mouracade P, Maurice M, Kara O, Nelson R, Chavali J, Kaouk JH. Frozen Sections for Margins During Partial Nephrectomy Do Not Influence Recurrence Rates. J Endourol 2018; 32:759-764. [DOI: 10.1089/end.2018.0314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Julien Dagenais
- Glickman Urological & Kidney Institute, Department of Urology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Pascal Mouracade
- Glickman Urological & Kidney Institute, Department of Urology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Matthew Maurice
- Glickman Urological & Kidney Institute, Department of Urology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Onder Kara
- Glickman Urological & Kidney Institute, Department of Urology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ryan Nelson
- Glickman Urological & Kidney Institute, Department of Urology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Jaya Chavali
- Glickman Urological & Kidney Institute, Department of Urology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Jihad H. Kaouk
- Glickman Urological & Kidney Institute, Department of Urology, Cleveland Clinic Foundation, Cleveland, Ohio
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5
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van Oostenbrugge TJ, Runneboom W, Bekers E, Heidkamp J, Langenhuijsen JF, Veltien A, Maat A, Mulders PFA, Hulsbergen-van de Kaa CA, Fütterer JJ. MRI as a tool to assess surgical margins and pseudocapsule features directly following partial nephrectomy for small renal masses. Eur Radiol 2018; 29:509-516. [PMID: 30043161 PMCID: PMC6302880 DOI: 10.1007/s00330-018-5630-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 06/18/2018] [Accepted: 06/22/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate the feasibility of ex vivo 7T MRI to assess surgical margins (SMs) and pseudocapsule (PC) features after partial nephrectomy (PN). MATERIALS AND METHODS In this prospective, IRB-approved study, seven patients undergoing a PN for nine tumours between November 2014 and July 2015 were included for analysis after obtaining informed consent. MRI of the specimen was acquired using a 7T small bore scanner. The imaging protocol consisted of anatomical T1-, T2- and diffusion-weighted imaging. After formalin fixation, specimens were cut for pathology work-up in the same orientation as the MR images were obtained. The entire specimen was processed into H&E slides that were digitally scanned, annotated and correlated with radiological findings for negative SMs, PC presence, PC continuity and extra-PC-extension (EPCE). Sensitivity and specificity of MRI for assessment of these endpoints were calculated. RESULTS The sensitivity and specificity for assessment of the SM were 100% and 75%, respectively. Two false-positive outcomes were reported, both in case of EPCE and a SM ≤0.5 mm. For the presence of a PC, sensitivity and specificity were 100% and 33%, respectively. Two false-positive scans with anatomical structures mimicking the presence of a PC occurred. If a PC was present, continuity and EPCE were assessed with a sensitivity and specificity of 75% and 100% and 67% and 100%, respectively. CONCLUSION Ex vivo 7T MRI is a feasible tool for perioperative evaluation of SMs, and if present, PC features after PN. This may facilitate maximal sparing of renal parenchyma without compromising oncological outcomes. KEY POINTS • Ex vivo MRI may contribute to improvement of negative surgical margins during partial nephrectomy. • Due to the assessment of surgical margins within a limited time span from obtaining the partial nephrectomy specimen, surgery for more complex tumours is possible with maximum sparing of healthy renal parenchyma without compromising oncological outcomes. • The intra operative assessment of pseudocapsule continuity along the resection margin enables maximal sparing of healthy renal parenchyma without delayed diagnosis of incomplete resection.
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Affiliation(s)
- Tim J van Oostenbrugge
- Department of Urology, Radboud University Medical Center, P.O. Box 9101, 6525 GA, Nijmegen, The Netherlands. .,Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Willemien Runneboom
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Elise Bekers
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jan Heidkamp
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Johan F Langenhuijsen
- Department of Urology, Radboud University Medical Center, P.O. Box 9101, 6525 GA, Nijmegen, The Netherlands
| | - Andor Veltien
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Arie Maat
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Peter F A Mulders
- Department of Urology, Radboud University Medical Center, P.O. Box 9101, 6525 GA, Nijmegen, The Netherlands
| | | | - Jurgen J Fütterer
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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6
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Wang M, Tulman DB, Sholl AB, Mandava SH, Maddox MM, Lee BR, Brown JQ. Partial nephrectomy margin imaging using structured illumination microscopy. JOURNAL OF BIOPHOTONICS 2018; 11:10.1002/jbio.201600328. [PMID: 28834287 PMCID: PMC5821599 DOI: 10.1002/jbio.201600328] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 05/19/2017] [Accepted: 08/17/2017] [Indexed: 06/07/2023]
Abstract
Partial nephrectomy (PN) is the recommended procedure over radical nephrectomy (RN) for patients with renal masses less than 4 cm in diameter (Stage T1a). Patients with less than 4 cm renal masses can also be treated with PN, but have a higher risk for positive surgical margins (PSM). PSM, when present, are indicative of poor clinical outcomes. The current gold-standard histopathology method is not well-suited for the identification of PSM intraoperatively due to processing time and destructive nature. Here, video-rate structured illumination microscopy (VR-SIM) was investigated as a potential tool for PSM detection during PN. A clinical image atlas assembled from ex vivo renal biopsies provided diagnostically useful images of benign and malignant kidney, similar to permanent histopathology. VR-SIM was then used to image entire parenchymal margins of tumor resection covering up to >1800× more margin surface area than standard histology. Aided by the image atlas, the study pathologist correctly classified all parenchymal margins as negative for PSM with VR-SIM, compared to standard postoperative pathology. The ability to evaluate large surgical margins in a short time frame with VR-SIM may allow it to be used intraoperatively as a "safety net" for PSM detection, allowing more patients to undergo PN over RN.
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Affiliation(s)
- Mei Wang
- Department of Biomedical Engineering, Tulane University, New Orleans, LA 70118
| | - David B. Tulman
- Bioinnovation Program, Tulane University, New Orleans, LA 70118
| | - Andrew B. Sholl
- Department of Pathology and Laboratory Medicine, Tulane University School of Medicine, New Orleans, LA 70112
| | - Sree H. Mandava
- Department of Urology, Tulane University School of Medicine, New Orleans, LA 70112
| | - Michael M. Maddox
- Department of Urology, Tulane University School of Medicine, New Orleans, LA 70112
| | - Benjamin R. Lee
- Division of Urology, University of Arizona College of Medicine, Tucson, AZ 85724
| | - J. Quincy Brown
- Department of Biomedical Engineering, Tulane University, New Orleans, LA 70118
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Laganosky DD, Filson CP, Master VA. Surgical Margins in Nephron-Sparing Surgery for Renal Cell Carcinoma. Curr Urol Rep 2017; 18:8. [DOI: 10.1007/s11934-017-0651-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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8
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Alemozaffar M, Filson CP, Master VA. The importance of surgical margins in renal cell and urothelial carcinomas. J Surg Oncol 2016; 113:316-22. [DOI: 10.1002/jso.24121] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 11/20/2015] [Indexed: 11/11/2022]
Affiliation(s)
| | - Christopher P. Filson
- Department of Urology; Emory University; Atlanta Georgia
- Atlanta Veterans Affairs Medical Center; Decatur Georgia
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9
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Alharbi FM, Chahwan CK, Le Gal SG, Guleryuz KM, Tillou XP, Doerfler AP. Intraoperative ultrasound control of surgical margins during partial nephrectomy. Urol Ann 2016; 8:430-433. [PMID: 28057986 PMCID: PMC5100147 DOI: 10.4103/0974-7796.192107] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Aims: To evaluate a simple and fast technique to ensure negative surgical margins on partial nephrectomies, while correlating margin statuses with the final pathology report. Subjects and Methods: This study was conducted for patients undergoing partial nephrectomy (PN) with T1–T2 renal tumors from January 2010 to the end of December 2015. Before tumor removal, intraoperative ultrasound (US) localization was performed. After tumor removal and before performing hemostasis of the kidney, the specimens were placed in a saline solution and a US was performed to evaluate if the tumor's capsule were intact, and then compared to the final pathology results. Results: In 177 PN(s) (147 open procedures and 30 laparoscopic procedures) were performed on 147 patients. Arterial clamping was done for 32 patients and the mean warm ischemia time was 19 ± 6 min. The mean US examination time was 41 ± 7 s. The US analysis of surgical margins was negative in 172 cases, positive in four, and in only one case it was not possible to conclude. The final pathology results revealed one false positive surgical margin and one false negative surgical margin, while all other margins were in concert with US results. The mean tumor size was 3.53 ± 1.43 cm, and the mean surgical margin was 2.8 ± 1.5 mm. Conclusions: The intraoperative US control of resection margins in PN is a simple, efficient, and effective method for ensuring negative surgical margins with a small increase in warm ischemia time and can be conducted by the operating urologist.
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Affiliation(s)
- Feras M Alharbi
- Department of Urology and Transplantation, Caen University Hospital, Caen, France
| | - Charles K Chahwan
- Department of Urology and Transplantation, Caen University Hospital, Caen, France
| | - Sophie G Le Gal
- Department of Urology and Transplantation, Caen University Hospital, Caen, France
| | - Kerem M Guleryuz
- Department of Urology and Transplantation, Caen University Hospital, Caen, France
| | - Xavier P Tillou
- Department of Urology and Transplantation, Caen University Hospital, Caen, France
| | - Arnaud P Doerfler
- Department of Urology and Transplantation, Caen University Hospital, Caen, France
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10
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Intraoperative and surgical specimen (ex vivo) ultrasound in the assessment of margins at partial nephrectomy. Int Urol Nephrol 2015; 47:1665-9. [PMID: 26267670 DOI: 10.1007/s11255-015-1083-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 08/05/2015] [Indexed: 12/14/2022]
Abstract
PURPOSE To correlate the accuracy of intraoperative and surgical specimen (ex vivo) ultrasound (US) with pathological margin status at partial nephrectomy. MATERIALS AND METHODS Patients undergoing partial nephrectomy for T1 renal tumours in the period May 2010-January 2014 at a single institution who had intraoperative specimen US were included. PN was performed by standardised technique with intraoperative tumour localisation. Following excision, surgical specimen (ex vivo) US was performed and the margin status was compared to the final histopathological analysis. The specificity of US to identify margin status was calculated as was the correlation between the ultrasonographic and final pathological margin. RESULTS Forty-five patients were included (median age 61 years). Mean tumour size was 28.1 ± 10 mm, and 89 % were renal cell carcinomas with the remainder being oncocytomas. Forty-four cases had negative surgical margins on pathological analysis, and US had a specificity of 100 %. There was a strong correlation between the margin as measured on US and final analysis (Pearson's r = 0.86, p < 0.001). CONCLUSION Results show that intraoperative, surgical specimen (ex vivo) US control of resection margins in patients undergoing PN is feasible and efficient. It represents a promising tool to ensure margin negativity during PN.
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11
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Gordetsky J, Gorin MA, Canner J, Ball MW, Pierorazio PM, Allaf ME, Epstein JI. Frozen section during partial nephrectomy: does it predict positive margins? BJU Int 2015; 116:868-72. [DOI: 10.1111/bju.13011] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Jennifer Gordetsky
- Departments of Pathology and Urology; The University of Alabama; Birmingham AL USA
| | - Michael A. Gorin
- Department of Urology; The Johns Hopkins Hospital; Baltimore MD USA
| | - Joe Canner
- Department of Surgery; Center for Surgical Trials and Outcomes Research; The Johns Hopkins Hospital; Baltimore MD USA
| | - Mark W. Ball
- Department of Urology; The Johns Hopkins Hospital; Baltimore MD USA
| | | | - Mohamad E. Allaf
- Department of Urology; The Johns Hopkins Hospital; Baltimore MD USA
| | - Jonathan I. Epstein
- Department of Urology; The Johns Hopkins Hospital; Baltimore MD USA
- Department of Pathology; The Johns Hopkins Hospital; Baltimore MD USA
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12
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Özsoy M, Klatte T, Wiener H, Siller-Matula J, Schmidbauer J. Intraoperative imprint cytology for real-time assessment of surgical margins during partial nephrectomy: A comparison with frozen section. Urol Oncol 2015; 33:67.e25-9. [DOI: 10.1016/j.urolonc.2014.07.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 07/26/2014] [Accepted: 07/28/2014] [Indexed: 11/26/2022]
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13
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Surgeons’ preferences and practice patterns regarding intraoperative frozen section during partial nephrectomy. Urol Oncol 2014; 32:864-8. [DOI: 10.1016/j.urolonc.2014.02.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Revised: 02/14/2014] [Accepted: 02/15/2014] [Indexed: 11/21/2022]
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14
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[Positive surgical margins in nephron sparing surgery for renal cell carcinoma]. Urologia 2014; 81:30-9. [PMID: 24803357 DOI: 10.5301/uro.5000067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2014] [Indexed: 01/20/2023]
Abstract
Nephron sparing surgery (NSS) with a minimal tumor-free margin is considered the cornerstone in the contemporary management of renal cell carcinoma (RCC) stage T1. The aim of this study is to review incidence, predictive risk factors, clinical significance and oncologic outcomes of positive surgical margins (PSM) in NSS. English articles published before March 2014 have been searched in Medline Databank.PSM are present in 0-7% of patients in all surgical approaches considered. Some predictive factors,such as tumor size, localization, and histology have been identified in the past. Other topics concerning surgical technique and approach are discussed.The majority of patients with PSM do not experience disease recurrence and PSM impact on overall survival and cancer-specific survival seems to be irrelevant. These results lead to more conservative clinical strategies. However, an active surveillance is mandatory for all patients with PSM and especially for those with high risk disease. Generalization of these results is limited by the low level of evidence of available studies. Further efforts are necessary to avoid PSM intraoperatively and to provide prospective information in order to standardize the postoperative management.
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15
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Laryngakis NA, Van Arsdalen KN, Guzzo TJ, Malkowicz SB. Tumor enucleation: a safe treatment alternative for renal cell carcinoma. Expert Rev Anticancer Ther 2014; 11:893-9. [DOI: 10.1586/era.11.68] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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16
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Venigalla S, Wu G, Miyamoto H. The Impact of Frozen Section Analysis During Partial Nephrectomy on Surgical Margin Status and Tumor Recurrence: A Clinicopathologic Study of 433 Cases. Clin Genitourin Cancer 2013; 11:527-36. [DOI: 10.1016/j.clgc.2013.05.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Revised: 05/13/2013] [Accepted: 05/14/2013] [Indexed: 12/11/2022]
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17
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18
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Hillyer SP, Yakoubi R, Autorino R, Isac W, Miocinovic R, Laydner H, Khalifeh A, Stein RJ, Haber GP, Kaouk JH. Utility of Intraoperative Frozen Section During Robot-Assisted Partial Nephrectomy: A Single Institution Experience. J Endourol 2013; 27:324-7. [DOI: 10.1089/end.2012.0206] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Shahab P. Hillyer
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Rachid Yakoubi
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Riccardo Autorino
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Wahib Isac
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ranko Miocinovic
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Humberto Laydner
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ali Khalifeh
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Robert J. Stein
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Jihad H. Kaouk
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
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19
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Ani I, Finelli A, Alibhai SM, Timilshina N, Fleshner N, Abouassaly R. Prevalence and impact on survival of positive surgical margins in partial nephrectomy for renal cell carcinoma: a population-based study. BJU Int 2013; 111:E300-5. [DOI: 10.1111/j.1464-410x.2012.11675.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Ifeanyi Ani
- Urology Institute; University Hospitals of Cleveland Case Medical Center; Cleveland; OH; USA
| | - Antonio Finelli
- Urological Oncology and Health Policy; Management and Evaluation Departments; Princess Margaret Hospital; University of Toronto; Toronto; ON; Canada
| | - Shabbir M.H. Alibhai
- Urological Oncology and Health Policy; Management and Evaluation Departments; Princess Margaret Hospital; University of Toronto; Toronto; ON; Canada
| | - Narhari Timilshina
- Urological Oncology and Health Policy; Management and Evaluation Departments; Princess Margaret Hospital; University of Toronto; Toronto; ON; Canada
| | - Neil Fleshner
- Urological Oncology and Health Policy; Management and Evaluation Departments; Princess Margaret Hospital; University of Toronto; Toronto; ON; Canada
| | - Robert Abouassaly
- Urology Institute; University Hospitals of Cleveland Case Medical Center; Cleveland; OH; USA
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20
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Borghesi M, Brunocilla E, Schiavina R, Martorana G. Positive surgical margins after nephron-sparing surgery for renal cell carcinoma: incidence, clinical impact, and management. Clin Genitourin Cancer 2012; 11:5-9. [PMID: 23083800 DOI: 10.1016/j.clgc.2012.09.010] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2012] [Revised: 09/19/2012] [Accepted: 09/19/2012] [Indexed: 10/27/2022]
Abstract
Nephron-sparing surgery (NSS) for renal cell carcinoma (RCC) offers comparable oncologic results but a lower risk of chronic kidney disease when compared with radical nephrectomy; however it can result in positive surgical margins (PSMs) and consequently to a possible risk of oncologic failure. The aim of this review is to evaluate the incidence of PSMs after nephron-sparing surgery, to assess their clinical and oncologic impact, and to provide an overview of the possible therapeutic management. We performed a nonsystematic review of the literature in the MEDLINE database using the following keywords: partial nephrectomy, nephron-sparing surgery, and positive margin. We reviewed articles published only in English from January 2002 to May 2012. The overall incidence of PSMs after NSS ranges from 0% to 7%, with no significant differences in open, laparoscopic, and robot-assisted techniques. Smaller tumor size could result in a higher risk of PSMs. Even if there is not a clear agreement in the clinical evidence, local recurrence seems to be more likely in patients with PSMs, especially in those with high-grade tumors. Development of metastases and cancer-specific survival, as seen in midterm follow-up studies, seems to be comparable to those in patients with negative surgical margins. Considering the globally low risk of local recurrence, development of metastasis, or cancer-specific mortality, careful surveillance could be the best management option for most patients with PSMs after NSS.
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Affiliation(s)
- Marco Borghesi
- Department of Urology, Azienda Ospedaliero-Universitaria Policlinico S. Orsola-Malpighi, Bologna, Italy.
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Marszalek M, Carini M, Chlosta P, Jeschke K, Kirkali Z, Knüchel R, Madersbacher S, Patard JJ, Van Poppel H. Positive surgical margins after nephron-sparing surgery. Eur Urol 2011; 61:757-63. [PMID: 22136987 DOI: 10.1016/j.eururo.2011.11.028] [Citation(s) in RCA: 164] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2011] [Accepted: 11/15/2011] [Indexed: 02/07/2023]
Abstract
CONTEXT Little is known on the natural history of positive surgical margins (PSMs) in partial nephrectomy (PN). Accumulating data suggest that secondary nephrectomy might not be necessary in all patients with PSMs after PN. OBJECTIVE Provide an overview on incidence and risk factors for PSMs after partial nephrectomy and on the rate of local and distant disease recurrence related to PSMs. We also provide recommendations on how to avoid and how to treat PSMs after PN. EVIDENCE ACQUISITION A nonsystematic literature research was based on Medline, Scopus, and Web of Science queries on these keywords: nephron-sparing surgery, partial nephrectomy/ies, and margin. Only human studies (original research) published in English were included. EVIDENCE SYNTHESIS PSMs are present in 0-7% of patients after open PN, in 0.7-4% after laparoscopic PN, and in 3.9-5.7% after robot-assisted PN. The thickness of healthy parenchyma surrounding the tumour is irrelevant as long as complete tumour removal is achieved. The coincidence of a highly malignant tumour and PSM increases the risk of local recurrence. Intermediate follow-up data indicate that the vast majority of patients with PSMs will not experience local or distant tumour recurrence. Frozen-section analysis for evaluation of resection margins during PN is of minor clinical significance, as the surgeon's gross assessment of macroscopically negative margins provides reliable results. CONCLUSIONS PSMs in PN are rare. As indicated by intermediate follow-up data, the majority of patients with PSMs after PN remain without disease recurrence, and a surveillance strategy seems preferable to surgical reintervention.
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Affiliation(s)
- Martin Marszalek
- Department of Urology and Andrology, Donauspital, Vienna, Austria.
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Han JS, Huang WC. Impact of Kidney Cancer Surgery on Oncologic and Kidney Functional Outcomes. Am J Kidney Dis 2011; 58:846-54. [DOI: 10.1053/j.ajkd.2011.07.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2011] [Accepted: 07/18/2011] [Indexed: 11/11/2022]
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Doerfler A, Cerantola Y, Meuwly JY, Lhermitte B, Bensadoun H, Jichlinski P. Ex vivo ultrasound control of resection margins during partial nephrectomy. J Urol 2011; 186:2188-93. [PMID: 22014810 DOI: 10.1016/j.juro.2011.07.100] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2011] [Indexed: 12/28/2022]
Abstract
PURPOSE Surgery remains the treatment of choice for localized renal neoplasms. While radical nephrectomy was long considered the gold standard, partial nephrectomy has equivalent oncological results for small tumors. The role of negative surgical margins continues to be debated. Intraoperative frozen section analysis is expensive and time-consuming. We assessed the feasibility of intraoperative ex vivo ultrasound of resection margins in patients undergoing partial nephrectomy and its correlation with margin status on definitive pathological evaluation. MATERIALS AND METHODS A study was done at 2 institutions from February 2008 to March 2011. Patients undergoing partial nephrectomy for T1-T2 renal tumors were included in analysis. Partial nephrectomy was done by a standardized minimal healthy tissue margin technique. After resection the specimen was kept in saline and tumor margin status was immediately determined by ex vivo ultrasound. Sequential images were obtained to evaluate the whole tumor pseudocapsule. Results were compared with margin status on definitive pathological evaluation. RESULTS A total of 19 men and 14 women with a mean ± SD age of 62 ± 11 years were included in analysis. Intraoperative ex vivo ultrasound revealed negative surgical margins in 30 cases and positive margins in 2 while it could not be done in 1. Final pathological results revealed negative margins in all except 1 case. Ultrasound sensitivity and specificity were 100% and 97%, respectively. Median ultrasound duration was 1 minute. Mean tumor and margin size was 3.6 ± 2.2 cm and 1.5 ± 0.7 mm, respectively. CONCLUSIONS Intraoperative ex vivo ultrasound of resection margins in patients undergoing partial nephrectomy is feasible and efficient. Large sample studies are needed to confirm its promising accuracy to determine margin status.
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Affiliation(s)
- Arnaud Doerfler
- Service d'Urologie, Centre hospitalier universitaire vaudois, Lausanne, Switzerland
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[Laparoscopic partial nephrectomy]. Actas Urol Esp 2011; 35:487-93. [PMID: 21641090 DOI: 10.1016/j.acuro.2011.03.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Revised: 03/21/2011] [Accepted: 03/29/2011] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To analyze the surgical and oncologic outcome of prospective experience with laparoscopic partial nephrectomy. We describe the surgical technique and mid term oncological results achieved. MATERIAL AND METHODS 60 patients were operated with this technique between June 2005 and June 2009. The mean age of patients was 58.9 [38-77] years, being 40 (66.7%) males and 20 (33.3%) women. The average BMI was 26.8 [18-40]. Laterality was 28 (46.7%) tumors rights and 32 (53.3%) left, being located in the upper pole in 14 (23.3%) patients, in the middle third in 13 (21.7%) in the lower pole in 22 (36.7%) and hiliar region in 11 (18.3%). In 23 cases (38.3%) tumors were located in the anterior valve, in 24 (40%) in posterior valve, in 10 (16.7%) at the outer edge and 3 (5%) at the inner edge. The average size tumor on CT was 3.3 [1-6.4] cm and in the surgical specimen 3.1 [1.2-7] cm. RESULTS The mean operative time was 107.17 [50-185] min, with a warm ischemia time of 33 [0-70] min. In 56 cases (93.3%) had a single artery and 4 (6.7%) cases had 2 arteries. The artery was clamped alone in 15 patients (25%), artery and vein in 44 (73.3%) and no clamping was performed in 1 (1.7%). We repaired the urinary tract in 32 patients (53.3%), leaving ureteral catheter in all patients. 20% of patients (12) required transfusion. Intraoperative complications occurred in 5 patients (8.7%). These were: 1 splenic injury requiring splenectomy (1.7%), 1 tear in the vena cava, sutured laparoscopically (1.7%) and 3 cases of bleeding due to bulldog malfunction (5%). Postoperative complications occurred in 11 patients (18.7%) and these were: 1 wall hematoma that required reoperation (1.7%), 1 urinary fistula ending in renal atrophy and subsequent nephrectomy (1.7%), 3 intracavitary hematomas hich resolved conservatively (5%), 1 arteriovenous fistula that needed embolization (1.7%), 1 urinoma that was resolved with percutaneous drainage (1.7%) and 3 cases of postoperative fever (5%). Margins were positive in 1 patient (1.7%). In 49 cases (81.7%) histology was renal cell carcinoma, in 8 (13.3%) oncocytoma, in 2 (3.3%) angiomyolipoma and 1 (1.7%) metastasis. The average stay was 5 [3-29] days. Median follow up was 31 [12-61] months. There was a local recurrence at 16 months (hiliar primary tumor 2.5 cm) and an ipsilateral adrenal metastasis at 34 months (primary tumor 5.6 cm in left lower pole). CONCLUSIONS In this series of laparoscopic partial nephrectomy low rate of complications, good oncologic results and low recurrence rate in the short term are shown. More patients and further monitoring is required to strengthen the functional and oncological outcomes of this surgical technique.
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Raz O, Mendlovic S, Shilo Y, Leibovici D, Sandbank J, Lindner A, Zisman A. Positive surgical margins with renal cell carcinoma have a limited influence on long-term oncological outcomes of nephron sparing surgery. Urology 2009; 75:277-80. [PMID: 19896179 DOI: 10.1016/j.urology.2009.06.110] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2009] [Revised: 06/12/2009] [Accepted: 06/25/2009] [Indexed: 01/31/2023]
Abstract
OBJECTIVES To define the rate of positive surgical margins (PSMs) and analyze the outcome of patients with PSMs. The outcome and proper management of patients with positive PSMs during nephron sparing surgery (NSS) are questionable. In this study we define the clinical outcomes of PSMs at NSS and suggest management. METHODS Clinical records of 114 renal units who underwent open NSS for a renal mass between May 1995 and September 2005 were reviewed. RESULTS PSMs were suspected on frozen section in 17 of 114 renal units (15%). Tumors with suspected PSMs at frozen section were smaller (2.9 +/- 1.6) in comparison to those with negative surgical margins (3.4 +/- 1.8 cm) (P = .001). Nine of 17 (53%) cases underwent total nephrectomy (5 immediately, 4 delayed). In 4 (24%), immediate re-excision of the renal crater was performed. A total of 4 (24%) that were followed up clinically were with no evidence of disease. Therefore, in 13 of 17 (77%) cases, the presence of tumor cells at the remaining side of the kidney could be evaluated histologically. In 2 cases from the immediate response group, tumor cells were found in the side opposite to the resection. There was no residual tumor in any case subjected to delayed nephrectomy. At median follow-up of 71 months, 15 of 17 patients are alive and with no evidence of disease. Two patients died because of unrelated causes. The overall 5-year survival rate is 98.2% and there is no cancer-specific mortality. CONCLUSIONS The true PSM rate is in the range of 1.75%-5.26%. No disease progression or deaths attributable to renal cell carcinoma were associated with PSMs. Total nephrectomy should be avoided as a response to PSMs.
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Affiliation(s)
- Orit Raz
- Department of Urology, Assaf Harofeh Medical Center, Zerifin, Israel.
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Bensalah K, Pantuck AJ, Rioux-Leclercq N, Thuret R, Montorsi F, Karakiewicz PI, Mottet N, Zini L, Bertini R, Salomon L, Villers A, Soulie M, Bellec L, Rischmann P, De la Taille A, Avakian R, Crepel M, Ferriere JM, Bernhard JC, Dujardin T, Pouliot F, Rigaud J, Pfister C, Albouy B, Guy L, Joniau S, van Poppel H, Lebret T, Culty T, Saint F, Zisman A, Raz O, Lang H, Spie R, Wille A, Roigas J, Aguilera A, Rambeaud B, Martinez Piñeiro L, Nativ O, Farfara R, Richard F, Roupret M, Doehn C, Bastian PJ, Muller SC, Tostain J, Belldegrun AS, Patard JJ. Positive surgical margin appears to have negligible impact on survival of renal cell carcinomas treated by nephron-sparing surgery. Eur Urol 2009; 57:466-71. [PMID: 19359089 DOI: 10.1016/j.eururo.2009.03.048] [Citation(s) in RCA: 204] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2009] [Accepted: 03/23/2009] [Indexed: 12/30/2022]
Abstract
BACKGROUND The occurrence of positive surgical margins (PSMs) after partial nephrectomy (PN) is rare, and little is known about their natural history. OBJECTIVE To identify predictive factors of cancer recurrence and related death in patients having a PSM following PN. DESIGN, SETTING, AND PARTICIPANTS Some 111 patients with a PSM were identified from a multicentre retrospective survey and were compared with 664 negative surgical margin (NSM) patients. A second cohort of NSM patients was created by matching NSM to PSM for indication, tumour size, and tumour grade. MEASUREMENTS PSM and NSM patients were compared using student t tests and chi-square tests on independent samples. A Cox proportional hazards regression model was used to test the independent effects of clinical and pathologic variables on survival. RESULTS AND LIMITATIONS Mean age at diagnosis was 61+/-12.5 yr. Mean tumour size was 3.5+/-2 cm. Imperative indications accounted for 39% (43 of 111) of the cases. Some 18 patients (16%) underwent a second surgery (partial or total nephrectomy). With a mean follow-up of 37 mo, 11 patients (10%) had recurrences and 12 patients (11%) died, including 6 patients (5.4%) who died of cancer progression. Some 91% (10 of 11) of the patients who had recurrences and 83% of the patients (10 of 12) who died belonged to the group with imperative surgical indications. Rates of recurrence-free survival, of cancer-specific survival, and of overall survival were the same among NSM patients and PSM patients. The multivariable Cox model showed that the two variables that could predict recurrence were the indication (p=0.017) and tumour location (p=0.02). No other variable, including PSM status, had any effect on recurrence. None of the studied parameters had any effect on the rate of cancer-specific survival. CONCLUSIONS PSM status occurs more frequently in cases in which surgery is imperative and is associated with an increased risk of recurrence, but PSM status does not appear to influence cancer-specific survival. Additional follow-up is needed.
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Affiliation(s)
- Karim Bensalah
- Department of Urology, University of Rennes, Rennes, France.
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Lam JS, Bergman J, Breda A, Schulam PG. Importance of surgical margins in the management of renal cell carcinoma. ACTA ACUST UNITED AC 2008; 5:308-17. [DOI: 10.1038/ncpuro1121] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2007] [Accepted: 03/20/2008] [Indexed: 02/02/2023]
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Algaba F, Arce Y, Santaularia JM, Villavicencio Mavrich H. [Frozen section in urological oncology]. Actas Urol Esp 2008; 31:945-56. [PMID: 18257364 DOI: 10.1016/s0210-4806(07)73758-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The indications of Frozen section diagnosis (FS) in surgery due to urologic neoplasia are quite specific, and this explains the fact that they amount to a mere 7.3% of the FSs performed in general hospitals. This also makes the knowledge of their usefulness necessary, and thus we are submitting the present review. Generally speaking, FS is not warranted to identify the nature of a tumoral mass, with the following exceptions: (1) Renal masses of a doubtf ul parenchymal origin, or in the urinary tract: (2) Intesticular neoplasias,when the possibility of a conservative treatment arises; (3) Determination of the presence of a prostate adenocarcinoma in an organ donor with high serum PSA; but even in these circumstances its need is widely controversial. Intraoperative determination of surgical margins is particularly useful in: (1) Partial nephrectomies (it may be limited to inspection after dyeing the margin with Indian ink--bed freezing is very seldom needed); (2) Urethral margins in women with total cystectomies and orthotopic substitution; (3) In partial penectomies (always studying the urethral margin and the cavernosal and spongIosal corpora margins). The study of the nodes is a widely debated issue, and except for those cases in which unexpectedly increased node size is found, systematic FS is indicated neither of the bladder nor of the prostate. The situation regarding penis carcinoma is different, as in the groups with intermediate and high risk of node metastasis, even though there is around 16%-18% of false negatives FS is recommended, particularly of radioisotope-marked sentinel nodes.
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Affiliation(s)
- F Algaba
- Sección de Patología, Fundación Puigvert, Barcelona.
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Laparoscopic versus open partial nephrectomy: analysis of the current literature. Eur Urol 2008; 53:732-42; discussion 742-3. [PMID: 18222599 DOI: 10.1016/j.eururo.2008.01.025] [Citation(s) in RCA: 162] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2007] [Accepted: 01/07/2008] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To critically review the current scientific evidence about open partial nephrectomy (OPN) and laparoscopic partial nephrectomy (LPN) to define the current role of these techniques in the treatment of renal tumours. METHODS PubMed and Medline were searched for reports about OPN and LPN that were published from 1990 to 2007 and the most relevant papers were reviewed. RESULTS OPN is an established curative approach for the treatment of small renal tumours. LPN is challenging and the technique is still under development. The intermediate-term oncologic and functional outcomes of LPN are similar to those of OPN in experienced centres. However, the ischaemia time is longer in laparoscopy and a long learning curve is needed to decrease the risk of complications. In the first phase of a surgeon's experience with LPN, a careful case selection based on the tumour growth pattern is required. CONCLUSION OPN is today the first treatment option for small renal tumours. LPN is technically challenging, but has been shown to achieve similar intermediate-term cancer cure and renal function results in centres with advanced laparoscopic expertise. Larger series with longer follow-up and prospective randomised studies are needed to confirm the safety and efficacy of LPN.
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Agrawal S, Jha MS, Khurana N, Ansari MSA, Dubey D, Srivastava A, Kapoor R, Kumar A, Jain M, Mandhani A. Nephron sparing surgery: A single institution experience. Indian J Urol 2007; 23:23-7. [PMID: 19675756 PMCID: PMC2721489 DOI: 10.4103/0970-1591.30260] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Objective: To report our experience in managing various benign and malignant renal tumors with nephron-sparing surgery. Materials and Methods: Records of patients who underwent nephron-sparing surgery (NSS) either through open or laparoscopic approach between May 1997 and June 2006 at our institution were reviewed. Patient and tumor-related characteristics, treatment modality and complications were noted. Results: There were 26 patients (29 renal units), including three with bilateral lesions who underwent nephron-sparing surgery. Mean age at surgery was 47.0 years (range 16-67 years). Mean tumor size was 4.7 cm (range 2-7.5 cm). Mean warm ischemia time was 41 min and 32.5 min, operative time 158 min and 186 min and blood loss 200ml and 85 ml in open (n=24) and laparoscopic approach (n=2) respectively. Complications were seen in five (19.2%) patients of whom two had postoperative bleeding requiring nephrectomy in one and angioembolization in another. One patient with persistent urinary leak required intervention. Local wound infection in one patient and incisional hernia in another were surgically managed. Histopathological profile revealed 13 (44.8%) benign lesions which included angiomyolipoma (eight), simple cyst (two), cortical adenoma (one), metanephric adenoma (one) and myelolipoma (one). The remaining 16 (55.2%) malignant lesions included renal cell carcinoma (15) and metastatic adenocarcinoma (one). At a mean follow-up of 38.6 months (range 1-91) no patient had local recurrence or distant metastasis. Cancer-specific survival was 100% and overall survival was 92.3%. Conclusions: Nephron-sparing surgery is a safe and effective alternative to nephrectomy in both benign and malignant lesions of the kidney.
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Affiliation(s)
- S Agrawal
- Department of Urology and Renal Transplantation, Sanjay Gandhi Post Graduate Institute of Medical Science, Lucknow, (UP), India
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Permpongkosol S, Colombo JR, Gill IS, Kavoussi LR. Positive surgical parenchymal margin after laparoscopic partial nephrectomy for renal cell carcinoma: oncological outcomes. J Urol 2006; 176:2401-4. [PMID: 17085113 DOI: 10.1016/j.juro.2006.08.008] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2006] [Indexed: 12/22/2022]
Abstract
PURPOSE The oncological efficacy of partial nephrectomy is related to obtaining a negative surgical margin intraoperatively. This study assesses the oncological outcomes of patients undergoing laparoscopic partial nephrectomy for a renal tumor who had positive surgical margin on final pathology. MATERIALS AND METHODS The experiences of 2 surgeons with 511 patients with a pathological diagnosis of renal cell carcinoma treated with laparoscopic partial nephrectomy were reviewed. Patients with a positive surgical margin were identified retrospectively. Oncological outcomes were assessed by followup with chest x-ray and computerized tomography every 6 to 12 months for 5 years. RESULTS There were 9 patients (1.8%) with a positive margin on final pathology. Mean tumor size was 2.8 cm (range 1.7 to 4.0). Two patients underwent secondary completion radical nephrectomy, one at 4 days and the other at 2 months following laparoscopic partial nephrectomy. No residual tumor was identified in the nephrectomy specimen in either patient. Of the remaining 7 patients who elected surveillance, 1 with von Hippel-Lindau disease died of metastatic renal cell carcinoma to pancreas 10 months after laparoscopic partial nephrectomy. The remaining patients were disease-free for a median followup of 32 months (range 6 to 76). No patient in the series had port site seeding. CONCLUSIONS A positive margin following laparoscopic partial nephrectomy does not necessarily indicate residual disease. However, vigilant monitoring is mandatory. While midterm outcomes parallel those of patients with a negative margin, longer followup is necessary to determine the ultimate oncological outcomes in this subgroup of patients.
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Affiliation(s)
- Sompol Permpongkosol
- James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions, 600 North Wolfe Street, Baltimore, MD 21287, USA
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Kwon EO, Carver BS, Snyder ME, Russo P. Impact of positive surgical margins in patients undergoing partial nephrectomy for renal cortical tumours. BJU Int 2006; 99:286-9. [PMID: 17155985 DOI: 10.1111/j.1464-410x.2006.06623.x] [Citation(s) in RCA: 108] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate the clinical outcome of patients undergoing partial nephrectomy (PN) for renal cortical tumours who had a positive surgical margin (SM), as recent studies have shown that a minimal SM is required to achieve equivalent disease-free survival (DFS). PATIENTS AND METHODS Between 1989 and 2005, 777 PNs were performed at the authors' institution. Clinical and pathology data were obtained from our prospective surgical database after obtaining institutional review board approval. Variables were analysed in a logistic regression model to determine predictors of positive SMs. The clinical outcome was reported for local recurrence and distant metastasis and analysed using the log-rank test. RESULTS Of the 777 PNs, the SM status was documented in 770; the SMs were positive in 57 of 770 (7%). Positive SMs occurred in 33 of 423 (8%) patients with tumours of high malignant potential, and in 24 of 347 (7%) patients with tumours of low malignant potential. On multivariate analysis, an imperative indication for a PN was a significant predictor for a positive SM (P = 0.003). With a median follow-up for survivors of 22 months, there was a local recurrence in two of 57 (4%) patients with a positive SM and four of 713 (0.5%) with a negative SM. No patients with a tumour of low malignant potential had a recurrence, despite having a positive SM. CONCLUSIONS Although local recurrence after PN for renal cortical tumours is rare, our data suggest that patients with a tumour of high malignant potential and a positive SM might have a higher incidence of local recurrence.
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Affiliation(s)
- Eric O Kwon
- Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA
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Abstract
Open partial nephrectomy, or nephron-sparing surgery (NSS), is now considered the standard of care for the treatment of small renal tumors. The oncologic efficacy and safety of NSS for the treatment of stage-T1a renal tumors has been repeatedly demonstrated to be equivalent to radical nephrectomy. NSS initially was reserved for patients with solitary kidneys, impaired renal function, hereditary tumor syndromes, bilateral renal tumors, and those with significant comorbidities predisposing to future renal failure. The indications have expanded recently to allow elective partial nephrectomy in the setting of a normal contralateral kidney. Furthermore, recent data demonstrate that partial nephrectomy for larger tumors (T1b), which have been historically treated with radical nephrectomy, is a viable option when surgical margins can safely be achieved. In the era of minimally invasive techniques, laparoscopic NSS is technically feasible, yet long-term studies are still needed to assess oncologic efficacy. New NSS ablative technologies, such as cryoablation and radiofrequency ablation, are on the horizon. In this article, we discuss the role of open NSS and surgical technique in the contemporary management of renal tumors.
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Affiliation(s)
- Brian Shuch
- Department of Urology, David Geffen School of Medicine, UCLA, Los Angeles, CA 90095-1738, USA
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Rosales Bordes A, Salvador Bayarri J, de Graeve N, Palou Redorta J, Villavicencio Mavrich H. Nefrectomía parcial laparoscópica transperitoneal en el tratamiento del tumor renal. Actas Urol Esp 2006; 30:492-500. [PMID: 16884100 DOI: 10.1016/s0210-4806(06)73486-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Laparoscopic surgery is a surgical technique the urologist should add to his surgical armamentarium. Its performance tries to mimic the surgical phases of open surgery, and also its indications. Laparoscopic partial nephrectomy is a sophisticated technique that requires wide experience in the performance of endoscopic strategies. We are submitting our experience with 35 laparoscopic partial transperitoneal nephrectomies with a mean follow-up of 25 months. The mean surgical time was 200 minutes, the mean bleeding 190 cc, and the mean hospitalisation five days. Two postoperative bleedings were identified, there were no conversions, and positive margins were notified in two cases, where upon a conservative attitude was adopted.
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Abstract
PURPOSE OF REVIEW This review defines the current role, indications, contraindications, advances, complications, and outcomes of laparoscopic partial nephrectomy in the management of renal tumors. RECENT FINDINGS Recent publications have widened the scope for the application of this technology. The new advances in the management of renal tumors and the tools for tumor excision, renal parenchymal reconstruction, hemostasis, renal vascular control to establish renal ischemia, and the ability to avoid positive surgical margins have made the procedure safe and feasible in the hands of an experienced laparoscopist. SUMMARY The trend toward nephron-sparing surgery has become stronger even in the presence of normal contralateral functioning kidney. Data on oncologic efficacy are promising, and partial nephrectomy is becoming a standard therapy for renal tumors less than 4 cm in size in many centers. Laparoscopic partial nephrectomy has evolved significantly during the past 10 years in our experience as well as that of others. It cannot be considered as a standard yet, but it is being performed in rapidly increasing numbers with good surgical efficiency and oncologic efficacy parallel to that of open surgery.
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Affiliation(s)
- Nasser Albqami
- Department of Urology, Elisabethinen Hospital, Linz, Austria
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Abstract
Laparoscopic partial nephrectomy is emerging as an attractive approach for selected renal masses, but has been performed with significant variability in technique. The procedure's evolution, a merger of proven open techniques with applicable laparoscopic techniques and limitations, is very much a work in progress. Just as long-term follow-up for open nephron-sparing surgery for selected renal masses has demonstrated recurrence-free survival equivalent to radical nephrectomy, a few large series of laparoscopic partial nephrectomy are beginning to surface that demonstrate its clinical efficacy, although duration of follow-up is still too short to make definitive statements. This article reviews the literature and the authors share their experience and preferences in technique, derived from 100 consecutive laparoscopic partial nephrectomies and from their assessment of the acute sealant effectiveness for partial nephrectomy in a large, hypertensive, porcine model that approximates clinical situations. This review aims to assist the urologic surgeon in determining which renal tumors to approach laparoscopically and which surgical approach best fits their laparoscopic expertise.
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Affiliation(s)
- William K Johnston
- Michigan Center for Minimally Invasive Urology, University of Michigan, Department of Urology, 1500 East Medical Center Drive, Ann Arbor, MI 48109-0330, USA
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