Experience with extracorporeal surgery and autotransplantation for renal cell and transitional cell cancer of the kidney

Surgical treatment of stage pT3b renal cell carcinoma in solitary kidneys: a case series

OBJECTIVE

To describe the surgical management of patients with renal cell carcinoma (RCC) in a solitary kidney (managed preferentially by nephron-sparing surgery, NSS, to avoid dialysis) and extending into the renal vein or inferior vena cava (T3b).

PATIENTS AND METHODS

We identified 13 patients treated surgically between 1977 and 2002 for stage T3b RCC in a solitary kidney; their charts were reviewed to ascertain details of management, pathology and outcomes.

RESULTS

NSS was successful in seven patients (four in situ and three extracorporeally). Five patients had radical nephrectomy (RN), four after failed NSS. The mean (sem) operative duration was longer for NSS, at 5.8 (0.7) h, than RN, at 3.3 (0.6) h. There was one death during surgery before nephrectomy, and eight other complications in six patients. At a median (range) follow-up of 24 (0-204) months, eight patients had died, four from RCC (all having had NSS) at a median interval of 9.5 (7-16) months. Of the five patients alive at a median follow-up of 25 months, four had no identifiable disease, whilst one had systemic recurrence.

CONCLUSIONS

NSS combined with venous tumour thrombectomy for treating T3b RCC involving a solitary kidney is feasible, albeit complicated. There was oncological success in a third of the patients. The treatment of these patients needs to be individualized, as alternatives to NSS (RN or observation) have obvious disadvantages.

Tumours of the ureter and renal pelvis treated with resection and renal autotransplantation: a study with up to 20 years of follow-up

OBJECTIVE

To report long-term follow-up data from patients treated with resection of urothelial neoplasms of the upper urinary tract combined with autotransplantation of the kidney.

PATIENTS AND METHODS

In a clinical and histopathological review of 23 patients who had 25 autotransplantations, they were followed for 7-20 years or until death. Nine patients had either a solitary kidney or bilateral renal pelvic tumours (group A) and 14 had a normal contralateral kidney (group B).

RESULTS

Seven operations were unsuccessful, ending in nephrectomy. Of the nine patients in group A two with high-grade renal pelvic tumours survived with no dialysis and recurrences for 127 and 238 months, respectively. Three patients required haemodialysis 0-3 times weekly for 27, 85 and 108 months, respectively. Three patients with low-grade disease developed invasive recurrences in the autotransplanted kidney after 16, 27 and 90 months, respectively, and later died from the disease. One patient died in an accident after 14 months. Of the 14 patients in group B, one developed a deeply invasive recurrence in the autotransplanted kidney after 86 months, despite frequent controls.

CONCLUSIONS

In patients with a normal contralateral kidney resection and renal autotransplantation is not indicated and might even be harmful, compared to standard nephroureterectomy. The operation might be beneficial in patients with solitary kidneys but other treatments should first be considered, including open or endoscopic resection, and nephroureterectomy and haemodialysis.

Kidney autotransplantation in a patient with renal pelvic and bladder carcinomas

A 66-year-old Japanese woman, whose left kidney was non-functioning, was referred to us with a diagnosis of invasive bladder carcinoma and right renal pelvic carcinoma. The latter tumor was clearly packed in the renal calyx and was considered to be of low-grade malignancy. Nephron preserving surgery of the right kidney was performed, followed by radical cystectomy and construction of an ileal conduit. The postoperative course was good, without significant complications. Renal function was restored and a postoperative imaging study showed a well-functioning transplanted kidney. At present (20 months after surgery), the patient is doing well and has presented no signs of recurrence of the disease.

Matched comparison of radical nephrectomy vs nephron-sparing surgery in patients with unilateral renal cell carcinoma and a normal contralateral kidney

OBJECTIVE

To report the long-term follow-up of a matched comparison of radical nephrectomy (RN) and nephron-sparing surgery (NSS) in patients with single unilateral renal cell carcinoma (RCC) and a normal contralateral kidney.

PATIENTS AND METHODS

Between August 1966 and March 1999, 1492 and 189 patients with unilateral RCC and a normal contralateral kidney underwent RN and NSS, respectively. Patients with renal impairment, previous nephrectomy, bilateral or multiple RCCs, metastasis, and familial cancer syndromes were excluded. A total 164 patients in each cohort were matched according to pathological grade, pathological T stage, size of tumor, age, sex, and year of surgery. The Kaplan-Meier method and stratified Cox proportional hazards model were used to estimate and compare overall, cancer-specific, local recurrence-free, and metastasis-free survival and survival free of chronic renal insufficiency. The 2 groups were evaluated for early (< or = 30 days) complications and proteinuria at last follow-up.

RESULTS

At last follow-up, 126 RN patients (77%) and 130 NSS patients (79%) were alive with no evidence of disease. There was no significant difference observed between patients who had RN and those who had NSS with respect to overall survival (risk ratio, 0.96; 95% confidence interval [CI], 0.52-1.74; P = .88) or cancer-specific survival (risk ratio, 1.33; 95% CI, 0.30-5.95; P = .71). At 10 years, similar rates of contralateral recurrence (0.9% for RN vs 1% for NSS) and metastasis (4.9% for RN vs 4.3% for NSS) were seen in each group, whereas the rate of ipsilateral local recurrence for patients who underwent RN and NSS was 0.8% and 5.4%, respectively (P = .18). There was no significant difference in the early complications between the RN and NSS groups. However, patients who underwent RN had a significantly higher risk for proteinuria as defined by a protein/osmolality ratio of 0.12 or higher (55.2% vs 34.5%; P = .01). At 10 years, the cumulative incidence of chronic renal insufficiency (creatinine > 2.0 mg/dL at least 30 days after surgery) was 22.4% and 11.6%, respectively, for the RN and NSS groups (risk ratio, 3.7; 95% CI, 1.2-11.2; P = .01).

CONCLUSIONS

This retrospective study of patients with unilateral RCC and a normal contralateral kidney suggests that NSS is as effective as RN for the treatment of RCC on long-term follow-up. The increased risk of chronic renal insufficiency and proteinuria after RN supports use of NSS.

Current Status of Partial Nephrectomy in the Management of Kidney Cancer

BACKGROUND: The technique of partial nephrectomy for managing renal cancers is well recognized, but guidelines regarding indications for its use are not generally accepted. METHODS: The authors review the indications for partial nephrectomy in various clinical situations, and they include their own experience to clarify the utility of the technique. RESULTS: Intraoperative renal ultrasound and helical computed tomography can assist the surgeon in technical decisions. Partial nephrectomy is considered when nephrectomy would render the patient anephric and dependent on dialysis. CONCLUSIONS: The technical and operative advances in partial nephrectomy make the approach increasingly attractive for patients with kidney cancer in a variety of clinical circumstances.

Renal transplantation in patients with bilateral renal carcinoma--how long should we wait?

Patients with bilateral renal carcinoma or malignancy in a solitary kidney are best managed by radical nephrectomy with subsequent dialysis and transplantation. Because of the risk of recurrence of the tumour, the timing of the transplant procedure is important. We report on two patients with bilateral renal carcinoma who were subjected to radical nephrectomy and then managed with dialysis and transplantation within 6 months.

Kidney preserving surgery in renal cell tumors: indications, techniques and results in 152 patients

Between 1975 and 1991, 142 patients with renal cell carcinoma and 10 with oncocytoma underwent a total of 164 kidney preserving operations. The indication for surgery was imperative (group 1, 47 patients) among those with a solitary kidney (9), renal insufficiency (17) or bilateral tumors (21). Of the patients with small or peripheral tumors and a healthy contralateral kidney 105 were selected for elective surgery (group 2). Most procedures were done either without ischemia (24%) or with warm ischemia (69%). In some patients from the imperative indication group hypothermia was achieved by in situ perfusion (5%) or ex vivo work bench surgery and autotransplantation (2%). Complication rates were 15% for group 1 and 9.5% for group 2. In group 1, 3 patients died of cancer, 5 lived with metastases and 2 had local tumor recurrence. No patient in group 2 had recurrences or metastases. The tumor-specific survival rate of patients with kidney preservation for renal cell carcinoma was comparable to that of a control group undergoing radical nephrectomy. Due to the high reliability and efficacy, kidney preserving surgery for renal cell carcinoma should be done more often, even in patients with a normally functioning contralateral kidney.

Renal cancer staging: comparison of contrast-enhanced CT and gadolinium-enhanced fat-suppressed spin-echo and gradient-echo MR imaging

Fifty-three consecutive patients with 61 solid or complex non-fat-containing renal masses compatible with renal cancer were examined with contrast-enhanced computed tomography (CT) and magnetic resonance (MR) imaging with pre- and postcontrast FLASH (fast low-angle shot) and fat-suppressed spin-echo sequences. CT and MR imaging were performed within a 1-month interval. CT and MR images were prospectively interpreted. Tumor detection and staging were determined in all patients. CT and MR imaging enabled detection of 54 and 58 of 61 renal tumors, respectively. CT and MR imaging showed 34 and 35 of 38 histologically proved renal tumors, respectively, in 31 patients. Tumor size on CT and MR images demonstrated good correlation and correlated well with the size of pathologic specimens of 34 of 38 resected tumors detected with CT and MR imaging (r = .99). Of the 31 tumors in 31 patients who underwent surgical resection, 24 were correctly staged with CT and 29 with MR imaging. CT and MR imaging both enabled correct staging of four of five additional tumors with biopsy proof of tumor stage. A moderate difference in staging was observed between CT and MR imaging (P = .05). CT showed 13 and MR imaging 15 of 15 tumor thrombi. CT and MR imaging both showed 11 of 11 cases of adenopathy. The results suggest that MR imaging is moderately better than CT for the detection and staging of renal cancer.

Pitfalls of "bench surgery" and autotransplantation for renal cell carcinoma

Under certain circumstances, extracorporeal surgical treatment ("bench surgery") followed by autotransplantation is indicated for renal cell carcinoma. During a 10-year period, 20 patients (16 men and 4 women) underwent bench surgery and attempted autotransplantation for renal cell carcinoma at our institution. The autotransplantation was successful in 16 patients but unsuccessful in 4 because of postoperative renal vascular thrombosis or extensive tumor involvement, which resulted in inadequate renal vein for anastomosis. Of the 16 patients who underwent successful autotransplantations, 4 (25%) subsequently had locally recurrent renal cell carcinoma (a mean of 35 months after initial autotransplantation). Only 6 of the 16 patients who underwent successful autotransplantation were ultimately free of both carcinoma and dialysis. Although an ex vivo surgical procedure can be beneficial for certain patients with renal cell carcinoma, computed tomographic scanning of the autotransplantation site should be performed every 3 to 6 months postoperatively for early detection of local tumor recurrence.

Long-term results of surgical treatment of renal carcinoma in solitary kidneys by extracorporeal resection and autotransplantation

We describe the technique and present the long-term results of extracorporeal partial nephrectomy and autotransplantation in 6 patients with renal carcinoma. During a follow-up period exceeding 5 years, dialysis was not required and the patients' blood pressure improved or remained within normal limits. One patient died post-operatively from gastrointestinal bleeding. The mean duration of follow-up was 54 months (range 14-97). The alternatives to extracorporeal resection and autotransplantation (such as complete nephrectomy and in situ resection of the tumour) are discussed.

Prolonged survival with a remnant kidney

Surgical ablation of five-sixths renal mass in Munich-Wistar rats fed a high protein diet leads to focal sclerosis in the remnant kidney and progressive renal failure. Experimental data suggest that this injury results from intraglomerular hypertension and/or chronic glomerular hyperfiltration. Data in humans largely are limited to patients with unilateral renal agenesis or uninephrectomy, either for unilateral renal disease or for kidney transplant donation. Isolated case reports have documented focal sclerosis and progressive renal failure in two patients with a remnant kidney. To obtain data in humans with a remnant kidney, we surveyed more than 800 urologists and nephrologists in the United States and abroad. Criteria for inclusion in the study were (1) surgical resection (in one or more operations) resulting in the presence of a remnant kidney; and (2) an adequate period of follow-up, defined as 5 years or greater. A total of 13 patients were identified (from 13 different centers). Twelve patients had renal cancer and one had tuberculosis. Six patients were observed for 10 or more years postoperatively and all have stable serum creatinine levels of less than 270 mumol/L (3.0 mg/dL); two of these six patients are now more than 25 and 30 years postoperation. The other seven patients, observed for 5 to 7 years, have serum creatinine levels less than 270 mumol/L (3 mg/dL), while one has an increasing serum creatinine level. The two longest surviving patients both have undergone successful pregnancy with no overall change in serum creatinine. These observations demonstrate that it is possible for humans to survive more than 30 years with a stable serum creatinine, despite the presence of only a remnant kidney.

Bench repair of complex renal arterial lesions

Between 1968 and 1989, 160 patients underwent aortorenal bypass for renovascular hypertension. During the same interval, 13 patients had ex-vivo bench repair of complex renal arterial pathology. There were eight men and five women, with a mean age of 36 years. Twelve of the 13 patients had fibromuscular disease; one had atherosclerosis. Twelve patients had renovascular hypertension with complex stenotic disease beyond the main renal artery. Seven of these also had an associated renal aneurysm as did the sole normotensive patient. Saphenous vein patch or bypass were used to correct stenotic segments in four patients, while the remaining nine patients had excision of stenotic or aneurysmal segments with primary arterial anastomosis. There were no deaths in the series. One kidney was lost because of arterial thrombosis. One patient required reoperation to control postoperative bleeding. Nine of the 12 patients with renovascular hypertension were normotensive off medication, and three were improved, with reduced medication controlling their blood pressure. Ureteric obstruction occurred in two patients; this settled spontaneously in one patient and was corrected by reoperation in the other. From this experience, we conclude that bench repair is a safe and effective way to maximize salvage of kidneys affected by complex arterial pathology.

Progression and survival after renal-conserving surgery for renal cell carcinoma: experience in 104 patients and extended followup

Of 104 patients who underwent a conservative operation for renal cell carcinoma 42 underwent partial nephrectomy, 60 underwent enucleation and 2 underwent a combination of these procedures. A total of 14 patients required an extracorporeal operation with autotransplantation. Forty patients had bilateral renal cell carcinoma (20 were synchronous and 20 were asynchronous) and 39 had either a solitary kidney or a poorly functioning contralateral renal unit. An operation was performed in the presence of a normal contralateral unit in 20 patients. The maximal duration of followup was 20 years (mean 4.9 years): 43, 17 and 7 patients were followed for 5 or more, 10 or more and 15 or more years, respectively. The 5-year cause-specific survival rates were 88.6 +/- 5.6, 91.6 +/- 4.7 and 88.9 +/- 3.8%, respectively, for the enucleation group, partial nephrectomy group and all patients combined. The percentages of patients free of local recurrence at 5 years for the enucleation and partial nephrectomy groups were 94.6 +/- 3.9 and 93.3 +/- 4.7%, respectively. The 14 patients who required an ex vivo approach had larger, higher stage and higher grade tumors, and a poorer outcome (5-year cause-specific survival rate and local rate free of recurrence were 54.9 +/- 17.2 and 85.7 +/- 13.2%, respectively). None of the 20 patients with a normal contralateral unit had progression. The local survival rate free of disease and cause-specific survival rate were not significantly different for the simple enucleation and partial nephrectomy groups. Even longer followup is needed to assess more clearly the definitive role of simple enucleation in the treatment of renal cell carcinoma and the clinical relevance of possible positive margins in a patient population that usually is older.

Renal carcinoma in a solitary kidney

We studied the clinical and pathological features of 26 patients with renal carcinoma of a solitary kidney, including 6 treated at this hospital. Four patients had a contracted kidney and 22 had previously undergone nephrectomy. Partial nephrectomy was performed in 16 patients, enucleation of the tumour in 5 and radical nephrectomy in 5 because of the size of the tumour. Ex vivo surgery was carried out in 4 patients. The duration of ischaemia ranged from 15 to 365 min but was longer in those who underwent ex vivo surgery (149 to 365 min). Of the 21 patients who underwent partial nephrectomy or enucleation, the serum creatinine level increased (greater than or equal to 2.0 mg/dl) post-operatively in 16 patients, of whom 9 required temporary haemodialysis. No recurrence has been noted in those who underwent partial nephrectomy, but 1 patient who underwent enucleation of the tumour developed a solitary pancreatic metastasis 2 years 6 months after surgery and was treated by a partial pancreatectomy. Kidney-preserving surgical procedures are considered to improve the quality of life, but careful follow-up is necessary.