The Adoption of Nephron-Sparing Surgery in Europe - A Trend Analysis in Two Referral Centers from Austria and Germany

Clinical experience of using virtual 3D modelling for pre and intraoperative guidance during robotic-assisted partial nephrectomy

Objective:

Surgical planning for robotic-assisted partial nephrectomy is widely performed using two-dimensional computed tomography images. It is unclear to what extent two-dimensional images fully simulate surgical anatomy and case complexity. To overcome these limitations, software has been developed to reconstruct three-dimensional models from computed tomography data. We present the results of a feasibility study, to explore the role and practicality of virtual three-dimensional modelling (by Innersight Labs) in the context of surgical utility for preoperative and intraoperative use, as well as improving patient involvement.

Methods:

A prospective study was conducted on patients undergoing robotic-assisted partial nephrectomy at our high volume kidney cancer centre. Approval from a research ethics committee was obtained. Patient demographics and tumour characteristics were collected. Surgical outcome measures were recorded. The value of the three-dimensional model to the surgeon and patient was assessed using a survey. The prospective cohort was compared against a retrospective cohort and cases were individually matched using RENAL (radius, exophytic/endophytic, nearness to collecting system or sinus, anterior/posterior, location relative to polar lines) scores.

Results:

This study included 22 patients. Three-dimensional modelling was found to be safe for this prospective cohort and resulted in good surgical outcome measures. The mean (standard deviation) console time was 158.6 (35) min and warm ischaemia time was 17.3 (6.3) min. The median (interquartile range) estimated blood loss was 125 (50–237.5) ml. Two procedures were converted to radical nephrectomy due to the risk of positive margins during resection. The median (interquartile range) length of stay was 2 (2–3) days. No postoperative complications were noted and all patients had negative surgical margins. Patients reported improved understanding of their procedure using the three-dimensional model.

Conclusion:

This study shows the potential benefit of three-dimensional modelling technology with positive uptake from surgeons and patients. Benefits are improved perception of vascular anatomy and resection approach, and procedure understanding by patients. A randomised controlled trial is needed to evaluate the technology further.

Level of evidence:

2b

Clinicopathological and radiological significance of the collateral vessels of renal cell carcinoma on preoperative computed tomography

This study aimed to investigate the clinicopathological and radiological significance of the collateral vessel of renal cell carcinoma (RCC) on preoperative computed tomography (CT). Preoperative contrast-enhanced CT of 236 consecutive patients with pathological documented RCC were retrospectively reviewed during the period of 2014. The associations of the presence of collateral vessels with perioperative clinicopathological and radiological features, as well as long term survival outcomes were analyzed. Totally, collateral vessels were detected by contrast-enhanced CT in 110 of 236 patients. The presence of collateral vessels was significantly associated with higher pathologic T stage, higher Fuhrman grade, higher overall RENAL scores, greater tumor size and enhancement, and more tumor necrosis (all P < 0.05). In patients with clear cell RCC, those harboring collateral vessels had significantly higher SSIGN scores (P < 0.001) and shorter overall survival (P = 0.01) than those without collateral vessel. The incidence of intraoperative blood loss, blood transfusion, radical nephrectomy (RN) and open surgery were also significantly higher in patients with collateral vessels (all P < 0.05). In multivariate analysis, the presence of collateral vessels was significantly associated with RN (P = 0.021) and open surgery (P = 0.012). The presence of collateral vessels was significantly associated with aggressive clinicopathological parameters and worse prognosis. It is worth paying attention to its association with the choice of RN and open surgery in clinical practice.

Changes in UK renal oncological surgical practice from 2008 to 2017: implications for cancer service provision and surgical training

OBJECTIVE

To determine and analyse the temporal changes in oncological nephrectomy practice and training opportunities using data obtained from the UK British Association of Urological Surgeons nephrectomy register from 2008 to 2017.

PATIENT AND METHODS

All nephrectomies within the dataset for this time period were analysed (n = 54 251). Cases were divided into radical nephrectomy (RN), partial nephrectomy (PN) and nephroureterectomy (NU). Simple nephrectomy, donor nephrectomy and benign PN were excluded. The annual frequencies for each oncological nephrectomy method, surgical approach, grade of surgeon, hospital caseload numbers and short-term surgical outcomes were determined.

RESULTS

Reported annual nephrectomy numbers increased by 2.5-fold in the 9-year time period. The number of hospitals performing nephrectomies decreased by 22%, however, more than 40% of centres performed more than 70 cases a year. There was a trend towards a decrease in overall length of hospital stay (9 vs 5 days; P < 0.01) and decreased transfusion rates. The proportion of minimally invasive procedures increased from 57% to 75%, with nephron-sparing rates increasing from 8.9% overall to 24.8%. With regard to surgical technique, robot-assisted surgery saw a mean annual increase of 222%. Overall, there was a 10% decrease in the proportion of PNs performed by trainee surgeons.

CONCLUSIONS

Renal surgery has changed considerably with regard to volume and also surgical approach, with rates of nephron-sparing surgery and minimally invasive surgery significantly increasing. Increasing hospital centralization and institutional experience, and a shift to robot-assisted surgery appear to have contributed to the observed improved patient outcomes. The increasing utilization of robot-assisted surgery has potential implications and challenges for the training of future urology surgeons.

Changing trends in surgical management of renal tumours from 2000 to 2016: a nationwide study of Medicare claims data

BACKGROUND

Guidelines recommend nephron sparing surgery where possible for patients with T1 renal tumours. The trends of nephron sparing surgery outside the USA are limited, particularly since the introduction of robotic-assisted partial nephrectomy (RAPN). The aim of this study was to describe contemporary surgical management patterns of renal tumours in Australia according to Medicare claims data.

METHODS

Claims data according to the Medicare Benefits Schedule on surgical management of renal tumours in adult Australians between January 2000 and December 2016 was collated. Analysis of absolute number, population-adjusted rate and renal cancer-adjusted rate of interventions according to age and gender were performed, as well as proportion of RAPN.

RESULTS

Between 2000 and 2016, the rate of partial nephrectomy (PN) increased while radical nephrectomy (RN) remained stable (PN: 0.87-4.16, RN: 6.52-6.70 per 100 000 population). Since 2015, PN has become more common than RN in patients aged 25 to 44 years (0.98 versus 0.95 procedures per 100 000 population). Renal cancer-adjusted rate exhibited a trend towards increasing utilization of PN and reduced RN across all age groups. An increase in overall surgical treatment was observed (25%-41%), mainly due to increased treatment of patients older than 75 years. The proportion of RAPN was seen to rapidly increase (4.7% in 2010 to 58% in 2016).

CONCLUSIONS

Treatment utilization for renal masses has markedly changed in Australia according to Medicare claims. PN is increasingly replacing RN in younger patients, and older patients are receiving more surgical treatment. The impact of increased RAPN utilization is yet to be determined.

Tumor-targeted Dual-modality Imaging to Improve Intraoperative Visualization of Clear Cell Renal Cell Carcinoma: A First in Man Study

Intraoperative imaging with antibodies labeled with both a radionuclide for initial guidance and a near-infrared dye for adequate tumor delineation may overcome the main limitation of fluorescence imaging: the limited penetration depth of light in biological tissue. In this study, we demonstrate the feasibility and safety of intraoperative dual-modality imaging with the carbonic anhydrase IX (CAIX)-targeting antibody ¹¹¹In-DOTA-girentuximab-IRDye800CW in clear cell renal cell carcinoma (ccRCC) patients.

Methods: A phase I protein dose escalation study was performed in patients with a primary renal mass who were scheduled for surgery. ¹¹¹In-DOTA-girentuximab-IRDye800CW (5, 10, 30, or 50 mg, n=3 ccRCC patients per dose level) was administered intravenously and after 4 days SPECT/CT imaging was performed. Seven days after antibody injection, surgery was performed with the use of a gamma probe and near-infrared fluorescence camera.

Results: In total, fifteen patients were included (12 ccRCC, 3 CAIX-negative tumors). No study-related serious adverse events were observed. All ccRCC were visualized by SPECT/CT and localized by intraoperative gamma probe detection (mean tumor-to-normal kidney (T:N) ratio 2.5 ± 0.8), while the T:N ratio was 1.0 ± 0.1 in CAIX-negative tumors. ccRCC were hyperfluorescent at all protein doses and fluorescence imaging could be used for intraoperative tumor delineation, assessment of the surgical cavity and detection of (positive) surgical margins. The radiosignal was crucial for tumor localization in case of overlying fat tissue.

Conclusion: This first in man study shows that tumor-targeted dual-modality imaging using ¹¹¹In-DOTA-girentuximab-IRDye800CW is safe and can be used for intraoperative guidance of ccRCC resection.

Low-energy shock wave preconditioning reduces renal ischemic reperfusion injury caused by renal artery occlusion

Purpose:

To evaluate whether low energy shock wave preconditioning could reduce renal ischemic reperfusion injury caused by renal artery occlusion.

Methods:

The right kidneys of 64 male Sprague Dawley rats were removed to establish an isolated kidney model. The rats were then divided into four treatment groups: Group 1 was the sham treatment group; Group 2, received only low-energy (12 kv, 1 Hz, 200 times) shock wave preconditioning; Group 3 received the same low-energy shock wave preconditioning as Group 2, and then the left renal artery was occluded for 45 minutes; and Group 4 had the left renal artery occluded for 45 minutes. At 24 hours and one-week time points after reperfusion, serum inducible nitric oxide synthase (iNOS), neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), creatinine (Cr), and cystatin C (Cys C) levels were measured, malondialdehyde (MDA) in kidney tissue was detected, and changes in nephric morphology were evaluated by light and electron microscopy.

Results:

Twenty-four hours after reperfusion, serum iNOS, NGAL, Cr, Cys C, and MDA levels in Group 3 were significantly lower than those in Group 4; light and electron microscopy showed that the renal tissue injury in Group 3 was significantly lighter than that in Group 4. One week after reperfusion, serum NGAL, KIM-1, and Cys C levels in Group 3 were significantly lower than those in Group 4.

Conclusion:

Low-energy shock wave preconditioning can reduce renal ischemic reperfusion injury caused by renal artery occlusion in an isolated kidney rat model.

Prediction of Intraoperative Urinary Collecting System Entry in Patients with Peripheral Renal Tumors Undergoing Partial Nephrectomy: Usefulness of Tumor-Centered Multiplanar Reconstruction

OBJECTIVE

To assess the usefulness of tumor-centered multiplanar reconstruction (TC-MPR) for predicting intraoperative urinary collecting system (UCS) entry in patients with peripheral renal tumors undergoing partial nephrectomy (PN).

METHODS

Dynamic computed tomography images of 50 peripheral cT1 renal tumors treated with laparoendoscopic PN were analyzed. TC-MPR generated a digital cross-sectional image showing the tumor center and the closest calyx on a same plane. Patients and tumor characteristics including the distance from the tumor margin to the closest calyx (MPR-distance), and the angle formed by 2 tangent lines from the closest calyx to the tumor (MPR-angle) were assessed.

RESULTS

Intraoperative UCS entry was observed in 15 patients (30%). The patients who experienced intraoperative UCS entry had a higher RENAL score, wider MPR-angle, and shorter MPR-distance than those who did not (p = 0.04, p = 0.001, p < 0.001, respectively). Multivariate analysis identified MPR-angle as an independent factor for intraoperative UCS entry (p < 0.001).

CONCLUSIONS

The spatial information assessed using TC-MPR serves as a predictive factor for intraoperative UCS entry during PN.

Small renal masses in the elderly: Contemporary treatment approaches and comparative oncological outcomes of nonsurgical and surgical strategies

Over the last decades, there has been a significant stage migration in renal cell carcinoma and especially older patients are getting diagnosed more frequently with low stage disease, such as small renal masses ≤4 cm of size. Considering the particular risk profile of an older population, often presenting with a nonnegligible comorbidity profile and progressive renal dysfunction, treatment approaches beyond aggressive radical surgical procedures have come to the fore. We sought to give a contemporary overview of the available different treatment strategies for incidental small renal masses in an elderly population with the focus on comparative oncological outcomes of nonsurgical and surgical modalities.

Laparoscopic Nephron Sparing Surgery Assisted with Laparoscopic Ultrasonography on Centrally Located Renal Tumor - Single Center Experience

OBJECTIVE

To investigate the clinical value of laparoscopic nephron sparing surgery (LNSS) assisted with laparoscopic ultrasonography (LUS) on centrally located renal tumors.

MATERIALS AND METHODS

Clinical data of 19 patients who underwent LNSS on centrally located renal tumors assisted with LUS were retrospectively analyzed. LUS was used to confirm the location, size, blood supply, and boundary of renal tumors, and to confirm that the tumor was removed completely with negative margin.

RESULTS

The 19 centrally located renal tumors were deep in renal parenchyma without obvious convex. Eleven cases were in the middle of the kidney, 3 cases were in the upper pole, and 5 cases were in the inferior pole. The tumor size was in the range 1.0-3.9 cm, with an average of 2.46 cm. The pathological results were 13 cases of renal clear cell carcinoma, 1 case of reninoma, 1 case of renal cyst, and 3 cases of angioleiomyolipoma. The surgical margins were negative in all 19 cases.

CONCLUSIONS

LUS has a high clinical value in LNNS on centrally located renal tumors and it helps to determine the location of centrally located tumors and guarantee negative margins.