Nephrectomy For Tumors Research Articles

MP28-12 THE IMPACT OF METASTASIS HISTOPATHOLOGY ON SURVIVAL FOR PATIENTS WITH ADVANCED RENAL CELL CARCINOMA

You have accessJournal of UrologyCME1 Apr 2023MP28-12 THE IMPACT OF METASTASIS HISTOPATHOLOGY ON SURVIVAL FOR PATIENTS WITH ADVANCED RENAL CELL CARCINOMA Rodrigo R. Pessoa, Reza Nabavizadeh, Fernando Quevedo, Daniel D. Joyce, Christine M. Lohse, Vidit Sharma, Brian A. Costello, Stephen A. Boorjian, R. Houston Thompson, Bradley C Leibovich, and John C. Cheville Rodrigo R. PessoaRodrigo R. Pessoa More articles by this author , Reza NabavizadehReza Nabavizadeh More articles by this author , Fernando QuevedoFernando Quevedo More articles by this author , Daniel D. JoyceDaniel D. Joyce More articles by this author , Christine M. LohseChristine M. Lohse More articles by this author , Vidit SharmaVidit Sharma More articles by this author , Brian A. CostelloBrian A. Costello More articles by this author , Stephen A. BoorjianStephen A. Boorjian More articles by this author , R. Houston ThompsonR. Houston Thompson More articles by this author , Bradley C LeibovichBradley C Leibovich More articles by this author , and John C. ChevilleJohn C. Cheville More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003256.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Multiple prognostic models exist to assess survival among patients with metastatic clear cell renal cell carcinoma (m-ccRCC). However, the relative contribution of metastasis histopathology to model performance has not been extensively studied. Herein, we compared models using clinical, primary tumor, and metastatic features to estimate cancer-specific survival (CSS) for patients with m-ccRCC METHODS: We studied 266 patients undergoing nephrectomy from 1970 to 2019 who had a single site of m-ccRCC completely resected. Select features were used to calculate two versions of the m-ccRCC score published by Leibovich et al. in 2005: one using grade and necrosis from the primary tumor, as originally reported, and one using grade and necrosis from the metastasis. The predictive ability of these two versions of the Leibovich m-ccRCC score, as well as a third model with metastatic features only (site, timing in relation to nephrectomy, grade, coagulative tumor necrosis, and sarcomatoid differentiation), were compared using c-indexes from Cox proportional hazards regression models RESULTS: Clinical, primary tumor, and metastatic features are shown in Table 1. A total of 197 patients died from RCC at a median of 2.3 years (IQR 1.1-4.5) with a median follow-up for survivors of 13.2 years (IQR 10.0-14.5). Model performance is summarized in Table 2. The Leibovich score calculated using grade and necrosis from the metastasis had similar predictive ability compared to the original score calculated using grade and necrosis from the primary tumor. A third model demonstrated that metastasectomy at the time of or within 2 years after nephrectomy, bone metastasis, advanced grade, and sarcomatoid differentiation in the metastatic tumor were significantly associated with death from RCC CONCLUSIONS: The Leibovich scoring algorithm, calculated with either primary or metastatic histopathology, can be used to estimate CSS for patients with m-ccRCC. These findings are of particular importance for instances when the primary tumor pathology is not readily available. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e375 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rodrigo R. Pessoa More articles by this author Reza Nabavizadeh More articles by this author Fernando Quevedo More articles by this author Daniel D. Joyce More articles by this author Christine M. Lohse More articles by this author Vidit Sharma More articles by this author Brian A. Costello More articles by this author Stephen A. Boorjian More articles by this author R. Houston Thompson More articles by this author Bradley C Leibovich More articles by this author John C. Cheville More articles by this author Expand All Advertisement PDF downloadLoading ...

Vascular injury during laparoscopic partial nephrectomy in a solitary kidney: management, outcome and audit

BackgroundVascular injury during laparoscopic partial nephrectomy is a dreadful complication. Though it is a commonly discussed complication, the literature on the circumstances leading to vascular injury, methods of managing the complication and reporting of final outcomes in those cases are limited. We report a case of vascular injury during laparoscopic partial nephrectomy for a hilar tumor in a solitary kidney. We highlight the management of the complication, present the outcome and review the surgical technique.Case presentationA 62-year-old male with solitary kidney presented with left renal hilar mass of size 4.4 × 3.8x3.6 cm. The renal nephrometry score was 10ph. The serum creatinine at the time of presentation to the hospital was 1.4 mg/dl. Laparoscopic partial nephrectomy was performed. The patient had severe intraoperative bleeding due to a segmental renal artery injury. The bleeding presented after hilar unclamping and was managed by intracorporeal vascular repair. The blood loss was around 500 ml. The postoperative period was uneventful without the need for hemodialysis. The histopathology report was suggestive of clear cell renal cell carcinoma with negative surgical margin. The follow-up magnetic resonance urogram did not show evidence of any arterial pseudoaneurysm or residual/recurrent tumor. At 18-month follow-up, the serum creatinine was 1.9 mg/dl and the patient did not have any complaints.ConclusionsComplication of vascular injury while performing laparoscopic partial nephrectomy for complex hilar tumors should be anticipated beforehand. Contingency plans to tackle this complication must be in place before attempting the surgery. Intracorporeal repair of vascular injury during laparoscopic partial nephrectomy is feasible when expertise is available. Low threshold for using endoscopic ultrasound, employing cold ischemia techniques, careful usage of hot cut during tumor resection and complete defatting of the kidney can all be considered ‘safe surgical practices’ during laparoscopic partial nephrectomy for complex hilar tumors. Following aforementioned ‘safe surgical practices’ helps in improving the outcomes and reducing the possibility of complication of vascular injury and helps in managing the complication effectively if it happens despite the precautions.

Analysis of trifecta outcomes in a single center with robot-assisted partial nephrectomy for T1b renal tumors.

This study was performed to investigate the preoperative factors associated with difficulty achieving trifecta in robot-assisted partial nephrectomy for clinical T1b renal cell carcinoma. Among 187 patients who underwent robot-assisted partial nephrectomy at our hospital from March 2012 to February 2022, we retrospectively examined 30 patients with unilateral single clinical T1b renal cell carcinoma with at least 6months of postoperative follow-up, excluding patients with hereditary disease. The following factors were examined in detail: patient-related factors, perioperative factors, surgical techniques, tumor factors, and R.E.N.A.L. nephrometry scores. We examined the preoperative factors associated with difficulty achieving trifecta. A positive surgical margin was pathologically defined as the presence of tumor cells at the margin of the resected specimen or visually defined as intraoperative tumor incision or pseudocapsular damage. Of the 30 patients in this study, 12 achieved trifecta and 18 did not. The reasons for not achieving trifecta were a warm ischemia time of >25 min (66.7%), positive surgical margin (23.3%), and Clavien-Dindo grade ≥3 complications (13.3%) (with overlapping factors). No patients had a pathologically positive surgical margin. Visually positive surgical margins were confirmed by the surgical records and surgical videos. Achieving trifecta was challenging in the multivariate analysis when the "L" component of the R.E.N.A.L. nephrometry score was ≥2 points. A preoperative "L" component of ≥2 points in the R.E.N.A.L. nephrometry score was associated with difficulty achieving trifecta.

An Improved Method for Estimating Nephron Number and the Association of Resulting Nephron Number Estimates with Chronic Kidney Disease Outcomes.

Nephron number currently can be estimated only from glomerular density on a kidney biopsy combined with cortical volume from kidney imaging. Because of measurement biases, refinement of this approach and validation across different patient populations have been needed. The prognostic importance of nephron number also has been unclear. The authors present an improved method of estimating nephron number that corrects for several biases, resulting in a 27% higher nephron number estimate for donor kidneys compared with a prior method. After accounting for comorbidities, the new nephron number estimate does not differ between kidney donors and kidney patients with tumor and shows consistent associations with clinical characteristics across these two populations. The findings also indicate that low nephron number predicts CKD independent of biopsy and clinical characteristics in both populations. Nephron number can be estimated from glomerular density and cortical volume. However, because of measurement biases, this approach needs refinement, comparison between disparate populations, and evaluation as a predictor of CKD outcomes. We studied 3020 living kidney donors and 1354 patients who underwent radical nephrectomy for tumor. We determined cortex volume of the retained kidney from presurgical imaging and glomerular density by morphometric analysis of needle core biopsy of the donated kidney and wedge sections of the removed kidney. Glomerular density was corrected for missing glomerular tufts, absence of the kidney capsule, and then tissue shrinkage on the basis of analysis of 30 autopsy kidneys. We used logistic regression (in donors) and Cox proportional hazard models (in patients with tumor) to assess the risk of CKD outcomes associated with nephron number. Donors had 1.17 million nephrons per kidney; patients with tumor had 0.99 million nephrons per kidney. A lower nephron number was associated with older age, female sex, shorter height, hypertension, family history of ESKD, lower GFR, and proteinuria. After adjusting for these characteristics, nephron number did not differ between donors and patients with tumor. Low nephron number (defined by <5th or <10th percentile by age and sex in a healthy subset) in both populations predicted future risk of CKD outcomes independent of biopsy and clinical characteristics. Compared with an older method for estimating nephron number, a new method that addresses several sources of bias results in nephron number estimates that are 27% higher in donors and 1% higher in patients with tumor and shows consistency between two populations. Low nephron number independently predicts CKD in both populations.

Comparison of perioperative outcomes of robotic vs. laparoscopic partial nephrectomy for renal tumors with a RENAL nephrometry score ≥7: A meta-analysis.

To compare the perioperative outcomes of robotic partial nephrectomy (RPN) vs. laparoscopic partial nephrectomy (LPN) for complex renal tumors with a RENAL nephrometry score ≥7. We searched PubMed, EMBASE and the Cochrane Central Register for studies from 2000 to 2020 to evaluate the perioperative outcomes of RPN and LPN in patients with a RENAL nephrometry score ≥7. We used RevMan 5.2 to pool the data. Seven studies were acquired in our study. No significant differences were found in the estimated blood loss (WMD: 34.49; 95% CI: -75.16-144.14; p = 0.54), hospital stay (WMD: -0.59; 95% CI: -1.24-0.06; p = 0.07), positive surgical margin (OR: 0.85; 95% CI: 0.65-1.11; p = 0.23), major postoperative complications (OR: 0.90; 95% CI: 0.52-1.54; p = 0.69) and transfusion (OR: 0.72; 95% CI: 0.48-1.08; p = 0.11) between the groups. RPN showed better outcomes in the operating time (WMD: -22.45; 95% CI: -35.06 to -9.85; p = 0.0005), postoperative renal function (WMD: 3.32; 95% CI: 0.73-5.91; p = 0.01), warm ischemia time (WMD: -6.96; 95% CI: -7.30--6.62; p < 0.0001), conversion rate to radical nephrectomy (OR: 0.34; 95% CI: 0.17 to 0.66; p = 0.002) and intraoperative complications (OR: 0.52; 95% CI: 0.28-0.97; p = 0.04). RPN is a safe and effective alternative to LPNs for or the treatment of complex renal tumors with a RENAL nephrometry score ≥7 with a shorter warm ischemic time and better postoperative renal function.

Cost-effectiveness of robotic-assisted surgery vs open surgery in the context of partial nephrectomy for small kidney tumors.

To evaluate the cost-effectiveness of robotic-assisted surgery compared to open surgery in the context of partial nephrectomy for small kidney tumor management. This is a retrospective study using data from 395 patients operated on by either robot-assisted surgery (RAPN) or by open partial nephrectomy (OPN); one hospital performed RAPN exclusively and the second hospital, OPN exclusively. Cost-effectiveness analysis was conducted from the perspective of the National Health Insurance System (NHIS) by considering the costs of the initial hospital stay and the cost of complications. Clinical outcome was defined by the avoidance of major complications during the 12months postoperatively. Major complications were absent in 82% of patients in the OPN group and 93% of patients in the RAPN group, with 11% in favor of robotic assistance (p < 0.001). The average cost per patient, including the costs of complications, were, respectively, 9637 € and 8305 € for the OPN and RAPN groups. Robotic assistance was associated with a 1332 € lower cost (p < 0.001). The incremental cost-effectiveness ratio (ICER) is estimated at -12,039 €. From the perspective of the public payer, robotic assistance was associated with a lower rate of postoperative complications and a lower average cost per patient. Robotic-assisted surgery was an efficient alternative to open surgery in partial nephrectomy. Trial registration number: NCT05089006 (October 22, 2021).

Perioperative, functional, and oncologic outcomes of robot-assisted versus open partial nephrectomy for complex renal tumors (RENAL score ≥ 7): an evidence-based analysis.

This study aims to assess the efficacy and safety of robot-assisted partial nephrectomy (RAPN) compared with open partial nephrectomy (OPN) in the management of complex renal tumors (defined as RENAL score ≥ 7). We conducted a comprehensive literature search in PubMed, Embase, Web of Science, and Cochrane Library to identify relevant comparative studies up to January 2023. This study was conducted with the Review Manager 5.4 software, and included RAPN and OPN-controlled trials for complex renal tumors. The prime outcomes were to assess the perioperative results, complications, renal function, and oncologic outcomes. A total of 1493 patients were included in seven studies. Compared to OPN, RAPN was associated with a significantly shorter hospital stay (weighted mean difference [WMD] - 1.53days, 95% confidence interval [CI] - 2.44, - 0.62; p = 0.001), less blood loss (WMD - 95.88mL, 95% CI - 144.19, - 47.56; p = 0.0001), lower transfusion rates (OR 0.33, 95% CI 0.15, 0.71; p = 0.005), fewer major complications (OR 0.63, 95% CI 0.39, 1.01; p = 0.05), and fewer overall complications (OR 0.49, 95% CI 0.36, 0.65; p < 0.00001). Nevertheless, no statistically significant differences were found between the two groups in operative time, warm ischemia time, estimated glomerular decline, intraoperative complications, positive surgical margins, local recurrence, overall survival, and recurrence-free survival. The study demonstrated that RAPN had superior perioperative parameters and fewer complications when compared to OPN for complex renal tumors. However, no significant differences were found in terms of renal function and oncologic outcomes.

Intraoperative Corrected Diagnosis of a Right Renal Para-Hilar Paraganglioma, Taken Preoperatively for a Renal Tumor

Nonfunctional retroperitoneal paragangliomas are rare tumors. They are defined as extra-adrenal chromaffin tumors and represent about 20% of chromaffin tumors. They are often asymptomatic and can grow to large dimensions. We report the observation of a 67-year-old patient admitted to the operating room for right total nephrectomy for right hilar renal tumor and whose intraoperative dissection of the renal pedicle could demonstrate an exorenal mass. Anatomopathological analysis was in favor of a paraganglioma. Malignant forms, more frequent than benign forms, present a locoregional invasion and metastasize late. The management of paragangliomas must be multidisciplinary but only surgical treatment is curative. However, there is no consensus on the usefulness of complementary therapies, which can nevertheless be used as a symptomatic adjunct. Paragangliomas are genetic in 25% of cases. A genetic investigation must be systematically proposed.

Percutaneous cryoablation versus partial nephrectomy for cT1b renal tumors: An inverse probability weight analysis.

To investigate differential clinical outcomes in patients treated with partial nephrectomy (PN) vs. percutaneous cryoablation (PCA) for cT1b renal tumors. We retrospectively analyzed the records of 119 patients who had undergone PN (n = 90) or PCA (n = 29) for cT1b renal tumors. Inverse probability weighting (IPW) was used for balancing patient demographics, including renal function and tumor complexity. Perioperative complications, renal function preservation rates, and oncological outcomes such as local recurrence-free, metastasis-free, cancer-specific, and overall survival were compared using IPW-adjusted restricted mean survival times (RMSTs). PCA was more likely to be selected for octogenarians (odds ratio: 11.4, 95% confidence interval [CI]: 3.33-45.1). During the median follow-up of 43 months in the PCA group and 36.5 months in the PN group, unablated local residue or local recurrence was noted in 6 patients in the PCA group and local recurrence was noted in 4 patients in the PN groups. Of the 6 patients in the PCA group, 4 underwent salvage PCA, and local control had been achieved at the last visit. In the IPW-adjusted population, PCA had significantly worse local recurrence-free survival compared with PN (IPW-adjusted RMST difference: -22.7 months, 95% CI: -45.3 to -0.4, P = 0.046). IPW-adjusted RMST for metastasis-free survival (P = 0.23), cancer-specific survival (P = 0.77), and overall survival (P = 0.11) did not differ between PCA and PN. In addition, PN was not a predictor for local control failure at the last visit (odds ratio: 0.30, 95%CI: 0.05-1.29). There were no statistically significant differences between PN and PCA in renal function preservation or overall/severe complication rates. In patients with cT1b renal tumor, although the local recurrence rate is higher for PCA than for PN, PCA provides comparable distant oncologic outcomes. PCA can be an alternative treatment option for elderly, comorbid patients, even those with cT1b renal tumors.

Renal functional and cardiovascular outcomes of partial nephrectomy versus radical nephrectomy for renal tumors: a systematic review and meta-analysis.

This systematic review and meta-analysis aimed to evaluate the postoperative renal and cardiovascular outcomes of partial nephrectomy (PN) versus radical nephrectomy (RN) for the treatment of renal carcinoma. A systematic literature search was performed on scientific databases including Scopus, Web of Science, MEDLINE, and EMBASE from their inception to September 2021. Studies comparing renal and cardiovascular outcomes between PN and RN in patients with renal cancer were included. The generic inverse variance method with random-effects models was used to determine the pooled hazard ratios and odds ratio for each outcome. Quality Assessment for observational studies was guided by the New-Castle Ottawa Scale. Overall, a total of 31 studies (n=51,866) reported renal outcomes, while 11 studies (n= 101,678) reported cardiovascular outcomes. When compared to PN, RN had a higher rate of new-onset postoperative EGFR <60 mL/min/1.73 m2 (HR 3.39; CI 2.45 - 4.70; I2=93%; P=<0.00001) and EGFR <45 mL/min/1.73 m2 (HR 4.70; CI 2.26 - 9.79; I2=98%; P=<0.0001). No difference was observed in new-onset advanced kidney disease and end-stage renal disease. A 19% reduction in cardiovascular events was observed in the PN group (HR 0.81; CI 0.70 - 0.93, P=0.002). No protective effect of PN was observed in new-onset or worsening hypertension (HR 0.85; CI 0.64 - 1.14, P=0.28) nor myocardial infarction (HR 0.86; CI 0.71 - 1.04, P=0.13). PN was associated with a decreased risk of postoperative early-stage CKD and cardiovascular events compared with RN. However, no benefit of PN over RN was observed in advanced CKD, new-onset or worsening hypertension, myocardial infarction, and cardiovascular mortality.

Outcomes of partial nephrectomy for non-metastatic cT2 renal tumors: Results from a Canadian multi-institutional collaborative.

690 Background: The role of partial nephrectomy (PN) is not well defined for cT2 renal cell carcinoma (RCC) as compared to radical nephrectomy (RN). The aim of this study was to examine oncological outcomes of PN as compared to RN for non-metastatic cT2 RCC. Methods: The Canadian Kidney Cancer information system was used to define patients who underwent surgery for non-metastatic cT2 RCC from January 2011 to October 2022. Patients with clear-cell, papillary, and chromophobe RCC were included. Other histology, multiple tumours, and hereditary RCC syndrome patients were excluded. Each PN patient was individually matched to RN up to 1:4 depending on availability of patients based on tumor size (+/- 1cm), histology, grade (clear cell and papillary), and necrosis (clear cell). Matched patients were analyzed as clusters. Results: A total of 1523 patients were identified, and 50 PN patients met study criteria who were then matched to 185 RN patients. Both groups had similar age, gender, smoking status, BMI, Charlson comorbidity index score, symptoms at presentation, baseline eGFR, hemoglobin and pathological characteristics. PN patients had smaller tumors (7.6 cm [IQR 2] vs 8.4 [IQR 2.4], p=0.05), had higher likelihood of undergoing open surgery (72.9% vs 31.8%, p&lt;0.0001) and less likely received adrenalectomy (2% vs 24.3%, p=0.0004). Positive surgical margin rates were similar in both groups (8.2% in PN vs 3.4% in RN, p=0.2). Median follow up was not significantly different in either group (3.6 yrs [IQR 4.7] in PN vs 3.3 [4.7] yrs in RN, p=0.9). During the follow up period, PN patients had higher risk of local recurrence (HR 3.0, 95%CI 1.08-8.37), lower risk of distant metastasis (HR 0.36, 95%CI 0.15-0.88), better cancer specific survival (HR 0.56, 95%CI 0.18-1.78) and overall survival (HR 0.36, 95%CI 0.11-1.19) and as compared to RN. At 6 months and beyond after surgery, PN patients had less decline in eGFR than RN patients (-16.6 [SD 21.1] vs -24.4[SD 16.2], p=0.0002). Complications rates between PN and RN were (18% vs 9%, p=0.057). Conclusions: In this multi-institutional Canadian cohort of patients with non-metastatic cT2 RCC undergoing surgery, PN compared to RN was associated with slightly higher risk of peri-operative complications, better preservation of renal function, and higher risk of local recurrence. The lower risk of distant metastasis and death was likely from residual confounding unaccounted for in the individual patient match. [Table: see text]

Laparoscopic versus robot-assisted partial nephrectomy for cT1 renal tumors in obese patients: Analysis of perioperative and follow-up functional outcomes (the RECORd2 project)

Laparoscopic versus robot-assisted partial nephrectomy for cT1 renal tumors in obese patients: Analysis of perioperative and follow-up functional outcomes (the RECORd2 project)

Redo robotic partial nephrectomy for recurrent renal tumors: Single high-volume center experience

Redo robotic partial nephrectomy for recurrent renal tumors: Single high-volume center experience

Anesthesia mumps with airway obstruction after radical nephrectomy: A case report and literature review.

Anesthesia mumps have rarely been reported. This article presents the diagnosis and treatment of a case of anesthesia mumps with airway obstruction in the urology department and reviews previous cases of the disease. A 58-year-old man had a history of hypertension and diabetes, and his blood pressure and glucose levels were well controlled. He underwent laparoscopic radical nephrectomy for a right renal tumor. Postoperatively, a swelling of approximately 5 × 4 cm was observed in the left parotid region and left eyelid, no palpable crepitation was detected, and the skin overlying the left parotid gland was mildly hyperemic and tender. Enhanced computed tomography of the head and neck revealed obvious swelling of the laryngopharyngeal airway, and electronic laryngoscopy showed narrow airway. Laboratory test results including white blood cell count, C-reactive protein, serum amylase, and lipase levels were normal. Glycosylated hemoglobin level was 6.8%, and the salivary culture from Stensen's duct was negative. The patient was managed with endotracheal intubation and a ventilator to maintain breathing along with anti-infection, expectorant, and symptomatic treatment. The swelling in the left parotid gland gradually resolved without recurrence, and the patient was extubated on the 7th postoperative day. In this case, the pathophysiology of anesthesia mumps may have been related to the incorrect positioning of the thick short neck and the use of a head ring, which can result in the squeezing of vessels. In most cases, the salivary gland swelling resolves with observation and symptomatic treatment. In patients with anesthesia mumps, emergency airway management and careful observation are necessary if upper airway obstruction occurs. This case report should increase awareness of anesthesia mumps and its complications among anesthesiologists, surgeons, and postoperative caregivers.

A Case of Severe Aortic Stenosis after Aortic Valve Neocuspidization Using Autologous Pericardium (Ozaki Procedure).

A 56-year-old man with a history of left nephrectomy for Wilms' tumor on chronic hemodialysis underwent aortic valve neocuspidization using autologous pericardium (Ozaki procedure) for aortic stenosis (AS) due to a bicuspid aortic valve 6 years ago. The AS gradually progressed and a decrease in the left ventricular ejection fraction was observed. Because of this, we decided to perform reoperative aortic valve replacement using a mechanical valve. Intraoperative findings showed severe calcification at the site where the autologous pericardium was sutured to the annulus. However, the degeneration of the valve leaflets themselves was mild. While excellent mid-term results have been reported for the Ozaki procedure, the long-term results are still unclear. In this case, the annulus was severely calcified, which reduced the mobility of the leaflet. We report the first case of AS progression requiring reoperation in the long-term period after the Ozaki procedure.

Embolization of Renal Pseudoaneurysm Following Partial Nephrectomy of Localized Tumour and Preserving Renal Function: Clinical Case and Review of Literature

Surgical procedures in highly vascularized renal parenchyma sometimes can cause iatrogenic vascular complications. Although incidence renal pseudoaneurysms after partial nephrectomy is low, around 1%, clinical presentation of these patients can be quite severe – hematuria, lumbar pain, dizziness, weakness. Prompt and precise diagnostics and treatment are essential. Ultrasound and Computed Tomography are two most common diagnostic approaches for the assessment of pseudoaneurysms or arteriovenous fistulas following partial nephrectomy. Endovascular selective microcoil embolization is a safe and effective kidney-preserving procedure for treating iatrogenic vascular complications. Although when embolizing renal arteries some of renal parenchyma loses perfusion and becomes fibrotic, no significant decrease in renal function in early post-embolization period was noted. Comparing open surgery to endovascular treatment of pseudoaneurysms, latter one allows shorter average hospital stay and less frequent cardiac and peripheral vascular complications. The article discusses a case of a patient that had developed renal pseudoaneurysm after partial nephrectomy. During a routine check-up of a middle-aged woman a presumable renal cyst was found. On more throughout examination the cyst was ruled as a tumour and partial nephrectomy was performed. After 12 days from surgery patient was admitted to hospital complaining macrohematuria, lower abdomen pain, episodic right-side ache. Urgent contrast enhanced computed tomography was performed, which confirmed that patient was bleeding from the operated kidney. Patient was admitted to interventional radiology departament and perform embolization of bleeding vessel. After embolization of pseudoaneurysm, bleeding was controlled and patient was completely treated.

The safety and efficacy of laparoscopic microwave ablation-assisted partial nephrectomy: a new avenue for the treatment of cystic renal tumors

Purpose Clinically, the management of cystic renal masses is tricky. The study aims to evaluate the safety and efficacy of laparoscopic microwave ablation-assisted partial nephrectomy (LMAPN) for cystic renal tumors. Methods and materials Between November 2017 and January 2022, LMAPN was performed on 43 patients (29 men and 14 women; age range: 22–80 years; median age 54 years) with Bosniak category III (n = 15) or IV (n = 28) cystic renal tumors (size range: 1.2–5.0 cm; mean size 2.8 cm). The median follow-up period was 26 months (range: 7–56 months). Baseline and perioperative data, pathological features, renal function, postoperative complications and oncologic outcomes were collected and evaluated. Results Forty-three cystic renal tumors were successfully managed by LMAPN. The mean operating time was 79 min (range: 40–130 min). The mean time of renal pedicle clamping was 19 min (range: 12–25 min). Mean intraoperative blood loss was 28.4 mL (range: 10–80 mL). The mean postoperative hospitalization duration was 4 days (range: 2–6 days). Negative surgical margins were diagnosed in all cases. During the follow-up, no patient appeared with distant metastasis, wound or peritoneal cavity implantation. No major but minor complications of Clavien–Dindo grade I were encountered after the operation. The 1-, 3- and 4-year overall survival rate was 100%, 96.6% and 88.5%, respectively. Conclusion This is the first study focusing on LMAPN for cystic renal tumors, demonstrating its favorable feasibility, safety and disease control. Long-term follow-up is necessary to draw conclusions on the preference and advantages of the new therapeutic approach.

Number of lymph nodes sampled in SFCE/SIOP 2001 patients with Wilms tumour: Is the goal of more than six achievable?

The number of lymph nodes (LN) that should be sampled during nephrectomy for Wilms tumour (WT) remains controversial but of utmost importance for staging purposes. The aim of this French national retrospective study of patients enrolled in SIOPWT2001 trial was to analyse the number of LN sampled according to their site and to determine if the number of six asked by the International Society of Paediatric Oncology - Renal Tumour Study Group (SIOP-RTSG) UMBRELLA protocol is achievable. We reviewed the data collected on central pathology review forms from 2002 to 2014 for only unilateral WT. LN were divided whether they were clearly identified by surgeons at nephrectomy or only found by pathologists on the nephrectomy specimen. A total of 539 patients (240 male/299 female) were included (458 localized/81 metastatic). Median age at surgery was 41.3months [0-189]. The number of LN sampled was 0, 1-6, ≥7 and unknown in 69 (12.8%), 293 (54.3%), 160 (29.7%) and 17 (3.2%) cases, respectively. The number of patients with sampled LN were higher if LN were identified by both the pathologist and the surgeon (n=231, 42.8%) (p=<.001). At least one invaded LN (LN+) was found in 66 patients (12.2%), more than half being found among patients having LN sampled by both pathologist and surgeon (p<.001). The mean number of identified LN was six if no LN+ was detected on final histological analysis, while it was 11 in case of LN+ (p<.001). The aim of sampling more than six LN is achievable, but only with the active collaboration of both surgeons and pathologists.

Association of ABC and RENAL Scoring Systems With Morbidity in Partial Nephrectomy.

Different nephrometry scoring systems (NSSs) are used to evaluate the surgical complexity and outcomes of partial nephrectomy (PN) in patients with small renal tumors. This study aimed to assess the validity of nephrometry scoring systems towards aiding the preoperative planning of laparoscopic partial nephrectomy (PN). Data of 77 patients who underwent partial nephrectomy at the Puerto Real University Hospital between January 2011 and December 2017 were retrospectively analyzed. Statistical analyses were carried out to determine whether there was an association between the complexity of the surgical procedure and the assigned nephrometry scores. Operative complications (bleeding volume, conversion to open surgery, perioperative bleeding, and postoperative fistula) were significantly associated with independent variables (age, sex, body mass index, radiological tumor size, and operative ischemia time) and with the classification of patients using arterial-based complexity (ABC) and radius endophytic/exophytic nearness anterior-posterior location (RENAL) scores. There was also a strong correlation between the RENAL and ABC scores [Cramer's V coefficient (0.682) and Fisher's test (p<0.0001)]. The RENAL and ABC scores are associated with the risk of the complexity of partial nephrectomy for T1 renal tumors, even for ≥T1b tumors and/or with complex anatomical features.

V-029 TOTALLY ENDOSCOPIC SUBLAY (TES) REPAIR FOR L2-L3 INCISIONAL HERNIA

Abstract Aim Endoscopic lateral incisional hernia (IH) repair provides advantages in terms of low infection rates and hospital stay when compared with open repair. Material and Methods 62 years old men with a history of HTA and an open radical right nephrectomy for a renal tumor, developed a symptomatic iliac IH. L2–3 W2 according to the European Hernia Society (EHS) classification was clinically diagnosed and confirmed with a CT scan. Full endoscopic abdominal wall repair with defect closure was proposed. 3 trocars in right retrorectus space were placed. Once the lateral edge of the rectus sheath is reached, the posterior rectus sheath is incised, access to the preperitoneal lateral plane. During hernia sac dissection, an opening of the hernia sac occurs. The posterior layer is closed by a barbed suture, an accessory trocar placement was necessary for the closure. Subsequently, the internal oblique and transversus abdominis muscles that formed the defect were approximated with a barbed suture. During dissection, a right inguinal hernia was identified and repaired. A trimmed 20 x15 cm polipropilene mesh is placed in the preperitoneal space without fixation. Results The patient was discharged on the 3rd postoperative day without complications. Follow-up in the outpatient clinic at 6 months did not show any signs of recurrence. Conclusion Endoscopic abdominal wall reconstruction with posterior component separation is an alternative to the open procedure for lateral IH, providing a complete abdominal wall repair. The mesh is placed extraperitoneal with the advantages in terms of less adhesions and postoperative pain.