Retroperitoneal Laparoscopic Partial Nephrectomy for Renal-Cell Carcinoma in a Solitary Kidney: Report of 56 Cases

Case Report: Retroperitoneal Laparoscopic Partial Nephrectomy for T2 Renal Cell Carcinoma During Pregnancy

Introduction: Renal cell carcinoma (RCC) found during pregnancy is rare. Treatment strategies and timing of surgeries are controversial. Retroperitoneal laparoscopic partial nephrectomy for T2 RCC during pregnancy has not been reported before.

Patient Concerns and Diagnosis: Herein, we report a case of T2 RCC found in a 36-year-old woman during her 21st week of pregnancy. Both ultrasound and magnetic resonance imaging (MRI) suggested a malignancy, possibly renal cell carcinoma.

Interventions and Outcomes: After discussion with a multidisciplinary team, the tumor was removed completely via retroperitoneal laparoscopic partial nephrectomy, and pathology result was clear cell RCC. A male infant was delivered full-term uneventful, and both the patient and the boy were in good health after a 46-month follow-up.

Conclusion: Partial nephrectomy with retroperitoneal laparoscopic technique is feasible and recommended in some T2 RCC patients.

How well do software assistants for minimally invasive partial nephrectomy meet surgeon information needs? A cognitive task analysis and literature review study

INTRODUCTION

Intraoperative software assistance is gaining increasing importance in laparoscopic and robot-assisted surgery. Within the user-centred development process of such systems, the first question to be asked is: What information does the surgeon need and when does he or she need it? In this article, we present an approach to investigate these surgeon information needs for minimally invasive partial nephrectomy and compare these needs to the relevant surgical computer assistance literature.

MATERIALS AND METHODS

First, we conducted a literature-based hierarchical task analysis of the surgical procedure. This task analysis was taken as a basis for a qualitative in-depth interview study with nine experienced surgical urologists. The study employed a cognitive task analysis method to elicit surgeons' information needs during minimally invasive partial nephrectomy. Finally, a systematic literature search was conducted to review proposed software assistance solutions for minimally invasive partial nephrectomy. The review focused on what information the solutions present to the surgeon and what phase of the surgery they aim to support.

RESULTS

The task analysis yielded a workflow description for minimally invasive partial nephrectomy. During the subsequent interview study, we identified three challenging phases of the procedure, which may particularly benefit from software assistance. These phases are I. Hilar and vascular management, II. Tumour excision, and III. Repair of the renal defects. Between these phases, 25 individual challenges were found which define the surgeon information needs. The literature review identified 34 relevant publications, all of which aim to support the surgeon in hilar and vascular management (phase I) or tumour excision (phase II).

CONCLUSION

The work presented in this article identified unmet surgeon information needs in minimally invasive partial nephrectomy. Namely, our results suggest that future solutions should address the repair of renal defects (phase III) or put more focus on the renal collecting system as a critical anatomical structure.

Ischemia Techniques in Nephron-sparing Surgery: A Systematic Review and Meta-Analysis of Surgical, Oncological, and Functional Outcomes

CONTEXT

The optimal ischemia technique at partial nephrectomy (PN) for renal masses is yet to be determined.

OBJECTIVE

To summarize and analyze the current evidence about surgical, oncological, and functional outcomes after different ischemia techniques (cold, warm, and zero ischemia) at PN.

EVIDENCE ACQUISITION

A computerized systematic literature search was performed by using PubMed (MEDLINE) and Science Direct. Identification and selection of the studies were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) criteria. Outcomes of interest were estimated blood loss (EBL), overall complications, positive surgical margins, local tumor recurrence, and renal function preservation. Meta-analysis and forest-plot diagrams were performed. Overall pooled estimates, together with 95% confidence intervals (CIs), of the incidence of all parameters were obtained using a random effect model (RE-Model) on the log transformed means (MLN), proportion, or standardized mean change, as deemed appropriate.

EVIDENCE SYNTHESIS

One hundred and fifty-six studies were included. No clinically meaningful differences were found in terms of EBL after cold (mean: 215.5; 95% CI: 154.2-276.8m), warm (mean: 201.8; 95% CI: 175.0-228.7ml), or zero (mean: 261.2; 95% CI: 171.0-351.3ml) ischemia technique. Overall, postoperative complications were recorded in 14.1% (95% CI: 6.7-27.4), 11.1% (95% CI: 10.0-12.3), and 9.7% (95% CI: 7.7-12.2) of patients after cold, warm, and zero ischemia (p<0.01), respectively. Positive surgical margins were recorded in 4.8% (95% CI: 1.9-10.9), 4.0% (95% CI: 3.4-4.8), and 5.6% (95% CI: 3.1-9.8) of patients after cold, warm, and zero ischemia (p<0.01), respectively. Local recurrence was recorded in 3.2% (95% CI: 1.9-5.2) and 3.1% (95% CI: 0.7-11.5) of patients after warm and zero ischemia (p<0.01), respectively. The log₂ of estimated glomerular filtration ratio mean changes were-1.37 (95% CI:-3.42 to 0.68),-1.00 (-2.04 to 0.03), and-0.71 (-1.15 to-0.27) ml/min after cold, warm, and zero ischemia, respectively. Low level of evidence, retrospective nature of most of included studies, a high risk of selection bias, and heterogeneity within included studies limited the overall quality of the analysis.

CONCLUSIONS

The effect of ischemia technique at PN is still debatable and subject to confounding by several factors, namely, patients' selection criteria, surgical technique used, and percentage of functional parenchyma spared during surgery. These confounders bias available evidence and were addressed by only a small part of available studies. Unfortunately, the overall quality of literature evidences and the high risk of selection bias limit the possibility of any causal interpretation about the relationship between the ischemia technique used and surgical, oncological, or functional outcomes. Thus, none of the available ischemia technique could be recommended over the other.

PATIENT SUMMARY

The present analysis shows that none of the available ischemia techniques, namely, cold, warm, or zero ischemia, is universally superior to the others, and other factors play a role in the surgical outcome.

Oncological outcomes of partial nephrectomy for tumours larger than 4 cm: A systematic review

INTRODUCTION

Many medical associations recommend nephron-sparing surgery (NSS) for tumours larger than 4 cm amenable to partial nephrectomy (PN). These recommendations are, however, mostly based on isolated reports. We systematically review the oncological outcomes of partial nephrectomy procedures performed for tumours larger than 4-cm.

METHODS

A PubMed search was carried out using keywords "partial nephrectomy" and "nephron sparing" for records dating back to 1995. In total, 2136 abstracts were analyzed; from these, 174 studies were scrutinized. We identified 32 manuscripts reporting size-specific cancer-specific survival rates for masses greater than 4 cm. From each of these studies, we recorded the number of PN, tumour diameter, follow-up duration, 5- and 10-year recurrence, overall and cancer-specific survival rates (OS, CSS). We also calculated weighted OS and CSS rates.

RESULTS

This systematic review includes 2445 patients with renal tumours larger than 4 cm who underwent PN: 1858 patients with tumours between 4 to 7 cm, 410 patients with tumours larger than 7 cm and 177 patients with tumours greater than 4 cm (exact size unknown). Our analysis revealed weighted 5-year CSS rates of 95.4%, 86.2% and 93.9% for tumours 4 to 7 cm, >7 cm, and all tumours >4 cm, respectively. The respective 5-year OS rates were 84.7%, 76.4%, and 84.7%.

CONCLUSIONS

We found excellent 5-year CSS and OS rates for patients with tumours 4 to 7 cm treated with PN. These outcomes compare favourably to those reported in historical radical nephrectomy (RN) series for similarly sized tumours. Thus, PN is an acceptable and often preferred treatment for renal masses >4 cm which are amenable to nephron-sparing procedures.

Robotic versus laparoscopic partial nephrectomy for tumor in a solitary kidney: a single institution comparative analysis

OBJECTIVES

To compare the outcomes of robot-assisted laparoscopic partial nephrectomy and laparoscopic partial nephrectomy for renal tumor in patients with a solitary kidney.

METHODS

We retrospectively reviewed data of patients with solitary kidney who underwent laparoscopic (n = 52) and robot-assisted (n = 15) partial nephrectomy for renal tumor at Cleveland Clinic, Cleveland, Ohio, USA, between June 2000 and April 2012. Patient demographic data, perioperative parameters and follow-up data were compared.

RESULTS

The two groups were similar in terms of patients and tumor characteristics, including preoperative renal function and etiology of solitary kidney. The median operative time (225 vs 171 min, P = 0.02), warm ischemia time (19 vs 15 min, P = 0.04) and hospital stay (4 vs 3 days, P = 0.03) were significantly shorter in the robotic group. No significant differences were found in terms of estimated blood loss, transfusion, complications, pathological results and margin status. The median percentage change of renal function was not significantly different between two groups. Long-term hemodialysis was required for three patients in the laparoscopic group (6%) and none of the patients in the robotic group. Median follow up was 15.6 and 5.9 months in the laparoscopic and robotic group, respectively.

CONCLUSIONS

Robot-assisted partial nephrectomy represents a safe and effective minimally-invasive treatment option for renal masses in patients with a solitary kidney. Early comparative outcomes suggest that it offers a significant benefit over the laparoscopic approach in terms of operative time, warm ischemia time and hospital stay. Further studies with a longer follow up are required to confirm the likelihood of better long-term functional and oncological outcomes.