Partial nephrectomy in the treatment of renal adenocarcinoma

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.

Laparoscopic partial nephrectomy: The McMaster University experience

INTRODUCTION

: Laparoscopic partial nephrectomy (LPN) remains one of the more challenging procedures in urology. Minimizing warm ischemia time (WIT) and bleeding requires efficient intracorporeal suturing. In addition, achieving negative surgical margins requires complete excision of the tumour. We report a large Canadian series of laparoscopic partial nephrectomy with intermediate follow-up.

METHODS

: Between September 2000 and August 2008, 152 consecutive laparoscopic partial nephrectomies were performed at our centre. Demographic, pathological and clinical data were collected through a retrospective review of the charts.

RESULTS

: The average tumour size was 2.68 cm (Range: 0.5-8.8. The vast majority of tumours were malignant (80%). All margins were negative, except for 2 patients who underwent an immediate re-resection. There were no local recurrences or distant metastasis during the follow-up period of 44.3 months. Most procedures required hilar clamping (93.4%) with a mean WIT of 34 minutes, with a clear trend for declining WIT with increasing experience. Five procedures were converted to laparoscopic radical nephrectomy, 10 converted to a hand-assisted procedure, and 1 was converted to an open partial nephrectomy. The average blood loss was 162 cc. Complications related to the procedure were classified according to the Clavien grading system. The average drop in the glomerular filtration rate was calculated by the Modification of Diet in Renal Disease (MDRD) Study equation between preoperative and 2.5 months postoperative was 8.6 mL/min/1.73 m(2).

CONCLUSIONS

: LPN is a challenging procedure that requires advanced laparoscopic skills. LPN is feasible with excellent oncological outcomes, and an acceptable complication profile. The short-term impact on overall renal function is minimal. The most common postoperative complication was pseudo-aneurysm requiring embolization, which reinforces the intra-operative need for meticulous and a quick suture-ligation of blood vessels during LPN.

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.

Nephron-sparing surgery: a call for greater application of established techniques

OBJECTIVES

To examine the results of open partial nephrectomy (OPN) over a 15-year period in a large UK teaching hospital and to compare results with other series including minimally invasive techniques, as nephron-sparing techniques are still under-utilized in the surgical treatment of renal carcinoma. A standardized technique is described that we think minimizes the risk of postoperative urinoma.

PATIENTS AND METHODS

We retrospectively reviewed a series of 141 patients who underwent OPN performed over a 15-year period in one centre by the senior author (D.M.A.W.). A notable feature of this series compared with others is the high proportion of patients undergoing other major synchronous surgery.

RESULTS

In all, 141 patients underwent 147 OPNs, with six undergoing bilateral procedures, of which 82 were for imperative indications (single kidney, bilateral synchronous tumours, or pre-existing renal impairment). There were three perioperative deaths, two in patients undergoing other synchronous major surgery. In all, 38 patients had postoperative complications: 28 patients required blood transfusion (four required intervention for their bleeding), five required acute dialysis and three late dialysis. There was a 90% cancer-specific survival rate at a median follow-up of 2 years.

CONCLUSIONS

This series confirms the trend towards improved outcomes and decreased complications in OPN at a time when its place is challenged by minimally invasive techniques.

Nephron sparing surgery for renal cell carcinoma in a solitary kidney

To determine functional and oncological outcomes of nephron sparing surgery (NSS) for renal cell carcinoma (RCC). We identified from our kidney database 103 consecutive patients undergoing NSS for solid renal tumors in a solitary kidney. After excluding 17 patients (16.5%) undergoing NSS with palliative intent in presence of preoperatively diagnosed metastatic disease (n = 15) or positive lymph nodes (n = 2) and 6 patients (5.8%) who turned out to have benign tumors, the remaining 80 patients with RCC were analyzed. Mean follow-up is 8.0 years (range: 0.1-25.8). Mean tumor size was 4.2 cm (range 1.2-11 cm). Chronic renal failure requiring hemodialysis developed after NSS in nine patients (11.2%). In the remainder, serum creatinine was 1.72 mg/dl (range: 0.45-4.6 mg/dl) at latest follow-up. The cancer specific survival rates at 1, 5 and 10 years were 97.2, 89.6 and 76%, respectively. The estimated local recurrence free survival rates at 1, 5 and 10 years were 97.8, 89.4 and 79.9%, respectively. Univariate analysis of correlation between clinical and pathologic features with death from RCC showed significant associations for grading and tumor size. The long-term data of our series support the concept of organ-sparing surgery for RCC in a solitary kidney since it provides excellent local tumor control and cancer specific survival and preserves renal function renal function so that 89% of patients remained free of dialysis in the long-run.

Nephron Sparing Surgery for Renal Cell Carcinoma With Normal Contralateral Kidney: 25 Years of Experience

PURPOSE

We report the long-term results of our consecutive series of 504 patients who underwent NSS for cancer suspicious, solid renal tumors in the presence of a normal opposite kidney at our institution since 1979.

MATERIALS AND METHODS

A total of 715 patients underwent NSS since 1969, including 504 for an elective indication, that is with a normal opposite kidney. Of these patients 381 (75.6%) had RCC, 123 (24.4%) had cancer suspicious benign lesions, including 53 (10.5%) with oncocytoma, 33 (6.5%) with angiomyo(lipo)ma, 23 (4.6%) with a complicated cyst and 13 (2.8%) with other benign lesions. Of the 381 patients with RCC 283 (74.3%) had clear cell, 68 (17.8%) had papillary and 30 (7.9%) had chromophobic RCC. Mean tumor diameter was 3.0 cm (range 0.5 to 11.0). Mean followup was 6.77 years (range 0.2 to 24.1). The oncological outcome was studied, including pathological features associated with tumor progression.

RESULTS

Estimated cancer specific survival rates at 5 and 10 years were 98.5% and 96.7%, respectively. Estimated survival rates free of distant metastasis at 5 and 10 years were 97.5% and 95.1%, respectively. Nine patients with localized RCC experienced local recurrence after NSS. Estimated survival rates free of local recurrence at 5 and 10 years were 98.3% and 95.7%, respectively.

CONCLUSIONS

The long-term results of our series support the concept of organ sparing surgery for RCC in the presence of a normal opposite kidney with excellent long-term survival and a low tumor recurrence rate.

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.

A HISTORY OF PARTIAL NEPHRECTOMY FOR RENAL TUMORS

PURPOSE

This article records the history of nephron sparing surgery for renal tumors.

MATERIALS AND METHODS

Multiple biomedical databases were queried. Original sources were reviewed to document the history of partial nephrectomy.

RESULTS

For more than a century partial nephrectomy evolved as treatment for renal tumors, first by accident, then rejected as a planned procedure in favor of radical nephrectomy, later in mandatory cases of solitary kidney, poor renal function or bilateral renal tumors and then to an accepted elective procedure in cases with a healthy opposite kidney. Partial nephrectomy became widely accepted only recently for many renal tumors due to parallel advances in tumor biology, radiological imaging and surgical technology.

CONCLUSIONS

The history of partial nephrectomy is a timely story setting important precedents for understanding current and future strategies to treat changing patterns of renal neoplasms.

Should there be a size limit for elective nephron-sparing surgery?

Nephron-sparing surgery (NSS) is a mandatory procedure for patients with solid renal masses who also have coexisting urologic or medical conditions that pose a threat to overall renal function. The excellent results observed with this procedure have led patients with normal contralateral kidneys to choose elective NSS as a treatment modality. However, the optimal selection criteria for NSS have not yet been defined. We review the developments in and recent results of NSS and discuss features critical in selecting patients for this procedure on an elective basis. Current data clearly support the use of elective NSS for localized solid renal masses under 4 cm in size.

Ultrasound-guided microwave thermotherapy on a VX-2 carcinoma implanted in rabbit kidney

A temperature greater than 60 degrees C was maintained for 60 s within a 5-mm radius of a microwave electrode implanted in a rabbit kidney using 2450 MHz at 100 W for 30 s. Histological examination revealed complete coagulation necrosis in that area. VX-2 cells were inoculated into the kidneys of 10 rabbits. One week later, five rabbits received ultrasound-guided microwave thermotherapy, and the remaining five rabbits received no treatment. All rabbits with microwave thermotherapy had a complete response to treatment while all rabbits without therapy died of cancer within 6 weeks of the VX-2 implantation. These results indicate that ultrasound-guided microwave thermotherapy has the potential of being a nephron-salvaging treatment for small renal tumors.

Organ preserving surgery of malignant germ cell tumors

If a tumor arises in a solitary testis the patient loses fertility and requires lifelong androgen substitution. We describe the technique and results of organ preserving enucleation resection performed in 14 patients. The tumor was excised under (cold) ischemia via a mini-surgical technique using 2-fold magnification and blood vessels were localized intraoperatively by Doppler sonography. The procedure was successful in 10 of 14 patients. In 2 patients the organ required ablation later because of insufficient blood supply. Two patients had subnormal testosterone levels after treatment. There were no local recurrences. Prerequisites for this type of treatment are detailed knowledge of the vascular anatomy of the testis, tumor not too close to the rete testis, largest diameter 20 mm. or less, normal preoperative plasma testosterone level, postoperative local irradiation with 20 Gy., followup biopsies and hormonal status obtained 6 months after enucleation resection, and meticulous followup for early detection of local recurrences or systemic progression.

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.

Synchronous bilateral multilocular renal cell carcinoma. A rare case

A rare case of multilocular primary renal cell carcinoma (two sites in each kidney) in a 48-year-old woman is presented. The preoperative diagnosis was based on the computerized tomography findings. The patient underwent bilateral total nephrectomy and subsequently maintained renal dialysis.

Indications for Performing Organ Conserving Operations in Renal Tumour Cases in the Age of Radical Surgery

The authors analyse 29 operations of malignant renal tumours performed during the last 10 years, where the organs were preserved. In 20 cases conservation of the organ was indicated by necessity due to disease or lack of the contralateral kidney, and in 9 cases due to a small extension of the tumour. The authors report their experience in preoperative examinations; they discuss some surgical techniques and describe their system of patient control. Based upon their experience, conservation of the organ is indicated in those cases where radical surgical removal is 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.

Our Experience in Conservative Treatment

From January 1983 to September 1992 conservative surgery was performed for renal tumors in 29 patients with renal cell carcinoma; bilateral neoplasia (8 patients), anatomical or functional solitary kidney (13 patients) and 8 patients with a contralateral healthy kidney (small, incidental, unique renale neoplasm). We performed partial nephrectomy with excision of a margin of normal tissue for oncological safety rather than enucleation. In our series we especially studied renal function by radionuclide imaging, in those with a follow-up of over 12 months. 23 patients are alive with stable renal function and no evidence of malignancy. Recently we have tried to utilize flow cytometry as an intra-operative test to obtain the result of this test at the same time as the intra-operative pathological examination, so as to have more elements for deciding on conservative surgery. Pre-intra-operative cytometric knowledge could be the new criterion for a well-considered decision between radical or conservative procedures.

Gallbladder and pancreatic metastases from bilateral renal carcinoma presenting with hematobilia and anemia

A case of bilateral metachronous renal cell carcinoma with gallbladder and pancreatic metastases, presenting with hematobilia and anemia is presented. The presentation of metastatic renal cell carcinoma with hematobilia and anemia is previously unreported. This case illustrates (1) the occasionally very long interval between metachronous renal carcinoma; (2) this tumor's propensity to unusual metastases and unpredictable presentation; and (3) the significant palliation which may be achieved by appropriate surgical resection of these metastases.

The use of interferon alpha-C in patients with metastatic renal cell carcinoma arising in a congenital solitary kidney

Three cases of renal cell carcinoma in a congenital solitary kidney are presented. Treatment with recombinant interferon alpha-C was administered in two cases. A subjective response occurred in one case. The literature is reviewed with respect to treatment options and prognostic factors.

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

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

Renal carcinoma in a solitary kidney

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

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.

Partial nephrectomy for tumour

Thirty-three cases of malignant renal tumour removed by partial nephrectomy are discussed. The indications of this conservative therapy as well as the surgical technique, the results obtained, especially survivals beyond 10 years, as well as the period of time after which the neoplastic disease can be considered as cured are presented.

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.

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.

Organ-preserving surgery in kidney tumours

After a survey of the international literature on organ-preserving surgery in kidney tumours, a surgical material of 12 cases is presented, in which a mean survival of 51 months has been attained. In similar cases medical treatment gave survivals of 7 months only. The factors affecting the survivals are analysed and resection in stage T1-2 is advocated on these grounds. Organ-preserving surgery is regarded as justified in stage T1N0M0, even if the other kidney is intact. The decisive importance of appropriate selection of the patients and of a meticulous surgical technique is emphasized.

The feasibility of surgical enucleation for renal cell carcinoma

Although partial nephrectomy for renal cell carcinoma has been recommended for tumors in solitary kidneys, surgical enucleation has been suggested as an alternative form of surgical management in highly selected patients. To verify the efficacy of surgical enucleation the surgical specimens from 16 standard radical nephrectomies were dissected carefully. The tumors were enucleated ex vivo and carefully investigated pathologically. It was possible to enucleate successfully some well circumscribed, low grade tumors but venous invasion, tumor heterogeneity, occult metastatic disease in lymph nodes, satellite tumor nodules in the kidney and extrinsic spread through the renal capsule were features that may not have been appreciated fully in the operating room. Computerized tomography could not always predict which patients were possible enucleation candidates. Partial nephrectomy remains the preferred surgical treatment in a parenchymal-sparing operation rather than simple enucleation.

Bilateral renal cell carcinoma and renal cell carcinoma in the solitary kidney

We report on 43 patients with renal cell carcinoma in a solitary kidney, 39 of whom underwent a potentially curative resection. Of 36 patients who had a nephron salvaging procedure only 4 required ex vivo surgical resection. The survival curves of patients with solitary or bilateral lesions are similar, and depend more on the adequacy of tumor resection and tumor stage than on the fate of the contralateral kidney. Crude survival in this series was 64 per cent for patients followed for more than 1 year.

Long-term results following partial nephrectomy for localized renal adenocarcinoma

From 1956 to 1980 partial nephrectomy was done on 23 patients with localized renal carcinoma occurring bilaterally or in a solitary functioning kidney. The mean postoperative followup was 5.4 years, and the 5-year patient survival rates considering death of renal cancer only or of any cause were 70.2 and 59.6 per cent, respectively. Survival was diminished in patients with bilateral asynchronous renal carcinoma. Renal carcinoma recurred postoperatively in 6 patients (26 per cent), including 3 (13 per cent) with local recurrence in the renal remnant. Currently, 12 patients (52 per cent) are alive with stable function and no evidence of malignancy. These long-term data support the efficacy of partial nephrectomy for selected patients with renal carcinoma.

In situ management of renal tumors: renal cell carcinoma and transitional cell carcinoma

In the last 8 years 15 patients with malignant neoplasms in functionally solitary kidneys underwent in situ excision of the tumor with preservation of renal parenchyma. Of 10 patients with renal cell carcinoma 8 underwent partial nephrectomy, 1 had a central wedge resection and 1 had enucleation of 3 tumors. After followup of 6 months to 4.7 years 6 patients are free of disease. One patient died of metastatic cancer and 1 of cardiovascular disease. Of 5 patients with transitional cell carcinoma of the kidney (including 2 with parenchymal invasion) 2 underwent partial nephrectomy and 3 underwent extensive resection of renal pelvic lesions. After followup of 6 months to 7 years 2 patients are alive, 2 died of metastatic disease and 1 died of metastatic bladder carcinoma. Only 1 of the 5 patients had locally recurrent tumor. These data demonstrate the efficacy of in situ management of renal tumors in selected patients with solitary kidneys or compromised renal function.

Renal cell carcinoma in solitary kidneys

We report 10 cases of renal tumors in a solitary kidney that were treated surgically with efforts to spare renal function. Three patients were rendered anephric to excise completely the renal cancer and 2 remain without disease. The remaining 7 patients had complete tumor excision with the aid of partial nephrectomy. One patient had bilateral oncocytomas. Of the 6 partial nephrectomy patients with cancer 1 (18 per cent) remains free of metastatic disease. Concern is expressed for the role of partial nephrectomy as curative surgery for renal cancer.

Bilateral renal cell carcinoma: influence of synchronous and asynchronous occurrence on patient survival

Twenty-seven patients with synchronous (19 cases) or asynchronous (8 cases) bilateral renal cell carcinoma were treated and followed for as long as 20 years. Tumor grade and stage generally were more favorable in the former group, which is reflected in the higher surgical intervention rate. Nonsurgical treatment yielded poor results. The 5-year survival rate for patients with synchronous bilateral renal cell carcinoma (77.8 per cent) was significantly higher than that for patients with asynchronous lesions (37.5% per cent). Because of its different presentation and favorable prognosis when treated surgically synchronous bilateral renal cell cancer should be distinguished from the asynchronous form, with its dismal outcome. For the latter cases thorough long-term followup may make early surgical intervention feasible, and thus, improve patient survival.

Aggressive management of bilateral renal cell carcinoma

We review 4 cases of bilateral renal cell carcinoma. Treatment included extracorporeal surgery with subsequent autotransplantation in 2 patients and radical nephrectomy combined with contralateral partial nephrectomy in the remaining 2 patients. Absence of recurrence as well as length of patient survival supports this aggressive therapy.