Simple tumor enucleation may not decrease oncologic outcomes for T1 renal cell carcinoma: A systematic review and meta-analysis

French AFU Cancer Committee Guidelines - Update 2024-2026: Management of kidney cancer

OBJECTIVE

To update the French recommendations for the management of kidney cancer.

METHODS

A systematic review of the literature was conducted for the period from 2014 to 2024. The most relevant articles concerning the diagnosis, classification, surgical treatment, medical treatment, and follow-up of kidney cancer were selected and incorporated into the recommendations. The recommendations have been updated specifying the level of evidence (strong or weak).

RESULTS

Kidney cancer following prolonged occupational exposure to trichloroethylene should be considered an occupational disease. The reference examination for the diagnosis and staging of kidney cancer is the contrast-enhanced thoraco-abdominal CT scan. PET scans are not indicated in the staging of kidney cancer. Percutaneous biopsy is recommended in situations where its results will influence therapeutic decisions. It should be used to reduce the number of surgeries for benign tumors, particularly avoiding unnecessary radical nephrectomies. Kidney tumors should be classified according to the pTNM 2017 classification, the WHO 2022 classification, and the ISUP nucleolar grade. Metastatic kidney cancers should be classified according to IMDC criteria. Surveillance of tumors smaller than 2cm should be prioritized and can be offered regardless of patient age. Robot-assisted laparoscopic partial nephrectomy is the reference surgical treatment for T1 tumors. Ablative therapies and surveillance are options for elderly patients with comorbidities for tumors larger than 2cm. Stereotactic radiotherapy is an option to discuss for treating localized kidney tumors in patients not eligible for other treatments. Radical nephrectomy is the first-line treatment for locally advanced localized cancers. Pembrolizumab is recommended for patients at high risk of recurrence after surgery for localized kidney cancer. In metastatic patients, cytoreductive nephrectomy can be immediate in cases of good prognosis, delayed in cases of intermediate or poor prognosis for patients stabilized by medical treatment, or as "consolidation" in patients with complete or major partial response at metastatic sites after systemic treatment. Surgical or local treatment of metastases can be proposed for single lesions or oligometastases. Recommended first-line drugs for metastatic clear cell renal carcinoma are combinations of axitinib/pembrolizumab, nivolumab/ipilimumab, nivolumab/cabozantinib, and lenvatinib/pembrolizumab. Patients with non-clear cell metastatic kidney cancer should be presented to the CARARE Network and prioritized for inclusion in clinical trials.

CONCLUSION

These updated recommendations are a reference that will enable French and French-speaking practitioners to optimize their management of kidney cancer.

Laparoscopic aspirator bracket: a new instrument facilitating the aspiration and exposure of operative field simultaneously in laparoscopic nephron-sparing surgery

Background

This study aims to describe a novel laparoscopic aspirator bracket (LAB) and its use in laparoscopic nephron-sparing surgery (NSS) by a simple enucleation (SE) technique.

Methods

A total of 123 renal tumor cases who underwent laparoscopic NSS via LAB or laparoscopic aspirator between July 2017 and April 2021 were retrospectively analyzed. General characteristics, perioperative data and postoperative follow-up data of patients were compared.

Results

The application of LAB in laparoscopic renal tumor SE surgery shortened the operation time (88.58 ± 38.25 vs. 102.25 ± 35.84 min, p < 0.05) and improved the zero ischemia rate (18.75% vs. 3.39%, p < 0.05), shortened warm ischemia time (16.17 ± 5.16 vs. 19.39 ± 5.62 min, p < 0.05) and decreased intraoperative blood loss (166.19 ± 111.60 vs. 209.15 ± 127.10 ml, p < 0.05). In addition, the serum creatinine and eGFR values in the LAB group also showed faster and better renal function recovery.

Conclusion

The new LAB could aspirate and expose the operative field with a single instrument. In operations that need to expose and aspirate simultaneously, such as in renal tumor simple enucleation, it could shorten operation time, reduce intraoperative blood loss and improve the postoperative renal function recovery.

Imaging Features of Renal Masses to Select Optimal Candidates for Tumor Enucleation Partial Nephrectomy

PURPOSE OF REVIEW

The goal of this paper was to critically evaluate preoperative findings that optimally select candidates for renal tumor enucleation partial nephrectomy.

RECENT FINDINGS

Tumor enucleation has been widely accepted as a management option for patients with chronic kidney disease, hereditary renal cell carcinoma, or multifocal disease. Recent evidence suggests safety and efficacy in the management of routine small renal masses. With recent advances in imaging, the literature for ruling out aggressive renal cell carcinoma and selection for tumor enucleation is robust. As the incidence of renal cell carcinoma rises, partial nephrectomy continues to be the mainstay of treatment for localized renal cell carcinoma. Tumor enucleation maximizes preservation of renal parenchyma without hindering oncologic outcomes. It is important to recognize key tumor radiologic findings which urologists may use to optimize patient selection for tumor enucleation.

Predictors of Positive Surgical Margins after Robot-Assisted Partial Nephrectomy for Localized Renal Tumors: Insights from a Large Multicenter International Prospective Observational Project (The Surface-Intermediate-Base Margin Score Consortium)

Background: To explore predictors of positive surgical margins (PSM) after robotic partial nephrectomy (PN) in a large multicenter international observational project, harnessing the Surface-Intermediate-Base (SIB) margin score to report the resection technique after PN in a standardized way. Methods: Data from consecutive patients with cT1-2N0M0 renal masses treated with PN from September 2014 to March 2015 at 16 tertiary referral centers and included in the SIB margin score International Consortium were prospectively collected. For the present study, only patients treated with robotic PN were included. Uni- and multivariable analysis were fitted to explore clinical and surgical predictors of PSMs after PN. Results: Overall, 289 patients were enrolled. Median (IQR) preoperative tumor size was 3.0 (2.3−4.2) cm and median (IQR) PADUA score was 8 (7−9). SIB scores of 0−2 (enucleation), 3−4 (enucleoresection) and 5 (resection) were reported in 53.3%, 27.3% and 19.4% of cases, respectively. A PSM was recorded in 18 (6.2%) patients. PSM rate was 4.5%, 11.4% and 3.6% in case of enucleation, enucleoresection and resection, respectively. Patients with PSMs had tumors with a higher rate of contact with the urinary collecting system (55.6% vs. 27.3%; p < 0.001) and a longer median warm ischemia time (22 vs. 16 min; p = 0.02) compared with patients with negative surgical margins, while no differences emerged between the two groups in terms of other tumor features (i.e., pathological diameter, PADUA score). In multivariable analysis, only enucleoresection (SIB score 3−4) versus enucleation (SIB score 0−2) was found to be an independent predictor of PSM at final pathology (HR: 2.68; 95% CI: 1.25−7.63; p = 0.04), while resection (SIB score 5) was not. Conclusions: In our experience, enucleoresection led to a higher risk of PSMs as compared to enucleation. Further studies are needed to assess the differential impacts of resection technique and surgeon’s experience on margin status after robotic PN.

Evaluation of the Surgical Margin Threshold for Avoiding Recurrence after Partial Nephrectomy in Patients with Renal Cell Carcinoma

PURPOSE

An adequate minimal surgical margin for partial nephrectomy (PN) has not yet been conclusively established. Therefore, we aimed to compare PN recurrence rates according to surgical margin status and to establish an adequate minimal surgical margin.

MATERIALS AND METHODS

We retrospectively studied patients with clinically localized renal cell carcinoma who underwent PN between 2005 and 2014. Surgical margin width (SMW) was assessed for all surgical tissues and divided into three groups: SMW <1 mm, SMW ≥1 mm, and positive surgical margin (PSM). The data were analyzed using the Kaplan-Meier method with log-rank tests and multivariate Cox regression models.

RESULTS

Of 748 patients (median age, 55 years; interquartile range, 46-64 years; 220 female), 704 (94.2%) and 44 (5.8%) patients had negative and PSMs, respectively. Recurrence-free survival was significantly lower in patients with PSMs (p<0.001) and was not significantly different between SMW ≥1 mm and <1 mm groups (p=0.604). PSM was a significant predictor of recurrence (hazard ratio: 8.03, 95% confidence interval: 2.74-23.56, p<0.001), in contrast to SMW <1 mm (p=0.680).

CONCLUSION

A PSM after PN significantly increases the risk of recurrence. We discovered that even a submillimeter safety surgical margin may be enough to prevent recurrence. To maximize normal renal parenchyma preservation and to avoid cancer recurrence in renal parenchymal tumor patients, PN may be a safe treatment, except for those with a PSM in the final pathology.

Tumor enucleation for the treatment of T1 renal tumors: A systematic review and meta-analysis

Purpose

To evaluate the clinical efficacy and safety of tumor enucleation (TE) compared with partial nephrectomy (PN) for T1 renal cell carcinoma.

Materials and Methods

According to protocol, we searched multiple data sources for published and unpublished randomized controlled trials and nonrandomized studies (NRSs) in any language. We performed systematic review and meta-analysis according to the Cochrane Handbook for Systematic Reviews of Interventions and rated the certainty of the evidence (CoE) using the GRADE framework.

Results

We are uncertain about the effects of TE on perioperative (mean difference [MD] 3.38, 95% CI 1.52 to 5.23; I²=68%; 4 NRSs; 942 participants; very low CoE) and long-term (MD 2.31, 95% CI -1.40 to 6.01; I²=57%; 4 NRSs; 542 participants; very low CoE) residual renal function. TE may result in little to no difference in short-term residual renal function (MD 1.04, 95% CI 0.25 to 1.83; I²=0%; 2 NRSs; 256 participants; low CoE). We are uncertain about the effects of TE on cancer-specific mortality (risk ratio [RR] 0.90, 95% CI: 0.11 to 7.28; I²=0%; 2 NRSs; 551 participants; very low CoE) and major adverse events (RR 0.48, 95% CI: 0.30 to 0.79; I²=0%; 10 NRS; 2,360 participants; very low CoE).

Conclusions

While TE appears to have similar effects on short term postoperative residual renal function, there were uncertainties on mortality and major adverse events. However, we need rigorous RCTs to elucidate the effects of TE as the evidence stems mostly from NRSs.

Is Preoperative Magnetic Resonance Imaging in a Daily Clinical Setting Useful to Evaluate Tumor Invasion Beyond the Pseudocapsule in Renal Cell Carcinoma?

Background

We wanted to clarify whether preoperative magnetic resonance imaging (MRI) in the clinical setting can evaluate the pathologic pseudocapsule (PC) morphology with high accuracy in renal cell carcinoma (RCC).

Methods

We retrospectively analyzed 34 consecutive patients who underwent MRI (1.5 or 3.0T, 5 mm slices) prior to partial nephrectomy (PN) for RCC at our institution between January 2010 and December 2019. First, the correlation between PC morphology (complete or incomplete) and tumor infiltration to the renal parenchyma was examined as pathologic validation. Second, the concordance rate of PC morphology between pathologic tissue and preoperative MRI was evaluated as radiologic validation. Third, risk factor for renal parenchymal invasion in RCC was analyzed.

Results

In the pathologic validation, parenchymal invasion rates were 11% and 28% in the "complete PC" and "incomplete PC" groups, respectively. In the radiologic validation, pathological PC morphology could be diagnosed on preoperative MRI in 17 patients (50.0%). "None PC" on MRI had the lowest positive predictive value (PPV) (0%), "partial PC" on MRI had a good PPV (76.5%), "complete PC" on MRI had a relatively low PPV (33.3%). Unfortunately, these data were insufficient for diagnostic accuracy. As risk factor for renal parenchymal invasion in RCC, only pathologic subtype (non-clear cell) was found to have significant differences in the multivariate analysis.

Conclusion

The results of this study suggest that renal tumors with pathologically incomplete PC have a high possibility of renal parenchymal invasion. However, it is currently difficult to accurately evaluate pathologic PC morphology by preoperative MRI in the clinical setting.

Robotic-assisted laparoscopic tumor enucleation is a feasible technique for renal hilar tumors: A retrospective study

BACKGROUND AND OBJECTIVE: This study aimed to evaluate the safety and efficacy of robot-assisted laparoscopic tumor enucleation (RAE) for the treatment of renal hilar tumors and to describe our experience with renorrhaphy-related surgical techniques.

METHODS

Retrospective data were collected from 173 consecutive patients who underwent RAE for localized renal tumors (cT1-cT2N0M0) at our hospital between September 2014 and November 2019.

RESULTS

Seventy-five patients had renal hilar tumors and 98 patients had nonhilar tumors. There were no statistical differences between the hilar and nonhilar groups in operation time (190 [115-390] vs. 190 [110-390] min, p = 0.889), warm ischemia time (26 [12-60] vs. 27 [17-41] min, p = 0.257), hospital stay duration (8 [3-16] vs. 7.5 [4-18] days, p = 0.386), renal function (estimated glomerular filtration rate, 102.5 [29.4-144] vs. 101.3 [64.2-134.7] ml/min/1.73 m² , p = 0.631); creatinine level, (76 [43-169] vs. 78.5 [50-281.3] µmol/L, p = 0.673), perioperative complications rate, or surgical margin status. However, patients with hilar tumors lost significantly more blood than did those with nonhilar tumors (250 [50-1500] vs. 200 [20-1200] ml, p = 0.007). During the follow-up period (median, 30 months), three patients in each group experienced recurrence. The 5-year recurrence-free rates were 93.0% and 95.4% in the hilar and nonhilar tumor groups, respectively (p = 0.640).

CONCLUSIONS

For experienced robot laparoscopists, RAE is a safe, effective, and feasible procedure for renal hilar tumors, without increased risk of positive surgical margins or worse midterm oncologic outcomes compared with nonhilar tumors.

Renal function after partial nephrectomy following intra-arterial embolization of renal tumors

Laparoscopic Partial Nephrectomy (LPN) after intra-arterial Embolization of renal tumors (LPNE) in a hybrid operating room allows renal tumor enucleation without dissection and clamping of the renal pedicle. The purpose was to assess the potential negative impact of embolization on the renal function. This prospective monocentric study included all patients treated with LPNE between May 2015 and June 2019. Clinical data was collected and incorporated into the UroCCR database (NCT03293563). Glomerular Filtration Rate (GFR) and Computed Tomography Renal Volume (CTRV) were compared before and after 6 months following LPNE. The mean post-operative GFR was 86.6 mL/min (SD 22.9). The mean GFR loss was 9.4% (SD 15.1) and the median renal parenchyma loss was 21 mL (SD 20.6). Using a threshold of 25% GFR loss, age was the only significant predictive factor of renal function impairment according to bivariate (59.5 vs 69.3 years, p = 0.017) and multivariable analysis (OR 1.075, CI 1–1.2], p = 0.05). Significant renal function impairment was not correlated with the renal parenchymal volume loss (OR 0.987, CI [0.95–1.02], p = 0.435). Renal function impairment after LPNE seems to be comparable to other techniques of partial nephrectomy.

Functional and oncological outcomes of 3D clampless sutureless laparoscopic partial nephrectomy for renal tumors with low nephrometry score

BACKGROUND

Renal cell carcinoma still represents 2-3% of all tumors but its mortality is decreased in the last decades due to the early detection of small masses and to the innovative surgical techniques. The aim of our study was to evaluate safety and feasibility of clampless and sutureless laparoscopic partial nephrectomy (CSLPN) in terms of intra- and postoperative functional results, complication rate and oncological outcome.

METHODS

We evaluated patients undergoing CSLPN between July 2013 and December 2019. Inclusion criteria were single, organ confined tumor with size ≤4 cm, intraparenchymal depth ≤1.5 cm, renal nephrometry score between 4 and 6 and no close contact with the collecting system.

RESULTS

Overall, 62 patients underwent CSLPN. Mean operative time was 105 minutes, mean intraoperative blood loss was 165 mL. Mean drain time and hospital stay were respectively 2.5 and 4.2 days. Mean 24 hours hemoglobin (Hb) decrease was 2.5 g/dL. No significative variations are described in pre- and postoperative renal function. Twelve patients had postoperative complications. At a median follow-up of 38.5 months all the patients are alive and disease free.

CONCLUSIONS

Different techniques have been proposed to reduce warm ischemia time (WIT). In our experience we found many benefits in an off-clamp procedure: it gives an ischemia-related advantage, reduces the overall operating time, eliminates the risks associated with the isolation of hilar vessels. In conclusion CSLPN is a safe and effective procedure for selected renal masses; it does not increase complication rate and offers excellent functional and oncological outcomes.

Tumor Enucleation vs. Partial Nephrectomy for T1 Renal Cell Carcinoma: A Systematic Review and Meta-Analysis

Purpose: Tumor enucleation (TE) and partial nephrectomy (PN) have both become main treatment strategies for T1 renal cell carcinoma (RCC), despite the discrepancy between their safety margin. We performed a meta-analysis on all the relevant trials in order to compare the clinical efficacy and safety of TE with those of PN for RCC treatment. Methods: In this meta-analysis, randomized controlled trials or retrospective studies were included if they compared TE and PN therapy in patients with localized renal cancer. The main outcomes extracted were perioperative data and post-operative outcomes. Subgroups for analyses were undertaken according to tumor size and duration of follow up. Data were pooled using the generic variance method with a fixed or random effects model and expressed as mean differences or odds ratios with 95% CI. Results: A total of 13 studies containing 1,792 patients undergoing TE and 3,068 undergoing PN were identified. Our study showed that the patients received TE had significantly shorter operative time (MD = -28.46, 95% CI = -42.09, -14.83, P < 0.0001), less hospital day (MD = -0.68, 95% CI = -1.04, -0.31, P = 0.0003), less estimate blood loss (MD = -59.90, 95% CI = -93.23, -26.58, P = 0.0004) and smaller change in estimated glomerular filtration rate (fixed effect: MD = 4.66, 95% CI = 1.67, 7.66, P = 0.002), fewer complications (fixed effect: OR = 0.65, 95% CI = 0.50, 0.85, P = 0.001) compared with those received PN. However, there were no significant differences in terms of warm ischemic time, positive margin rates, recurrence rates and survival rates between the two groups. All the subgroup analyses presented consistent results with the overall analyses. Conclusions: Our findings suggested that TE is not only less-traumatizing and beneficial for recovery, but also better for renal function protection. Moreover, it did not show the evidence of an increase relapse rate or mortality rate when compared with PN.

The feasibility and safety of modified robot-assisted enucleation for highly complex renal tumors: research on a surgical technique

BACKGROUND

To report the technical feasibility and oncological safety of modified robot-assisted enucleation for highly complex renal tumors using the combined retroperitoneoscopic and transperitoneoscopic accesses.

METHODS

The present research is a retrospective analysis of 166 cases of highly complex renal tumors that underwent a partial nephrectomy at a tertiary academic institution between September 2014 and August 2017. Consecutive consented patients were grouped into two cohorts. Seventy-two cases underwent conventional robot-assisted partial nephrectomy (C-RAPN), and 94 cases were treated with modified robot-assisted tumor enucleation (MRATE). The perioperative and oncological outcomes of both groups were reported. Furthermore, pathological examinations of 225 cases of highly complex renal tumors treated with radical nephrectomy were analyzed.

RESULTS

Although preoperative clinical data were similar between the two groups, the perioperative outcomes were distinctly different. Total renal function at postoperative day 1 was better (P<0.001), and the surgical margin width was narrower (P<0.001) in the MRATE group. In addition, the MRATE group presented less blood loss (143.29 and 90.76 mL; P<0.001) and lower 30-d complication rates (4.2% and 16.7%, respectively; P=0.033). Mean ischemia time and operative time was 3 and 14 minutes shorter in the MRATE group, respectively. Finally, histopathological analysis of 225 cases of renal tumors with high surgical complexity provided objective evidence for the feasibility of MRATE.

CONCLUSIONS

MRATE technique may offer an efficient and safe method to treat anatomically complex renal masses in referral centers. The long-term outcome of MRATE technique merits further investigation.

Accuracy of magnetic resonance imaging to identify pseudocapsule invasion in renal tumors

PURPOSE

To evaluate accuracy of MRI in detecting renal tumor pseudocapsule (PC) invasion and to propose a classification based on imaging of PC status in patients with renal cell carcinoma.

METHODS

From January 2017 to June 2018, 58 consecutive patients with localized renal cell carcinoma were prospectively enrolled. MRI was performed preoperatively and PC was classified, according to its features, as follows: MRI-Cap 0 (absence of PC), MRI-Cap 1 (presence of a clearly identifiable PC), MRI-Cap 2 (focally interrupted PC), and MRI-Cap 3 (clearly interrupted and infiltrated PC). A 3D image reconstruction showing MRI-Cap score was provided to both surgeon and pathologist to obtain complete preoperative evaluation and to compare imaging and pathology reports. All patients underwent laparoscopic partial nephrectomy. In surgical specimens, PC was classified according to the renal tumor capsule invasion scoring system (i-Cap).

RESULTS

A concordance between MRI-Cap and i-Cap was found in 50/58 (86%) cases. ρ coefficient for each MRI-cap and iCap categories was: MRI-Cap 0: 0.89 (p < 0.0001), MRI-Cap1: 0.75 (p < 0.0001), MRI-Cap 2: 0.76 (p < 0.0001), and MRI-Cap3: 0.87 (p < 0.0001). Sensitivity, specificity, positive predictive value, negative predictive value, and AUC were: MRI-Cap 0: Se 97.87% Spec 83.3%, PPV 95.8%, NPV 90.9%, and AUC 90.9; MRI-Cap 1: Se 77% Spec 95.5%, PPV 83.3%, NPV 93.5%, and AUC 0.86; MRI-Cap 2- iCap 2: Se 88% Spec 90%, PPV 79%, NPV 95%, and AUC 0.89; MRI-Cap 3: Se 94% Spec 95%, PPV 88%, NPV 97%, and AUC 0.94.

CONCLUSIONS

MRI-Cap classification is accurate in evaluating renal tumor PC features. PC features can provide an imaging-guided landmark to figure out where a minimal margin could be preferable during nephron-sparing surgery.

Tumor-parenchyma interface and long-term oncologic outcomes after robotic tumor enucleation for sporadic renal cell carcinoma

OBJECTIVE

Tumor enucleation has been shown to be oncologically safe for elective treatment of renal cell carcinoma (RCC); yet, evidence on long-term oncologic outcomes after robotic tumor enucleation is lacking. In this study we provide a detailed histopathological analysis of tumor-parenchyma interface and the long-term oncologic outcomes after robotic tumor enucleation for sporadic RCC in a high-volume referral center.

MATERIALS AND METHODS

We selected consecutive patients undergoing robotic tumor enucleation for sporadic RCC by experienced surgeons with at least 4 years of follow-up. Pattern of pseudocapsule (PC) invasion, thickness of healthy renal margin removed with the tumor, margin status and recurrence rate were the main study endpoints. Multivariable models evaluated independent predictors of PC invasion.

RESULTS

Overall, 140 patients were eligible for the study. Of these, 127 (91%) had complete data available for analysis. Median thickness of healthy renal margin was 0.57 mm (interquartile range [IQR] 0.24-103). A distinct peritumoral PC was present in 121/127 (95%) tumors with a median thickness of 0.28 mm (IQR 0.14-0.45). In 24/121 (19.8%) cases, RCC showed complete PC invasion. At multivariable analysis, increasing tumor diameter, endophytic rate > 50% and papillary histology were significantly associated with complete PC invasion. Positive surgical margins were reported in 3/127 (2.4%) cases. At a median follow-up of 61 months (range 48-76), one patient died due to metastatic RCC. Among patients alive at follow-up, no cases of recurrence at the enucleation site were recorded, while three cases (2.4%) of renal recurrence (elsewhere in the ipsilateral kidney) and three cases (2.4%) of systemic recurrence were found.

CONCLUSIONS

Distinct RCC-related features were associated with complete PC invasion. By providing a microscopic layer of healthy renal margin in almost all cases, robotic tumor enucleation achieved negative surgical margins in the vast majority of patients, even in case of complete PC invasion. At long-term follow-up, no recurrences were found at the enucleation site. Although our findings need to be confirmed by larger studies with longer follow-up, robotic tumor enucleation appears oncologically safe in experienced hands for the treatment of sporadic RCC.