Excision Of Renal Cell Carcinoma Research Articles

MP85-07 RENAL TRANSPLANTATION AFTER RENAL TUMOUR EXCISION: A SYSTEMATIC REVIEW

You have accessJournal of UrologyTransplantation & Vascular Surgery: Renal Transplantation & Vascular Surgery II1 Apr 2015MP85-07 RENAL TRANSPLANTATION AFTER RENAL TUMOUR EXCISION: A SYSTEMATIC REVIEW Jinna Yao, Howard MH Lau, Richard Allen, Henry CC Pleass, and Vincent WT Lam Jinna YaoJinna Yao More articles by this author , Howard MH LauHoward MH Lau More articles by this author , Richard AllenRichard Allen More articles by this author , Henry CC PleassHenry CC Pleass More articles by this author , and Vincent WT LamVincent WT Lam More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1861AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Availability of renal transplantation is limited by an inadequate supply of organs. Worldwide, there is an expanding population of patients being maintained on dialysis. To increase the supply of donors to meet this demand, renal transplantation using ‘restored’ kidneys following excision of renal tumours has been proposed. In this systematic review, we aim to collate and evaluate the published evidence for this novel approach. METHODS A literature search of databases (MEDLINE and EMBASE) was undertaken to identify published studies of renal transplantation after renal tumour excision, focusing on selection criteria, operative strategy, tumour recurrence and graft and patient survival outcomes. RESULTS Nine case series and 8 case reports were included for review. A total of 125 patients underwent renal transplantation using grafts restored following excision of renal tumours. Eighty-nine percent (111/125) of grafts were from live donors. Thirteen of 17 studies reported intraoperative frozen section of the excised renal tumour prior to renal transplantation. Eighty-four percent (105/125) were proven to be malignant renal cell carcinoma (RCC) on pathology. Ninety-nine percent (104/105) of these RCC were less than 4 cm in size. Fourteen studies reported tumour margin status, all of which were negative. Sixteen studies reported follow-up time; the median value was 56(15-138) months. Fourteen studies reported graft outcomes; 5(4%) patients lost their grafts and returned to dialysis. All 17 studies reported patient survival outcomes, and 13(10%) patients died with a functioning graft. Of the total 105 patients with renal transplants after excision of RCC, there was one recurrence in the graft kidney at 9 years. CONCLUSIONS Current evidence suggests that renal transplantation using kidneys after renal tumour excision is safe and feasible in selected patients with end-stage renal failure. Future studies are required to further define the selection criteria for the donor kidneys and the renal transplant recipients. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e1069 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jinna Yao More articles by this author Howard MH Lau More articles by this author Richard Allen More articles by this author Henry CC Pleass More articles by this author Vincent WT Lam More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Renal Transplantation After Renal Tumour Excision: A Systematic Review.

PURPOSE: Availability of renal transplantation is limited by an inadequate supply of organs. Worldwide, there is an expanding population of patients being maintained on dialysis. To increase the supply of donors to meet this demand, renal transplantation using ‘restored’ kidneys following excision of renal tumours has been proposed. In this systematic review, we aim to collate and evaluate the published evidence for this novel approach. METHODS: A literature search of databases (MEDLINE and EMBASE) was undertaken to identify published studies of renal transplantation after renal tumour excision, focusing on selection criteria, operative strategy, tumour recurrence and graft and patient survival outcomes. RESULTS: Nine case series and 8 case reports were included for review. A total of 125 patients underwent renal transplantation using grafts restored following excision of renal tumours. Eighty-nine percent (111/125) of grafts were from live donors. Thirteen of 17 studies reported intraoperative frozen section of the excised renal tumour prior to renal transplantation. Eighty-four percent (105/125) were proven to be malignant renal cell carcinoma (RCC) on pathology. Ninety-nine percent (104/105) of these RCC were less than 4 cm in size. Fourteen studies reported tumour margin status, all of which were negative. Sixteen studies reported follow-up time; the median value was 56(15-138) months. Fourteen studies reported graft outcomes; 5(4%) patients lost their grafts and returned to dialysis. All 17 studies reported patient survival outcomes, and 13(10%) patients died with a functioning graft. Of the total 105 patients with renal transplants after excision of RCC, there was one recurrence in the graft kidney at 9 years. CONCLUSIONS: Current evidence suggests that renal transplantation using kidneys after renal tumour excision is safe and feasible in selected patients with end-stage renal failure. Future studies are required to further define the selection criteria for the donor kidneys and the renal transplant recipients.

Restored Kidney Transplant Using Kidneys Affected by Small Tumors: Outcomes and Lessons Learned

Objectives: The use of kidneys with small tumors has been focused as a potential source for solving the organ donor shortage. Buell, Mannami, and Nicol respectively reported 14, 8, and 31 transplants using kidneys after excision of renal cell carcinoma (RCC). Nalesnik et al. recently collected data to clarify the risk of cancer transmission to optimize organ usage. Based on Mannami's published series, we initiated a prospective open clinical trial and then extended the series after completion of the first stage. Methods: At first, our trial that utilized resected kidneys for transplant into unrelated recipients after restoration had an estimated enrollment of 5 patients with one year of follow-up and was approved by Tokushukai Joint Ethics Committee and registered with U.S. ClinicalTrials.gov. Donors were selected from among patients who opted to undergo nephrectomy for small tumors after extensive discussion of other possible treatment modalities. After nephrectomy, the tumor was removed from each kidney, which was restored and transplanted into an unrelated recipient who was selected by a third-party selection committee based on the blood group match, high clinical evaluation score, and negative cross-match test. The trial was extended to enroll another 5 patients after the fifth transplant because of requests from other waiting patients. In addition to these 9 cases, we have reviewed the eight cases reported by Mannami. Results: In the initial trial, five men aged 51-79 years were the kidney donors. The nephrometry RENAL scores for their renal tumors (Kutikov-Uzzo) were 5-7, suggestive of low-moderate complexity. A total of 56 dialysis patients aged 31-83 years (mean: 58.7 years) were enrolled as candidate recipients. Two recipients had a history of kidney transplant. All patients received triple immunosuppression and 4 are steroid-free. Four recipients have experienced rejection episodes so far and the latest serum creatinine levels range from 1.22 to 1.67 mg/dl after 15 to 23 months of follow-up. There has not been any recurrence of RCC. In the extended trial, 4 patients aged 46-65 years have undergone restored kidney transplant so far and their recent creatinine levels range from 1.06 to 1.80 mg/ml without tumor recurrence. Two patients from Mannami's series are surviving with functioning graft and without tumor at 62 and 118 months after transplant. Conclusions: Selected candidates can benefit from restored kidney transplant, achieving good renal function without cancer. In full understanding of cancer-transmission possibility, transplant candidates may benefit from accepting these marginal kidneys (discarded kidneys with small tumors) in exchange for a shorter waiting time on dialysis. Source of Funding: None

Restored Kidney Transplant Using Kidneys Affected by Small Tumors: Outcomes and Lessons Learned

Objectives: The use of kidneys with small tumors has been focused as a potential source for solving the organ donor shortage. Buell, Mannami, and Nicol respectively reported 14, 8, and 31 transplants using kidneys after excision of renal cell carcinoma (RCC). Nalesnik et al. recently collected data to clarify the risk of cancer transmission to optimize organ usage. Based on Mannami's published series, we initiated a prospective open clinical trial and then extended the series after completion of the first stage. Methods: At first, our trial that utilized resected kidneys for transplant into unrelated recipients after restoration had an estimated enrollment of 5 patients with one year of follow-up and was approved by Tokushukai Joint Ethics Committee and registered with U.S. ClinicalTrials.gov. Donors were selected from among patients who opted to undergo nephrectomy for small tumors after extensive discussion of other possible treatment modalities. After nephrectomy, the tumor was removed from each kidney, which was restored and transplanted into an unrelated recipient who was selected by a third-party selection committee based on the blood group match, high clinical evaluation score, and negative cross-match test. The trial was extended to enroll another 5 patients after the fifth transplant because of requests from other waiting patients. In addition to these 9 cases, we have reviewed the eight cases reported by Mannami. Results: In the initial trial, five men aged 51-79 years were the kidney donors. The nephrometry RENAL scores for their renal tumors (Kutikov- Uzzo) were 5-7, suggestive of low-moderate complexity. A total of 56 dialysis patients aged 31-83 years (mean: 58.7 years) were enrolled as candidate recipients. Two recipients had a history of kidney transplant. All patients received triple immunosuppression and 4 are steroid-free. Four recipients have experienced rejection episodes so far and the latest serum creatinine levels range from 1.22 to 1.67 mg/dl after 15 to 23 months of follow-up. There has not been any recurrence of RCC. In the extended trial, 4 patients aged 46-65 years have undergone restored kidney transplant so far and their recent creatinine levels range from 1.06 to 1.80 mg/ml without tumor recurrence. Two patients from Mannami's series are surviving with functioning graft and without tumor at 62 and 118 months after transplant. Conclusions: Selected candidates can benefit from restored kidney transplant, achieving good renal function without cancer. In full understanding of cancer-transmission possibility, transplant candidates may benefit from accepting these marginal kidneys (discarded kidneys with small tumors) in exchange for a shorter waiting time on dialysis.

Hand-assisted laparoscopic radical nephrectomy in the treatment of a renal cell carcinoma with a level ii vena cava thrombus

Excision of renal cell carcinoma (RCC) with corresponding vena cava thrombus is a technical challenge requiring open resection and vascular clamping. A 58 year old male with a right kidney tumor presented with a thrombus extending 1 cm into the vena cava. Using a hand-assisted transperitoneal approach through a 7 cm gel-port, the right kidney was dissected and the multiple vascular collaterals supplying the tumor were identified and isolated. The inferior vena cava was mobilized 4 cm cephalad and 4 cm caudal to the right renal vein. Lateral manual traction was applied to the right kidney allowing the tumor thrombus to be retracted into the renal vein, clear of the vena cava. After laparoscopic ultrasonographic confirmation of the location of the tip of the tumor thrombus, an articulating laparoscopic vascular stapler was used to staple the vena cava at the ostium of the right renal vein. This allowed removal of the tumor thrombus without the need for a Satinsky clamp. The surgery was completed in 243 minutes with no intra-operative complications. The entire kidney and tumor thrombus was removed with negative surgical margins. Estimated blood loss was 300 cc. We present a laparoscopic resection of a renal mass with associated level II thrombus using a hand-assisted approach. In patients with minimal caval involvement, our surgical approach presents an option to the traditional open resection of a renal mass.

Management of Small Renal Masses

Surgical excision of renal cell carcinoma is the current standard of care for localized disease. Series for small renal masses treated with surgery demonstrate excellent oncologic outcomes with 5-year survival rates over 95%. Minimally invasive ablative technologies, such as cryotherapy and radiofrequency ablation, have recently emerged with similar short- and intermediate-term results. Additionally, recent data on active surveillance have demonstrated survival rates comparable to surgery and ablation in selected patient populations. We review the currently available data regarding the management of small renal masses by excision, ablation, or observation.

Venacavoscopy During Nephrectomy for Renal Cell Carcinoma With Inferior Vena Caval Thrombus

Renal cell carcinoma with inferior vena caval thrombus remains a complex challenge for the urologist. Aggressive surgery to remove all tumor can result in long-term survival. Liver transplant techniques, assistance from cardiac surgeons and bypass techniques can yield optimal vascular control but there is still a blind element inside the inferior vena cava when the thrombus is evacuated. We present data on a technique using a flexible cystoscope to evaluate the lumen of the intrahepatic and suprahepatic inferior vena cava after nephrectomy and tumor thrombectomy. Seven patients underwent radical nephrectomy and tumor thrombectomy for renal cell carcinoma with inferior vena caval thrombus. During surgery and after removal of the tumor thrombus a flexible cystoscope was inserted into the venacavotomy for direct inspection of the inferior vena caval lumen. Any residual tumor was manipulated out of the lumen and removed. Patient records were reviewed for data on the time of this procedure, estimated blood loss, residual tumor, postoperative complications and survival. Venacavoscopy required an average additional 5.6 minutes and residual tumor was found in 3 of 7 patients. Average estimated blood loss was 1,170 cc and it was not affected by venacavoscopy. One patient experienced acalculous cholecystitis, possibly as a result of this procedure. Mean followup was 17.6 months with 5 of 7 patients alive. Venacavoscopy is a safe, reliable method of intraoperative inspection of the inferior vena cava that uses equipment and techniques familiar to every urologist. This can help prevent incomplete thrombectomy and disastrous pulmonary embolus.

Laparoscopic application of radio frequency energy enables in situ renal tumor ablation and partial nephrectomy.

To our knowledge we present the initial series of renal mass in situ laparoscopic radio frequency ablation. We also discuss the indications for and results of subsequent laparoscopic partial nephrectomy. Laparoscopic radio frequency ablation was performed in 13 patients with a mean age of 59 years (range 18 to 81) and a total of 17 small enhancing renal masses. In 5 patients the tumor was subsequently excised completely, whereas in 7 it was left in situ after treatment. In 1 patient with 5 lesions only the largest lesion was excised, while the other 4 were left in situ. Mean tumor size was 1.96 cm. (range 0.9 to 3.6). Tumors that remained in situ tended to be endophytic and located in the mid pole. Pathological analysis revealed renal cell carcinoma in 10 patients, angiomyolipoma in 2 and oncocytoma in the patient with multiple lesions. None of the 8 patients with renal cell carcinoma who had at least 6 weeks of followup (mean 9.8 months, range 1.5 to 22) had any evidence of persistent tumor enhancement on surveillance computerized tomography or any other evidence of disease progression. There was 1 focal positive margin in a patient who underwent radio frequency ablation and excision of renal cell carcinoma but the patient remained disease-free 1 year after treatment. Early experience with laparoscopic radio frequency ablation in situ or combined with partial nephrectomy shows that it appears to be a safe method of managing small enhancing renal masses. Radio frequency assisted laparoscopic partial nephrectomy is reserved for easily accessible exophytic tumors, while strict surveillance is required for lesions remaining in situ after ablation. Additional followup is required to assess long-term effectiveness.

Laparoscopic Application Of Radio Frequency Energy Enables In Situ Renal Tumor Ablation And Partial Nephrectomy

To our knowledge we present the initial series of renal mass in situ laparoscopic radio frequency ablation. We also discuss the indications for and results of subsequent laparoscopic partial nephrectomy. Laparoscopic radio frequency ablation was performed in 13 patients with a mean age of 59 years (range 18 to 81) and a total of 17 small enhancing renal masses. In 5 patients the tumor was subsequently excised completely, whereas in 7 it was left in situ after treatment. In 1 patient with 5 lesions only the largest lesion was excised, while the other 4 were left in situ. Mean tumor size was 1.96 cm. (range 0.9 to 3.6). Tumors that remained in situ tended to be endophytic and located in the mid pole. Pathological analysis revealed renal cell carcinoma in 10 patients, angiomyolipoma in 2 and oncocytoma in the patient with multiple lesions. None of the 8 patients with renal cell carcinoma who had at least 6 weeks of followup (mean 9.8 months, range 1.5 to 22) had any evidence of persistent tumor enhancement on surveillance computerized tomography or any other evidence of disease progression. There was 1 focal positive margin in a patient who underwent radio frequency ablation and excision of renal cell carcinoma but the patient remained disease-free 1 year after treatment. Early experience with laparoscopic radio frequency ablation in situ or combined with partial nephrectomy shows that it appears to be a safe method of managing small enhancing renal masses. Radio frequency assisted laparoscopic partial nephrectomy is reserved for easily accessible exophytic tumors, while strict surveillance is required for lesions remaining in situ after ablation. Additional followup is required to assess long-term effectiveness.

COMPLETE RADICAL NEPHRECTOMY AND VENA CAVAL THROMBECTOMY DURING CIRCULATORY ARREST

A modification of radical nephrectomy for renal carcinoma and vena caval tumor thrombectomy for supradiaphragmatic tumor extension under hypothermic circulatory arrest is presented. Nephrectomy was performed during the circulatory arrest time in 16 consecutive patients during the last 4 years. Average hypothermic circulatory arrest time increased by 6 minutes. By elimination of manipulation of tumor and thrombus before circulatory arrest potential thrombus fragmentation and embolization were minimized. There were no significant differences in blood loss or complications compared to a prior series of 10 patients undergoing the procedure using conventional techniques. Performance of complete radical nephrectomy along with venal caval embolectomy during circulatory arrest increases the safety of the procedure without significant morbidity.

Application of the flexible cystoscope to the excision of renal cell carcinoma with intracaval tumor thrombus

Cardiopulmonary bypass, temporary cardiac arrest, and exsanguination have facilitated the surgical resection of renal tumors with intracaval thrombi that extend above the hepatic veins or into the atrium. The bloodless field provided by this approach enables the surgeon to utilize a flexible cystoscope to ensure that the caval thrombus has been removed entirely from the hepatic veins.

Management of Renal Cell Carcinoma with Coexistent Renal Artery Disease

Coexistence of renal cell carcinoma and renal artery disease is an unusual and challenging problem. From 1969 to 1991, 34 patients presented with localized renal cell carcinoma and renal artery disease affecting all of the functioning renal parenchyma. These patients represented 4 categories: 1) a solitary kidney with renal cell carcinoma and renal artery disease (5), 2) bilateral renal cell carcinoma and coexistent renal artery disease (5), 3) unilateral renal cell carcinoma and contralateral renal artery disease (13), and 4) unilateral renal cell carcinoma and bilateral renal artery disease (11). Atherosclerosis was the most common cause of renal artery disease (30), followed by medial fibroplasia (2), renal artery aneurysm (1) and arteriovenous malformation (1). A total of 23 patients (68%) presented with azotemia (serum creatinine 1.5mg./dl. or more) and 11 (32%) presented with hypertension.All patients underwent complete surgical excision of renal cell carcinoma. A nephron sparing operation was performed preferentially (30 patients) and bilateral renal cancer operations were staged. Eight patients underwent simultaneous partial (6) or radical (2) nephrectomy and surgical renal revascularization. There were no operative deaths. Postoperatively, preservation of renal function was achieved in 33 patients and 1 required chronic dialysis. At mean followup of 47 months 23 patients (68%) were alive with no evidence of malignancy and 2 were alive with recurrent renal cell carcinoma. Three patients died of metastatic renal cell carcinoma, while 6 died of unrelated causes. All of the latter 6 patients were free of renal cell carcinoma at death. Nephron sparing surgery combined occasionally with renal arterial reconstruction can yield gratifying results in this complex patient population.

Five-year survival following excision of renal cell carcinoma extending into inferior vena cava

Fifteen consecutive patients having radical nephrectomy and excision of tumor extension from the inferior vena cava for pathologic Stage 3A renal cell carcinoma were followed up for a minimum of five years. Survival was compared with patients having radical nephrectomy for Stage 2 or Stage 3 renal cell carcinoma in the same time interval. Five-year survival in the Stage 3A group (47%) was similar to that for patients with Stage 2 tumors (54%) and significantly better than Stage 3 patients with positive lymph nodes at surgery (12%). Renal cell carcinoma with venous extension has a reasonable prognosis after surgical excision and warrants an aggressive surgical approach.