Long-term results following partial nephrectomy for localized renal adenocarcinoma

The history of urologic pathology: an overview

This article begins with the testis and a legendary figure, Sir Astley Cooper, who wrote an early text on the organ. The early 20th century saw the first major development, the description of the seminoma by the French investigator Maurice Chevassu, but the pace of knowledge did not accelerate until after World War II with a major article from the Armed Forces Institute of Pathology (AFIP) by Nathan B. Friedman and Robert A. Moore, soon followed by the first series testis fascicle by Frank J. Dixon and Moore. Other noteworthy contributions were made by two masters of gonadal pathology, Gunnar Teilum and Robert E. Scully. In the 1970s, Niels E. Skakkebaek played a seminal role in elaborating in-situ neoplasia of the testis. The school of British testicular tumour authored, in the mid-1970s, under the editorship of Roger C. B. Pugh, one of the best texts on testicular pathology. Advances in more recent years have been largely spearheaded by Thomas M. Ulbright of the Indiana University School of Medicine. Observations on the prostate gland date back to Andreas Vesalius and William Cheselden, the latter appearing to have introduced the word for the gland. Note is made of contributions on the anatomy and histology of the gland by Oswald Lowsley, L. M. Franks, and John McNeal. Diagnosing carcinoma of the prostate was brought into the modern age in a landmark 1953 article by Robert S. Totten et al. In the 1960s, Donald F. Gleason introduced a grading system that is now in use worldwide. The topic of premalignant lesions has been well established only for approximately three decades, based initially on the work of Dr McNeal and David G. Bostwick. One of the first to write a book on the bladder was the remarkable British surgeon-pathologist Sir Henry Thompson. Workers at the AFIP, including Colonel James E. Ash and Fatallah K. Mostofi, wrote many outstanding articles on bladder pathology. The roles of other institutions, such as Johns Hopkins University, the Mayo Clinic, and St Peter's Hospital Institute of Urology, London, and those who worked there are noted. Knowledge of the pathology of the urachus dates largely back to the remarkable book on the topic in 1916 by the Hopkins investigator Thomas S. Cullen. Information on renal tumours dates largely to the work of Paul Grawitz, but awareness of the many variants of renal cell carcinoma in general was slow to evolve, and has only accelerated in recent years. The AFIP group of Dr Mostofi, ably assisted by Colonel Charles J. Davis and Isabell A. Sesterhenn, has contributed to knowledge of renal neoplasia with articles of note on oncocytoma, metanephric adenoma, and medullary carcinoma. In the mid-1980s, the German workers Wolfgang Thoenes and Stephan Störkel recognised the distinctive tumour known as chromophobe renal cell carcinoma. Work on renal tumours in the young owes much to J. Bruce Beckwith. The observational talents of numerous investigators have, in just over a century, advanced our knowledge of diseases of the urinary tract and testis remarkably.

Do we know (or just believe) that partial nephrectomy leads to better survival than radical nephrectomy for renal cancer?

PURPOSE

Partial nephrectomy (PN) has become the gold standard for treating small renal masses amenable to such an approach. Surprisingly, the single randomized controlled trial of PN versus radical nephrectomy (RN) indicated an overall survival benefit for RN over PN. Recent studies have shed light on this discordance, and this review will attempt to discern what is known at present.

RESULTS

Multiple retrospective observational studies have demonstrated superior outcomes with PN compared with RN. Whether the observed survival benefit with PN is the result of renal functional advantages or the result of selection bias and other unmeasured variables is up for discussion. A meta-analysis of 21 studies including the EORTC 30904 found a 19 % reduction in all-cause mortality (p = 0.0001) and 29 % reduction in cancer-specific mortality (p = 0.0002) with PN versus RN. Recent analysis of SEER-Medicare data revealed that patients undergoing RN had similar survival when compared with non-cancer controls, further supporting concerns about selection biases in prior observational series.

DISCUSSION

Although PN is clearly of benefit for those likely to experience end-stage renal disease with RN, a survival benefit with PN in the elective setting is not proven at present. While experts may still believe PN to improve survival for these patients, the only level I evidence in the field would suggest otherwise, and selection bias is undoubtedly responsible for a significant part of the improved survival observed in retrospective studies. Given recent evidence, any further push to limit the role of RN should be tempered until we know PN is indeed superior.

Quantitative assessment of renal arterial occlusion in a porcine model using spatial frequency domain imaging

We present the results of a feasibility study with spatial frequency domain imaging (SFDI) to produce quantitative measurements of optical property and chromophore concentration maps of three porcine kidneys utilizing a renal occlusion model at the near-infrared wavelengths of 658, 730, and 850 nm. Using SFDI, we examined the dynamics of absolute oxygen saturation (StO2). The mean StO2 for the kidneys varied from approximately 60% before occlusion, to 20% during occlusion, to 55% after reperfusion. We also present, for the first time to the best of our knowledge, reduced scattering coefficient (μ(s)') maps of the kidney during occlusion. We observed a substantial decrease in the wavelength dependence of scattering (i.e., scattering power) in the three kidneys, with a mean decrease of 18%±2.6%, which is indicative of an increase in scatterer size, and is likely due to tissue changes such as edema that follow from occlusion and inflammation.

[Partial nephrectomy. Rationale and limitations of an organ-preserving approach]

The rising incidence of renal cell cancer in recent decades has led to a revision in the therapy of this malignancy. For small renal masses, partial nephrectomy has become the standard surgical treatment instead of radical nephrectomy. This approach can lead to a higher overall survival due to preservation of renal function. Avoiding chronic kidney disease is mandatory for patients with benign or small non-aggressive tumors; however, partial nephrectomy correlates with higher complication rates and is conditioned by operator skills. The role of partial nephrectomy compared to radical nephrectomy is still to be established particularly for larger tumors. The results of studies so far are mostly based on non-randomized retrospective data. This article will present the pros and cons of partial nephrectomy and will focus on the steps required to promulgate the indications of nephron-sparing surgery.

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.

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.

[Long-term outcome of conservative surgery for kidney cancer: survival, blood pressure, and renal function]

PURPOSE

Nephron-sparing surgery (NSS) for renal cell carcinoma (RCC) remains controversial for elective indications (low stage RCC in the presence of a normal contralateral kidney). In this single center study survival rate and, as novel aspects, the frequency of postoperative arterial hypertension and renal function parameters were investigated to evaluate safety and efficacy of NSS.

PATIENTS AND METHODS

The complete data of 248 patients operated nephron-sparing for RCC between 1975 and 1995 were evaluated. One hundred and seventy-five patients were treated for elective indication (95% with tumor stage T1 or T2), 73 patients for mandatory indication (bilateral tumors, solitary kidney, renal insufficiency). The mean follow-up was 75 months (maximum 23 years).

RESULTS

Mean tumor-size was lower under elective (3.8 cm) than under mandatory (4.7 cm) indication. Overall tumor-specific survival after 5 years for both indications was 88%. Comparing preoperative vs. follow-up values, arterial blood pressure and serum-creatinine values remained unchanged for both indications. The incidence of postoperative proteinuria (19% imperative, 11% elective indication) was strongly related to hypertension.

CONCLUSIONS

NSS for RCC under elective indication achieves patient survival comparable to the results of radical nephrectomy. The presented data do not indicate significant longterm complications such as arterial hypertension, proteinuria or deterioration of renal function as a result of glomerulosclerosis or hyperfiltration. This gives further argument for the concept of NSS in RCC as an alternative to radical nephrectomy in the presence of a healthy contralateral kidney.

Pathologic examination of renal cell cancer by means of step-sectioning

BACKGROUND

Because incidental detection of small renal cell cancers (RCC) has recently become increasingly common, nephron-sparing surgery for these cases has been more widely performed. Renal cell cancer was investigated by means of step-sectioning in order to determine which cases were suitable for nephron-sparing surgery and how it should be performed.

METHODS

Pathology specimens obtained from 90 cases of radical nephrectomy were examined in 5 mm sections. We excluded large and invasive tumors from the present study. Particular attention was given to satellite tumor nodules (STN), pseudocapsules of the main tumor and vascular invasion.

RESULTS

Satellite tumor nodules of cancer (STN-Ca) were found in seven of 90 cases (7.8%). Tumor size and grade was not correlated with the existence of STN-Ca. The distance between the main tumor and STN-Ca varied. with the pathology of the STN-Ca mostly resembling that of the main tumor. Pseudocapsules of the main tumor were incomplete in 53 cases (58.9%), but extracapsular invasion of more than 1 mm was not seen in tumors less than 50 mm in diameter. Through step-sectioning, a further six cases with microscopic vascular invasion were found. Vascular invasion within the main tumor was confirmed in 16 of 17 cases (94.1%) and within normal renal tissue in only one case.

CONCLUSIONS

The incidence of existing STN-Ca was not high (7.8%) in the present study, we had not any characteristics in the cases with STN-Ca. As STN-Ca were rarely near the main tumor, we could not expect to resect STN-Ca with main tumor, resection to more than 1 mm outside the pseudocapsule was needed for complete resection of main tumor less than 50 mm in diameter. Normal renal tissue between the tumor and pelvis is a requirement for selecting appropriate cases in nephron-sparing surgery, but we could not remove the risk of leaving STN-Ca completely.

Complex renal reconstruction

This article provides a complete review of current renal reconstructive techniques. The techniques described include partial nephrectomy, intrasinusal surgery, anatrophic nephrolithotomy, nonvascular bench procedures with autotransplantation, and allograft partial nephrectomy in renal transplantation. A detailed discussion on renovascular and collecting system anatomy and current indications for these procedures is presented.

Case Report of a Patient with Bilateral Renal Cell Carcinoma Successfully Maintained on Continuous Ambulatory Peritoneal Dialysis after Bilateral Nephrectomy

We report on a patient who developed bilateral renal cell carcinoma during continuous ambulatory peritoneal dialysis for chronic renal failure. He was successfully maintained on this type of dialysis after bilateral abdominal nephrectomy.

Flow-cytometric DNA analysis of paraffin-embedded renal cell carcinoma tissue from patients treated by parenchymal-sparing surgery

OBJECTIVE

To determine the utility of deoxyribonucleic acid (DNA) ploidy pattern, detected by flow cytometry, in predicting the outcome of renal cell carcinoma (RCC).

PATIENTS AND METHODS

DNA content was retrospectively assessed by flow cytometry in 28 primary paraffin-embedded RCCs from 24 patients (16 men and eight women, mean age 61.9 years, range 40-89) who had undergone renal parenchymal-sparing surgery.

RESULTS

Tumour recurred locally in three patients, two with diploid tumours and one with aneuploid tumour. Two patients with diploid tumours had metastatic disease 11-58 months after surgery. Only one patient with aneuploid tumour developed metastatic disease. There was no difference in local recurrence or metastases with the type of renal parenchymal-sparing surgery used (enucleation or partial nephrectomy) nor any significant difference in overall survival (P = 0.11).

CONCLUSION

While DNA content might be of considerable predictive value for patients with RCC, these results showed that there was no difference in mortality rate, recurrence rate, or type of renal parenchymal-sparing surgery used between aneuploid and diploid tumours.

Acquired crossed renal ectopia secondary to a giant renal cyst

We report a case of contralateral renal displacement due to a giant ipsilateral renal cyst. Drainage and partial excision of the cyst was followed by return of the kidney and liver to their normal positions. Incidentally, a small focus of renal cell carcinoma was found after pathologic examination of the cyst wall. The relevant literature is reviewed.

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.

Ultrasound characteristics of renal cryosurgery

The ability to visualize renal cryosurgery using ultrasound was tested in an animal model. Five dogs underwent open laparotomy and ultrasound-monitored cryosurgery of both kidneys. On each kidney two cryolesions were made. The borders of the frozen region were identified on ultrasound as a hyperechoic rim created by the interface between frozen and unfrozen tissue. The thawed cryolesion appeared hyperechoic compared with the unfrozen kidney. Excellent correlation between the ultrasound and autopsy measurements of the cryolesions was obtained. Knowing this, renal cryosurgery under ultrasound monitoring may be possible.

Renal malignancy in von Hippel-Lindau's disease. Case reports

We present our experience with 4 patients with von Hippel-Lindau's disease. They all had asymptomatic renal malignancy, and three patients had bilateral tumors. None of the patients had metastases from their renal tumors, but two patients had developed new tumors which demanded surgery. Abdominal computerized tomography was first choice in the initial evaluation, eventually supplemented by renal angiography. The treatment should be conservative, but bilateral nephrectomy and hemodialysis may be required. Screening of at-risk family members and close and lifelong follow-up is emphasized.

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.

Anatomical background for nephron-sparing surgery in renal cell carcinoma

3-Dimensional endocasts of intrarenal structures were analyzed on the basis of their importance for performing nephron-sparing surgery. In 86.6% of the endocasts the superior pole was related to 3 arteries involved in its resection. Management of the superior (apical) segmental artery as well as ligature of the artery related to the anterior surface of the upper infundibulum are generally not difficult. Ligature of the posterior segmental artery branch related to the superior pole is critical due to the risk of injuring this segmental artery and loss of a great portion of renal parenchyma. In 62.2% of the endocasts the inferior pole resection involved ligature of the inferior segmental artery with no risk to the posterior segmental artery. A deep anatomical knowledge is mandatory to perform mid kidney resection. In 36.4% of the endocasts this region received subdivision branches of arteries from superior and inferior poles, and in 62.2% the mid kidney resection involved amputation of calices that are dependent on polar calices. The middle branch of the posterior segmental artery also is involved in mid kidney resection and its ligature demands much care to avoid injury to the posterior segmental artery itself. In the dorsal kidney the posterior segmental artery is involved and must be safeguarded in all cases of either superior pole or mid kidney resection. In 37.8% of the cases the posterior segmental artery also may be involved in inferior pole resection. When present (69.2%), the retropelvic vein must be previously ligated to provide safe management of the posterior segmental artery.

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.

Laparoscopic nephrectomy: initial case report

A tumor-bearing right kidney was completely excised from an 85-year-old woman using a laparoscopic approach. A newly devised method for intra-abdominal organ entrapment and a recently developed laparoscopic tissue morcellator made it possible to deliver the 190 gm. kidney through an 11 mm. incision.

Application of microwave tissue coagulation in partial nephrectomy

Microwave tissue coagulation was used during partial nephrectomy in 10 mongrel dogs, without clamping the renal artery. There were no major complications, such as retroperitoneal hematoma, abscess formation, or macroscopic infarction of the kidney tissue related to this new procedure. The advantages of microwave coagulation are reduced blood loss, shorter operative time, and minimal risk of vascular injury.

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.

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.

Enucleation of tumor versus partial nephrectomy as conservative treatment of renal cell carcinoma

In patients with renal insufficiency, solitary kidney, or bilateral renal malignancies, conservative surgery for renal cell carcinoma has been suggested. The authors treated 17 such patients with either enucleation of tumor or partial nephrectomy. Overall survival from disease in this series was 58.8%. Seventy percent of patients undergoing enucleation and 42.9% undergoing partial nephrectomy survived with a mean follow-up period of 5 years. Survival or local recurrence rate after enucleative surgery is an effective treatment of renal carcinoma in selected patients, and despite concerns about tumor invasion of the pseudocapsule, the clinical data do not indicate any difference in survival. There was no significant difference between enucleation of tumor and partial nephrectomy regarding morbidity, mortality, or recurrence rate.

Failed partial nephrectomy: local recurrence vs. multicentric disease

Candidates for partial nephrectomy for renal cell carcinoma include those with (1) bilateral synchronous lesions, (2) tumour in a solitary kidney and (3) renal mass and borderline renal function. Present imaging techniques aid in the identification of appropriate candidates for partial nephrectomy and in the preoperative assessment for technical feasibility of the operation. Studies have shown that the postoperative local recurrence rate ranges from 9 to 13%. We submit a case report in which a 65-year-old male with a history of colon carcinoma four years earlier was found to have a 3 cm left lower pole lesion on his follow-up abdominal CT scan. Upon intended partial nephrectomy, a small synchronous upper pole mass was noticed as well as numerous cortical lesions despite extensive preoperative imaging to the contrary. It is our feeling that finer imaging techniques including thinner CT cuts, additional imaging planes and continued use of renal ultrasound will aid in the identification of ipsilateral, synchronous lesions and draw further distinction between local recurrence and multicentric disease.

Renal cell carcinoma in a renal cyst: a case report and review of the literature

We report a case of renal cell carcinoma within a simple renal cyst in the lower pole of the right kidney. Excretory urography showed a mass and ultrasonography revealed multiple renal cysts with a solid component arising from the wall in 1. This finding also was visualized by computerized tomography. Analysis of the cystic fluid showed a high cholesterol level but negative cytological results. At operation a 7 mm. tumor arose from the wall of the cyst. Histopathological examination showed grade 3 renal cell carcinoma with an aneuploid deoxyribonucleic acid content.

Long-term serum creatinine values after radical nephrectomy

Both pre- and postnephrectomy levels of serum creatinine were measured in 52 consecutive patients who underwent radical nephrectomy for localized renal cell carcinoma between 1971 and 1976. At the time of follow-up, 17 patients were alive and 35 had died, 14 of renal cell carcinoma and 21 of other causes. Follow-up lasted a minimum of 115.5 months (mean 151.1 months, median 141.1, range 115.5-211.3 months) for 16 of the 17 patients who were alive. In this group only 2 patients had elevations in the serum creatinine level above 1.6 mg/dL-1.9 mg/dL and 2.4 mg/dL, respectively. The patient whose value was 2.4 mg/dL was a diabetic who required insulin. No serious renal failure, renal disease, or tumors in the contralateral kidney occurred among the total group of 52 patients. These data indicate that renal function remains adequate in patients who have a normal contralateral kidney and are treated by radical nephrectomy.

Results of radical nephrectomy for peripheral well-circumscribed renal cell carcinoma

Recently, several authorities have argued that, whenever surgically feasible, parenchyma-conserving surgery rather than radical nephrectomy should be the preferred treatment for renal cell carcinoma. They affirm that the results reported following partial nephrectomy are as good as those reported following radical nephrectomy for renal cell carcinoma. However, parenchyma-conserving surgery is usually performed only for relatively small, well-circumscribed tumors that do not involve the collecting system extensively or the renal hilum. To determine the results when radical nephrectomy is used to manage similar tumors, we reviewed the clinical records and arteriograms of 111 patients with renal cell carcinoma. Review of the arteriograms showed that parenchyma-conserving surgery could have been performed in 10 cases (9%). The disease-free survival rate for these 10 patients after radical nephrectomy was 100 percent, and they had no local recurrences. On the basis of these data, we believe that radical nephrectomy remains the best treatment for all patients who have renal cell carcinoma and a normal contralateral kidney.

Conservative surgery for renal cell carcinoma: a single-center experience with 100 patients

From January 1956 to March 1987, 100 patients underwent a conservative (parenchyma-sparing) operation as curative treatment for renal cell carcinoma at our clinic. This series includes 56 patients with bilateral (28 synchronous and 28 asynchronous) and 44 with unilateral renal cell carcinoma; in the latter category the contralateral kidney was either absent or nonfunctioning (17 patients), functionally impaired (17), involved with a benign disease process (6) or normal (4). The pathological tumor stage was I in 75 patients, II in 9, III in 10 and IV in 6. A nephron-sparing operation was performed in situ in 86 patients and ex vivo in 14. Postoperatively, 93 patients experienced immediate function of the operated kidney, while 7 required dialysis (4 temporary and 3 permanent). The incidence of dialysis was greater after ex vivo than in situ surgery (p equals 0.0005). The mean postoperative serum creatinine level in 97 patients with renal function was 1.7 mg. per dl. (range 0.9 to 4.6 mg. per dl.). The over-all actuarial 5-year patient survival rate in this series is 67 per cent including death of any cause and 84 per cent including only deaths of renal cell carcinoma. Survival was improved in patients with stage I renal cell carcinoma (p less than 0.05). Survival also was improved in patients with unilateral renal cell carcinoma (p less than 0.05) and fewer patients in this category had recurrent disease postoperatively (p less than 0.0005). Nine patients (9 per cent) had local tumor recurrence postoperatively and 5 of these were rendered free of tumor by secondary surgical excision. Conservative surgery provides effective therapy for patients with localized renal cell carcinoma in whom preservation of renal function is a relevant clinical consideration.

Controversies in urologic oncology

The persistent controversies that characterize urologic oncology reflect the significant advances that have been made in our understanding of genitourinary malignancy and the objective posture that has been taken both by those active in this area and by those whose interests are more indirect. Ultimately, the beneficiaries of these controversies are the patients and their physicians. As continued problems are recognized and investigations are designed to explore them, controversy and skepticism become a healthy concomitant so that true knowledge and understanding can be achieved and such issues ultimately resolved.

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

During a 14-year period 36 patients who presented with renal cell carcinoma underwent conservative surgical treatment. The patients were divided into 3 groups according to treatment indications and condition of the contralateral kidney: group 1 included patients with a solitary kidney or bilateral tumors, group 2 patients had a damaged contralateral kidney and group 3 patients were without abnormalities of the contralateral kidney. Cumulative 6-year survival rates were 58 per cent for group 1, and 90 per cent for groups 2 and 3 combined. The over-all cumulative 6-year survival rate was 74 per cent. Based on these data extension of the indication for conservative surgical treatment seems to be justified in patients who present with low stage tumors and partial or potential damage to the contralateral organ.

Adult segmental cystic disease of the kidney: a renal-sparing management approach

Segmental cystic disease of the kidney is a rare entity with the gross and microscopic features of autosomal dominant polycystic kidney disease localized to only a portion of a kidney. We report a renal-sparing management approach to a patient in whom a multifocal cystic process localized to 1 pole of the kidney was recognized preoperatively. Since neither computerized tomography nor ultrasound can exclude an underlying neoplastic process, surgery remains indicated. However, an understanding of the spectrum of diagnostic possibilities can have an impact on planning the most appropriate surgical approach. We conclude that partial nephrectomy, with appropriate intraoperative pathological assessment, may represent a satisfactory renal-sparing therapeutic algorithm for the management of localized cystic disease.

Retrograde transvenous perfusion cooling of the kidney, a valuable adjunct to in situ partial nephrectomy in complex renal cell carcinoma. First clinical results

We report two cases of complex renal carcinoma in which retrograde transvenous perfusion cooling (RTPC) of the kidney was used as adjunct to in situ partial nephrectomy. Definite advantages seem to favour this technique of regional renal hypothermia. We are hopeful that RTPC of the kidney will in future allow to reduce the frequency of potentially harmful extracorporeal bench surgery with autotransplantation in the conservative management of renal carcinoma. Renal RTPC is applicable whenever the kidney is approached transperitoneally with preliminary exposure of the renal vascular pedicle. Tumour cell spill has to be discussed as possible complication of this method. Both patients are alive 25 and 19 months, respectively, after surgery without evidence of haematogenous, peritoneal or retroperitoneal tumour disease.

Ex situ study of the effectiveness of enucleation in patients with renal cell carcinoma

We wished to identify the efficacy of enucleation (excavation) in the treatment of renal cell carcinoma. Surgical specimens from 26 patients with polar or peripheral lesions, 50 per cent of which were found incidentally by computerized tomography scan, were considered amenable to this form of treatment and were studied by ex situ enucleation after standard radical nephrectomy. Eleven patients were determined to have unsuccessful enucleation after histopathological study demonstrated capsular invasion, vascular invasion, residual tumor in the bed or multicentric tumors. Preoperative computerized tomography assessment did not accurately predict success of enucleation. The presence of a fibrous pseudocapsule of compressed renal parenchyma, which might facilitate a dissection plane and successful enucleation, did not correlate with tumor size. Microscopic examination of pseudocapsular integrity frequently revealed areas of thinning, disruption and penetration by neoplasm. When parenchymal preservation is necessary in the treatment of renal cell carcinoma, as wide a margin of adjacent renal parenchyma as possible should be excised with the tumor. In this study enucleation alone was associated with a significant risk of incomplete excision and, therefore, potential for treatment failure. We do not recommend enucleation in the presence of a normal contralateral kidney.

Surgical treatment of localized renal cell carcinoma in von Hippel-Lindau's disease

From 1981 to 1986, 10 patients with von Hippel-Lindau's disease underwent an operation for bilateral nonmetastatic renal cell carcinoma. Of the patients 9 underwent unilateral partial nephrectomy and contralateral radical nephrectomy, and 1 underwent bilateral nephrectomy with subsequent hemodialysis and cadaver renal transplantation. Pathologically, the tumor was stage I in 9 patients and stage III in 1. Currently, 8 patients are alive after partial nephrectomy (5 to 56 months) with good renal function (mean serum creatinine 2.0 mg. per dl.) and no evidence of malignancy; 1 of these patients underwent excision of a cerebral metastasis 2 years after partial nephrectomy. One patient is alive on dialysis after removal of the renal remnant for local tumor recurrence. The patient who underwent transplantation is free of tumor with a well functioning allograft. The distinctive features of renal cell carcinoma in von Hippel-Lindau's disease that influence the management of these patients are reviewed.

Management of locally recurrent renal cell carcinoma after partial nephrectomy

While partial nephrectomy can provide effective treatment for selected patients with renal cell carcinoma, postoperative local tumor recurs in approximately 10 per cent of the cases. We describe 4 patients in whom tumor recurred in a solitary renal remnant after partial nephrectomy for renal cell carcinoma 1 to 6 years previously. The original tumor was pathological stage I in 2 patients and stage III in 2. Neither of the patients with stage I renal cell carcinoma had metastatic disease when locally recurrent carcinoma was noted. A second partial nephrectomy was done in these patients and they are alive 1 and 10 years later. Both patients with stage III renal cell carcinoma also had metastatic disease when locally recurrent carcinoma was noted. One patient died 1 year later and the other is alive 1 year later. Patients who undergo partial nephrectomy for renal cell carcinoma should be followed closely to allow for early detection of local tumor recurrence. When this occurs, secondary surgical treatment may be possible with complete tumor excision and the opportunity for extended survival.

Strategies of management for advanced or recurrent kidney, adrenal, and miscellaneous genitourinary cancers

To formulate reasonable strategies of management requires critical appraisal of all available treatments and determination of the goals of therapy, which may be definitive, investigative, or palliative. Definitive therapy is given to eradicate all known disease in patients without clinically apparent metastases. Investigative therapy has the same intent but there is less assurance of success because therapy is untested or inconsistently effective; surgery for patients with metastatic disease and all protocols for chemohormonal therapy, immunotherapy, and biologic response modifiers are examples. Palliative therapy intends to relieve but not cure, a most worthwhile goal in patients whose comfort and sense of well-being are so often threatened. Strategies for palliation include surgery, irradiation, embolization/infarction, chemotherapy, hormonal therapy, and observation with only symptomatic relief. The last may be optimal for some patients since potential benefits must always outweigh the expected morbidity for therapy to be appropriate.

Long-term effects of initial therapy

The long term effects of initial therapy are a combined consequence of the effects of treatment on the cancer and on the host. Local tumor control, whatever its impact on the occurrence of metastasis, is an achievable and worthwhile goal of therapy and the methods for attaining it may have significantly different effects on quality of life. These considerations are grossly illustrated for renal cell, bladder and prostatic cancers.

Surgical enucleation for renal cell carcinoma

The results of an enucleative operation in 33 patients with renal carcinoma present bilaterally or in a solitary kidney are reviewed. All of the excised tumors were low grade and the majority of the patients had pathological stage I renal carcinoma. Postoperative followup ranged from 9 to 156 months (mean 45 months). The 3-year actuarial survival rate was 90 per cent. Tumor recurred locally in 2 patients (6 per cent). We conclude that enucleation is a safe technique that can yield excellent tumor control in selected patients with renal carcinoma.

Bilateral renal oncocytoma: report of 2 cases and review of literature

We report 2 cases of synchronous bilateral renal oncocytoma treated by radical nephrectomy on 1 side and by partial nephrectomy on the other side. Long-term followup serves to confirm the noninvasive nature of this disease. We recommend conservative management based upon radiological and gross pathological findings.