Treatment of renal cell carcinoma by in situ partial nephrectomy and extracorporeal operation with autotransplantation

Experience with Renal Autotransplantation: Typical and Atypical Indications

Introduction and Objectives

Renal autotransplantation is a kidney-saving surgical procedure used in selected patients. The purpose of this report is to review nine typical and atypical indications for kidney autotransplantation and evaluate its effectiveness in maintaining kidney function and avoiding cancer recurrence.

Materials and Methods

From 1999 till 2014, nine renal autotransplantations were performed in our center. A retrospective case review was done. Four of nine patients had a solitary functioning kidney. Typical indications for autotransplantation included extended ureteric disease in 5 patients, intrasinusal tumor on a solitary kidney in 1 patient, and renal artery aneurysm in 1 patient. Atypical indications consisted in bilateral urothelial tumors in 1 patient and interrupted live kidney transplantation in 1 patient. Mean cold ischemia time was 209 minutes. Demographic factors, indications, renal function before and after surgery, and in the long term, cancer recurrence and disease-free survival were evaluated.

Results

Renal function was maintained in 8 patients during the early follow-up. No serious complications occurred in the postoperative period. Median duration of follow-up was 50 months. In 4 patients with a normal contralateral kidney, mean preoperative and at discharge creatinine clearance were 105.45 ml/min and 121.02 ml/min, respectively. Although values showed an improvement in the kidney function, the difference was not significant (p value 0.3). In the other 4 patients with a solitary kidney, mean discharge creatinine clearance was 99.24 ml/min surprisingly higher than the preoperative value 96.92 ml/min. At the last follow-up, kidney function was preserved for the two groups (normal contralateral kidney/solitary kidney) with relatively stable creatinine clearance values: 108.45 ml/min and 85.9 ml/min, respectively. No patients required secondary dialysis.

Conclusion

Renal autotransplantation is a rare, safe, and effective surgical procedure for the treatment of complex urologic conditions. In some instances, it may be of great utility for kidney salvage in some carefully selected patients.

Kidney function after partial nephrectomy: current thinking

PURPOSE OF REVIEW

With clinical guidelines recommending partial nephrectomy for small renal masses, it is essential to understand the benefits of partial nephrectomy in regards to renal function. Our objective was to review current evidence and highlight emerging issues for partial nephrectomy and renal function.

RECENT FINDINGS

A recent clinical trial of partial and radical nephrectomy found minimal differences in survival or adverse renal sequelae. However, most observational studies and systematic reviews suggest that partial nephrectomy decreases the risks of adverse renal function, in particular, new-onset severe chronic kidney disease, and improves overall survival. Key features associated with long-term renal function include treatment modality (observation, ablation, surgery), ischemia type and duration, amount of healthy renal preservation, and baseline renal function.

SUMMARY

Partial nephrectomy should remain the standard of care for small renal masses, if the renal tumor size and complexity are amenable to such a surgical approach. Efforts to minimize ischemia time are important for long-term renal functional recovery, and hypothermia should be considered if longer warm ischemia times are anticipated (i.e. >25 min). Although the preliminary results of zero ischemia partial nephrectomy are promising, further research is needed to determine if these surgical techniques are safely adaptable in the broader urologic community.

Contemporary use of nephron-sparing surgery for children with malignant renal tumors at freestanding children's hospitals

OBJECTIVE

It is widely accepted that, when feasible, nephron-sparing surgery (NSS) is preferable to radical nephrectomy (RN) for treatment of renal tumors in adults. However, RN is more frequently used in children. We sought to compare in-hospital outcomes after NSS and RN for malignant pediatric renal tumors.

MATERIAL AND METHODS

The pediatric health information system (PHIS) combines data from more than 40 North American pediatric hospitals. We queried PHIS to identify children with malignant renal tumors who underwent surgery from 2003 to 2009. We examined whether outcomes (complication rates, cost, and length of stay) differed by procedure type. Multivariate regression models were used to adjust for confounding, and generalized estimating equations were used to adjust for hospital clustering.

RESULTS

We identified 1235 children with renal tumors who underwent RN (91%) or NSS (9%). Patients undergoing RN and NSS had similar median comorbidity scores (P = .98), hospital lengths of stay (each 6.0 days, P = .54), in-hospital charges, ($25,700 vs $37,000, P = .11), and surgical complication rates (16.4 vs 20.5%, P = .24). These outcomes remained similar after adjusting for other patient and hospital factors.

CONCLUSIONS

Most children with malignant renal tumors treated at children's hospitals undergo RN. RN and NSS use were not significantly different in terms of their length of hospital stay, in-hospital charges, and complication rates. Although oncological outcomes are lacking, these data suggest that NSS may be performed in selected children with malignant renal tumors without significantly increasing their hospital charges, length of stay, or surgical complication rates.

Variation in the incidence of and risk factors for the development of nephrolithiasis after radical or partial nephrectomy

OBJECTIVE

to examine incidence of and risk factors for the development of nephrolithiasis in patients treated with radical nephrectomy (RN) or partial nephrectomy (nephron-sparing surgery, NSS).

PATIENTS AND METHODS

the study comprised a single-centre review of 749 patients treated with RN or NSS from August 1987 to June 2006. Demographics, medical and stone history, metabolic variables and postoperative stone events were recorded. Data were analysed within subgroups based on treatment (RN vs NSS). Multivariate analysis was used to identify risk factors for postoperative stone formation.

RESULTS

in all, 499 patients had RN and 250 had NSS (mean age 57.9 years; mean follow-up 6.3 years). There were no significant differences in their demographic factors, but tumours were significantly larger in RN (P < 0.001). There was no significant difference in preoperative urinary pH < 6.0 or stone history. Significantly fewer patients after NSS than RN formed calculi (NSS 1.6% vs RN 8.4%, P < 0.001), developed hypobicarbonataemia (NSS 7.2% vs RN 12.8%, P= 0.020), and a urinary pH of <6.0 (NSS 11.2% vs RN 19.4%, P= 0.004). Multivariate analysis showed that RN (odds ratio 18.18), postoperative urinary pH < 6 (15.63), previous stone disease (13.7), age <60 years (7.33, all P < 0.001), body mass index ≥ 30 kg/m(2) (3.26, P= 0.033), male gender (2.67, P= 0.039), and hypobicarbonataemia (2.46, P= 0.034) were significantly associated with the development of postoperative calculi.

CONCLUSIONS

patients undergoing RN have a significantly higher incidence of postoperative nephrolithiasis than a well-matched cohort undergoing NSS. In addition to RN, male sex, urinary pH < 6.0, hypobicarbonataemia, history of stone disease, obesity, and age <60 years were significantly associated with postoperative stone formation.

Contemporary use of partial nephrectomy at a tertiary care center in the United States

PURPOSE

The use of partial nephrectomy for renal cortical tumors appears unacceptably low in the United States according to population based data. We examined the use of partial nephrectomy at our tertiary care facility in the contemporary era.

MATERIALS AND METHODS

Using our prospectively maintained nephrectomy database we identified 1,533 patients who were treated for a sporadic and localized renal cortical tumor between 2000 and 2007. Patients with bilateral disease or solitary kidneys were excluded from study and elective operation required an estimated glomerular filtration rate of 45 ml per minute per 1.73 m(2) or greater. Predictors of partial nephrectomy were evaluated using logistic regression models.

RESULTS

Overall 854 (56%) and 679 patients (44%) were treated with partial and radical nephrectomy, respectively. In the 820 patients treated electively for a tumor 4 cm or less the frequency of partial nephrectomy steadily increased from 69% in 2000 to 89% in 2007. In the 365 patients treated electively for a 4 to 7 cm tumor the frequency of partial nephrectomy also steadily increased from 20% in 2000 to 60% in 2007. On multivariate analysis male gender (p = 0.025), later surgery year (p <0.001), younger patient age (p = 0.005), smaller tumor (p <0.001) and open surgery (p <0.001) were significant predictors of partial nephrectomy. American Society of Anesthesiologists score, race and body mass index were not significantly associated with treatment type.

CONCLUSIONS

The use of partial nephrectomy is increasing and it is now performed in approximately 90% of patients with T1a tumors at our institution. For reasons that remain unclear certain groups of patients are less likely to be treated with partial nephrectomy.

Optimized haemostasis in nephron-sparing surgery using small-intestine submucosa

Background

The indications for nephron-sparing surgery are expanding constantly. One major contributing fact for this development is the improvement of haemostatic techniques following excision of the tumor. Nevertheless, postoperative bleeding complications still occur. To prevent this, we prospectively studied the effect of application of small-intestine submucosa (SIS) over the renal defect.

Methods

We performed 55 nephron-sparing surgeries applying SIS between 08/03 and 10/06 in 53 pts. (mean age: 59 yrs., range 29 – 79 yrs.). After resection of the renal tumor and application of a haemostyptic agent, we used SIS to secure and apply compression on the defect.

Results

The final pathology revealed clear-cell and papillary carcinoma, papillary adenoma, oncocytoma, and angiomyolipoma in 39 (70.9%), 6 (10.9), 1 (1.8%), 2 (3.6%) and 7 (12.7%) patients, respectively. The 45 malignant lesions (81.8%) were classified as pT1a and pT1b in 35 (77.8%) and 10 (22.2%) patients, respectively. The median tumor size was 4.5 cm (range: 1.3 – 13 cm). The median operating time was 186 min (range: 90 – 260 min). 18 (32.7%) procedures were performed without ischemia. 23 (41.8%) and 14 (25.5%) cases were operated in in-situ cold and warm ischemia, respectively. The median intraoperative blood loss was 730 cc (range: 100 – 2500 cc). No open operative revision was indicated due to postoperative bleeding complications. Furthermore, there was no necessity to substitute persistent blood loss from the drains postoperatively. No urinoma occurred.

Conclusion

SIS is a highly effective and easy-to-use instrument for preventing postoperative bleeding and urinary fistula complications in nephron-sparing surgery.

Radical nephrectomy for pT1a renal masses may be associated with decreased overall survival compared with partial nephrectomy

PURPOSE

We reviewed our surgical experience with small renal tumors, comparing overall survival in patients treated with radical and partial nephrectomy.

MATERIALS AND METHODS

Using our nephrectomy registry we identified patients with sporadic, unilateral, solitary and localized renal masses 4 cm or less who underwent radical or partial nephrectomy between 1989 and 2003. Patients with a solitary kidney or impaired renal function at presentation were excluded, leaving 648 available for analysis. Overall survival was estimated using the Kaplan-Meier method and associations with death were evaluated using Cox proportional hazards regression.

RESULTS

At last followup 146 patients had died of any cause and 502 were alive at a median of 7.1 years. Radical and partial nephrectomy was performed in 290 and 358 patients, respectively. In all patients radical nephrectomy was not significantly associated with death from any cause compared with partial nephrectomy (RR 1.12, p = 0.52). However, there was a significant interaction with age, leading us to stratify our analysis at the median age of 65 years. In 327 patients younger than 65 years radical nephrectomy was significantly associated with death from any cause compared with partial nephrectomy (RR 2.16, p = 0.02). The increased risk of death persisted after adjusting for year of surgery (p = 0.02), preoperative creatinine (p = 0.03), Charlson-Romano index (p = 0.04), symptoms at presentation (p = 0.02), diabetes at presentation (p = 0.03) and histology (p = 0.02).

CONCLUSIONS

Our results suggest that, compared with partial nephrectomy, radical nephrectomy is associated with decreased overall survival in younger patients with small renal masses.

Evolution to nephron-sparing surgery for renal cell carcinoma

Earlier diagnosis of renal cell carcinoma has lent itself to significant developments in its management. Traditional treatment has been with radical open nephrectomy; however, minimal invasive procedures and nephron-sparing surgery have now established themselves as contemporary treatment methods for this condition.

The Impact of Ischemia Time During Open Nephron Sparing Surgery on Solitary Kidneys: A Multi-Institutional Study

PURPOSE

The safe duration of ischemia during nephron sparing surgery remains controversial. We performed a multi-institutional study to evaluate the renal effects of vascular clamping in patients with solitary kidneys.

MATERIALS AND METHODS

Using the Cleveland Clinic and Mayo Clinic databases, we identified 537 patients with solitary kidneys who underwent open nephron sparing surgery. Renal complications were compared among patients who did not require vascular clamping (85), and those who had warm ischemia (174) and cold ischemia (278).

RESULTS

Median patient age (63, 65, 64 years) and preoperative creatinine (1.4, 1.3, 1.4 mg/dl) were similar among patients with no ischemia, warm ischemia and cold ischemia, respectively. Median tumor size was smaller in patients with no ischemia (2.5 cm), compared to patients with warm (3.5 cm) and cold (4.0 cm) ischemia (p <0.001). Warm and cold ischemia was associated with a significantly increased risk of urine leak (p = 0.006), acute (p <0.001) and chronic (p = 0.027) renal failure, and temporary dialysis (p = 0.028) compared to patients with no ischemia. Warm ischemia longer than 20 minutes and cold ischemia longer than 35 minutes were associated with a higher incidence of acute renal failure (p = 0.002 and p = 0.003, respectively). Additionally, warm ischemia more than 20 minutes was associated with an increased risk of chronic renal insufficiency (41% vs 19%, p = 0.008), increase in creatinine greater than 0.5 (42% vs 15%, p <0.001) and permanent dialysis (10% vs 4%, p = 0.145).

CONCLUSIONS

Vascular clamping during open nephron sparing surgery is associated with a higher incidence of renal complications. Attempts to limit warm ischemia to 20 minutes and cold ischemia to 35 minutes should be used when vascular clamping is necessary.

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.

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

OBJECTIVE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Imaging-guided radiofrequency ablation of solid renal tumors

OBJECTIVE

We performed a retrospective review of imaging-guided radiofrequency ablation of solid renal tumors.

MATERIALS AND METHODS

Since May 2000, 35 tumors in 20 patients have been treated with radiofrequency ablation. The size range of treated tumors was 0.9-3.6 cm (mean, 1.7 cm). Reasons for patient referrals were a prior partial or total nephrectomy (nine patients), a comorbidity excluding nephrectomy or partial nephrectomy (10 patients), or a treatment alterative to nephron-sparing surgery (one patient who refused surgery). Tumors were classified as exophytic, intraparenchymal, or central. Sixteen patients had 31 lesions that showed serial growth on CT or MR imaging. Of these 16 patients, four patients with 10 lesions had a history of renal cell carcinoma, and two patients with 11 lesions had a history of von Hippel-Lindau disease. Four patients had incidental solid masses, two of which were biopsied and shown to represent renal cell carcinoma, and the remaining two masses were presumed malignant on the basis of imaging features. Successful ablation was regarded as any lesion showing less than 10 H of contrast enhancement on CT or no qualitative evidence of enhancement after IV gadolinium contrast-enhanced MR imaging.

RESULTS

Of the 35 tumors, 22 were exophytic and 13 were intraparenchymal. Twenty-seven of the 35 were treated percutaneously using either sonography (n = 22) or CT (n = 5). Two patients had eight tumors treated intraoperatively using sonography. Patients were followed up with contrast-enhanced CT (n = 18), MR imaging (n = 5), or both (n = 5) with a follow-up range of 1-23 months (mean, 9 months). No residual or recurrent tumor and no major side effects were seen.

CONCLUSION

Preliminary results with radiofrequency ablation of exophytic and intraparenchymal renal tumors are promising. Radiofrequency ablation is not associated with significant side effects. Further follow-up is necessary to determine the long-term efficacy of radiofrequency ablation.

Prospective analysis of computerized tomography and needle biopsy with permanent sectioning to determine the nature of solid renal masses in adults

PURPOSE

We prospectively determined the accuracy of computerized tomography (CT) and needle biopsy of solid renal masses.

MATERIALS AND METHODS

A total of 100 patients with a solid renal mass who were scheduled for operation were prospectively evaluated. CT was performed before radical or partial nephrectomy. Biopsy of the surgical specimens was done twice through the tumor using an 18 gauge biopsy gun. Specimens were sent for permanent section and review by 2 pathologists blinded to each other and to the whole tissue specimens. Images were reviewed by 2 radiologists blinded to each other and to the results of pathological analysis. Results of CT and permanent biopsy were compared with the results of whole tissue specimen analysis.

RESULTS

Specimens were obtained from 59 radical and 41 partial nephrectomies. Malignant neoplasms were present in 85 patients (85%). Overall accuracy was 77% and 72%, the nondiagnostic rate was 20% and 21%, sensitivity was 81% and 83%, and specificity was 60% and 33%. For the 2 radiologists overall accuracy was 60% and 66%, the nondiagnostic rate was 31% and 23%, sensitivity was 70% and 77%, and specificity was 20% and 20%, respectively.

CONCLUSIONS

Overall permanent biopsy results were accurate in more than 72% of cases and CT was accurate in more than 60%. However, because the nondiagnostic rate for CT and needle biopsy was 20% and 31%, respectively, and specificity was low, we do not recommend routine preoperative CT and subsequent needle biopsy to guide treatment decision making. Rather, cases must be decided individually.

[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.

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.

Endoloop-assisted laparoscopic partial nephrectomy

PURPOSE

To determine the safety and feasibility of Endoloop-assisted laparoscopic partial nephrectomy in a large-animal model.

MATERIALS AND METHODS

Twelve female Yucatan mini-pigs underwent either left (N = 6) or right (N = 6) transperitoneal laparoscopic lower-pole nephrectomy following cinching of a 1-0 Vicryl suture loop (Endoloop) proximal to the resected lower pole until ischemic discoloration was achieved. The ischemic lower pole was excised with Endo-scissors and the lower pole removed using a laparoscopic bag. Follow-up involved evaluation under anesthesia with retrograde pyelography and intravenous urography and subsequent sacrifice for pathologic evaluation at 3 (N = 4), 14 (N = 4), or 60 (N = 4) days.

RESULTS

All procedures were completed successfully. In two cases, the Endoloop slipped off the retained parenchyma. Both problems were corrected immediately with no sequelae. At sacrifice, all upper-pole renal segments functioned, as shown by urography, and no urinomas or abscesses were found. In one animal, there was moderate hydronephrosis presumably secondary to ureteral scarring, and in another, mild extravasation was demonstrated on the retrograde pyelogram.

CONCLUSION

We were able to perform laparoscopic partial nephrectomy with the Endoloop safely and effectively in the current model. Modification of the Endoloop to allow more controlled pressure application may allow clinical application of this method for polar laparoscopic partial nephrectomy.

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

OBJECTIVE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Imaging in the staging of renal cell carcinoma

Imaging is extremely important in determining the type of surgery undertaken in patients with proven renal cell carcinoma. In this review, the strength and limitations of each of the relevant techniques are outlined, highlighting particularly the correlation between the imaging findings and the pathological staging. Over the past decade, CT has become the most widely used technique for staging renal cell carcinoma, partly due to the very high overall accuracy of up to 90% that has been achieved. MRI appears to have a similar overall accuracy to CT, whereas ultrasound is less accurate than CT or MRI in the overall staging of tumours. However, ultrasound is extremely accurate in identifying and localising the clinically important tumour extension into the intra-hepatic vena cava and right atrium and if local surgical practice requires only a knowledge of venous invasion, a technically adequate ultrasound examination may suffice. All techniques are unreliable in detecting early perinephric spread.

Partial nephrectomy: technique, complications and pathological findings

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

In situ perfusion by retrograde cannulation of a tumor artery for nephron-sparing surgery

BACKGROUND

Although ice slush cooling or ex situ perfusion with bench surgery is most widely used for protecting ischemic renal damage which possibly accompanies complicated nephron-sparing surgery, each has its own disadvantages. The former does not allow excessively long ischemia and the latter requires complicated procedures as autotransplantation. In order to mitigate against these problems, we devised a novel method of in situ renal perfusion with intracellular hyperosmolar solution.

METHODS

One renal segmental artery mainly supplying a tumor was isolated and cannulated with a small feeding tube. The tube was introduced through a small arteriotomy incision directed towards the proximal side, advanced until its tip remained in the main or first branch of the renal artery, and then it was anchored to that artery. After the main renal artery and vein were clamped, the kidney was perfused with cold Euro-Collins' solution through the tube, while the venous blood and perfusate were drained from the left gonadal vein or small venotomy incision of the right renal vein.

RESULTS

In one case of renal cell carcinoma and three cases of angiomyolipoma, two of which ruptured, nephron-sparing surgery was carried out under in situ hyperosmolar perfusion. Ischemic time of these four cases was an average of 96 minutes, varying from 45 to 145 minutes. All the kidneys functioned well postoperatively.

CONCLUSIONS

The method presented here is very simple, requires no unusual dexterity and safely allows for a long period of renal ischemia. This method is best indicated in cases where simple clamping of the renal pedicle with ice-slush cooling appears insufficient, yet ex situ surgery with autotransplantation seems excessive.

Multicentricity in renal cell carcinoma

In the era of ultrasound and computerized tomography, when more than 50% of renal cell carcinomas are detected incidently, with a high proportion of small tumors, the standard treatment of radical nephrectomy in the presence of a normal contralateral kidney should be questioned. The main objection against conservative surgery for renal cell carcinoma has been the concern about satellite small renal cell carcinomas, which have been reported in 7% and 19.7% of 100 and 66 kidneys, respectively. We studied the incidence of multicentric neoplasms in 50 kidneys: 27 with renal cell carcinoma and 23 autopsied normal kidneys. The incidence of small renal cell carcinoma in the kidneys with a tumor was 11.1% and that of small nodules in normal autopsied kidneys was 13% (none of them was malignant). The incidence of satellite malignant nodules in patients with renal cell carcinoma 3 cm. or smaller was 3.7% in our series, and 0% and 3% in other series. Therefore, patients who undergo nephrectomy for tumors up to 3 cm. in diameter may be considered as overtreated in 96 to 100% of the cases. We conclude cautiously that partial nephrectomy should be widely accepted in patients with small renal carcinoma and in the presence of a normal contralateral kidney.

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

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

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

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

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

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

Intraoperative renal ultrasonography: a useful adjunct to partial nephrectomy

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

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

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

Oncologic imaging. Staging and follow-up of renal and adrenal carcinoma

Computed tomography (CT) has emerged from the 1980s to play a dominant role in the pretreatment staging of renal and adrenal carcinomas. For detection, definition (staging), and determination of resectability or recurrence, CT with intravenous contrast enhancement, and more recently, magnetic resonance imaging (MRI) with gadolinium-DTPA, may be the only cross-sectional imaging studies required before institution of appropriate therapy. Carcinoma of the kidney is frequently diagnosed by serendipity or detected on incidental ultrasound or CT examinations. Real-time ultrasound and color flow Doppler offer unique information on tumor vascularity and major venous vascular involvement. Positive predictive values of 96% can be achieved for the diagnosis of renal cell carcinoma using contrast-enhanced CT scanning. For follow-up CT and MRI are the best imaging techniques for evaluation of the retroperitoneum. MRI may distinguish tumor recurrence from fibrosis in selected cases. Because primary neoplasms of the adrenal gland are rare and often exceed 10 cm at the time of initial diagnosis, the functional nature (endocrine) of adrenal carcinoma may be part of the clinical presentation. Because initial stage is critical to survival and extent of surgical therapy, a knowledge of tumor classification is essential to the optimal diagnostic evaluation. Newer imaging tests, CT and MRI, have superseded conventional urography, ultrasound, and radionuclide studies for the diagnosis and staging of adrenal cancer. Early diagnosis and low stage at presentation are critical to survival in patients with adrenal carcinoma. The current concepts for pretreatment imaging evaluation and the role of CT, MRI, and ultrasound are outlined. An oncologic imaging approach based on tumor staging and classification for patients with real or suspected renal cell carcinoma and adrenal carcinoma is essential to optimal patient care.

Nephron-sparing surgery for renal cell carcinoma with venous involvement

A nephron-sparing operation recently has been shown to provide extended survival free of disease in selected patients with localized renal cell carcinoma, particularly for tumors of lower stage. To define better the role of conservative surgical treatment in more locally advanced renal cell carcinoma we reviewed 9 patients with venous tumor involvement in solitary functioning kidneys who underwent a nephron-sparing operation. Complete tumor resection with adequate preservation of renal function was accomplished in all cases. Of the 9 patients 5 had no evidence of disease 7 to 93 months (mean 33.2 months) postoperatively. The remaining 4 patients died of metastatic renal cell carcinoma 17 to 47 months (mean 35.5 months) postoperatively, 2 of whom had concomitant local recurrences in the renal remnant. Based on previously reported results of total nephrectomy for renal cell carcinoma with venous involvement and the morbidity associated with renal replacement therapy, we believe that a nephron-sparing operation is a viable option in the management of these patients.

Incidence and properties of renal masses and asymptomatic renal cell carcinoma detected by abdominal ultrasonography

Renal ultrasonography was performed in 45,905 adults, including 41,364 without any signs suggesting urinary tract malignancies, 1,667 with microscopic hematuria only and 2,874 with some signs of malignancy. Renal lesions were found in 355 adults (0.858%) in the asymptomatic, 39 (2.3%) in the microscopic hematuria and 75 (2.6%) in the symptomatic groups, respectively. Renal cell carcinoma was found in 35 (7.5%) lesions: 19 (5.4%) in the asymptomatic, none in the microscopic hematuria and 16 (21.3%) in the symptomatic groups. A total of 47 patients, including 12 other renal cell carcinoma patients transferred from related hospitals, was grouped into 28 without and 19 with symptoms. Primary tumor size and clinical stages were significantly smaller and lower, respectively, in the asymptomatic group than in the symptomatic group. Radical nephrectomy was performed in all but 2 asymptomatic patients. The 5-year survival rates after nephrectomy were 94.7 and 60.9% for the asymptomatic and symptomatic groups, respectively (p less than 0.01). The results indicate that ultrasonography is a useful tool to detect low stage asymptomatic renal cell carcinoma at low cost.

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.

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.