Conservative surgical treatment of renal cell carcinoma: clinical experience and reappraisal of indications

Emerging surgical treatments for renal cell carcinoma

Treatment of renal cell carcinoma has evolved considerably over the last few years. While total nephrectomy is necessary at times, nephron-sparing surgery, with a goal of renal function preservation, should always be considered. Although open partial nephrectomy is considered the gold standard approach for nephron-sparing surgery, laparoscopic- or robotic-assisted techniques allow urologists to perform renal surgery less invasively, with excellent long-term oncological outcomes. Cryotherapy and radiofrequency ablation are less invasive management approaches for carefully selected patients with small renal masses. Active surveillance should be considered in elderly or patients who are unfit for surgery. Ultimately, the method chosen for management of a renal mass is an informed decision made by the physician and patient.

The management of small renal masses: what is likely to change?

The diffusion of imaging has determined an increased discovery of small renal masses (SRMs). Recent publications have been reviewed to present the state of the art in the management of SRMs and to try to foresee the next steps in this challenging condition. The role of percutaneous biopsies is expanding, since management algorithms include also active surveillance and ablative therapies. However up to 30% of biopsies fail to provide histological diagnosis and there is the risk of under-evaluating high-grade tumors. Active surveillance has been proposed in patients with reduced life expectancy and numerous comorbidities. The average growth of SRMs is slow, and metastatic progression has been observed in about 1%. Ablative therapies (cryotherapy and radiofrequency ablation) are used in patients with relevant comorbidities or advanced age and unfit for surgery, but who desire active treatment. Compared to conservative surgical treatment both techniques have increased local progression rates, while metastatic progression is relatively low.Partial nephrectomy (PN) is the recommended curative treatment for SRMs and can be performed open, laparoscopically or robotically. Open PN represents the benchmark, with similar cancer specific survival and better preservation of renal function compared to nephrectomy. Laparoscopy is comparable to open surgery in terms of oncologic results, but a long learning curve is necessary. Perioperative outcomes of robot-assisted PN appear superior to laparoscopy and the learning curve is shorter, but data for oncological results are still immature. With the increasing diffusion of robotic technology it is likely more SRMs will be managed with this approach.

Simple Enucleation for the Treatment of Renal Cell Carcinoma Between 4 and 7 cm in Greatest Dimension: Progression and Long-Term Survival

PURPOSE

We present our findings in a series of patients treated with simple enucleation for RCC 4 to 7 cm in greatest dimension. We specifically report the incidence of local and systemic recurrence, and the disease specific survival rate.

MATERIALS AND METHODS

We retrospectively reviewed clinical and pathological data on 71 patients who underwent nephron sparing surgery by simple enucleation between 1986 and 2004 for sporadic, unilateral, pathologically confirmed, 4 to 7 cm RCC. Patients with a solitary kidney due to previous RCC treated with radical nephrectomy were excluded from study. None of the patients had preoperative or intraoperative suspicion of positive nodes. All patients were free of distant metastases before surgery (M0). Patient status was last evaluated in May 2005. Mean followup was 74 months (median 51, range 12 to 225).

RESULTS

Pathological review according to the 2002 TNM classification showed that 42% of the tumors (30 of 71) were pT1a, 44% (31 of 71) were pT1b and 14% (10 of 71) were pT3a. Mean tumor greatest dimension +/- SD was 4.7 +/- 0.81 cm (median 4.5, range 4.0 to 7.0) cm. None of the patients died within the first 30 days of surgery. There were no major complications requiring open reoperation, such as bleeding and urinary leakage/urinoma. Five and 8-year cancer specific survival was 85.1% and 81.6%, respectively. Five-year cancer specific survival in patients with pT1a (4 cm), pT1b and pT3a disease was 95.7%, 83.3% and 58.3%, respectively (pT1a vs pT1b p = 0.254, pT1a vs pT3a p = 0.006 and pT1b vs pT3a p = 0.143). Overall 10 patients experienced progressive disease (14.9%), of whom 3 had local recurrence (4.5%) alone or local recurrence associated with distant metastases.

CONCLUSIONS

Simple tumor enucleation is a useful and acceptable approach to nephron sparing surgery for 4 to 7 cm RCC. It provides long-term cancer specific survival rates similar to those of radical nephrectomy and is not associated with a greater risk of local recurrence than partial nephrectomy for RCC less than 4 cm in greatest dimension.

Intraoperative Conversion of Laparoscopic Partial Nephrectomy

PURPOSE

To assess the incidence of conversion from laparoscopic partial nephrectomy (LPN) to open surgery or laparoscopic radical nephrectomy (LRN) when liberal selection criteria are utilized.

PATIENTS AND METHODS

A retrospective review of medical records was done for all patients scheduled for LPN at our institution from January 2000 through March 2004. The preoperative risk factors, intraoperative course, and pathologic outcomes of patients who were converted to LRN were compared with those of the cohort of patients who underwent LPN as originally scheduled.

RESULTS

Among the 257 operations that started as LPN, 35 (13.6%) were converted to LRN and 4 (1.6%) to open surgery. Age, tumor size, operating time, and hypertension were significantly higher in patients requiring conversion in than those who underwent completed LPN. Patients over the age of 70 had a 3.8-fold higher risk of requiring conversion, and, independent of age, patients with tumor>4.0 cm had a 4-fold increase in the likelihood of conversion to LRN.

CONCLUSION

Of the preoperatively determined factors compared across the cohort of patients who underwent LPN and the cohort of patients converted to LRN, only tumor size and patient age were predictive of an increased risk of conversion. Other variables, including sex, side of affected kidney, clinical stage, ASA score, comorbidity with hypertension or diabetes mellitus, and surgeon were not significant in predicting conversion.

PROGRESSION AND LONG-TERM SURVIVAL AFTER SIMPLE ENUCLEATION FOR THE ELECTIVE TREATMENT OF RENAL CELL CARCINOMA: EXPERIENCE IN 107 PATIENTS

PURPOSE

We present our findings in a series of T1a renal cell carcinoma treated with elective simple enucleation, specifically reporting the incidence of local recurrence, and progression-free and disease specific survival rates.

MATERIALS AND METHODS

A total of 107 patients who underwent elective nephron sparing surgery performed with simple enucleation from January 1989 to December 2000 were studied retrospectively. None of the patients had preoperative or intraoperative suspicion of positive nodes. All patients were free from distant metastases before surgery (M0). Patient status was last evaluated in July 2004. Mean (median, range) followup was 88.3 (84, 44 to 175) months.

RESULTS

Pathological review according to the 2002 TNM classification showed that 95% (102 of 107) of tumors were pT1a, 4% (4 of 107) pT1b and 1% (1 of 107) pT3a. Mean (SD, median, range) tumor greatest dimension was 2.7 (0.93, 2.5, 0.6 to 5) cm. None of the patients died in the immediate postoperative period (within the first 30 days). There were no major complications such as bleeding and urinary leakage/urinoma requiring reoperation. The 5 and 10-year cancer specific survival was 99% and 97.8%, respectively. The 5 and 10-year progression-free survival was 98.1% and 94.7%, respectively. Overall 3 patients had disease progression (2.8%) of whom 2 (1.9%) were local recurrence, 1 alone and 1 associated with distant metastases diagnosed 12 months earlier.

CONCLUSIONS

Simple tumor enucleation is a safe and acceptable approach for elective nephron sparing surgery. It provides excellent long-term progression-free and cancer specific survival rates, and is not associated with an increased risk of local recurrence compared with partial nephrectomy.

Surveillance after radical or partial nephrectomy for localized renal cell carcinoma and management of recurrent disease

Surveillance after surgery for RCC is important because approximately 50% of these patients will develop a disease recurrence, two thirds of who will recur within the first year. Although the prognosis is generally poor in these patients, some may respond favorably to immunotherapy. The small subset of patients who develop solitary metastases has the greatest chance to achieve long-term survival. Aggressive surgical resection is an integral part of this success. Proposed surveillance protocols using a stage-based approach or an integrated approach combining stage with other important prognostic factors attempt to provide a rational approach to identifying treatable recurrences while minimizing unnecessary examinations and patient anxiety. However, strict adherence to follow-up guidelines may not be appropriate for all patients. Factors including patient comorbidities and patient willingness to pursue aggressive management in the event of recurrence may alter the follow-up for each individual.

Psycho-social well-being and general health status after surgical treatment for localized renal cell carcinoma

OBJECTIVE

To comparatively assess the psychological, social well-being and general state of health in patients with stage 1 renal cell carcinoma (RCC) (according to 1997 TNM), who underwent either elective nephron sparing surgery (NSS) or radical nephrectomy.

PATIENTS AND METHODS

We evaluated the health-related quality of life (HR-QoL) in 88 patients who underwent radical nephrectomy and in 56 treated with elective NSS. The measurement of the main QoL components has been made using domain-specific questionnaires tested and validated in Italian language. Each questionnaire has been self-administrated during follow-up (cross-sectional study).

RESULTS

The two analysed group resulted perfectly comparable regarding age, gender, civil status, educational level, profession and mean follow-up. A low level anxiety has been documented in 11.4% of patients after radical nephrectomy and in 1.8% of those treated with an elective conservative surgery. The mean score difference between the two groups resulted statistically significant (p = 0.003). A mild depression has been recorded in 7% of patients who underwent radical nephrectomy and in 2.3% of NSS group. The mean score difference between the two groups was statistically significant (p = 0.01). The general health status was impaired in 12.5% of cases after radical nephrectomy and in 7% after elective NSS. Social problems were present in 18% of patients who underwent radical nephrectomy and in 18% of NSS group. There was no significant difference between radical and conservative group in terms of both General health Questionnaire and Social Problem Questionnaire mean scores.

CONCLUSION

HR-QoL in patients who underwent surgery for RCC is not particularly negatively affected. Nevertheless, the comparative analysis of the results showed that, at a long term follow-up, radical surgery seems to eventually cause a more relevant negative impact on the psychological well-being than conservative surgery.

Evaluation of organ sparing operation results from planned indications in patients with kidney cancer

An analysis in 53 patients with kidney cancer has been conducted, a group on which kidney sparing operations have been performed. 25 women and 28 men have been examined at the age of 53.7 in the postoperative period of 7 divided by 130 months. The average observation time without any recurrences or metastases was 48.8 months. 5.7% local and 1.9% remote decease related recurrences have been found. The stage of clinical progression and the degree of histological malignancy are factors determining the five-year survival being 98.0%, while without any recurrences or metastases being 88.4%.

Comparison of complications after radical and partial nephrectomy: results from the National Veterans Administration Surgical Quality Improvement Program

OBJECTIVE

To determine whether radical nephrectomy causes less morbidity, less mortality and is associated with a shorter hospital stay than is partial nephrectomy.

PATIENTS AND METHODS

A total of 1885 nephrectomies (1373 radical and 512 partial) conducted between 1991 and 1998 in the Department of Veterans Affairs (VA) National Surgical Quality Improvement Program were evaluated. Using multivariate analyses, outcomes were risk-adjusted based on 45 preoperative variables to compare mortality and morbidity rates.

RESULTS

The unadjusted 30-day mortality was 2.0% for radical and 1.6% for partial nephrectomy (P = 0.58). Risk-adjusting the two groups did not result in a statistically significant difference in mortality. The 30-day overall morbidity rate was 15% for radical and 16.2% for partial nephrectomy (P = 0.52); risk-adjusted morbidity rates were not statistically different. There were no statistically significant differences in the rates of postoperative progressive renal failure, acute renal failure, urinary tract infection, prolonged ileus, transfusion requirement, deep wound infection, or extended length of stay.

CONCLUSIONS

Partial nephrectomy carried out in the VA program has low morbidity and mortality rates, comparable with the complication rates after radical nephrectomy.

Small renal masses: assessment of lesion characterization and vascularity on dynamic contrast-enhanced MR imaging with fat suppression

OBJECTIVE

The aim of our study was to characterize renal lesions equal to or smaller than 3.0 cm using dynamic contrast-enhanced MR imaging with fat suppression by means of quantitative analysis of signal intensity.

MATERIALS AND METHODS

We retrospectively reviewed the MR imaging examinations of 35 patients (20 with renal cell carcinoma, eight with angiomyolipoma, and seven with complicated cysts) who were studied with spin-echo and dynamic fat-suppressed gradient-recalled echo MR sequences, before and after the administration of gadopentetate dimeglumine. Every 30 sec after contrast injection, we measured the lesion percentage of enhancement and the ratio of contrast (lesion-renal cortex signal intensity difference) to noise.

RESULTS

Ten renal cell carcinomas were classified as hypervascular (enhancement greater than that of renal cortex) and 10 as hypovascular. The percentage of enhancement of hypervascular carcinomas was similar to that of renal cortex until 150 sec and greater in the late sequences (180-210 sec, p < 0.01). Hypovascular carcinomas had a lower percentage of enhancement than hypervascular carcinomas (60-210 sec, p < 0.005). Angiomyolipomas, after an early enhancement peak, showed values similar to those of hypovascular carcinomas. Complicated cysts had very low enhancement (p < 0.001). The baseline contrast-to-noise ratio was negative for all lesions (hypointensity with respect to renal cortex). After gadolinium injection, the contrast-to-noise ratio of hypervascular carcinomas rose, becoming positive after 150 sec. Until 60 sec, the contrast-to-noise ratio of hypovascular carcinomas declined slightly, whereas that of angiomyolipomas and cysts fell sharply; then the three curves remained stable (60-210 sec, p < 0.05 for all matches except angiomyolipomas versus cysts).

CONCLUSION

Quantitative analysis of signal intensity variations during dynamic contrast-enhanced MR imaging with fat suppression can be useful in the characterization of small renal lesions.

Adenocarcinoma of the kidney: nephron-sparing surgical approach vs. radical nephrectomy

BACKGROUND AND OBJECTIVES

Radical nephrectomy has been the traditional surgical treatment for renal cell carcinoma in patients with a normally functioning contralateral kidney. The necessity for a less aggressive surgical approach has emerged in cases in which there is a need to preserve renal function.

METHODS

We retrospectively evaluated the records of 41 patients with localized, symptomless small renal masses (<5 cm) treated with nephron-sparing surgery (group A) and 48 patients matched for age, tumor location, size, and stage who were treated with radical nephrectomy (group B).

RESULTS

The 5-year cancer-specific survival rates were 97.5% and 98. 4% for the treated patients of groups A an B, respectively. No statistical association was found between cancer-specific survival and surgical approach, tumor stage, tumor location, or recurrence. The size of the primary tumor did not seem to influence the cause-specific survival. Local recurrence was observed in 3 patients (7.3%) who underwent partial nephrectomy. In our series, the overall incidence of multifocality was 10.4%.

CONCLUSIONS

We propose segmental renal resection for unifocal small adenocarcinoma of the kidney in preference to radical surgery as it is corroborated by the presented data.

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 cell carcinoma: preoperative assessment for enucleative surgery with angiography, CT, and MRI

PURPOSE

Our purpose was to assess various imaging methods in detecting a pseudocapsule of renal cell carcinoma (RCC), which is critical for successful tumor enucleation.

METHOD

In 42 patients with histopathologically proven RCC, images obtained at angiography (n = 42), CT (n = 30), and MRI (n = 19) were investigated retrospectively. All patients underwent treatment (enucleation: n = 15; nephrectomy: n = 27). The imaging criteria for the presence of a pseudocapsule were as follows: a surrounding radiolucent rim on angiography, a low or high density rim on CT, and a low intensity rim on MRI. All images were retrospectively reviewed by three radiologists without knowledge of the clinical and histological findings.

RESULTS

Thirty-three of 42 RCCs showed a pseudocapsule on the surgical specimen. A pseudocapsule was detected in 67% of tumors (22/33) on angiography, 26% (6/23) on CT, 27% (4/15) on T1-weighted MRI, 93% (14/15) on T2-weighted MRI, 67% (8/12) on dynamic enhanced T1-weighted MRI, and 15% (2/13) on delayed enhanced T1-weighted MRI.

CONCLUSION

T2-weighted MR images are superior for visualizing a pseudocapsule of RCC and for providing reliable selection criteria for tumor enucleation.

Partial nephrectomy: technique, complications and pathological findings

PURPOSE

We evaluate whether partial nephrectomy can be performed safely and efficaciously for renal tumors.

MATERIALS AND METHODS

The results of 67 partial nephrectomies performed between 1977 and 1994 for renal cell carcinoma (51), oncocytoma (9), angiomyolipoma (3), transitional cell carcinoma (3) and other nonneoplastic lesions (2) were analyzed retrospectively in detail.

RESULTS

Diminished complication rates were noted after 1988, and were attributed to improvements in surgical technique and an increased incidence of smaller, serendipitously discovered tumors. Although 35.5% of the patients had preoperative renal impairment (mean serum creatinine 2.1 mg./dl.), there were minimal changes in renal function and no patient required acute hemodialysis following partial nephrectomy. Among 42 patients with clinical stage T1 to T2 renal cell carcinoma undergoing partial nephrectomy local recurrence was identified in 8.3% of those with primary neoplasms. All 6 patients with local recurrence had negative surgical margins, recurrence often, distant from the operative site and multifocal disease, implicating multicentricity as the etiology of local recurrence. Five patients (83.3%) with local recurrence were alive and asymptomatic at a mean of 138 months after partial nephrectomy. Since capsular penetration was identified in 5 of 27 renal cell carcinomas (18.5%) with a diameter of 3.5 cm. or less, aggressive surgical resection with adequate tumor-free parenchymal and perinephric margins is necessary even for small lesions.

CONCLUSIONS

With improved surgical techniques, including regional hypothermia, intraoperative sonography, meticulous dissection and injection of the collecting system with methylene blue, partial nephrectomy is safe and effective in properly selected patients.

Intrarenal satellites of renal cell carcinoma: histopathologic manifestation and clinical implication

OBJECTIVES

This study was designed to gain more insight into the incidence of satellites of renal cell carcinoma related to the pathologic stage and grade of the primary tumor.

METHODS

One hundred eight nephrectomized kidneys with renal cell carcinoma were sectioned at 3-mm intervals and inspected microscopically for satellite carcinomas. The number, site, size, and distance of satellite carcinomas found were recorded in relation to the primary carcinoma.

RESULTS

The overall incidence of satellite carcinoma was 6.5% (7 of 108). The incidence of satellite carcinoma in relation to the pathologic staging of the primary tumor was 7.1% (1 of 14) in pT1, 3.0% (2 of 66) in pT2, and 14.3% (4 of 28) in pT3. The incidence was higher in patients with N1 disease (25%) than in those with NO (5.0%), and higher in M1 disease (25%) than in those in MO (5.77%). There was no relationship between the grade and multicentricity.

CONCLUSIONS

The incidence of satellite carcinoma was higher in cases with high-stage primary carcinoma. However, even in localized diseases (PT1, pT2), satellite carcinomas were found at at 3.75% incidence. When nephron-sparing surgery is indicated in low-stage cases, precise clinical staging using a combination of various imaging modalities is mandatory, with intraoperative ultrasonography being one possible modality for detecting a concomitant satellite carcinoma.

Transitional cell carcinoma of residual kidney after partial nephrectomy for renal adenocarcinoma

Transitional cell carcinoma of the superior calyces was found 1 year after ipsilateral partial nephrectomy for renal adenocarcinoma. The main special features of the case are the rare occurrence of two primary tumours in the same kidney and the previous conservative surgery. A review of the literature has revealed no earlier case of this type.

Renal cell carcinoma: considerations for nephron-sparing surgery

OBJECTIVES

The performance of nephron-sparing surgery in patients with a normally functioning contralateral kidney is controversial. To explore the risk factors that may contribute to the success or failure of nephron-sparing surgery, we examined the radiology and pathology reports of 278 patients who underwent radical nephrectomy for the treatment of clinically localized renal cell carcinoma.

METHODS

We collated patient data from the records of 278 patients with Stage III renal cell carcinoma entered into the Eastern Cooperative Oncology Group protocol EST 2886 and compared preoperative clinical staging with postoperative pathologic results. Patients were considered potential candidates for nephron-sparing surgery if their preoperative radiographic studies indicated that the carcinoma was a single polar lesion 5 cm or less in diameter.

RESULTS

Of 278 radical nephrectomy specimens, 36 had primary lesions 5 cm or less in diameter. Preoperative radiographic studies showed 14 of 36 would not have been considered eligible for nephron-sparing surgery. Of the remaining 22 potential candidates, pathologic studies showed multifocal lesions in 11, renal vein disease in 4, and nodal disease in 2. Only 5 of 22 patients might have had specimen-confined disease (T3a lesion).

CONCLUSIONS

Capsular-penetrating (T3a) renal cell carcinoma is not often appreciated preoperatively and is associated frequently with multifocal lesions, renal vein or nodal disease. Frozen section studies to rule out T3a disease at the time of nephron-sparing surgery may help determine which patients need radical surgery.

Management of small unilateral renal cell carcinomas: radical versus nephron-sparing surgery

OBJECTIVES

There is controversy concerning the management of small unilateral renal cell carcinomas. The present study was undertaken to evaluate the relative efficacy of radical nephrectomy versus nephron-sparing surgery in such patients.

METHODS

Patients with a single, small (less than 4 cm), localized, unilateral, sporadic renal cell carcinoma (RCC) were identified from an institutional registry. From 1975 to 1992, 88 patients fulfilling these criteria were treated with either radical nephrectomy (n = 42) or nephron-sparing surgery (n = 46). The mean postoperative follow-up interval is 48 +/- 29 months.

RESULTS

The radical and nephron-sparing surgical groups were well matched for patient age, sex, renal function, diabetes, hypertension, tumor size, tumor location, and tumor stage. All patients in both groups had low pathologic stage RCC. There was no difference between the two groups in terms of the mean hospital stay, the requirement for blood transfusions, or the occurrence of surgical complications. There was no difference in the mean preoperative and postoperative serum creatinine levels for patients in the nephron-sparing surgery group. However, the mean postoperative serum creatinine levels were significantly higher than the mean preoperative levels for patients in the radical nephrectomy group (P < 0.001). A single patient in each group developed recurrent RCC postoperatively. The cancer-specific 5-year survival rate for patients in the radical and nephron-sparing surgical groups is 97% and 100%, respectively.

CONCLUSIONS

Radical nephrectomy and nephron-sparing surgery each provide safe and effective curative treatment for patients with a single, small, unilateral localized RCC. The long-term renal functional advantage of nephron-sparing surgery in this setting is not established.

Renal parenchyma-sparing surgery as conservative treatment of renal cell carcinoma

OBJECTIVE

To evaluate the role of parenchyma-sparing surgery in patients with renal cell carcinoma (RCC).

PATIENTS AND METHODS

Between 1965 and 1990, 34 patients with RCC underwent renal parenchyma-sparing surgery. There were 22 men and 12 women with a mean age of 62 years (range 40-89). Ten patients underwent enucleation (Group A), 15 partial nephrectomy (Group B), and nine a combination of procedures (Group C). Conservative surgery was performed in the presence of a normal contralateral unit in four patients (12%).

RESULTS

Five patients developed local recurrence. Metastases appeared in six patients (18%) from 12 to 58 months post-operatively. Adequate renal function was obtained in 32 of the 34 patients. The mean follow-up for all patients was 64.6 months overall, 75.6 months for group A, 64.1 months for group B and 53.4 months for group C. The 3 and 5 year probabilities of survival for all patients were 77.8% and 69.5% respectively. The probabilities of 3 and 5 year survival were 80% for group A, 80% for group B and 71.4% and 57.1% for group C.

CONCLUSION

Enucleation and partial nephrectomy are both viable options in the management of solitary or bilateral RCC, as there is no decline in effective tumour control and prognosis. Larger groups and longer follow-ups are needed to assess the role of renal parenchyma-sparing surgery more definitively.

Partial nephrectomy for incidental renal cell carcinoma

OBJECTIVE

To evaluate the role of nephron-sparing surgery in patients with incidental renal cell carcinoma and a normal contralateral kidney.

PATIENTS AND METHODS

A total of 230 patients underwent curative surgery for unilateral renal cancer between 1979 and 1991. Of these, 41 had a partial nephrectomy. The numbers of patients who underwent partial or radical nephrectomy over the course of the study are compared.

RESULTS

The number of partial compared to total nephrectomies increased from 8% in 1979-84, to 20% in 1984-88 and 30% in 1989-91. This reflected increased detection of incidental renal tumours by radiological imaging. The local recurrence rate in those patients who underwent partial nephrectomy was 2% and survival was 95%, with an average follow-up of 3 years (range, 2-13).

CONCLUSION

Nephron-sparing excision of small, incidental renal tumours achieved comparable early results to radical nephrectomy.

Nephron sparing surgery in incidental versus suspected renal cell carcinoma

From 1956 to 1992 nephron sparing surgery was performed in 216 patients with sporadic renal cell carcinoma. Renal cell carcinoma was suspected in 121 patients and was an incidental finding in 95. Compared to suspected renal cell carcinoma, incidental tumors were smaller (p = 0.0004), more often unilateral (p = 0.001) and of lower pathological stage (p = 0.001). Incidental tumors were also associated with improved 5-year cancer-specific survival (p = 0.003) and a lower rate of postoperative tumor recurrence (p = 0.001). The overall 5-year cancer-specific survival rate was improved in patients with stage I versus higher stage renal cell carcinoma (p = 0.0002), unilateral versus bilateral disease (p = 0.0001), a single versus multiple tumors in the operated kidney (p = 0.01) and tumors smaller than 4 cm. versus larger tumors (p = 0.03). There were no postoperative tumor recurrences and the 5-year cancer-specific survival rate was 100% in patients with unilateral, stage I tumors smaller than 4 cm. These data define specific eligibility criteria for nephron sparing surgery in patients with localized unilateral renal cell carcinoma and a normal contralateral kidney.

Complications of nephron sparing surgery for renal tumors

The technical results of 259 nephron sparing operations for renal cell carcinoma or renal oncocytoma were reviewed. Local or renal related complications occurred after 78 procedures (30.1%). The incidence of complications was less for operations performed after 1988 (22% versus 37%, p = 0.009) and for incidentally detected versus suspected tumors (p = 0.009). The most common complications were urinary fistula formation (45 operations) and acute renal failure (33). Significant predisposing factors for urinary fistula formation included central tumor location (p = 0.001), tumor size greater than 4 cm. (p = 0.001), the need for major reconstruction of the collecting system (p = 0.001) and ex vivo surgery (p = 0.001). Only 1 urinary fistula required open operative repair, while the remainder resolved either spontaneously (30) or with endoscopic management (14). Significant predisposing factors for acute renal failure included a solitary kidney (p = 0.001), tumor size greater than 7 cm. (p = 0.008), greater than 50% parenchymal excision (p = 0.001), greater than 60 minutes of ischemia time (p = 0.035) and ex vivo surgery (p = 0.001). Acute renal failure resolved in 28 patients, of whom 9 required temporary dialysis, while 5 required permanent dialysis. Overall, 8 complications (3.1%) required repeat open surgery for treatment while all other complications resolved with noninterventive or endourological management. Surgical complications contributed to an adverse clinical outcome in only 7 patients (2.9%). Nephron sparing surgery can be performed safely with preservation of renal function in most patients with renal tumors.

Expanding indications for conservative renal surgery in renal cell carcinoma

OBJECTIVE

To more clearly define the selection criteria for conservative renal surgery in renal cell carcinoma.

METHOD

The survival experience of 42 patients who underwent in situ partial nephrectomy (21), enucleation (18), or both (3) over an eighteen-year period was examined. The presence or a history of contralateral cancer, type of surgery, gender, grade, diameter of tumor, age at diagnosis, presenting symptoms, positive surgical margins, smoking history, and stage were examined with regard to prognostic significance.

RESULTS

The five-year cancer-specific survival rates were 100 percent for those patients undergoing partial nephrectomy and 84 percent for those undergoing enucleation. The local recurrence rate was 4.8 percent (2/42) for the group, with both recurrences occurring in patients with von Hippel-Lindau disease. The mean diameter of tumor resected was 4.2 cm. Those patients found to have a positive surgical margin (6) had a significantly shorter disease-specific survival than those who did not (37) (p = 0.004), and those with a smoking history (23) had a significantly shorter survival than non-smokers (19) (p = 0.038).

CONCLUSIONS

We conclude that both partial nephrectomy and enucleation are acceptable approaches to renal cell carcinoma in select cases, with survival rates that closely approximate those found in radical nephrectomy series. Renal carcinomas that are peripherally located and small in diameter (< or = 5 cm) are most appropriate for these procedures, and given the excellent results noted to date, the expanded use of these approaches to include very young patients and those with any disease process that may affect renal function is warranted. A positive surgical margin is an ominous pathologic finding and should be avoided by frozen section biopsy at surgery or possibly intraoperative ultrasonography. Additionally, smokers with renal cell carcinoma have a poorer disease-specific survival than non-smokers, further questioning a carcinogenic etiology in this disease.

Three-dimensional imaging and display of renal tumors using spiral CT: a potential aid to partial nephrectomy

OBJECTIVE

A new technique for creating three-dimensional (3D) images of renal tumors using contrast-enhanced spiral computed tomography (CT) is described and preliminarily investigated.

METHODS

3D spiral CT was employed in 2 patients before radical nephrectomy and in 5 patients before partial nephrectomy. Preoperative and postoperative image analyses were conducted to evaluate the ability of the images to depict key anatomic relationships in planning partial nephrectomies.

RESULTS

3D spiral CT defined the tumor's location and relationship to the kidney surface better than the tumor's proximity to renal hilar vessels and collecting system. Negative surgical margins were obtained in all 4 patients with renal cell carcinoma, and post-operative serum creatinine remained less than 2 mg/dL in all 5 patients after partial nephrectomy.

CONCLUSIONS

This early experience suggests that 3D spiral CT can help in the planning of partial nephrectomy and in attaining complete resection of renal cell carcinoma while conserving normal renal tissue.

Detection of secondary tumours in patients with renal carcinoma: comparative study of ex vivo ultrasonography and histological examination

Seventeen kidneys removed from patients with renal carcinoma were submitted to ex vivo ultrasonography and then to serial pathological examination in an attempt to detect secondary tumours in apparently normal tissue. Ex vivo ultrasonography failed to reveal further tumours, but 2 lesions measuring 5 and 8 mm were found on pathological examination. These preliminary data suggest that intra-operative ultrasonography may be of little value in detecting secondary tumours in conservative surgery for renal carcinoma.

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.

Radical and Conservative Surgery of Renal Cell Carcinoma

After having outlined the approaches for radical nephrectomy and after some critical considerations, the authors dwell upon the current indications for conservative surgery of renal cell carcinoma. They discuss the problems related to such therapy, emphasizing the advantages and possible risks. In particular, the problems connected with multifocal lesions and peritumoral spread are examined, the real clinical meaning of which is at present unknown, as shown by the discrepancy between experimental and clinical data. Then the authors present their own experience concerning 11 cases of renal carcinoma who underwent conservative surgical treatment between January 89 and September 92. None had relapses nor further progression. The conclusion is that, although the results of such surgery are very encouraging, nonetheless prospective studies and a wider selection of cases are required in order to define its role in the treatment of renal carcinoma.

The incidence of multicentricity in renal cell carcinoma

We established the frequency of cancer multicentricity in kidneys removed for renal cell carcinoma by examining 100 intact, formalin preserved kidneys with a diameter of less than 80 mm. (1987 to 1989). The mean diameter of the predominant tumors was 51 mm. (range 15 to 80 mm). After the capsules were removed the kidneys were serially sectioned at 3 mm. intervals, and cortical and intraparenchymal nodules were removed for histological examination. A total of 3 kidneys had multiple tumors found previously on routine pathological examination. In addition, we discovered another 11 nodules in 10 other kidneys. Four nodules had histological features consistent with carcinoma. The size of the nodules ranged from 2 to 5 mm. The rest of the nodules consisted of 3 adenomas, 1 adrenal rest, 1 oncocytoma coexisting with an adenoma and 1 carcinoma permeating through the lymphatic vessels. The mean size of the predominant tumors in the kidneys bearing multiple nodules was 49 mm. Therefore, we observed a 13% incidence of small renal nodules and a 7% multicentricity of renal cell carcinoma in kidneys from patients who underwent nephrectomy.

Intraoperative renal ultrasonography: a useful adjunct to partial nephrectomy

Several evolutionary changes in ultrasonographic instrumentation, including miniaturization of transducers and marked improvement in resolution, have made intraoperative renal ultrasonography a valuable adjunct for intrarenal surgery. We investigated its use in 6 patients undergoing partial nephrectomy for treatment of renal cell carcinoma. In addition, 14 kidneys with renal tumors were scanned immediately after radical nephrectomy and the specimens were subjected to simulated partial nephrectomy. Transverse and longitudinal real-time sonographic images were obtained with a 5 MHz. sector scanner or a 7.5 MHz. convex array transducer. With ultrasonography to define tumor extent and location, negative surgical margins were obtained in all 6 individuals undergoing partial nephrectomy. A negative surgical margin was obtained in 13 of the 14 radical nephrectomy specimens subjected to simulated partial nephrectomy. A small satellite lesion was not identified and not resected in 1 of the radical nephrectomy specimens. We found that intraoperative renal ultrasonography helps to identify the location and extent of deep intraparenchymal lesions. It also provides a guide for a more accurate nephrotomy, which facilitates the attainment of negative resection margins during partial nephrectomy.

Partial nephrectomy for renal cell carcinoma: indications, results and implications

Of 52 patients who underwent partial nephrectomy for tumor 44 were found to have renal cell carcinoma. The indications for this parenchyma-sparing procedure were categorized according to the initial status of the contralateral kidney and included bilateral tumors or tumor in a solitary kidney in 16 patients (mandatory indications), unilateral carcinoma with compromise of the contralateral kidney by a benign disease process in 9 (relative indications) and small peripheral tumor with a normal contralateral kidney in 19 (elective indications). There were 4 recurrences that accounted for 3 deaths, all in patients with mandatory indications. All patients who underwent partial nephrectomy for relative or elective indications were without definite evidence of recurrent disease at last followup (over-all mean 36 months). Our results suggest that conservative surgery can often provide effective and advantageous therapy for renal cancer and we encourage further consideration of the role of partial nephrectomy as an alternative to radical nephrectomy in selected patients with small peripheral tumors and normal contralateral kidneys.

Is there a place for conservative surgery in the treatment of renal carcinoma?

Since 1981, 31 patients have undergone conservative surgery for malignant renal tumours and have been followed up for at least 2 years. The techniques included enucleation or resection (wedge resection or partial nephrectomy). In 10 patients the indications for kidney-sparing surgery were absolute, while in the remainder the conservative surgical approach was a deliberate choice. The tumours varied in diameter from 1.3 to 12 cm and no metastases were detected on pre-operative screening. One patient died post-operatively from myocardial infarction. In the remaining 30 there were no local recurrences. Two patients died from skeletal metastases (1 with bilateral malignancy) and 2 underwent surgery in the post-operative period for haemorrhagic complications. The efficacy of conservative surgery in the local control of renal cancer is an argument in favour of its wider use.