Margin Of Normal Parenchyma Research Articles

25, 50 & 75 years ago.

25, 50 & 75 years ago.

Органосохраняющие операции по поводу опухоли почки в условиях нулевой ишемии. Нужно ли нам 3D-моделирование?

our aim was to assess and compare a zero ischemia enucleation and enucleoresection of tumor, as well as classical partial nephrectomy. In addition, we defined a role of a three-dimensional reconstruction of the tumor for the planning of intervention. a total of 83 patients with localized renal tumors were included in the study. There were 48 men (57.8%) and 35 women (42.2%), with mean age 56.8+/-11.9 years. The patients were divided into 3 groups depending on the type of intervention. The enucleation, enucleoresetion and classical partial nephrectomy with removal of 0.5-1 cm margin of normal parenchyma was performed in Group 1 (n=41), Group 2 (n=31) and Group 3 (n=11), respectively. A computer program Amira was used for the reconstruction of 3D-model of tumor during preoperative planning. On the basis of 3D-model, an information about the structures situated beneath the tumor was obtained, as well as anatomy of vessels and relationship between the renal pelvis system and the tumor. In all cases the interventions were performed laparoscopically. Transperitoneal access was used in 34 (41%) cases, while retroperitoneal access was chosen in 49 patients (59%). The amount of blood loss was higher in 23 patients (27.7%) with tumors located in renal sinus (205.7+/-29.1 ml), than in patients with exophytic and endophytic tumors (142.3+/-15.2 and 208.2+/-35.9 ml, respectively; p=0.005). The duration of the surgery was less in those cases where parenchyma was under the bottom of the tumor, according to the 3D-model (58.3+/-6.8 min), compared to the patients with collecting system or vessels located under the tumor (87,6+/-5.2 min, p=0.005). The amount of blood loss was 179.4 +/- 41.8 ml in patients with one vessel located beneath the tumor, according to the 3D-model, in comparison with those cases with three vessels (360.0+/-87.2 ml). There was no need for clamping of the renal vessels or conversion to the open surgery. In the enucleation group, neither intraoperative nor postoperative complications were observed. According to the results, we can conclude that 3D modeling undoubtedly gives clear advantages for the urologist during the planning of the intervention. Tumor enucleation seems to be the optimal method of partial nephrectomy, which allows to perform a dissection near to the renal sinus with the small risk of complications.

Retroperitoneoscopic Partial Nephrectomy Using Radiofrequency Coagulation for Small Renal Tumors

Adoption of laparoscopic partial nephrectomy (LPN) has been limited by lack of reliable hemostatic techniques. We evaluated radiofrequency coagulation (RFC) in obtaining hemostasis during LPN for small renal masses. Over 4 years LPN was performed by a retroperitoneal approach in 11 patients with solitary, predominantly exophytic renal tumors. A retroperitoneal approach was used in all patients. The renal hilum was not exposed. RF energy was delivered to coagulate the lesion and a margin of normal parenchyma. Tumors were excised together with at least a 0.5-cm margin of normal parenchyma, with the use of ultrasonic shears. Mean tumor size was 2.2 cm (range, 1.5 to 3.0). Mean operative time was 222 minutes (range, 130 to 305 minutes) and mean blood loss was 51 mL (range, 10 to 200 mL). During excision bleeding from the cut renal surface was minimal, and structure of the cortex and medulla still could be clearly distinguished after coagulation. No serious complications such as uncontrolled bleeding or urine leakage occurred. One patient had a thermal burn develop at the site of needle electrode insertion and hydronephrosis caused by pyeloureteral junction (PUJ) stricture. In follow-up, ranging from 8 to 53 months, no local recurrence or distant metastasis was detected by computed tomography. Hemostatic capability of RFC is excellent, improving visibility and ease of operation during LPN, and eliminating need for hilar clamping. Further experience and advancement of RF technology will be needed for the application of this method to larger, centrally located tumors.

Intermediate‐term prospective results of radiofrequency‐assisted laparoscopic partial nephrectomy: a non‐ischaemic coagulative technique

OBJECTIVE To report the first intermediate-term oncological outcomes of laparoscopic radiofrequency coagulation followed by laparoscopic partial nephrectomy (RF-LPN) to treat small renal masses, as LPN is limited by the technical difficulty of efficient tumour resection and parenchymal repair during warm ischaemia of the kidney. PATIENTS AND METHODS A prospective database was searched to identify patients treated with RF-LPN; in each case the tumour was first RF coagulated with a margin of normal parenchyma, and then excised. Only fibrin glue was applied to the haemostatic resection site to prevent urinary leaks. In all, 32 tumours were treated with this approach, and a radiographic follow-up was completed yearly. RESULTS All PNs were accomplished with no hilar clamping, with a mean blood loss of 80 mL; 72% of masses were renal cell carcinoma. There was a positive margin in four masses (13%); 29 tumours (mean size 1.9 cm) were eligible for analysis of oncological outcomes, with a mean follow-up of 31 months. There were no tumour recurrences at the last follow-up, giving a cancer-specific survival rate of 100%. CONCLUSIONS RF-LPN with no hilar clamping simplifies the surgical technique and appears to have excellent cancer control in the intermediate term. In the few patients with a positive surgical margin, it is possible that coagulation beyond the tumour margin kills any residual microscopic tumour, minimizing or obviating the risk of tumour recurrence. Nevertheless, vigilance during tumour excision and margin identification is mandatory.

Cirugía conservadora de cáncer renal en injerto funcionante: A propósito de un caso

We present nephron sparing renal surgery as a therapeutic option for the conservative treatment of renal cancer by reporting one case of de novo renal cell carcinoma (RCC) presenting in a functioning renal graft.We describe one case of de novo RCC presenting in a functioning renal graft 51 months after transplantation. Tumorectomy was carried out with a margin of normal parenchyma and the base was free of tumor. Definitive pathologic study showed type I papillary renal cell carcinoma, Fuhrman grade 2, pathological stage I with free margins. There were not post operative complications and immunosuppression therapy was not modified. After almost three years of follow-up there is no evidence of tumor recurrence and an adequate renal function.Renal graft RCC is rare. Conservative surgery in selected patients may be a safe and effective technique when the tumor appears in a functioning graft, because it offers good oncological control and preserves renal function, avoiding transplant nephrectomy and the need of haemodialysis.

Percutaneous radiofrequency ablation of renal tumors: technique, limitations, and morbidity

Objectives To evaluate our evolving experience with percutaneous radiofrequency (RF) renal tumor ablation and focus on our technique to ensure maximal treatment efficacy and reduce the possibility of complications. Methods Fifteen patients with small (less than 4 cm) posterior or lateral contrast-enhancing (more than 10 Hounsfield units) renal tumors were candidates for RF treatment. Of these patients, 12 (13 tumors) received computed tomography-guided percutaneous RF ablation. General anesthesia was administered in all but our first 2 patients, who received intravenous sedation. After treatment, patients were closely followed up with computed tomography scans at 6 weeks and 3, 6, and 12 months, and every 6 months thereafter. Successful ablation was defined as a lesion along with a margin of normal parenchyma that no longer enhanced (less than 10 Hounsfield units) on follow-up contrast imaging. Results The mean tumor size was 2.4 ± 0.6 cm. The average procedure time was 95 minutes (range 60 to 150) and length of stay 0.9 days. All patients underwent the procedure without any major complications. At a mean follow-up of 4.9 months, 12 (93%) of 13 tumors were successfully ablated. In 3 patients, the procedure was not performed because of intervening bowel or lung parenchyma when positioned in the prone position before the procedure. Conclusions Computed tomography-guided percutaneous RF ablation of small renal tumors is a viable minimally invasive treatment option with a high short-term success rate and low morbidity. This new technology must be uniformly applied to assess its long-term efficacy.

Novel modification of partial nephrectomy technique using porcine small intestine submucosa

Introduction To describe a novel partial nephrectomy technique that uses small intestine submucosa (SIS) to ensure a watertight closure of the collecting system and minimize parenchymal bleeding. The indications for nephron-sparing surgery have increased in recent years. The most prevalent complications after partial nephrectomy include urinary leakage/fistula and parenchymal bleeding. Porcine SIS has been used in animal models to reconstruct portions of the urinary tract successfully. Technical considerations Twenty-two consecutive patients underwent 24 partial nephrectomies that required entry into the collecting system for presumed renal cell carcinoma. After temporary occlusion of the renal vessels and renal hypothermia, the tumor and a margin of normal parenchyma were excised. The cut surface was cauterized with an argon beam coagulator, and visible vessels were suture ligated. The collecting system was reapproximated with interrupted, absorbable sutures. A multilayer piece of hydrated SIS was sutured in place over the exposed collecting system and parenchymal defect with several figure-of-eight chromic sutures. With a mean follow-up of 18.4 months, none of the 22 patients experienced postoperative urinary leaks/fistulas or postoperative hemorrhage requiring transfusion. The serum creatinine returned to within 0.2 mg/dL of baseline in all patients after surgery. Conclusions We describe a novel technique of partial nephrectomy using SIS, which, we believe, aids in closure of the collecting system and decreases parenchymal bleeding.

RADIO FREQUENCY COAGULATION TO FACILITATE LAPAROSCOPIC PARTIAL NEPHRECTOMY

The advent of cryotherapy and radio frequency ablation technology offers the opportunity to treat renal tumors in a minimally invasive fashion. Drawbacks of these techniques include the possibility of incomplete ablation and the need for aggressive followup imaging. As an alternative laparoscopic partial nephrectomy has been limited by difficult hemostasis in some cases. To overcome this problem we combined these techniques and performed radio frequency coagulation of a renal mass before laparoscopic resection. CASE REPORT A 48-year-old woman presented with left flank pain. Computerized tomography revealed a partially exophytic, enhancing 1.5 cm. left renal mass. All treatment options were discussed and the patient elected laparoscopic partial nephrectomy. She was placed in the modified flank position, and 2, 10 mm. and 2, 5 mm. transperitoneal ports were placed as for standard laparoscopic nephrectomy. The descending colon was reflected and Gerota’s fascia was opened. The middle and lower poles were mobilized, and the tumor was easily identified on the lateral aspect of the kidney (fig. 1, A). Laparoscopic ultrasound confirmed the distinct nature of the mass. Using laparoscopic visualization, the “dry” radio frequency 16 gauge, 7 prong needle electrode probe was percutaneously positioned into the lesion. The prongs were deployed to 1.5 cm. into and through the lesion (fig. 1, B). Radio frequency was delivered at 50 W. and then autoregulated to maintain an average temperature of 100C at this level for 8 minutes according to the recommendation of the manufacturer. Coagulation of the tumor was obvious with visible charring. The tumor and a 0.5 cm. margin of normal parenchyma were excised (fig. 2). Frozen section analysis of the deep margin was negative for tumor. As a safety measure the argon beam coagulator was used to coagulate the cut surface before fibrin glue was applied. There was no appreciable blood loss during tumor excision. The patient was discharged home on postoperative day 1. Radio frequency coagulation did not alter cellular architecture allowing for accurate histological assessment. Final pathological examination revealed grade 2, clear cell renal cell carcinoma with negative margins, including overlying fat. DISCUSSION

Renal parenchyma-sparing surgery in carcinoma.

There is controversy regarding the role of renal-sparing surgery in patients with kidney cancer who have a functioning contralateral kidney. The present study aimed to review the recent experience of renal-sparing surgery at Royal Prince Alfred Hospital (RPAH), Sydney. Eighteen consecutive patients undergoing conservative surgery for kidney tumours at RPAH between February 1987 and January 1995, were reviewed. Eleven patients had imperative indications for conservative surgery and the remaining seven patients had elective indications. Ten patients had modified enucleation with a margin of normal parenchyma. Six patients underwent partial nephrectomy and two had wedge resections. Patients were followed up at 1, 6 and 12 months, and thence every 6-12 months. Follow-up ranged from 9 to 104 months (mean: 46.2 months, median: 48 months). Sixteen of the 18 patients were still alive at the end of the follow-up (October 1995), with no clinical evidence of local or distant metastasis. The two deaths were not related to the fact that these patients had conservative surgery. The average tumour dimensions were 43 mm x 49 mm, with an average volume of 194 mm3. All resections were complete, with margins ranging between 1.0 and 20.0 mm (mean: 8.7 mm). The survival rate in the present study is comparable to those found by other researchers. Conservative surgery is indicated in renal tumours where radical surgery would render the patient anephric. Conservative surgery, however, is controversial in a patient with a normal contralateral kidney. The present study has shown that renal parenchyma-preserving surgery for localized tumours provides a feasible treatment option.