Indications For Nephron-sparing Surgery Research Articles

Nephron-Sparing Surgery for Upper Urinary Tract Urothelial Carcinoma

Radical nephroureterectomy (RNU) remains the gold standard for the surgical management of upper tract urothelial carcinoma (UTUC) from the ureterovesical junction to the renal pelvis. However, the removal of the ipsilateral intact kidney causes morbidity due to renal functional deterioration after RNU. Recently, the indications for nephron-sparing surgery (NSS) in UTUC have been expanded to preserve the intact kidney. Minimally invasive surgical approaches, including endourological, laparoscopic, and robotic-assisted techniques for segmental resection of the distal ureter with ureteral reimplantation have shown favorable oncological and clinical outcomes (for both noninvasive and invasive ureteral tumors). The established guidelines for UTUC have limited indications for NSS. Because of low tumor burden, stage Ta/T1 UTUC is considered the best indication for NSS. NSS requires close follow-up and managing the risk of recurrence in the preserved ipsilateral ureter and/or renal pelvis. To overcome these limitations, adjuvant administration of various immuno-chemotherapeutic agents is being explored to overcome the resistance to therapeutic cell death and evasion of immune destruction from current therapies with better prognostic outcomes. The aim is to reduce urothelial cancer recurrence improving the effectiveness of NSS and to achieve comparable outcomes to RNU in UTUC. In this review article, we have comprehensively discussed the different types of NSS in UTUC, the indications for NSS in the international guidelines, and oncological outcomes of each of the NSS techniques.

953 Outcomes of Partial Nephrectomy for pT3a Renal Cell Cancer Over 20 Years at a Single Centre

Abstract Aim There is limited information on outcomes of pT3a RCC treated with PN. Retrospective studies of cT1/2 upstaged to pT3a treated with RN vs PN show contradictory results. Method Retrospective analysis of all pT3a renal tumours removed by either RN or PN between 2000-2020 at a single centre performed by 6 surgeons with a median follow up period of 4 years. Results 186 cases of pT3a RCC were treated with RN and 78 with PN. There was CT suspicion of T3a disease in 1 PN and 6 RN cases. The mean tumour size in PN vs RN was 4.5cm vs. 8cm. Preoperative and postoperative eGFR were similar between RN and PN groups with a smaller drop in eGFR from preop to post op in the PN vs RN group (16 vs 20ml/min) The number of patients who went on to have renal replacement therapy for end stage renal failure was 6 in the RN group and 2 in the PN group. At median 4 years follow up, 86% of PN patient were alive vs 93% who had RN. Of the patients who had died 5.6% were due to renal cancer in the PN group vs 8.6% in the RN group. The rate of any recurrence or spread of renal cancer detected at follow up was 21% in the PN group and 38% in the RN group. Conclusions This case series suggests PN for pT3a tumours is a reasonable option for patients who have strong indications for nephron sparing surgery.

V13-06 OPEN RIGHT PARTIAL NEPHRECTOMY WITH INFERIOR VENA CAVA THROMBECTOMY FOR RENAL CELL CARCINOMA

You have accessJournal of UrologyCME1 May 2022V13-06 OPEN RIGHT PARTIAL NEPHRECTOMY WITH INFERIOR VENA CAVA THROMBECTOMY FOR RENAL CELL CARCINOMA Ryan Nasseri, Devin Patel, Daniel Holst, Margaret Meagher, and Ithaar Derweesh Ryan NasseriRyan Nasseri More articles by this author , Devin PatelDevin Patel More articles by this author , Daniel HolstDaniel Holst More articles by this author , Margaret MeagherMargaret Meagher More articles by this author , and Ithaar DerweeshIthaar Derweesh More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002646.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: We present a case of a 65 year-old female with cT3b renal cell carcinoma (RCC) and inferior vena cava (IVC) tumor thrombus who underwent open right partial nephrectomy (PN) with IVC thrombectomy at our institution. METHODS: 65 year-old female with CKD stage III [baseline estimated Glomerular Filtration Rate (eGFR) 57 ml/min.1.73m2] and active segmental pulmonary emboli (PE) presented with locally advanced RCC with venous tumor extension to the level of the intrahepatic IVC. Patient was deemed to not be optimal surgical candidate due to symptomatic PE and poor performance status (ECOG 2 status) and also had strong indication for nephron preservation. The patient ultimately underwent systemic therapy with 12 cycles of nivolumab and 6 cycles of ipilimumab with shrinkage of primary tumor and regression of tumor thrombus to the infrahepatic IVC. RESULTS: Open right PN with IVC thrombectomy was undertaken. A reverse-hockey stick incision was made. Large and small intestinal medial reflection was conducted with liver mobilization. Cranial and caudal IVC control was obtained as well as control of the contralateral renal vein. IVC clamping and control of the contralateral renal vein in addition to clamping of the main renal artery was conducted, and the tumor and IVC tumor extension were resected en bloc via a venotomy and longitudinal cavotomy, primary closure of which were performed with 6-0 and 3-0 Prolene. Collecting system entries and segmental vessels were closed with 3-0 Monocryl and 4-0 PDS. The cortical defect was then approximated with 0 Chromic suture and hemostatic agents.Final pathology demonstrated pT3b clear cell RCC/ISUP grade 2 with protrusion into IVC. Negative margins for primary tumor and distal caval margins. Postoperative creatinine was 1.01 ng/dL with eGFR of 55 mL/min/1.73m2. No evidence of disease was noted at 3-month radiologic follow up. CONCLUSIONS: PN with IVC thrombectomy may be safely achieved for select patient with imperative indication for nephron sparing surgery. Further investigation of long-term oncologic outcomes and efficacy are requisite. Source of Funding: Stephen Weissman Kidney Cancer Research Fund © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e1032 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ryan Nasseri More articles by this author Devin Patel More articles by this author Daniel Holst More articles by this author Margaret Meagher More articles by this author Ithaar Derweesh More articles by this author Expand All Advertisement PDF DownloadLoading ...

The surgical and oncological rational of partial nephrectomy for the treatment of localized renal cell carcinoma

Background and objectives:The more frequent use of partial nephrectomy (nephron sparing surgery) in renal cancer treatment derives from a spectacular rise in the incidental diagnosis of renal tumors in patients undergoing abdominal ultrasound or computed tomography for abdominal diseases. This has markedly increased the detection of small, asymptomatic tumors. The aim of this study is to analyze the current evidence of efficacy and safety of open partial nephrectomy in patients with renal cell carcinoma and to speculate its indications and complications. Methods: Hos- pital based case-prospective & retrospective study. A Total of 36 patients with renal cell carcinoma who underwent nephron sparing surgery between september 2017 and March 2019 at Rizgary Teaching Hospital and Zheen Interna- tional Hospital were investigated, Tumor related characteristics, indication for nephron sparing surgery, postoperative complications, full histopathological data, and follow up results were reviewed. Results: Open partial nephrectomy was done successfully to treat patients with renal cell carcinoma; during the follow-up period one patient developed bleeding at day of surgery, three patients suffered from haematuria at 4th day, two weeks & one month postoperative- ly & one patient complicated by urine leakage & fistula formation, all complications were managed successfully. No patients were experienced disease progression (local recurrence and distant metastasis), there were no deaths from surgery, there was no acute renal failure, no postoperative dialysis & the disease specific survival rate was 100 %. Conclusions: artial Nephrectomy appears to be safe and effective procedure to control cases of renal tumors with relative and absolute indications for NSS.

Safety and efficacy of retroperitoneal sutureless zero ischemia laparoscopic partial nephrectomy for low nephrometry score masses.

To evaluate oncological feasibility and oncological and functional results of retroperitoneal sutureless zero ischemia laparoscopic partial nephrectomy (LPN). Patients with posterior renal masses with low nephrometry score (RENAL ≤ 7) treated who underwent retroperitoneal sutureless zero ischemia.in a single center from January 2016 to November 2017. Clinical, surgical and pathological data were prospectively collected. Complications were reported according to the modified Clavien classification. Retroperitoneal sutureless zero ischemia laparoscopic partial nephrectomy was performed on 15 patients. The indication for nephron-sparing surgery was elective in 11 (73%) patients and imperative in 4 (27%). Median RENAL score was 5 (IQR: 5-7), median tumor diameter 25 mm (IQR: 20-35). In 11 cases, the tumor was located polar (85%), and in 2 cases hilar (15%). There were no intraoperative complications. No cases were converted to radical nephrectomy, and in no case parenchyma suture was necessary. Median operative time was 90 min (IQR:40-150), in no case clamping of the renal artery was necessary, median hospital stay was 4 days, median estimated blood loss (EBL) was 310 (180-500) ml. Pathological analysis showed renal cell carcinoma in 11 patients (85%), 9 (60%) staged T1a and 2 (13%) T1b. In 4 (27%) an oncocytoma was found. There were no positive surgical margins. One patient developed a major postoperative complication (postoperative renal bleeding requiring super-selective embolization). Trifecta rate was 93%. Sutureless retroperitoneal zero ischemia LPN for the treatment of low-complexity posterior renal masses showed to be safe and feasible. Longer follow-up and higher numbers of patients are, however, warranted to draw definitive conclusions on functional outcomes.

27 - Does expansion of indications for nephron sparing surgery reflects on the increasing incidence of local recurrence?

27 - Does expansion of indications for nephron sparing surgery reflects on the increasing incidence of local recurrence?

Key issues of nephron spring surgery for renal neoplasms

In recent years the incidence of small renal carcinoma is increasing, and nephron sparing surgery(NSS) becomes the mainstream to treat it. NSS is considered based on comprehensive analysis: the imaging examination, systemic evaluation of the patients, and the indications of NSS. There are three common surgical approaches: intraperitoneal approach, retroperitoneal approach and the joint approach. It is recommended to do intraoperative frozen pathology. If the edge is positive, it is better to cut a deeper layer of the tissue around the renal tumor or transform to radical nephrectomy. Attention should also be paid to reduce heat ischemia time, in order to protect renal function and reduce postoperative renal atrophy. In addition, there are some factors, such as the accurate preoperative evaluation of renal function and surgical skill of the doctors, which can reduce the incidence of postoperative complications and improve survival and quality of life.

Is Nephron Sparing Surgery Justified in Wilms Tumor With Beckwith-Wiedemann Syndrome or Isolated Hemihypertrophy?

Patients with Beckwith-Wiedemann syndrome (BWS) or isolated hemihypertrophy (HH) treated for a Wilms tumor (WT) carry an increased risk of developing metachronous lesion. There are no guidelines on precise indications for nephron sparing surgery (NSS) in unilateral WT (UWT). The objective of this retrospective study was to delineate the indications of NSS in patients with BWS/HH treated for WT and to evaluate their outcome. All cases of BWS/HH treated for a WT according to SIOP protocols from 1980 to 2013 were reviewed. Patients were divided into two groups (G): isolated UWT (G1) and bilateral lesions (G2) with two subgroups: bilateral tumors suspected of malignancy (G2a), and unilateral tumor suspected of malignancy with contralateral nephroblastomatosis (G2b). Forty-six patients were included (34 G1, three G2a, and nine G2b). Nine NSS and 25 total nephrectomies (TN) were performed in G1, two bilateral NSS and one NSS with contralateral TN in G2a, and eight NSS and one TN in G2b. The 3-year event-free survival was 92.3% (95% CI [77.9-97.5%]). One death occurred after a local relapse following a TN for a stage III stromal WT (G1) and another after a combined local and distant relapse following a NSS for a stage I diffuse anaplastic WT (G2b). There were two metachronous WT (4%), 3 years after a TN (G1) and 12 years after a NSS (G2b). NSS is recommended in bilateral WT and may be an option in selected UWT patients with BWS/HH because it was not associated with an increased risk of local relapse.

Use of Personalized Printed 3-Dimensional Kidney Models for Simulation before Nephron Sparing Surgery: Methodology and Examples from a Case Series

IntroductionNephron sparing surgery may be challenging in cases of complex or aberrant renal anatomy. 3-Dimensional printing technology has allowed the creation of 3-dimensional models that can aid in preoperative surgical planning and simulation. We describe the construction of personalized 3-dimensional kidney models, and present a series of patients with complex surgical anatomy to illustrate their use in surgical planning and performance of complex nephron sparing surgery. MethodsThree patients with complex renal masses were identified. Contrast enhanced computerized tomography studies were used to create segmentation images based on separate scan phases, which were overlaid to create virtual 3-dimensional models. High-fidelity 3-dimensional physical models were then created using 3-dimensional printing technology. The 3-dimensional models were used as an aid in the surgical planning and performance of nephron sparing surgery. ResultsThree patients with complex renal anatomy presented with T1b or T2 renal masses. Two patients had absolute or relative indications for nephron sparing surgery and in 1 patient a benign mass was suspected on imaging. The 3-dimensional kidney models were constructed based on preoperative cross-sectional imaging to evaluate the feasibility of nephron sparing surgery and to simulate the surgical approach. All patients underwent successful nephron sparing surgery with negative surgical margins and preservation of renal function at followup. ConclusionsWe describe the creation of personalized 3-dimensional kidney models to facilitate the visualization of the renal mass and its relationship with surrounding structures, the identification of renal and tumor vasculature, and the evaluation of aberrant anatomy. These 3-dimensional models represent a valuable tool for preoperative planning and simulation in cases with complex anatomical considerations.

Nephron-sparing surgery across a nation - outcomes from the British Association of Urological Surgeons 2012 national partial nephrectomy audit.

To determine the scope and outcomes of nephron-sparing surgery (NSS), i.e. partial nephrectomy, across the UK and in so doing set a realistic benchmark and identify fresh contemporary challenges in NSS. In 2012 reporting of outcomes of all types of nephrectomy became mandatory in the UK. In all, 148 surgeons in 86 centres prospectively entered data on 6 042 nephrectomies undertaken in 2012. This study is a retrospective analysis of the NSS procedures in the dataset. A total of 1 044 NSS procedures were recorded and the median (range) surgical volume was 4 (1-39) per consultant and 8 (1-59) per centre. In all, 36 surgeons and 10 centres reported on only one NSS. The indications for NSS were: elective with a tumour of ≤4.5 cm in 59%, elective with a tumour of >4.5 cm in 10%, relative in 7%, imperative in 12%, Von Hippel-Lindau in 1%, and unknown in 11%. The median (range) tumour size was 3.4 (0.8-30) cm. The technique used was minimally invasive surgery in 42%, open in 58%, with conversions in 4%. The histology results were: malignant in 80%, benign in 18%, and unknown in 2%. In patients aged <40 years 36% (36/101) had benign histology vs 17% (151/874) of those aged ≥40 years (P < 0.01). In patients with tumours of <2.5 cm 29% (69/238) had benign histology vs 14% (57/410) with tumours of 2.5-4 cm vs 8% (16/194) with tumours of ≥4 cm (P = 0.02). In patients aged <40 years with of tumours of <2.5 cm 44% (15/34) were benign. The 30-day mortality was 0.1% (1/1 044). There were major complications (Clavien-Dindo grade of ≥IIIa) in 5% (53/1 044). There was an increased risk of complications after extended elective NSS of 19% (19/101) vs elective at 12% (76/621) (relative risk [RR] 1.54; P < 0.01). Margins were recorded in 68% (709/1 044) of the patients, with positive margins identified in 7% (51/709). Positive surgical margins after NSS for pathological T3 (pT3) tumours were found in 47.8% (11/23) vs 6.1% (32/523) for pT1a, tumours (RR 5.61; P < 0.01). In all, 14% (894/6 042) of the patients underwent surgery for T1a tumours: 55% (488/894) by NSS, 42% (377/894) by radical nephrectomy (RN), and in 3% (29/894) the procedure used was unknown. Major complications after occurred in 4.9% (24/488) of NSS vs 1.3% (5/377) of RN (P < 0.01). Limitations included poor reporting of renal function data and no data on tumour complexity. In its first year, mandatory national reporting has provided several challenging contemporary insights into NSS.

Hand-assisted laparoscopic versus open partial nephrectomy in patients with T1 renal tumor: Comparative perioperative, functional and oncological outcome

Objective: Studies comparing hand-assisted laparoscopic partial nephrectomy (HALPN) and open partial nephrectomy (OPN) for T1 kidney tumors are scarce. This study investigated the perioperative, functional and oncological outcomes of these methods. Materials and methods: A prospective institutional kidney tumor register was used to identify patients between January 2006 and May 2014 undergoing HALPN (n = 139) or OPN (n = 165) for tumors 7 cm or smaller with non-absolute indication for nephron-sparing surgery. The outcomes were compared using univariate and multivariate statistical methods. Results: HALPN and OPN groups were similar with regard to tumor characteristics but HALPN patients were 2 years younger (p = 0.001) and had less comorbidity. Fewer intraoperative complications were encountered in HALPN than in OPN patients (7.2% vs 12.7%, p = 0.043). HALPN patients had less all-grade postoperative 30 day complications than OPN patients (27% vs 41%, p = 0.037), but there was no significant difference in Clavien 3–5 complications. Glomerular filtration rate 3 months after operation was lower in the HALPN than in the OPN group (7.1 ± 12.7% vs 10.0 ± 12.4%, p = 0.054). There was no difference in overall survival or recurrence-free survival during the median follow-up of 35 months. Conclusions: HALPN is a feasible method to achieve equal perioperative, functional and oncological outcomes compared to OPN in patients with tumors 7 cm or smaller in diameter.

Robotic radical nephrectomy for renal cell carcinoma: a systematic review.

BackgroundLaparoscopic radical nephrectomy (LRN) is the actual gold-standard for the treatment of clinically localized renal cell carcinoma (RCC) (cT1-2 with no indications for nephron-sparing surgery). Limited evidence is currently available on the role of robotics in the field of radical nephrectomy. The aim of the current study was to provide a systematic review of the current evidence on the role of robotic radical nephrectomy (RRN) and to analyze the comparative studies between RRN and open nephrectomy (ON)/LRN.MethodsA Medline search was performed between 2000–2013 with the terms “robotic radical nephrectomy”, “robot-assisted laparoscopic nephrectomy”, “radical nephrectomy”. Six RRN case-series and four comparative studies between RRN and (ON)/pure or hand-assisted LRN were identified.ResultsCurrent literature produces a low level of evidence for RRN in the treatment of RCC, with only one prospective study available. Mean operative time (OT) ranges between 127.8-345 min, mean estimated blood loss (EBL) ranges between 100–273.6 ml, and mean hospital stay (HS) ranges between 1.2-4.3 days. The comparison between RRN and LRN showed no differences in the evaluated outcomes except for a longer OT for RRN as evidenced in two studies. Significantly higher direct costs and costs of the disposable instruments were also observed for RRN. The comparison between RRN and ON showed that ON is characterized by shorter OT but higher EBL, higher need of postoperative analgesics and longer HS.ConclusionsNo advantage of robotics over standard laparoscopy for the treatment of clinically localized RCC was evidenced. Promising preliminary results on oncologic efficacy of RRN have been published on the T3a-b disease. Fields of wider application of robotics should be researched where indications for open surgery still persist.

Partielle Tumornephrektomie

The rising incidence of renal cell cancer in recent decades has led to a revision in the therapy of this malignancy. For small renal masses, partial nephrectomy has become the standard surgical treatment instead of radical nephrectomy. This approach can lead to a higher overall survival due to preservation of renal function. Avoiding chronic kidney disease is mandatory for patients with benign or small non-aggressive tumors; however, partial nephrectomy correlates with higher complication rates and is conditioned by operator skills. The role of partial nephrectomy compared to radical nephrectomy is still to be established particularly for larger tumors. The results of studies so far are mostly based on non-randomized retrospective data. This article will present the pros and cons of partial nephrectomy and will focus on the steps required to promulgate the indications of nephron-sparing surgery.

Nephron-Sparing Surgery: Our Experience

To analyze the data of our department with regard to the treatment of kidney cancer, with particular attention to nephron-sparing surgery (NSS). Data of initial experience on robot-assisted partial nephrectomy (RAPN) were also analyzed. Between January 2005 and December 2010, at the Urology Clinic of Padua, 780 procedures for kidney cancer were performed: 462 radical nephrectomies (RN), 289 open partial nephrectomies (OPN), and 29 robot-assisted partial nephrectomies (RAPN). Between January 2010 and July 2011 41 RAPN as well as 38 OPN were performed. The average volume of tumors treated with RAPN was 2.17 cm, 1.98 cm, and 2.78 cm in the first, second, and third half-year, respectively. The mean operative time was 220 minutes, 200 minutes, and 180 minutes in the first, second, and third half-year, respectively. The average warm ischemia time was 24 minutes, 22 minutes, and 21 minutes in the first, second, and third half-year, respectively. The average estimated blood loss was 170 mL, 160 mL, and 180 mL in the first, second, and third half-year, respectively. In the same period, the average volume of tumors treated with OPN was 3.7 cm, 3.9 cm, and 5.7 cm respectively in the first, second, and third half-year. We have observed a gradual extension of the indications for NSS. The systematic application of robotic surgery has allowed for the treatment of even more complex cases with relatively low learning curve. OPN has therefore become a technique that should be reserved for more complex cases.

Delayed proximal ureteric stricture formation after complex partial nephrectomy

• To report and review our incidence of delayed ureteric stricture (US) after complex nephron-sparing surgery (NSS). • Using our institutional kidney cancer database, we identified 720 patients who underwent NSS from 1 January 2000 until 31 December 2010 and identified eleven (1.5%) patients with a delayed US. • Patient and tumour characteristics were reviewed. • Median (range) tumour size and RENAL nephrometry score was 4.1 (2-7.2) cm and 10p (4-11p), respectively. • There were eight of 10 solitary tumours (80%) located in the lower or mid-pole of the kidney. • There were eight of 11 patients with delayed US (72.7%) who experienced a postoperative urinary leak. • There were two of 11 (18.2%) patients who experienced a postoperative retroperitoneal haemorrhage, with one of these patients requiring selective embolization. • All US were in the upper third of the ureter and were diagnosed at a minimum of 10 weeks postoperatively (median 154 days, range 70-400 days). • US formation is an uncommon and under-reported event after complex NSS. • Risk factors appear to include tumour complexity, imperative indications, mid- or lower pole location, postoperative urinary leak and haemorrhage. • Although uncommon, postoperative US can occur after NSS for complex renal masses, necessitating patient counselling and diligent postoperative surveillance.

982 NO IMPACT OF TUMOR LOCATION ON THE RESIDUAL RENAL FUNTION AFTER NEPHRON-SPARING SURGERY IN THE PATIENTS WITH RENAL TUMORS

You have accessJournal of UrologyKidney Cancer: Localized II1 Apr 2010982 NO IMPACT OF TUMOR LOCATION ON THE RESIDUAL RENAL FUNTION AFTER NEPHRON-SPARING SURGERY IN THE PATIENTS WITH RENAL TUMORS Jumpei Iizuka, Tsunenori Kondo, Yasunobu Hashimoto, Hirohito Kobayashi, and Kazunari Tanabe Jumpei IizukaJumpei Iizuka More articles by this author , Tsunenori KondoTsunenori Kondo More articles by this author , Yasunobu HashimotoYasunobu Hashimoto More articles by this author , Hirohito KobayashiHirohito Kobayashi More articles by this author , and Kazunari TanabeKazunari Tanabe More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1951AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Nephron-sparing surgery (NSS) has become a golden standard for small renal masses. Ninety-five percent of tumors of 4cm or less are resected with NSS in our department at present. In this study, we analyzed residual renal function after NSS according to the tumor location. We also examined the surgical difficulty of NSS as well. METHODS From July 2003 until April 2009, 599 patients underwent curative surgery for renal tumor. Of these, 193 patients who underwent NSS were the subjects of this study. The indication for NSS was elective in 125 patients and imperative in 68. Tumor location was categorized with three factors, including the circumferential location (anterior, posterior, inner-side and outer-side), the location along the long axis (upper, mid, lower), the depth (exophytic, endophytic), and the hilar location. We compared operation time, blood loss, total ischemic time□@(TIT), perioperative complications, and reduction rate of renal function 1-year after surgery according to the tumor location. Renal function was assessed using the estimated glomerular filtration rate (e-GFR) calculated using the MDRD equation recently modified for Japanese patients, as regulated by The Japanese Society of Nephrology. RESULTS The all tumors were excised completely without a positive surgical margin. There was no local recurrence found after NSS. Mean tumor size was 33.2□}21.6 mm (range, 8-200 mm). Twenty-tree patients underwent laparoscopic NSS and 160 patients underwent open NSS included ex-vivo NSS followed by autotransplantation. Histological study showed RCC in 171 patients and benign tumors in 22. With respect to operation results, the operation time and the blood loss were higher in inner-side tumors than the other circumferential locations (p<0.05). Hilar or endophtic tumors resulted in the prolonged operation time, and TIT, and increased blood loss. Buried tumors enhanced the surgical difficulty. In contrast to surgical results, any location factors did not negatively influence the residual renal function. CONCLUSIONS Hilar or inner-side tumors increase the technical difficulty of NSS but did not compromise the residual renal function. Thus the indication of NSS should be extended aggressively to the hilar, buried, or inner-side tumors. Tokyo, Japan© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e381-e382 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jumpei Iizuka More articles by this author Tsunenori Kondo More articles by this author Yasunobu Hashimoto More articles by this author Hirohito Kobayashi More articles by this author Kazunari Tanabe More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Predictors of Unilateral Renal Function After Open and Laparoscopic Partial Nephrectomy

To retrospectively evaluate clinical, tumor, and surgical factors that were potential predictors of postoperative unilateral renal function after laparoscopic and open partial nephrectomy. Sixty-five patients who had undergone partial nephrectomy and had postoperative renal scintigraphy performed were evaluated on the basis of multiple factors as potential predictors of postoperative renal function in the ipsilateral kidney. These factors include patient age, indication for nephron-sparing surgery, type of procedure (laparoscopic vs open), preoperative and postoperative glomerular filtration rate, tumor depth, radiographic and pathologic tumor size, warm ischemia time, and intraoperative visual assessment of functional renal parenchyma preserved. The correlation of each clinical factor to actual postoperative differential renal function, as determined by technetium-99m-mercaptoacetyltriglycine renal scintigraphy, was calculated. In univariate regression analysis, the only factors found to be significantly correlated with postoperative unilateral renal function as assessed by renal scintigraphy were intraoperative visually estimated preserved parenchyma volume (P <.001), tumor size (radiologic, P = .017; pathologic, P = .041), and procedure type (P = .021). Tumor depth (P = .050) showed borderline significant relation to postoperative unilateral renal function. Multivariate analysis revealed no factors that were jointly prognostic for postoperative scintigraphic differential renal function. Intraoperative visually estimated functioning residual renal volume was the most accurate predictor of actual postoperative unilateral renal function. Tumor depth had intermediate prognostic value in estimating postoperative split renal function. During both laparoscopic and open partial nephrectomy, intraoperative visual estimation of preserved renal parenchyma volume should be routinely documented.

The impact of renal surgery on global renal function and non-oncologic morbidity

Nephron preservation has been increasingly prioritized in the treatment of small renal tumors. Radical nephrectomy is now understood as a risk factor for development of chronic kidney disease, which is known to increase the risk of cardiovascular events and all-cause mortality. Indications for nephron-sparing surgery (NSS) have broadened from solitary kidney, bilateral tumors, and hereditary tumor syndromes to essentially all small renal tumors. Laparoscopic NSS has demonstrated excellent cancer control as well as good functional preservation despite the need for warm ischemia. There has been ongoing debate regarding safe parameters for warm ischemia, which are thought to vary with patient factors. Focal ablative therapies have been developed for use in high-risk surgical candidates (eg, radiofrequency ablation, cryoablation) to minimize renal and other treatment-related morbidity. Emphasis on minimally invasive approaches and advances in preventing renal dysfunction and other morbidity after NSS will guide the future of these therapies.

Video-Assisted Minilaparotomy Surgery (VAMS): Challenging Cases of Nephron-Sparing Surgery in a Solitary Kidney

Kyo Chul Koo, Woong Kyu Han, Seung Choul Yang From the Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea Although radical nephrectomy is the mainstay in the surgical management of renal cell carcinoma (RCC), a solitary kidney with RCC is an imperative indication for nephron-sparing surgery (NSS). In this rare setting, radical nephrectomy can potentially render the patient anephric, leading to dialysis or renal transplantation. Although open surgery is still the gold standard for NSS, there has been an upsurge in the number of minimally invasive NSS procedures that have demonstrated excellent long-term oncologic, surgical, and functional outcomes. Complex renal tumors in the setting of a solitary kidney add an additional challenge to minimally invasive NSS. Here we describe 3 complex cases of RCC in a solitary kidney treated successfully by video-assisted minilaparotomy surgery-NSS. (Korean J Urol 2009;50:288-292) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏

Treatment options in localised and metastatic renal cell carcinoma

Renal cell cancer (RCC) accounts for 2% of all malignancies. RCC shows a rising incidence and overall mortality is the highest among all urologic malignancies. In localised disease, radical cancer surgery remains the only potential curative treatment option. Indications for nephron-sparing surgery include renal tumours 4 cm or less in diameter and patients with solitary kidneys or bilateral synchronous RCC. Nephron-sparing surgery is also recommended in patients with conditions that might lead to impaired kidney function later on. In metastatic RCC (mRCC), cytoreductive surgery followed by the immunotherapy has proven to be a mainstay in patients with a good performance status. Chemotherapy has no role in the treatment of mRCC. Pharmacological treatment of mRCC has significantly changed in the last months due to the approval of targeted therapies such as sunitinib, sorafenib, bevacizumab or temsirolimus, which have largely replaced immunotherapy. Immunological therapy has been the standard of care in the treatment of mRCC in the last decade. Sequencing therapy and combination of different treatment modalities may further increase therapeutic options in the future. The purpose of the following short review is to summarize the contemporary treatment options in localised and metastatic RCC.