Efficacy Of Nephron-sparing Surgery Research Articles

The safety and efficacy of nephron sparing surgery in T1N0M0 renal cell carcinoma

Background: Renal cell carcinoma (RCC) accounts for approximately 3% of adult malignancies and 90-95% of neoplasm arising from the kidney. Objective was to explore the safety and efficacy of nephron sparing surgery (NSS) for T1N0M0 renal cell carcinomas (RCC) and to assess the oncological outcome of NSS in T1N0M0 RCC.Methods: A total of 31 cases were enrolled for the study of which 11 (35.5%) underwent NSS and 20 (64.5%) underwent radical nephrectomy (RN). The clinical results were followed up and comparatively analyzed.Results: NSS was performed using a margin of 1cm, no positive surgical margin was detected. The mean blood loss and mean duration of surgery in NSS and RN was comparable. Among all one patient from NSS group experienced urinary leak which was managed by placement of DJ stent. The overall complication rate was 9.1% in NSS. Lab. tests before surgery and after surgery at 6month was done in the both groups and results obtained was within normal limits. Only one patient developed metastasis from NSS group and died at 14th month of fallow-up, whereas neither metastasis nor mortality were recorded in RN group.Conclusions: Nephron sparing SURGERY has proven to be a safe and effective approach for Renal cell carcinoma with comparable clinical results to radical nephrectomy especially in tumour ≤4cm.

Nephron-sparing surgery in the treatment of pediatric renal cell carcinoma associated with Xp11.2 translocation/TFE3 gene fusions

PurposeTo investigate the safety and efficacy of nephron-sparing surgery (NSS) in the treatment of pediatric Xp11.2 translocation renal cell carcinoma (RCC). MethodsClinical characteristics of 9 RCC children (7 males and 2 females) with Xp11.2 translocation who received NSS between January 1973 and December 2015 were retrospectively analyzed. The mean age was 7.8years (range: 4.5–13.5years). Xp11.2 translocation RCC was found in the left side in 4 patients and right in 5. 3 tumors were located in the upper pole of the kidney, 1 in the middle dorsal, 1 in the middle ventral and 4 in the lower pole. RCC presented with painless gross hematuria in 4 patients, abdominal mass in 1, and as an incidental finding by ultrasound examination in 4 patients. The mean course of hematuria was 3months (range: 1–7months). The mean tumor diameters were 3.7cm (range: 2.2–6.9cm). ResultsAll the patients received NSS with open transperitoneal approach. The mean operative time and estimated blood loss were 115min and 40ml, respectively. The time of renal pedicle clamping was 19–25min (mean: 21.5min). No complications (such as leakage of urine, prolonged drainage or secondary bleeding) were noted. No patients experienced local recurrence during the mean of 50.1-month follow-up (range: 13–117months). Intravenous urography (IVU) or contrast-enhanced CT was conducted at 6months after surgery which showed favorable kidney function in all patients. ConclusionXp11.2 translocation RCC is a predominant pathological but biologically inert type of pediatric RCC. For Xp11.2 translocation RCC sized <4–7cm in diameter and located in one pole, NSS is safe and feasible. Type of studyTreatment Studies, LEVEL IV.

The clinical application of nephron-sparing surgery(NSS)in selective T2 renal cell carcinoma

Objective To investigate the safety and efficacy of nephron-sparing surgery(NSS)for selective T2 stage renal tumor. Methods The surgical database of 26 patients treated with NSS for clinical T2 stage renal cell carcinomas between March 2010 and May 2013 were collected and analyzed retrospectively. There were 17 males and 9 females, with a mean age of 52 years (39-74 years), mean tumor size of 10.3 cm(7.2-16.5 cm), and mean R. E.N.A.L score of 7.5 (6-10). Patients' demographics, clinical characteristics, oncologic outcomes, renal function were reviewed. Results The renal masses were removed successfully and the surgical margins were negative. There were 21(80.8%)cases of clear cell carcinoma, 4 (15.4%) papillary carcinoma and 1(3.8%)chromophobe carcinoma. The mean ischemia time was (28.3±12.5) minutes (7 patients were clamp-free). Three patients needed transfusion, one experienced urine fistula and cured by conservative treatment, and one patient's renal function got progressive worsening and required long-term hemodialysis. The average serum creatinine was 121 μmol/L before and 136 μmol/L after surgery (P=0.06). After a period of 22-47 months' follow-up, no patient had local recurrence or metastasis. Conclusions NSS can be safely performed and provide effective oncologic outcomes for selective patients with clinical T2 stage renal cell carcinomas. R. E.N.A.L nephrometry is an important factor and should be used to evaluate the feasibility of NSS. Key words: Kidney neoplasms; Nephron-sparing surgery(NSS); Clinic outcome; Renal function

Is the R.E.N.A.L. Nephrometry Scoring System Predictive of the Functional Efficacy of Nephron Sparing Surgery in the Solitary Kidney?

We evaluated the ability of renal tumor complexity, as assessed by the R.E.N.A.L. (radius, exophytic, nearness to collecting system, anterior/posterior and location) nephrometry scoring system, to predict the functional efficacy of nephron sparing surgery. We evaluated 42 patients who presented with an anatomically (32) or a functionally (10) solitary kidney and underwent partial nephrectomy. Each renal unit was assigned a R.E.N.A.L. nephrometry score using preoperative imaging. The CKD-EPI equation was applied to calculate the estimated glomerular filtration rate. The difference between the estimated glomerular filtration rate at baseline and at postoperative time points served as a measurement of the renal functional loss attributable to partial nephrectomy. In the 42 patients who underwent partial nephrectomy the mean preoperative estimated glomerular filtration rate was 61.5 ml/minute/1.73 m(2). The median total nephrometry score was 8 (range 4 to 10). In the immediate postoperative period the cohort mean estimated glomerular filtration rate of 48.6 ml/minute/1.73 m(2) was significantly less than the preoperative value (p <0.0001). At 6-month followup the mean estimated glomerular filtration rate had recovered at 54.1 ml/minute/1.73 m(2) but it remained significantly less than the preoperative value (p = 0.0002). We noted no relationship between the postoperative decrease in the estimated glomerular filtration rate and the assigned total nephrometry score or in any individual component of the R.E.N.A.L. scoring system related to the targeted lesion. Neither the individual components of the R.E.N.A.L. nephrometry scoring system nor the total nephrometry score predicted the realized functional loss, as assessed by the estimated glomerular filtration rate in patients with a solitary kidney treated with nephron sparing surgery. However, nephron sparing surgery was quite efficacious for preserving renal function since only a durable 11.6% decrease was noted in the estimated glomerular filtration rate.

Use of R.E.N.A.L. nephrometry scoring system to predict the functional efficacy of nephron-sparing surgery in the solitary kidney.

399 Background: Recently, the R.E.N.A.L. nephrometry scoring system was introduced to objectively describe renal masses with respect to size, the degree to which they are exo/endophytic, the nearness to the collecting system, whether they are anterior or posterior and the location relative to polar lines. It is our aim to evaluate the R.E.N.A.L. nephrometry scoring system’s ability to predict functional renal loss attributed to nephron-sparing surgery (NSS). Methods: We evaluated 42 patients presenting with either an anatomic (32) or functionally solitary (10) kidneys undergoing partial nephrectomy (PN). Each renal unit was assigned a R.E.N.A.L. nephrometry score utilizing pre-operative cross-sectional imaging. The CKD−EPI equation was applied to serum creatinine levels to generate corresponding estimated glomerular filtration rates (eGFR). The difference between the eGFR at baseline and at post-operative time points served as a measurement of renal function loss attributed to PN. Results: Forty-two patients underwent PN with mean pre-operative eGFR of 61.5 mL/min/1.73m2. The median total nephrometry score was 8, ranging from 4–10. Twenty-eight (66.7%) of the renal lesions were ≤ 4 cm, 13 (31%) were between 4 and 7 cm, and 1 (2.4%) was &gt;7 cm in diameter. The majority (54.8%) of the patients had tumors with more than 50% of tumor burden lying outside the expected renal border whereas 3 patients (7.1%) had tumors considered to be completely endophytic. Twenty-seven (64.3%) were within 4 mm of the collecting system. Tumor locations defined as: completely polar, interpolar, and completely central were assigned to 11, 15, and 16 lesions respectively. By post-operative month 6, the overall average eGFR of 53.9 mL/min/1.73m2 was significantly less (p = 0.0293) than the pre-operative value. However, we were unable to correlate change in post-operative eGFR with pre-operative total or individual R.E.N.A.L. scoring parameters. Conclusions: Neither the individual components of the R.E.N.A.L. nephrometry scoring system nor the total nephrometry score correlated with realized functional loss as assessed by eGFR in patients with a solitary kidney undergoing NSS.

The R.E.N.A.L. Nephrometry Score: A Comprehensive Standardized System for Quantitating Renal Tumor Size, Location and Depth

Treatment decisions for renal malignancies depend largely on qualitative data, including a description of tumor anatomy and the experience of the treating surgeon. Currently characterization of renal tumor anatomical elements is descriptive and lacks standardization. Surgical decision making and data set comparisons would be significantly enhanced by a consistent, reproducible system that quantitates the pertinent characteristics of localized renal lesions. We have developed and propose a standardized nephrometry scoring system (R.E.N.A.L. Nephrometry Score) to quantify the anatomical characteristics of renal masses on computerized tomography/magnetic resonance imaging. The nephrometry score is based on 5 critical and reproducible anatomical features of solid renal masses. Of the 5 components 4 are scored on a 1, 2 or 3-point scale with the 5th indicating the anterior or posterior location of the mass relative to the coronal plane of the kidney. We applied the R.E.N.A.L. Nephrometry Score to 50 consecutive masses resected at Fox Chase Cancer Center. The R.E.N.A.L. Nephrometry Score consists of (R)adius (tumor size as maximal diameter), (E)xophytic/endophytic properties of the tumor, (N)earness of tumor deepest portion to the collecting system or sinus, (A)nterior (a)/posterior (p) descriptor and the (L)ocation relative to the polar line. The suffix h (hilar) is assigned to tumors that abut the main renal artery or vein. The nephrometry scoring system accurately classified the complexity of 50 consecutive tumors undergoing excision at our institution. Standardized reporting of renal tumor size, location and depth is essential for decision making and effective comparisons. The R.E.N.A.L. Nephrometry Score is a reproducible standardized classification system that quantitates the salient anatomy of renal masses. This novel approach for the systematic characterization of renal tumors provides a tool for meaningful comparisons of renal masses in clinical practice and in the urological literature.

Functional and Oncological Outcomes of Partial Nephrectomy of Solitary Kidneys

We examined outcomes after partial nephrectomy in patients with tumors in a solitary kidney to determine the extent to which patient, surgery and tumor specific variables influenced the glomerular filtration rate and local recurrence postoperatively. Demographics, renal function, comorbidities, renal cell carcinoma history, and operative and pathological data were recorded. The effect on changes in early and late postoperative glomerular filtration rate and local recurrence were analyzed. In 84 patients undergoing a total of 89 partial nephrectomies the mean immediate postoperative decrease in the glomerular filtration rate in those with no ischemia, warm ischemia (mean 12 minutes) and cold ischemia (mean 33 minutes) was 29%, 37% and 45%, respectively (p <0.01). Late glomerular filtration rate decreases were 12%, 6% and 16%, respectively (p = 0.17). Cold ischemia and multiple vascular risk factors were associated with immediate glomerular filtration rate decreases (p = 0.008 and 0.04, respectively). Local recurrence, which developed in 13 patients (18%), was associated with positive margins and T stage (p = 0.01 and 0.02, respectively). End stage renal disease developed in 3 patients (4%) and an additional 5 (6%) required nephrectomy for local recurrence. Partial nephrectomy generally results in a small decrease in the glomerular filtration rate, and limited warm and cold ischemia does not appear to adversely affect long-term renal function. Positive margins and T stage greater than 2 are the most important predictors of local recurrence in a solitary kidney. They pose a significant risk to end stage renal disease-free survival due to the need for completion nephrectomy in many of these patients. Partial nephrectomy should be considered the standard of care in all patients with tumor in the solitary kidney.

Feasibility and outcomes of repeat partial nephrectomy: Johnson A, Sudarshan S, Liu J, Linehan WM, Pinto PA, Bratslavsky G, Urologic Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, MD

Purpose Despite the proven efficacy of nephron sparing surgery, patients with hereditary renal cancer remain at risk for tumor recurrence. Management options for recurrent tumors include completion nephrectomy, ablation, and repeat partial nephrectomy. We examine the feasibility and outcomes of repeat partial nephrectomy performed on the same renal unit. Materials and Methods We retrospectively reviewed the records of 51 attempted repeat partial nephrectomy procedures in 47 patients from 1992 to 2006. Demographic information as well as intraoperative, perioperative, and renal functional outcome data were collected. Comparison of preoperative and postoperative renal function was performed using the 2-tailed t -test. Results Major perioperative complications or reoperations occurred in 10 of 51 (19.6%) cases that included 1 perioperative mortality (1.9%). In cases of successful repeat partial nephrectomy, there was a statistically significant increase in postoperative serum creatinine (1.35 vs. 1.16 mg/dL, P P = 0.05) and renogram split function (52.3% vs. 54.8%, P Conclusions Repeat partial nephrectomy is technically feasible. Although there is a statistically significant decrease in postoperative renal functional studies, most patients retained sufficient function to avoid hemodialysis. Repeat partial nephrectomy may provide acceptable oncological control despite the anticipated development of locally recurrent or de novo tumors.

Feasibility and Outcomes of Repeat Partial Nephrectomy

Despite the proven efficacy of nephron sparing surgery, patients with hereditary renal cancer remain at risk for tumor recurrence. Management options for recurrent tumors include completion nephrectomy, ablation and repeat partial nephrectomy. We examine the feasibility and outcomes of repeat partial nephrectomy performed on the same renal unit. We retrospectively reviewed the records of 51 attempted repeat partial nephrectomy procedures in 47 patients from 1992 to 2006. Demographic information as well as intraoperative, perioperative and renal functional outcome data were collected. Comparison of preoperative and postoperative renal function was performed using the 2-tailed t test. Major perioperative complications or reoperations occurred in 10 of 51 (19.6%) cases that included 1 perioperative mortality (1.9%). In cases of successful repeat partial nephrectomy there was a statistically significant increase in postoperative serum creatinine (1.35 vs 1.16 mg/dl, p <0.05), and a significant decrease in creatinine clearance (84.6 vs 95.3 ml per minute, p = 0.05) and renogram split function (52.3% vs 54.8%, p <0.05). Two patients required long-term hemodialysis (3.9%). Of the 51 renal units 10 (19.6%) required subsequent operations for additional local recurrence or de novo tumor formations with a median time to subsequent surgery of 50 months. Of 47 patients 46 are alive at a median followup of 56 months. Repeat partial nephrectomy is technically feasible. Although there is a statistically significant decrease in postoperative renal functional studies, most patients retained sufficient function to avoid hemodialysis. Repeat partial nephrectomy may provide acceptable oncological control despite the anticipated development of locally recurrent or de novo tumors.

Radical Nephrectomy for pT1a Renal Masses May be Associated With Decreased Overall Survival Compared With Partial Nephrectomy

We reviewed our surgical experience with small renal tumors, comparing overall survival in patients treated with radical and partial nephrectomy. 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. 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). Our results suggest that, compared with partial nephrectomy, radical nephrectomy is associated with decreased overall survival in younger patients with small renal masses.

MP-16.23: Efficacy of nephron sparing surgery for renal cell carcinoma > 4 cm

Nephron sparing surgery (NSS) and radical nephrectomy (RN) are equivalent for the treatment of patients who have a single, small (less than 4 cm) renal cell carcinoma (RCC) and a normal contralateral kidney. However, if the tumor size is above 4 cm, the role of NSS is less documented. The aim of our study is to compare outcomes of patients undergoing nephron sparing surgery (NSS) and radical nephrectomy (RN) for renal cell carcinomas (RCC) with a tumor size > 4 cm.

Open Partial Nephrectomy for Tumor in a Solitary Kidney: Experience With 400 Cases

We present a series of 400 patients with tumor in a solitary kidney who underwent open surgical partial nephrectomy performed by a single surgeon (ACN) with a primary focus on postoperative long-term kidney function. A total of 400 patients with sporadic nonfamilial kidney tumors in a solitary kidney underwent open partial nephrectomy between 1980 and 2002. In 323 patients (81%) the contralateral kidney had been surgically removed, while the remaining 77 (19%) had a congenital solitary kidney. Renal insufficiency was present preoperatively in 184 patients (46%). Adverse risk factors for partial nephrectomy were present in a large percent of patients. Intraoperative and postoperative parameters were evaluated at a mean followup of 44 months. In the overall series 5 and 10-year cancer specific survival was 89% and 82%, respectively. Surgical complications occurred in 52 patients (13%), most commonly urinary leakage. Early postoperative renal function was achieved in 398 patients (99.5%). Only 2 patients required permanent dialysis postoperatively. Satisfactory long-term renal function was achieved in 382 patients (95.5%). A total of 18 patients had progressed to renal failure a mean of 3.6 years after surgery. Patient age, the amount of renal parenchyma resected, a congenitally absent or atrophic contralateral kidney and the time of contralateral nephrectomy were noted to be significantly associated with postoperative renal function. Open surgical partial nephrectomy can be safely performed in patients with tumor in a solitary kidney. Long-term cancer-free survival with the preservation of renal function can be reliably expected in most of these cases.

Résultats à long terme de la chirurgie conservatrice pour le cancer du rein : survie, pression sanguine et fonction rénale

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.

Nephron-sparing surgery for renal angiomyolipoma.

Renal angiomyolipoma (RAML) is a benign tumor composed of varying amounts of mature adipose tissue, smooth muscle and thick-walled blood vessels. RAML tend to grow over time requiring active intervention due to serious associated complications, such as hemorrhage and pain. Although RAML is an ideal tumor for organ preservation, data concerning efficacy of nephron-sparing surgery (NSS) are sparse. The aim of the study was to evaluate the efficacy of NSS in RAML with regard to renal function, tumor recurrence and surgical feasibility. Charts of patients with pathologically confirmed RAML were reviewed and data recorded: tumor size, associated symptoms, intraoperative blood loss, serum creatinine, follow-up data with regard to tumor recurrence and long-term renal function. A total of 28 patients were identified with RAML who underwent NSS because of tumor size > 4 cm, pain and/or to rule out malignancy due to radiographic features of uncertain interpretation. The median follow-up of all patients is 58 (3-114) months; median age was 55.6 (34-78) years, 24 patients were women, 4 patients were men. None of the patients developed a local recurrence. Median size of enucleated tumors was 5.5 (2.5-15) cm; indication for NSS was symptomatic tumor with hemorrhage in 4 patients (16%), prophylaxis of hemorrhage in 5 patients (20%) and radiographic features suspicious for malignancy in 16 patients (64%). In those cases, unenhanced and enhanced CT scans exhibit a hyperdense and a hypodense lesion as compared to the adjacent normal renal cortex, respectively. There were no intraoperative complications, median blood loss was 320 (50-1200) ml, none of the patients required blood transfusions. Post-operative course was uneventful in 26 patients (96%), 2 patients (7.1%) developed a urinary fistula managed by an endoluminal stent. Pre-operative serum creatinine was 0.9 (0.7-1.3) mg/dl, post-operative creatinine was 1.23 (0.7-1.5) mg/dl and serum creatinine at last follow-up was 0.95 (0.7-1.2) mg/dl. NSS can be performed with a high success rate in RAML when surgical management is indicated. Long-term follow-up reveals no local tumor recurrences and stable renal function even in patients with a solitary kidney.

Nephron sparing surgery of patients with renal cell carcinoma in a solitary kidney or bilateral renal cell carcinoma

The objective of this study is to evaluate the efficacy of nephron sparing surgery for renal cell carcinoma in patients with a solitary kidney or bilateral tumors. From 1982 to 1994, a total of 12 patients with a solitary kidney or bilateral tumors underwent nephron sparing surgery. The survival and complications were examined. The patients were 11 males and 1 female. Three patients were in stage 1, 6 in stage 2, 2 in stage 3, and 1 in stage 4, and the mean tumor size was 3.4 cm (0.8-6.5). The complications were post-operative bleeding in one patient and slight transient renal dysfunction which didn't require hemodialysis in 3 patients. The local recurrence was observed in 1 patient (8.3%), metastasis in 3 (25%), no evidence of disease in 8 (66.7%), alive with cancer in 1 (8.3%), death due to cancer in 2 (16.7%), death due to other disease in 1 (8.3%), and the 5 year survival of all patients was 62.5%, that was almost the same as the result of 141 renal cell carcinoma patients treated with nephrectomy in our hospital. The disease free survival rate of the patients in stage 1 and 2 seems to be higher than in stage 3 and 4 with no significant difference (p = 0.0956). These results suggest that nephron sparing surgery for renal cell carcinoma in patients with a solitary kidney or bilateral tumors is a useful therapy.