The feasibility of surgical enucleation for renal cell carcinoma

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According to protocol, we searched multiple data sources for published and unpublished randomized controlled trials and nonrandomized studies (NRSs) in any language.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.

Effect of histopathologic characteristics on pseudocapsular invasion in the case of partial nephrectomy for renal tumours

OBJECTIVE

It is aimed to define the existence of pseudocapsular structure on renal tumours, illuminate the relation between pseudocapsular invasion and Fuhrman grade histological type that are among histopathologic prognostic risk factors and determine the relation between surgical margin positivity and existence of pseudocapsular invasion. Sequential partial nephrectomy series and relevant pathological preparations were retrospectively reviewed in order to evaluate these issues.

METHODS

The study includes 123 patients diagnosed with T1 renal tumour and treated with partial nephrectomy in between January 2007 and June 2016. Benign angiomyolipoma was excluded due to complete non-existence of pseudocapsule. 99 T1 patients diagnosed with renal cell cancer whose pathological slides can be duly analysed were included in the study. Clinical and pathological details were evaluated for all patients. Existence of pseudocapsule was revealed for all patients. Pseudocapsule invasion was classified by existence of expansive and infiltrative type and non-existence of pseudocapsule invasion. The groups have been assessed by their histopathologic characteristics.

RESULTS

Compared to the group in which pseudocapsular invasion was not detected, clear-cell histological subtype was observed more frequently in a statistically significant way in the group with expansive pseudocapsular invasion and infiltrative pseudocapsular invasion respectively (p = 0.017 and p < 0.001). Pathological tumour sizes were found out to be statistically similar (p = 0.874). There was not a statistically significant difference in terms of Fuhrman grade (p = 0.220). There was not a statistically significant difference in terms of surgical positive margin (p = 0.609).

CONCLUSION

It was indicated in our study that only the histological subtype affected pseudocapsular invasion in group of patients treated with partial nephrectomy but tumour size, tumour stage, tumour location as well as endophytic and exophytic character did not affect invasion. It has also been revealed that surgical margin positivity is not correlated with pseudocapsular invasion.

Saudi Oncology Society and Saudi Urology Association combined clinical management guidelines for renal cell carcinoma 2017

In this report, we update the previously published Saudi guidelines for the evaluation and medical and surgical management of renal cell carcinoma. It is categorized according to the stage of the disease using the tumor node metastasis staging system 7th edition. The recommendations are presented with supporting evidence level.

Saudi Oncology Society and Saudi Urology Association combined clinical management guidelines for renal cell carcinoma 2017

In this report, we update the previously published Saudi guidelines for the evaluation and medical and surgical management of renal cell carcinoma. It is categorized according to the stage of the disease using the tumor node metastasis staging system 7^th edition. The recommendations are presented with supporting evidence level.

Histopathologic analysis of tumor bed and peritumoral pseudocapsule after in vitro tumor enucleation on radical nephrectomy specimen for clinical T1b renal cell carcinoma

PURPOSE

This study was designed to assess the feasibility and histopathologic safety of tumor enucleation for renal cell carcinoma, through histopathologic analysis of the tumor bed and peritumoral pseudocapsule (PC) after in vitro tumor enucleation.

MATERIALS AND METHODS

We studied 176 radical nephrectomy specimens for clinical T1b renal cell carcinoma in our institution, from January 2013-February 2016. Immediately after the kidney was excised, the tumor of radical specimen was enucleated in vitro. The tumor bed parenchyma of 15mm beyond the PC was examined to investigate the possible presence of tumor invasion or satellite lesions. The PC invasion was also evaluated.

RESULTS

The average tumor size was 5.7±0.7cm. The histopathologic evaluation revealed that 68.2% of tumors were clear cell renal cell carcinoma (RCC). The pathological staging showed that 92.6% of tumors were pT1b, 2.8% were pT2, and 4.5% were pT3a. For clinical T1b RCC, tumor infiltration on tumor bed was detected in 6 cases (3.4%), and satellite lesion was detected in 3 (1.7%). In the group of grade 1 to 2, 4 (2.3%) were found with residual tumor, and 5 (2.8%) in the group of grade 3 to 4 (P = 0.133). Papillary RCC had the highest rate of residual tumors (8.8%). A statistically significant association of peritumoral PC invasion with tumor size and pathologic grade was observed. Median follow-up was 23 months (range: 6-43) with a recurrence rate of 6.3% (11 of 176) and a cancer-specific mortality rate of 2.8% (5 of 176).

CONCLUSIONS

For clinical T1b renal cell carcinoma, the risks of tumor infiltration or satellite lesions on enucleation tumor bed or both are relatively low. Peritumoral PC invasion is associated with tumor size and pathologic stage. Tumor enucleation is a histopathologically safe technique for patients undergoing partial nephrectomy.

Saudi Oncology Society and Saudi Urology Association combined clinical management guidelines for renal cell carcinoma

This is an update to the previously published Saudi guidelines for the evaluation, medical, and surgical management of patients diagnosed with renal cell carcinoma (RCC). It is categorized according to the stage of the disease using the tumor node metastasis staging system 7(th) edition. The guidelines are presented with supporting evidence level, they are based on comprehensive literature review, several internationally recognized guidelines, and the collective expertise of the guidelines committee members (authors) who were selected by the Saudi Oncology Society and Saudi Urological Association. Considerations to the local availability of drugs, technology, and expertise have been regarded. These guidelines should serve as a roadmap for the urologists, oncologists, general physicians, support groups, and healthcare policy makers in the management of patients diagnosed with RCC.

Saudi oncology society and Saudi urology association combined clinical management guidelines for renal cell carcinoma

In this report, updated guidelines for the evaluation, medical and surgical management of renal cell carcinoma are presented. They are categorized according the stage of the disease using the tumor node metastasis staging system 7(th) edition. The recommendations are presented with supporting evidence level.

Stereotactic body radiotherapy of primary and metastatic renal lesions for patients with only one functioning kidney

BACKGROUND

About 2% of patients with a carcinoma in one kidney develop either metastases or a new primary tumor in the contralateral kidney. Often, renal cancers progress rapidly at peripheral sites and a metastasis to the second kidney may not be the patient's main problem. However, when an initial renal cancer is more indolent yet spreads to the formerly unaffected kidney or a new primary tumor forms there, local treatment may be needed. Stereotactic body radiotherapy (SBRT) has been demonstrated as a valuable treatment option for tumors that cause local symptoms. Presented here is a retrospective analysis of patients in whom SBRT was used to control primary or metastatic renal disease.

PATIENTS AND METHODS

Seven patients with a mean age of 64 (44-76) were treated for metastases from a malignant kidney to its contralateral counterpart. Dose/fractionation schedules varied between 10 Gy x 3 and 10 Gy x 4 depending on target location and size, given within one week. Follow-up times for patients who remained alive were 12, 52 and 66 months and for those who subsequently died were 10, 16, 49 and 70 months.

RESULTS

Local control, defined as radiologically stable disease or partial/complete response, was obtained in six of these seven patients and regained after retreatment in the one patient whose lesion progressed. Side effects were generally mild, and in five of the seven patients, kidney function remained unaffected after treatment. In two patients, the creatinine levels remained moderately elevated at approximately 160 micromol/L post treatment. At no time was dialysis required.

CONCLUSION

These results indicate that SBRT is a valuable alternative to surgery and other options for patients with metastases from a cancer-bearing kidney to the remaining kidney and provides local tumor control with satisfactory kidney function.

Histopathologic analysis of peritumoral pseudocapsule and surgical margin status after tumor enucleation for renal cell carcinoma

BACKGROUND

The oncologic safety of blunt tumor enucleation (TE) of renal cell carcinoma (RCC) depends on the presence of a continuous pseudocapsule (PS) around the tumor and on the possibility of obtaining negative surgical margins (SMs).

OBJECTIVE

To investigate the PS and SMs after TE to define the real need to take a rim of healthy parenchyma around the tumor to avoid the risk of positive SMs. The risk of PS invasion related to other clinical and pathologic variables was also evaluated.

DESIGN, SETTING, AND PARTICIPANTS

Between September 2006 and December 2007, data were gathered prospectively from 187 consecutive patients who had kidney surgery. Overall, 90 consecutive patients who had TE for RCC were eligible for the study. All specimens were evaluated using an image analyzer by a dedicated uropathologist.

INTERVENTION

TE was done by blunt dissection using the natural cleavage plane between the tumor and the normal parenchyma.

MEASUREMENTS

PS, SM, and routinely available clinical and pathologic variables were recorded.

RESULTS AND LIMITATIONS

In 60 RCC tumors (67%) the PS was intact and free from invasion (PS-) while in 30 (33%) there were signs of penetration within its layers, with or without invasion beyond it. Indeed, 26.6% had PS that had been penetrated on the parenchymal side and 6.6% had penetration on the perirenal fat tissue side. The odds of having PS penetration increased significantly with an increase in clinical tumor size. PS penetration was also significantly associated with pathologic tumor dimensions and grade. In all cases the SMs were negative after TE. The present patients, followed for >2 yr, will enable us to correlate the risk of local recurrence with PS status.

CONCLUSIONS

The risk of PS penetration is associated with clinical and pathologic tumor dimensions and grade. If there is PS invasion into normal parenchyma, the presence of a thin layer of tissue allows for negative SM even if a TE is performed.

A 7-case anatomopathology revision in the presence of renal relapse after conservative therapy: implications on surgical technique

Anatomopathology revision of the cases which underwent second surgery because of a renal neoplasm relapsing after conservative surgery in order to find possible relations with the surgical technique.

Materials and Methods.

At our institution, Nephron-sparing surgery (NSS) is currently indicated as elective technique for neoplasms smaller than 4cm in diameter. The technique involves the removal of the neoplasm with a margin of healthy parenchyma and with the perilesional fat. The patients are monitored with a first CT check after 4 months and then with ultrasound/CT checks every 6 months in the first 2 years and then once a year. In the present study we analyze the records of the cases in the period 1994–2005 undergoing a second operation for a renal tumor relapsing in the operated kidney after NSS. All specimens were reviewed by a single experienced uro-pathologist, who determined the size of the surgical margins and the relations between the seat of recidivism and the seat of the preceding enucleoresection.

Results.

Seven cases with renal relapse were found out of 267 undergoing conservative surgery in the same period (incidence: 2.6%). The diagnosis had always been made lacking any other disease localizations at a complete re-staging; the average relapse latency was 19.4 months (8–46 months). In 5 cases the second tumor was found in the seat of the previous NSS: for these cases the minimum margin of the enucleoresection was lower than 3mm (median minimum margin: 1.6 mm). Differently, in the remaining 2 cases, both with a wider surgical margin (median minimum margin: 12.0 mm), the seat of the first and that of the second neoplasm were distant. In particular, in one case a multifocal relapse with a spread microvascular embolization was found, while in the other the two neoplasms showed a different histotype.

Discussion and Conclusions.

In the 5 cases with a little resection margin and relapsing tumor in the seat of the enucleoresection, the persistence of a peritumoral microscopic neoplastic disease can be assumed. In the other 2 cases showing a wider surgical margin the relapse can be attributed to the widespread microscopic multifocality in one case, and to the development of a second de novo neoplasm in the other case. The extension of the surgical margin seems then to have played a role in determining a relapse in the seat of enucleoresection.

Enucleoresection for the Elective Treatment of Small Renal Cell Carcinoma: Can It Be the Treatment of Choice?

BACKGROUND

We present our findings in a series of T1 renal cell carcinomas (RCC) treated with excision of the tumor surrounded by a minimal layer of grossly normal parenchyma.

PATIENTS AND METHODS

A total of 43 patients who underwent elective nephron-sparing surgery performed with enucleoresection were studied retrospectively. None of the patients had preoperative or intraoperative suspicion of positive nodes and were free from distant metastases before surgery (N0, M0). Patients status was last evaluated in January 2006.

RESULTS

Median age was 58.7 years (35-78). Median tumor size was 3.3 cm (1.5-7). There were no major complications such as bleeding and urinary leakage/ urinoma requiring re-operation. Pathological stage was pT1a in 38 (89%), pT1b in 4 (9%) and pT3a in 1 (2%) patient. Median followup was 32 months (6-89). A total of 5 patients with RCC had died as of January 2006. Overall, 3 (6.9%) patients had disease progression, of whom 2 (4.6%) were local recurrence, 1 alone and 1 associated with distant metastases. The overall cancer-specific survival was 95.4%, and the overall progression-free survival was 93%.

CONCLUSIONS

Enucleoresection reproduces the results of partial and radical nephrectomy with minimal morbidity. It is a safe and acceptable approach for elective nephronsparing surgery.

Long-term results of simple enucleation for the treatment of small renal cell carcinoma

OBJECTIVE

We have analyzed our institutional experience with simple enucleation for the treatment of small renal tumors for elective indications.

MATERIALS AND METHODS

A total of 30 patients underwent elective nephron-sparing surgery (NSS) from May 1997 to January 2001. All patients underwent NSS by means of enucleation. The tumor bed was coagulated carefully for haemostatic and partly for oncological reasons. Median follow-up was 71 months (range: 49-91 months).

RESULTS

Pathological review according to the 2002 TNM classification showed that 70 % (21 of 30) of tumors were pT1a, 26.7 % (8 of 30) pT1b and 3.3 % (1 of 30) pT3a. Median tumor size was 3.7 cm. (range: 3.0 - 5.5 cm). There was no perioperative mortality (within the first 30 days). Bleeding had not been recorded during perioperative period. Urinary leakage was observed in 1 patient (3.3%). No case of local recurrence was observed. Five and 7-year cumulative survival was 96.6% and 93.3%, respectively. Five and 7-year cancer specific survival was 100% and 96.5%, respectively.

CONCLUSIONS

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

Lessons learned in the surgical management of renal cell carcinoma

Surgical excision, the mainstay of management of renal cell carcinoma (RCC), has evolved significantly over the last 4 decades. Radiological imaging is crucial to the diagnosis and staging of RCC, and technological advances have facilitated more precise preoperative assessment. Additionally, wider use of cross-sectional imaging modalities has led to increasing incidental diagnosis of small, early-stage RCC. Nephron-sparing surgery (NSS), originally developed to treat RCC arising in a solitary functioning kidney, has been demonstrated to be a safe and effective alternative to radical nephrectomy. NSS is now also applicable to tumors of suitable size and anatomy in patients with a normal contralateral kidney, thus facilitating preservation of renal function and management of metachronous contralateral pathology. Laparoscopic and percutaneous approaches have developed over the last decade, thus providing minimally invasive modalities, with shortened convalescence and improved cosmesis. Advanced RCC, involving venous extension or nodal spread, is increasingly amenable to surgical management, although appropriate patient selection is crucial. Furthermore, surgical excision of the primary lesion appears to be an integral part of systemic therapy for metastatic RCC.

Long term results of excision of small renal cancer surrounded by a minimal layer of grossly normal parenchyma: review of 94 cases

OBJECTIVE

To assess safety and effectiveness of excision of small renal cancer.

METHODS

We reviewed the records of 94 patients, who underwent, from 1992 to 2001, excision of renal tumor leaving around it a thin layer of grossly normal parenchyma and adjacent perinephric fat. This technique has been called enucleoresection, as it is not a simple enucleation but neither a conventional partial nephrectomy. Patients were followed up mean routine blood examination, ultrasound and computed tomography scan every 6 months for 2 years and annually thereafter.

RESULTS

Median age was 63 years (35-76). Median tumour size was 2.1cm (1.1-4.5). Clamping of renal pedicle was performed in 54 cases. Major complications included 4 cases of haemorrhage; only 1 patient required surgical exploration. Pathological stage was pT1a in 87, pT1b in 4 and pT3a in 3 patients. Surgical margins were always negative. Median follow-up was 59 months (range 10-128). Eight patients died without evidence of tumour recurrence. One pT3a patient developed distant metastases and died 2 years after surgery. Five years survival rate was 95.7% (90/94 patients), cancer specific survival rate 98.9% (93/94) and disease free survival rate 98.9% (93/94).

CONCLUSIONS

Enucleoresection of small renal tumors surrounded by a minimal layer of grossly normal renal parenchyma reproduces the results of partial and radical nephrectomy with minimal morbidity.

Nephron-sparing surgery for renal cell carcinoma--long-term results

OBJECTIVES

Renal cell carcinoma (RCC) is most often treated using radical nephrectomy. However, in patients with only one kidney or with bilateral RCC, nephron-sparing surgery (NSS) is mandatory. NSS may also be undertaken in patients with a normal contralateral kidney, providing that the tumour is fairly small and not unfavourably located. The aim of the present study was to determine the long-term results in patients treated with NSS for RCC.

MATERIAL AND METHODS

We reviewed the records of 87 patients with RCC subjected to NSS between 1980 and 1999. The survival rate was determined, as well as the tumour grade (Skinner classification) and stage (1992 World Health Organisation classification).

RESULTS

Cancer-specific survival, in patients with no demonstrable distant metastases and regardless of stage and grade, was 80% and 75% at 5 and 10 years, respectively. Long-term survival was significantly dependent on tumour stage and grade.

CONCLUSION

In this patient series, long-term survival did not differ from the results obtained using radical nephrectomy, judging from the available literature. An exception was found in patients with high-stage RCC, where NSS appeared to be a less favourable procedure. We therefore recommend that NSS should be performed in cases with bilateral tumour disease or an absent/malfunctioning contralateral kidney. NSS may also be considered in cases of low-stage RCC with a normal contralateral kidney, especially in patients with local or systemic conditions that may adversely affect renal function in the future.

Which Is the Real Gold Standard for Small-Volume Renal Tumors? Radical Nephrectomy versus Nephron-Sparing Surgery

BACKGROUND AND PURPOSE

Until recently, the gold standard for treatment of localized renal-cell carcinoma with a normal contralateral unit was deemed to be a formal radical nephrectomy. Advocates of nephron-sparing surgery have recently challenged this concept; we wished to evaluate the evidence to determine which treatment is objectively superior for patients with renal tumors up to 4 cm.

MATERIALS AND METHODS

MEDLINE, CANCERLIT, and EMBASE computer literature searches were performed to identify peer-reviewed papers pertaining to radical nephrectomy (RN), nephron-sparing surgery (NSS), or comparisons of these methods for tumors as large as 4 cm in maximum diameter. Review of the bibliographies of recovered articles and data in recent textbooks were used to supplement the computerized searches. There were a total of 797 cases in the RN group and 1211 in the NSS group. The parameters specifically evaluated were evidence of local recurrence, disease progression, and death within 33 months, this period being chosen primarily because it was the shortest follow-up in the studies evaluated. The data were then subjected to rigorous statistical analysis. Laparoscopic radical nephrectomy (LRN) and laparoscopic nephron-sparing surgery (LNSS) articles were also reviewed; however, current follow-up periods were considered too short to draw a statistically significant conclusion.

RESULTS

Disease-specific survival rates (P=0.001; Mann-Whitney test) as well as the incidence of metastases (P<0.05; Mann-Whitney test) were significantly better in the NSS group. The incidence of local recurrence (P=0.22; Mann-Whitney test) was not significantly different. It should be borne in mind that there are different follow-up periods for each study, and this may have had an impact on the results.

CONCLUSION

Nephron-sparing surgery seems to be as effective as RN in patients with renal cell tumours up to 4 cm, although only a large randomized controlled trial with long follow-up periods would provide a definite answer.

The role of partial nephrectomy for renal cell carcinoma in contemporary practice

Partial nephrectomy has proved to be a safe and effective treatment modality, even for patients with normal contralateral kidneys. The indications for elective partial nephrectomy continue to evolve as contemporary series demonstrate low morbidity approaching that of radical nephrectomy. Furthermore, patients who undergo partial nephrectomy have a significantly decreased risk of future renal insufficiency. As such, a rationale exists for expanding indications in an era of excellent technical outcomes and increased patient longevity. Characterization of newer diagnostic (three-dimensional imaging) and treatment (laparoscopic partial nephrectomy, cryosurgery) modalities will allow continued evolution of nephron-sparing techniques.

Retroperitoneal laparoscopic cryoablation of small renal tumors: intermediate results

OBJECTIVES

To present our experience with laparoscopic renal cryoablation with up to 3 years of follow-up. Laparoscopic renal cryoablation remains a viable option for the treatment of small peripheral renal masses in patients with significant comorbidities. Although partial nephrectomy has been shown to be a safe and reliable method of renal parenchymal preservation, laparoscopic cryoablation still requires longer term data to prove its efficacy.

METHODS

Twenty patients with small renal masses (1.4 to 4.5 cm) underwent laparoscopic renal cryosurgery at our institution. A retroperitoneal laparoscopic approach was used to expose the kidney. Intraoperative ultrasound guidance was used to localize the lesions and monitor iceball formation. A double-freeze technique was used. Needle biopsies of solid masses were performed intraoperatively.

RESULTS

Renal biopsies revealed renal cell carcinoma in 11 of the 20 patients. Of these 11 patients, none had evidence of recurrent disease at last follow-up, and follow-up scans showed no enhancement of any lesions. Of the 8 patients with follow-up of 2 years or greater, 4 had complete resolution of the renal lesions. The remainder had lesions that were reduced and stable in size. Complications included surgical re-exploration to evaluate pancreatic injury in 1 patient and failure to ablate a lesion in another.

CONCLUSIONS

Laparoscopic renal cryoablation appears to be an effective tool for ablation of small renal lesions. A moderate length of follow-up continues to demonstrate efficacy because no patients had growth of treated pathologic lesions or developed metastasis to date. Continued maturation of data is necessary to determine the long-term efficacy.

Renal cell carcinoma in the solitary kidney: an analysis of complications and outcome after nephron sparing surgery

PURPOSE

We evaluated surgical techniques, pathological features and extended outcomes in patients with renal cell carcinoma in a solitary kidney treated with surgical excision.

MATERIALS AND METHODS

Between 1970 and 1998, 76 patients underwent nephron sparing surgery for sporadic renal cell carcinoma in a solitary kidney, including 63 with tissue specimens available for pathological review who comprised the cohort. Six (9.5%) patients had a congenitally absent kidney and 57 (90.5%) had previously undergone contralateral nephrectomy for renal cell carcinoma. The clinical and pathological features examined were patient age at nephron sparing surgery, sex, type of nephron sparing surgery (enucleation, partial nephrectomy or ex vivo resection), tumor size, nuclear grade, histological subtype and 1997 tumor stage. Overall cancer specific, local recurrence-free and metastasis-free survival as well as early (within 30 days of nephron sparing surgery) and late (30 days to 1 year after nephron sparing surgery) complications were assessed. Univariate and multivariate analyses were done to test for the associations of clinical and pathological features with outcome.

RESULTS

Most patients were treated with enucleation (36.5%), standard partial nephrectomy (38.1%) or the 2 procedures (11.1%) and in 8 (12.7%) ex vivo tumor resection was done. The renal cell carcinoma histological subtypes were clear cell in 82.5% of cases, papillary in 15.9% and chromophobe in 1.6%. Grade was 1 to 3 in 10 (15.9%), 42 (66.7%) and 10 (15.9%) tumors, respectively. At 5 and 10 years the overall survival rate was 74.7% and 45.8%, the cancer specific survival rate was 80.7% and 63.7%, the local recurrence-free survival rate was 89.2% and 80.3%, and the metastasis-free survival rate was 69% and 50.4%, respectively. Tumor stage and nuclear grade were significantly associated with death from any cause, death from renal cell carcinoma and distant metastases on multivariate analysis. Notably no patient with papillary or chromophobe renal cell carcinoma died of renal cell carcinoma, or had recurrence or metastasis. The type of nephron sparing surgery was not significantly associated with outcome, although there were too few patients with recurrence to assess the association of the type of nephron sparing surgery with local recurrence. The most common early complication was acute renal failure in 12.7% of cases, while the most common late complications were proteinuria in 15.9% and renal insufficiency in 12.7%.

CONCLUSIONS

The 1997 tumor stage and nuclear grade were significant predictors of death from any cause, death from renal cell carcinoma and distant metastases in patients treated with nephron sparing surgery for renal cell carcinoma involving a solitary kidney. Nephron sparing surgery in a solitary kidney can be performed safely and with minimal morbidity.

Is a 1-CM margin necessary during nephron-sparing surgery for renal cell carcinoma?

OBJECTIVES

To determine whether a 1-cm margin is necessary for cancer control during nephron-sparing surgery (NSS) for renal cell carcinoma (RCC).

METHODS

A retrospective review of 67 patients who underwent NSS for RCC between 1990 and 2000 was conducted. The data collected included patient demographics, tumor size and location, histologic type and grade, margin status (positive or negative), and the shortest distance of normal parenchyma (in millimeters) around the tumor in the final pathologic specimen. Recurrence was determined from the clinical follow-up, which included physical examination, ultrasonography or computed tomography, and various laboratory tests.

RESULTS

Fifty-five cases were performed open and 12 laparoscopically. The mean follow-up was 60 months (range 5 to 124). The mean tumor size was 3.0 cm (range 0.9 to 11.0). Seven patients were found to have a positive margin; 1 died of metastatic RCC, 1 was alive with systemic recurrence, and 5 had no evidence of disease. Of 11 patients with a negative margin distance of less than 1 mm, 9 were recurrence free, 1 had simultaneous local and pulmonary relapse, and the other had pulmonary recurrence only. The remainder of the study patients (n = 49) had negative margins greater than 1 mm, and all were alive without evidence of disease at the last follow-up.

CONCLUSIONS

This review questions the necessity of a 1-cm margin to prevent recurrence after NSS for RCC. Additional studies to determine the optimal margin distance should be conducted.

Renal parenchyma-sparing surgery in carcinoma

BACKGROUND

There is controversy regarding the role of renal-sparing surgery in patients with kidney cancer who have a functioning contralateral kidney.

METHODS

The present study aimed to review the recent experience of renal-sparing surgery at Royal Prince Alfred Hospital (RPAH), Sydney. Eighteen consecutive patients undergoing conservative surgery for kidney tumours at RPAH between February 1987 and January 1995, were reviewed. Eleven patients had imperative indications for conservative surgery and the remaining seven patients had elective indications. Ten patients had modified enucleation with a margin of normal parenchyma. Six patients underwent partial nephrectomy and two had wedge resections. Patients were followed up at 1, 6 and 12 months, and thence every 6-12 months. Follow-up ranged from 9 to 104 months (mean: 46.2 months, median: 48 months).

RESULTS

Sixteen of the 18 patients were still alive at the end of the follow-up (October 1995), with no clinical evidence of local or distant metastasis. The two deaths were not related to the fact that these patients had conservative surgery. The average tumour dimensions were 43 mm x 49 mm, with an average volume of 194 mm3. All resections were complete, with margins ranging between 1.0 and 20.0 mm (mean: 8.7 mm). The survival rate in the present study is comparable to those found by other researchers.

CONCLUSIONS

Conservative surgery is indicated in renal tumours where radical surgery would render the patient anephric. Conservative surgery, however, is controversial in a patient with a normal contralateral kidney. The present study has shown that renal parenchyma-preserving surgery for localized tumours provides a feasible treatment option.

Surgical enucleation for renal cell carcinoma (RCC). Prognostic significance of tumour stage, grade and DNA ploidy

This study reviews a total of 26 renal cell carcinoma (RCC) who underwent enucleation of the tumour with functionally and anatomically normal controlateral kidney and no evidence of systemic renal disease. At follow-up, after a mean of 62 months the disease specific survival rate for this series was 88.5%. Survival rates according to the pathologic stage, grading, tumour diameter and ploidy are reported. Local recurrences were documented in 4 of the 26 RCC. All 4 RCC were more than 5 cm in diameter and recurred in the remaining parenchyma. After local recurrence, three tumours with aneuploid DNA content underwent radical nephrectomy, whereas 1 with diploid DNA content was submitted to a new enucleation of the recurrence. To date the diploid case is still alive 3 years after the original resection of the primary tumour whereas the other 3 patients died for metastatic disease. In our experience the ideal candidate for renal sparing surgery in the presence of a normal opposite kidney is an asymptomatic patient that incidentally is brought to our attention with a small size (less than 5 cm in diameter), low stage (T1-T2) tumour, well surrounded by a pseudocapsule. DNA content is a valuable prognostic factor in patients submitted to conservative surgery. Diploid tumours have been seen to have a better prognosis and in case of local recurrence they may be reconsidered for a new enucleation of the recurrence.

Evaluation of color Doppler intraoperative ultrasound in parenchymal sparing renal surgery

A renal parenchymal sparing surgical approach may be recommended in select patients with von Hippel-Lindau disease and renal cancer or in those with sporadic renal cancer and limited normal renal function. We performed 27 partial nephrectomies or enucleations in 17 patients with the use of intraoperative ultrasound to examine a subset of all renal lesions identified on preoperative examination. Of 24 lesions deep in the renal parenchyma that were examined, localized or identified with intraoperative ultrasound 18 were characterized as cystic and 6 as solid. The deep cystic lesions were characterized with ultrasound as benign simple cysts. Intraoperative ultrasound was used to locate and mark the line of incision over 2 impalpable solid renal cell carcinomas. Four solid renal cell tumors extended deep into the renal parenchyma where color Doppler intraoperative ultrasound helped to define the plane of dissection adjacent to vital vascular structures. Renal hypothermia was not used in 3 renal operations based on intraoperative ultrasound findings.

Laparoscopic enucleation of a renal cell carcinoma

The purpose of this study was to report on the feasibility of laparoscopic excision of renal cell carcinoma. An 81-year-old female with renovascular disease underwent a laparoscopic excisional operation for a 2-cm tumor localized in the left kidney. Pathological evaluation showed a low-grade tumor without any extension through the renal capsule (grade I Hand Broder, stage I Robson). The postoperative course was uneventful; there was minimal postoperative pain. The patient was discharged home on the sixth day. Laparoscopic excision would appear to be a safe and effective technique in selected cases.

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.