Impact of renal cryoablation on urine composition

Laparoscopic surgery for renal cell carcinoma

New minimally invasive technologies are currently being applied to the management of renal cell carcinoma in an effort to decrease operative time, pain, morbidity and hospital stay. Foremost among these is the burgeoning role of laparoscopy in tumor destruction and complete in vivo resection. The primary modalities in clinical use today are laparoscopic radical nephrectomy, laparoscopic partial nephrectomy, laparoscopic renal cryoablation and laparoscopic radiofrequency ablation. Most initial reports include only highly selected patients with unifocal, small, exophytic, peripheral lesions away from the collecting system. As experience with these techniques increases, larger and more difficult lesions are being approached laparoscopically, with promising anecdotal results reported. Laparoscopic access to the kidney may be retroperitoneal or transperitoneal. Complete tumor destruction with maximal preservation of unaffected nephrons remains the goal. Herein, an update on laparoscopic surgery for renal cell carcinoma is presented. For each procedure, the current indications and contraindications, perioperative data, complications and oncological outcomes are described. In the future, it appears likely that laparoscopy will play a major role in the established treatment options for renal cell carcinoma, with open surgery being reserved for specific indications.

Nonneoplastic kidney diseases in adult tumor nephrectomy and nephroureterectomy specimens: common, harmful, yet underappreciated

CONTEXT

Nonneoplastic kidney diseases, such as arterionephrosclerosis and/or diabetic nephropathy, are commonly encountered in tumor nephrectomy and nephroureterectomy specimens. Although any nonneoplastic kidney disease may be encountered in these resection specimens by chance, additional diseases that may be related to the underlying neoplasm or its treatment regimen include thrombotic microangiopathy, Amyloid A amyloidosis, membranous nephropathy, immunoglobulin A nephropathy, membranoproliferative glomerulonephritis, pauci-immune crescentic glomerulonephritis, focal segmental glomerulosclerosis, minimal-change disease, acute interstitial nephritis, and xanthogranulomatous pyelonephritis. Given the morbidity of chronic kidney disease and the relatively favorable 5-year survival rates for urothelial and renal cell carcinomas, accurate evaluation of the nonneoplastic kidney parenchyma is important.

OBJECTIVES

We will discuss our approach for evaluating the nonneoplastic kidney parenchyma in tumor nephrectomy and nephroureterectomy specimens. The pathologic features of the aforementioned kidney diseases as well as pertinent references will be reviewed. The identification of glomerular abnormalities, including mesangial sclerosis or hypercellularity, segmental sclerosis, crescent formation, glomerulitis, or glomerular basement membrane alterations, should lead to additional immunofluorescence and electron microscopic studies. Safeguards to ensure that the nonneoplastic parenchyma is not overlooked include adding this important parameter to synoptic reports and obtaining periodic acid-Schiff and/or Jones methenamine silver stains prior to microscopic evaluation of the neoplasm.

DATA SOURCES

Relevant literature and University of Chicago Medical Center pathology archives.

CONCLUSIONS

The practicing surgical pathologist should be aware of the importance of both correctly classifying the resected renal or urothelial neoplasm and the concomitant nonneoplastic kidney disease that may be present in these specimens.

Review of minimally invasive renal therapies: Needle-based and extracorporeal

Management of the small renal mass (< or = 3 cm) is a topic of significant debate among urologists worldwide. With the advent of needle-based therapies and, less frequently, reports of extracorporeal approaches, along with ongoing refinements in each technology, patients with such masses may have the option of being treated in a truly minimally invasive, or even noninvasive, manner. Herein we review the body of available clinical literature on these modalities with respect to patient selection, success and complication rates, follow-up information, energy delivery devices, and current probe configurations.

Minimally invasive nephron-sparing surgery

Open partial nephrectomy, with its excellent 5- and 10-year oncologic follow-up data, is the gold standard against which all other nephron-sparing alternatives must be compared. The evolving minimally invasive nephron-sparing alternatives can essentially be divided into three categories: excision (laparoscopic partial nephrectomy), probe ablation (eg, cryotherapy, radiofrequency ablation), and noninvasive ablation (high-intensity focused ultrasound). A proposed algorithm for the evolving indications of minimally invasive nephron-sparing surgical options is presented in Fig. 23. Currently, by emulating the established techniques of open partial nephrectomy, laparoscopic partial nephrectomy has the most immediate clinical application and relevance. Emerging data support the efficacy and reproducibility of renal cryotherapy. Five-year follow-up data should be available in the near future. Although renal radiofrequency ablation has the potential to further minimize morbidity, serious concerns remain regarding the completeness of cancer cell kill and the reliability of intraoperative monitoring. Noninvasive technologic advancements such as high-intensity focused ultrasound have considerable potential for the future.