Laparoscopic Management of Kidney Cancer: Updated Review

Outcomes after transperitoneal laparoscopic ureteronephrectomy for the treatment of primary renal neoplasia in seven dogs

OBJECTIVE

To describe the perioperative characteristics and outcomes in dogs that underwent transperitoneal laparoscopic ureteronephrectomy (TLU) for primary renal neoplasia.

STUDY DESIGN

Short case series.

ANIMALS

Seven client-owned dogs.

METHODS

Medical records were reviewed and data extracted regarding perioperative characteristics and animal outcomes. TLU was performed using a single-port + 1 or multiple port techniques. Hemostatic clips or a vessel-sealing device were used for occlusion of renal hilar vessels. The ureter was occluded and transected close to the ureterovesicular junction and the tumor was placed in a specimen retrieval bag for extraction from the abdomen.

RESULTS

Preoperative contrast enhanced computed tomography (CECT) was performed in 6/7 dogs. Median estimated tumor volume measured from abdominal CECT removed by TLU was 32.42 cm³ (interquartile range [IQR] 14.76-94.85). Median surgery time for TLU was 90 minutes (IQR 85-105). In one dog, elective conversion to open laparotomy was performed due to large tumor size. Median time to discharge was 31 hours (IQR 24-48). No major perioperative complications occurred and all dogs survived to discharge. Progression free survival in four dogs was 422 days (IQR 119-784).

CONCLUSION

TLU was performed for the extirpation of modest sized primary renal tumors with acceptable perioperative outcomes and a low complication rate.

CLINICAL RELEVANCE

TLU may be considered for the treatment of selected cases of primary renal neoplasia in dogs.

Use of Minimally Invasive Surgery in the Diagnosis and Treatment of Cancer in Dogs and Cats

Surgical management of neoplastic disease is common in veterinary medicine. Minimally invasive surgery (MIS) has gained widespread acceptance by veterinary surgeons and is experiencing rapid growth and frequency of use. Many neoplastic diseases in the abdomen and thorax of dogs and cats can be treated as effectively with MIS as with traditional open surgery. Additionally, MIS allows for less invasive options for organ biopsy in cancer patients either for initial diagnosis or for staging to inform prognosis and treatment. Despite the recent increase in MIS, additional research is required to further characterize the benefits to oncology patients and to ensure that surgical oncologic principles and patient outcomes are not compromised by the use of MIS.

Comparison of the Clinical Efficacy of Retroperitoneal Laparoscopic Partial Nephrectomy and Radical Nephrectomy for Treating Small Renal Cell Carcinoma: Case Report and Literature Review

Background

Renal cell carcinoma (RCC) is a common malignancy of the urinary system with high rates of morbidity and mortality.

Objectives

This study aimed to investigate and analyze the clinical efficacy of retroperitoneal laparoscopic partial nephrectomy and laparoscopic radical nephrectomy for the treatment of small RCC.

Methods

In this retrospective study of 45 patients with small RCC, the patients were divided into two treatment groups: Group A (retroperitoneal laparoscopic partial nephrectomy, 25 cases) and Group B (retroperitoneal laparoscopic radical nephrectomy, 20 cases).

Results

There were no statistically significant differences in the operative time, amount of intraoperative blood loss, length of hospital stay, preoperative creatinine level, postoperative creatinine level after 24 hours, and survival rate after 1, 2, and 3 years between the two groups (P > 0.05).

Conclusions

There were no significant differences in the survival rates and short-term postoperative complications between the laparoscopic partial nephrectomy group and the laparoscopic radical nephrectomy group for small RCC, but the former was slightly more effective.

Laparoscopic partial nephrectomy

Laparoscopic partial nephrectomy (LPN) compares favorably to traditional open nephron-sparing surgery (NSS) in terms of oncologic and surgical principles for kidney tumors. Studies have shown the modality to be feasible with similar oncologic efficacy and superior renal functional outcomes compared with laparoscopic radical nephrectomy (LRN) for tumors. The main advantages of LPN include marked improvements in estimated blood loss, decreased surgical site pain, shorter postoperative convalescence, better cosmesis, and nephron preservation. This review article evaluates the literature regarding LPN and discusses the main steps of the operation, the perioperative workup and management, surgical complications, and its role in the surgical management of kidney masses.

Optimal management of renal cell carcinoma in the elderly: a review

Both the aging population and the incidence of renal cell carcinoma (RCC) are growing, making the question of tumor management in the elderly a real challenge. Doctors should be aware of the importance of assessing this specific subpopulation. An aggressive therapeutic approach may be balanced by the benefit of the treatment - care or cure - and the life expectancy and willingness of the patient. The treatment for local disease can be surgery (radical or partial nephrectomy) or ablative therapies (radiofrequency, cryotherapy). Even if in most cases surgery is safe, complications such as alteration of renal function may occur, especially in the elderly, with physiological renal impairment at baseline. More recently, another option has been developed as an alternative: active surveillance. In the past decade, new drugs have been approved in the metastatic setting. All the phase 3 trials have included patients without a limit on age. Nevertheless, data concerning the elderly are still poor and concern only a very selective subpopulation. The toxicity profile of targeted agents may interfere with pre-existent comorbidities. Furthermore, the metabolism of several agents via cytochrome P450 can cause drug interaction. The importance of quality of life is a major factor with regard to management of therapy. Finally, to date, there is no recommendation of systematic a priori dose reduction in the elderly. In this review we describe the various possibilities of treatment for localized RCC or metastatic RCC in an aging population.

Laparoscopic radical nephrectomy for patients with pathologic T3b renal-cell carcinoma: the Johns Hopkins experience

BACKGROUND AND PURPOSE

Surgical therapy for renal-cell carcinoma (RCC) with vascular involvement has traditionally been performed via an open approach. As laparoscopic techniques have improved, more surgeons are attempting laparoscopic nephrectomy for higher stage RCC. The goal of our study was to evaluate the safety and short-tem oncologic efficacy of laparoscopic radical nephrectomy in patients with renal vein involvement.

PATIENTS AND METHODS

We reviewed the clinical and pathologic data for 37 patients who underwent a pure laparoscopic radical nephrectomy for RCC with renal vein thrombus from 2005 to 2008 by dedicated laparoscopic surgeons. Perioperative and oncologic outcomes were assessed. Median age of our study population was 65 years, and mean follow-up was 14 months.

RESULTS

Median pathologic tumor size was 7.5 cm. One (2.7%) patient needed conversion to an open procedure. Median estimated blood loss (EBL) was 200 mL (interquartile range [IQR]) 100-850), and median length of stay (LOS) was 3 days (range 3-5 d). The overall perioperative complication rate was 14%, and there were no perioperative mortalities. Of the 32 patients without metastatic disease at the time of surgery, 29 (91%) are alive without evidence of disease.

CONCLUSION

Laparoscopic radical nephrectomy in the setting of renal vein thrombus is a complex surgical procedure that necessitates significant laparoscopic skills. Our data demonstrate that laparoscopic radical nephrectomy is safe and effective in patients with RCC who have renal vein involvement, albeit with short-term oncologic follow-up. Long-term follow-up in larger series of patients is necessary to further define the role of laparoscopic nephrectomy in this subset of patients.

The UCI Seldinger technique for percutaneous renal cryoablation: protecting the tract and achieving hemostasis

PURPOSE

To describe our Seldinger technique of percutaneous renal cryoablation that was devised to facilitate renal biopsy, cryoprobe placement, and instillation of adjunctive hemostatics while protecting surrounding tissues from cryoinjury.

PATIENTS AND METHODS

This approach was used to manage 13 renal masses in 12 adult patients. Under CT-fluoroscopic guidance, an access needle was inserted to abut the surface of the tumor, followed by an Amplatz super-stiff guidewire and a customized coaxial catheter system, which was used as a conduit for needle biopsy, cryoprobe insertion, and FloSeal instillation. In addition, a porcine model was used to compare the temperature readings adjacent to the sheathed and the unsheathed cryoprobe during percutaneous renal cryoablation.

RESULTS

In all patients, the use of this access approach was accomplished without incident. Two patients needed blood transfusions. No patient had significant skin, muscle, or nerve debility. At a mean follow-up of 11 months, none had evidence of persistent disease on CT or MRI contrast imaging. In the porcine model, the customized sheath protected the surrounding tissues from reaching temperatures below 5 degrees C while temperatures down to -15 degrees C were obtained when no insulating sheath was used.

CONCLUSIONS

A modified Seldinger technique enabled us to perform percutaneous renal cryotherapy through a single access channel, which facilitated access for biopsy, cryoprobe placement, and instillation of hemostatic agents. This approach may provide a protective barrier against cryogenic damage to neighboring tissues and could theoretically help minimize the chance of tract seeding.

No improvement in renal cell carcinoma survival: a population-based study in the Netherlands

BACKGROUND

The increased finding of kidney 'incidentalomas' and more frequent surgery in patients with renal cell cancer (RCC) metastases may have improved survival from the disease. However, recent data on survival of unselected population-based series of patients with RCC are sparse.

METHODS

We collected the follow-up data for all the patients registered with RCC in the population-based cancer registry held by the Comprehensive Cancer Centre East, the Netherlands.

RESULTS

Patients (1504) diagnosed with RCC between 1989 and 2002 were included. Eighty-three percent of all tumours were histologically confirmed; 17% of all diagnoses were based on clinical examination only. The latter group was older, had a worse stage distribution, often did not receive any kind of therapy and showed a 5-year relative survival of 8%. Five-year relative survival for patients with a histologically confirmed RCC was 60% and did not improve over the last 15 years. A low resection rate in patients with metastasis was observed, most pronounced in elderly, without a tendency of increase in more recent years.

CONCLUSION

The relative survival of RCC did not improve over the years. The resection rate in patients with metastasised disease did not increase over time, despite current knowledge concerning its benefit on tumour complications, time to progression and response to immunotherapy.