Nephron-sparing Surgery For Renal Tumors Research Articles

Utilizing RENAL nephrometry in pediatric patients undergoing nephron-sparing surgery for renal tumors: A single-institutional cohort

RENAL Nephrometry is a complexity score validated in adults with renal tumors and describes the likelihood of complication after partial nephrectomy (PN). Utilization in pediatrics has been limited. Thus, our goal is to quantify inter-rater agreement as well as determine how scores correlate with outcomes. We hypothesize that the RENAL Nephrometry Score is reproducible in children with renal tumors and is related to perioperative and post-operative complications. All pediatric patients who underwent PN for a renal mass from 2006 to 2019 were identified. Patient data, operative details, and outcomes were aggregated. Pre-operative CT/MR imaging was anonymized and scored by 2 pediatric radiologists and 2 pediatric urologists using RENAL Nephrometry metrics. Statistical analysis utilized Fleiss' kappa and the intraclass correlation coefficient (ICC). Comparative analyses were performed based on Nephrometry Score <9 and≥9. 28 patients undergoing 33PN were identified. Median age at surgery was 3.2 years (IQR 1.8-4.0). There is moderate-good agreement across scorers on the domains of RENAL Nephrometry Score, with the lowest agreement noted for anterior vs posterior tumors. Comparing patients with scores <9 and≥9, there was increased operative time (357 vs 267min, p=0.003) and LOS for those with a higher score, but no difference in the incidence of 30-day complications. RENAL Nephrometry Score is an easily reproducible complexity score for renal tumors in pediatric patients. Higher scores are associated with increased length of stay and estimated blood loss but not complications. Reporting of nephrometry scores in future publications on pediatric renal tumors should become standard in the literature.

Effect on Pre-operative Anxiety of a Personalized Three-dimensional Kidney Model Prior to Nephron-sparing Surgery for Renal Tumor.

Effect on Pre-operative Anxiety of a Personalized Three-dimensional Kidney Model Prior to Nephron-sparing Surgery for Renal Tumor.

Robotic nephron-sparing surgery for renal tumors: Current status.

There have been a number of advances in robotic partial nephrectomy (RPN) for renal masses. We reviewed these advances with emphasis on the evolution of technique and outcomes as well as the expanding indications for RPN. Literature in the English language was reviewed using the National Library of Medicine database. Relevant articles were extracted, and their citations were utilized to broaden our search. The identified articles were reviewed and summarized with a focus on novel developments. RPN is an evolving procedure and is an emerging viable alternative to laparoscopic partial nephrectomy and open partial nephrectomy with favorable outcomes. The contemporary techniques used for RPN demonstrate excellent perioperative outcomes. The short-term oncologic outcomes are comparable to those of laparoscopic and open surgical approaches. Further studies are needed to assess long-term oncologic control.

Nephron-Sparing Surgery for Renal Tumors Measuring More Than 7 cm: Morbidity, and Functional and Oncological Outcomes

BackgroundThe purpose of this study was to evaluate morbidity, functional, and oncological outcomes after NSS in renal tumors > 7 cm. Materials and MethodsWe retrospectively analyzed data from 168 patients with tumors > 7 cm who were treated using NSS between 1998 and 2012. ResultsImperative and elective indications accounted for 76 (45.2%) and 92 (54.8%) patients, respectively. Major perioperative complications and renal function deterioration occurred in 33 (19.6%) and 51 patients (30.4%), respectively. In multivariate analysis, age older than 60 years (P = .001; hazard ratio [HR], 5) and tumor malignancy (P = .014; HR, 6.7) were prognostic factors for renal function deterioration whereas imperative indication was a risk factor for major postoperative complications (P = .0019; HR, 2.7). In 126 (75%) patients with malignant tumors, after a median follow-up of 30 months (range, 1-254 months), 25 patients (20.2%) died. In multivariate analysis, imperative indication (P = .023; HR, 4.2), positive surgical margin (P = .021; HR, 3.3), and Fuhrman grade > II (P = .013; HR, 3.7) were prognostic indicators for cancer-free survival (CFS). Imperative indication (P = .04; HR, 8.5) and Fuhrman grade > II (P = .04; HR, 3.9) were predictive factors of cancer-specific survival (CSS). In case of elective indication, positive surgical margin, local recurrence, and cancer-related death occurred in 4 (7.6%), 1 (1.1%), and 1 (1.1%) cases, respectively. For elective indication, 5-year estimates of CFS, CSS, and overall survival rates were: 85.7%, 98%, and 93.9%, respectively. ConclusionIn this selected population, imperative vs. elective indication status seems to play a critical role in oncologic outcomes. Oncologic results for elective indications are close to those reported with radical nephrectomy.

Reply

We appreciate the editorial comment on our article. The comment highlighted the 2 most important aspects in organ sparing surgery, cancer control and preservation of function of the native organ. With regard to these aspects, testicular-sparing surgery (TSS) draws comparison with nephron-sparing surgery for renal tumors. Both surgeries aim for complete tumor resection while preserving the functions of the remaining organs, but while nephron-sparing surgery has evolved over many years and is now considered a standard procedure for small renal tumors, TSS is an evolving surgical technique that is not yet widely practiced. Editorial CommentUrologyVol. 81Issue 4PreviewThe authors describe an interesting technique for testicular preservation surgery using a hook wire localization method in conjunction with intraoperative Doppler imaging to remove a testicular mass. A similar technique using placement of a comparable needle adjacent to the tumor was reported by Hallak et al (referenced above) but the current report involves needle deployment directly into the testicular lesion. Both reports advocate cold ischemia resection, but the current article does not use concurrent frozen section assessment of tumor margins. Full-Text PDF

Editorial Comment

The authors describe an interesting technique for testicular preservation surgery using a hook wire localization method in conjunction with intraoperative Doppler imaging to remove a testicular mass. A similar technique using placement of a comparable needle adjacent to the tumor was reported by Hallak et al (referenced above) but the current report involves needle deployment directly into the testicular lesion. Both reports advocate cold ischemia resection, but the current article does not use concurrent frozen section assessment of tumor margins. Hook Wire Localization for Testis Sparing SurgeryUrologyVol. 81Issue 4PreviewTo describe a novel technique for localizing small testicular mass during testicular-sparing surgery (TSS). Full-Text PDF ReplyUrologyVol. 81Issue 4PreviewWe appreciate the editorial comment on our article. The comment highlighted the 2 most important aspects in organ sparing surgery, cancer control and preservation of function of the native organ. With regard to these aspects, testicular-sparing surgery (TSS) draws comparison with nephron-sparing surgery for renal tumors. Both surgeries aim for complete tumor resection while preserving the functions of the remaining organs, but while nephron-sparing surgery has evolved over many years and is now considered a standard procedure for small renal tumors, TSS is an evolving surgical technique that is not yet widely practiced. Full-Text PDF

Comparative Analysis of Radiologically Measured Size and True Size of Renal Tumors

PurposeWe evaluated the differences between radiologically measured size and pathologic size of renal tumors.Materials and MethodsThe data from 171 patients who underwent radical or partial nephrectomy for a renal tumor at Ajou University Hospital were reviewed. Radiologic tumor size, which was defined as the largest diameter on a computed tomographic scan, was compared with pathologic tumor size, which was defined as the largest diameter on gross pathologic examination.ResultsMean radiologic size was significantly larger than mean pathologic size for all tumors (p=0.019). When stratified according to radiologic size range, mean radiologic size was significantly larger than mean pathologic size for tumors <4 cm (p=0.003), but there was no significant difference between the sizes for tumors 4-7 cm and >7 cm. When classified according to histologic subtype, mean radiologic size was significantly larger than mean pathologic size only in clear cell renal cell carcinomas (p=0.002). When classified according to tumor location, mean radiologic size was significantly larger than mean pathologic size in endophytic tumors (p=0.043) but not in exophytic tumors. When endophytic tumors were stratified according to radiologic size range, there was a significant difference between the mean radiologic and pathologic sizes for tumors <4 cm (p=0.001) but not for tumors 4-7 cm (p=0.073) and >7 cm (p=0.603).ConclusionsOur results suggest that in planning a nephron-sparing surgery for renal tumors, especially for endophytic tumors of less than 4 cm, the tumor size measured on a computed tomography scan should be readjusted to get a more precise estimate of the tumor size.

Renal function after nephron-sparing surgery for renal tumors

Nephron sparing surgery (NSS) is a technique more frequently utilized in the case of surgical treatment of kidney tumor. The aim of the study is to assess renal function in patients treated with NSS for renal tumors. Twenty patients, after NSS performed for renal tumor, were included in the study. In each patient dynamic renal scintigraphy was performed before surgical treatment (test No. 1) and after a mean interval of 12 months after surgical procedure (test No. 2). In each test renographic curves were evaluated. Creatinine levels and GFR rates were also assessed. Mean GFR was 84 ml/min/1.73 m2 before surgery, and 79 ml/min/1.73 m2 after surgical procedure. Mean change of GFR value after the surgical procedure was -5.1 (p >0.058). On renography significant deterioration of renal function was observed in the operated kidneys of 4 patients (20%) after NSS, insignificant deterioration - in four patients (20%) and improvement of renal function of operated kidney was found in one patient. In 12 patients (60%) no change was observed. The relative percentage GFR-share of operated kidney decreased by the average value of 3.8% (p >0.005). Multifactorial analysis did not identify significant effect of potential risk factors on the function of the kidney subjected to NSS. Preliminary results of this study confirm that deterioration of renal function after NSS is a rare event.

1533 COMPARISON OF RATES AND RISK FACTORS FOR DEVELOPMENT OF ERECTILE DYSFUNCTION AFTER RADICAL OR PARTIAL NEPHRECTOMY

You have accessJournal of UrologySexual Function/Dysfunction/Andrology: Evaluation1 Apr 20111533 COMPARISON OF RATES AND RISK FACTORS FOR DEVELOPMENT OF ERECTILE DYSFUNCTION AFTER RADICAL OR PARTIAL NEPHRECTOMY Ryan Kopp, Jonathan Silberstein, Reza Mehrazin, Aditya Bagrodia, Robert Wake, Anthony Patterson, Jim Wan, and Ithaar Derweesh Ryan KoppRyan Kopp San Diego, CA More articles by this author , Jonathan SilbersteinJonathan Silberstein New York, NY More articles by this author , Reza MehrazinReza Mehrazin Memphis, TN More articles by this author , Aditya BagrodiaAditya Bagrodia Memphis, TN More articles by this author , Robert WakeRobert Wake Memphis, TN More articles by this author , Anthony PattersonAnthony Patterson Memphis, TN More articles by this author , Jim WanJim Wan Memphis, TN More articles by this author , and Ithaar DerweeshIthaar Derweesh San Diego, CA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.1528AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Nephron Sparing Surgery (NSS) has emerged as a preferred treatment option for small renal masses, comparing favorably with radical nephrectomy (RN) from the standpoint of oncologic efficacy and conferring superior renal functional preservation. Erectile function may be affected by declining renal function. We examined the incidence of and risk factors for development of erectile dysfunction (ED) in patients who underwent RN and NSS. METHODS Retrospective review of 432 patients (264 RN/168 NSS, mean age 58 years, mean follow-up 5.8 years) who underwent RN or NSS for renal tumors at two institutions from 1/1998 to 12/2007. Demographics and disease characteristics, metabolic parameters [estimated Glomerular Filtration Rate (GFR), serum creatinine, hyperlipidemia, diabetes mellitus (DM)], pre- and postoperative ED (Sexual Health Inventory for Men score <22) and response rate to 5-phosphodiesterase inhibitor therapy (5-PDEi) were recorded in sexually active men. Data were analyzed within subgroups based on treatment (RN vs. NSS). Multivariate analysis (MVA) was conducted to elucidate risk factors for development of de novo ED. RESULTS RN and NSS groups had similar demographics and comorbidities. Tumor size (cm) was significantly larger for RN (RN 7.0 vs. NSS 3.7, p<0.001). No significant differences were observed for preoperative eGFR, hyperlipidemia, and DM. Significantly more preoperative ED existed in NSS vs. RN (p=0.042). Postoperatively, significantly higher rates of de novo DM (11.4% vs. 4.2%, p=0.015), eGFR<60 mL/min/1.73m2 (33.0% vs. 9.8%, p<0.001), and ED (29.5% vs. 9.5%, p<0.001) developed in RN vs. NSS cohorts, respectively. Overall response rate to 5-PDEi was 63% without significant difference between the two groups (p=0.896). MVA demonstrated RN (OR 3.56, p<0.001), hyperlipidemia (OR 2.32 p = 0.014), postoperative DM (OR 2.93, p<0.001), preoperative (OR 8.77, p<0.001) and postoperative (OR 2.64, p<0.001) eGFR <60mL/min/1.73m2 were significantly associated with de novo ED. CONCLUSIONS Patients undergoing RN had significantly higher de novo ED compared to a contemporary, well-matched cohort undergoing NSS. RN, DM, and eGFR<60 were associated with development of ED. Further investigation on effects of nephron loss on ED is requisite. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e615-e616 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ryan Kopp San Diego, CA More articles by this author Jonathan Silberstein New York, NY More articles by this author Reza Mehrazin Memphis, TN More articles by this author Aditya Bagrodia Memphis, TN More articles by this author Robert Wake Memphis, TN More articles by this author Anthony Patterson Memphis, TN More articles by this author Jim Wan Memphis, TN More articles by this author Ithaar Derweesh San Diego, CA More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

Short-Term Functional and Oncologic Outcomes of Nephron-Sparing Surgery for Renal Tumours ≥7 cm

BackgroundNephron-sparing surgery (NSS) for renal tumours preserves renal function and has become the standard approach for small renal tumours. Little is known about perioperative and oncologic outcomes of patients following NSS in renal tumours ≥7cm in the presence of a healthy contralateral kidney. ObjectiveTo analyse oncologic outcomes and perioperative morbidity in patients treated by NSS for renal tumours ≥7cm. Design, setting, and participantsIn total, 5767 patients were treated for renal tumours at two institutions from 1984 to 2009. In 91 patients, elective NSS was performed for renal tumours ≥7cm. MeasurementsComplication rates were assessed in detail and stratified using the Clavien-Dindo score (CDS). Oncologic outcomes for overall survival (OS), cancer-specific survival (CSS), and progression-free survival (PFS) were estimated using the Kaplan-Meier method. Logistic regression analysis was used to identify clinical risk factors for complications and prognosticators that have an oncologic impact on OS. Results and limitationsThe median follow-up was 28 mo (range: 1–247 mo). Twenty-seven patients (29.6%) had perioperative complications and, of these, 89.1% had CDS grade 1 and 2.Twenty-seven percent of the 91 patients had benign lesions. Seven patients (10.6%) died from cancer-related causes. The 5- and 10-yr rates for OS, CSS, and PFS were 88% and 64%, 97% and 83%, and 91% and 78%, respectively. None of the analysed parameters had an impact on morbidity or OS in the univariate analysis. Limitations of this study were its retrospective nature and the relatively short follow-up period for oncologic outcome. ConclusionsNSS for renal tumours ≥7cm can be performed with acceptable complication rates and with oncologic outcomes comparable to radical nephrectomy studies. Our findings support NSS whenever technically feasible to reduce the loss of renal function.

Imperative and Elective Indications for Nephron-Sparing Surgery for Renal Tumors: Long-Term Oncological Follow-Up

Nephron-sparing surgery (NSS) is mandatory for patients with renal tumors in both kidneys or in a solitary kidney in order to preserve renal function (imperative indication). NSS has also become the gold standard (elective indication) for small unilateral renal tumors (< 4 cm) with a normal contralateral kidney. We report the oncological long-term follow-up of NSS of our own series and discuss the results of the current literature. From 1979 until 2006, a total of 851 patients was treated at our institution by NSS. The mean tumor diameter was 3 cm (0.5-11 cm) for elective cases and 4.2 cm (1.2-11 cm) for imperative cases. The median follow-up for elective cases is 4.7 years (0.1-24.1 years) and imperative cases 8 years (0.1-25.8 years). Cancer-specific survival (CSS) and local recurrence-free survival (RFS) were estimated. Estimated CSS at 5 and 10 years for elective indications were 98.5% and 96.7% and for imperative indications (solitary kidney) 89.6% and 76%. RFS after 5 and 10 years for elective indications were 98.3% and 95.7%; and for imperative indications (solitary kidney) 89.4% and 79.9%. Chronic renal failure requiring haemodialysis developed after NSS in a solitary kidney in nine patients (11.2%). NSS can be performed with oncologically safe and good functional results in imperative indications. In elective indications the resectability of a tumour rather than size and location is the limiting factor.

Nephron-sparing surgery for renal tumours on kidney transplantation

IntroductionNowadays, nephron-sparing surgery for renal carcinoma achieves good oncological results, similar to radical surgery, with the advantage of preserving renal function. Renal cell carcinomas appear de novo in 4.6% of post-transplant patients compared with 3% of tumors in the general population, affecting less than 10% to renal allograft. ObjectiveThe purpose is to analyze our experience and make a literature review about the role of nephron-sparing surgery to treat de novo renal tumours in renal grafts. Material and methodsA retrospective and descriptive analysis has been realized, finding four patients who presented with de novo renal tumours over renal graft after kidney transplantation and treated by nephron-sparing surgery. A Medline review is done to search similar series published. Oncological and functional results were reviewed and analyzed. We worked with SPSS 12.0 software. ResultsMedium age at diagnosis was 46.5 and (42–62). Medium size was 2.4cm. (1.5–3.5) and final histology showed medium tumours size of 3.0cm. (1.7–3.5). Medium hospital stay was 6.0d. Medium time from transplantation to diagnosis was 92 months (42–192). NSS was done in all cases, in 3 cases tumorectomy and one partial nephrectomy. Transfusion was only needed in one case. All cases had pT1aN0M0 RCC histology exam. Renal function did not change from preoperative. All patients are free of progression with a medium follow-up of 46.5 months (15–58). ConclusionsNSS could be an option to treat graft tumours in selected cases, preserving renal function. In our experience, it is a safe and efficient treatment in patients with small de novo renal tumours over renal graft.

Comparison of rates and risk factors for developing chronic renal insufficiency, proteinuria and metabolic acidosis after radical or partial nephrectomy

To investigate the incidence of and risk factors for developing chronic renal insufficiency (CRI), proteinuria and metabolic acidosis (MA) in patients treated with radical nephrectomy (RN) or nephron-sparing surgery (NSS). We retrospectively reviewed 749 patients (mean age 57.7 years; mean follow-up 6.4 years) who had RN or NSS for renal tumours between July 1987 and June 2006 at our institution. The demographics and outcomes were analysed and recorded. The primary outcome variable was the development of an estimated glomerular filtration rate (eGFR) of <60 mL/min/1.73 m(2), with secondary outcomes being the development of a serum creatinine level of > or =2.0 mg/dL, MA (serum bicarbonate <22 mmol/L), and proteinuria (> or =1+ on dipstick testing). Multivariate logistic regression (MV) was used to identify risk factors for developing an eGFR of <60 mL/min/1.73 m(2), a creatinine level of > or =2.0 mg/dL and MA. Of the 749 patients, 499 had RN and 250 NSS; there were no significant demographic differences between the groups. After surgery a significantly greater proportion of the RN than the NSS group had a low eGFR (44.7% vs 16.0%, P < 0.001), MA (12.8% vs 7.2%, P = 0.02), proteinuria (22.2% vs 13.2%, P = 0.003) and elevated creatinine (14.2% vs 8.4%, P = 0.022). MV showed that diabetes mellitus (odds ratio 8.96, P = 0.002), RN (5.32, P < 0.001), hypertension (4.55, P = 0.003), a body mass index (BMI) of > or =30 kg/m(2) (3.51, P = 0.017), age > or =60 years (2.91, P = 0.015) and smoking (2.44, P = 0.014) were risk factors for developing a low eGFR; and that age > or =60 years (2.00, P = 0.019), diabetes mellitus (10, P < 0.001), hypertension (7.41, P = 0.002), smoking (5.29, P < 0.001) and RN (3.08, P < 0.001) were risk factors for developing an elevated creatinine level; and that being male (2.50, P = 0.019), age > or =60 years (3.13, P = 0.002), a BMI > or =30 (3.52, P < 0.001), RN (9.82, P < 0.001), preoperative eGFR <60 (9.71, P < 0.001) and elevated creatinine (5.9, P = 0.008) were risk factors for developing MA. Patients undergoing RN had significantly greater CRI, MA and proteinuria rates than a well-matched group undergoing NSS. In addition to RN, age > or =60 years, diabetes mellitus, hypertension and smoking were associated with progression to CRI after surgery.

Application of CT angiography in laparoscopic nephron-sparing surgery for renal tumors

Objective To discuss the application value of CT angiography (CTA) in evaluating renal artery anatomy of laparoscopic nephron-sparing surgery (LNSS) before operation. Methods Retroperitoneal LNSS was performed in 87 patients with renal tumors. Forty cases underwent CTA before LNSS, volume rendering and maximum intensity projection of renal artery were used as three-dimensional reconstruction. The other 47 without CTA were compared as control. Treatment out-comes of the 2 groups were compared, including operation time, warm ischemia time, blood loss, con-version to open surgery, hospitalization stay after operation, and complications after operation. Re-sults All the procedures were completed laparoscopically with no conversion to open surgery in CTA group. One patient underwent conversion to open surgery in the control group. In CTA and control group, the operation time was 94 min(range, 76-118)and 115 min(90-190, P<0.05). The warm ischemia time was 23 min(12-39)and 29 min(18-40, P<0.05). Blood loss was 90 ml(9.0-160) and 130 m1(90-600, P<0.01). Hospitalization stay after operation was 4.1 d(3-5) and 5.5 d(3-9), respectively(P<0.05). The pathologic examination showed negative surgical margin in all cases of renal cell carcinoma. The patients were followed up for 4 months to 32 months. Neither distant nor local recurrences were observed, and the renal function was normal in all cases. Urinary leakage oc-curred in 1 patient of each group. Conclusions CTA could be an effective method in evaluating the supply blood vessels of kidney before LNSS. And it can shorten the operation time and warm ischemia time, reduce the blood loss, as the result of helping the operaters deal with renal artery more quickly and accurately. Key words: Kidney neoplasms; Laparoscopes; Nephron-sparing surgery; Tomography, X-ray computed; Reconstruction

Laparoscopic Partial Nephrectomy in a Solitary Kidney

Purpose: Nephron-sparing surgery for renal tumors in solitary kidneys has several technical difficulties and complications, including renal failure. We evaluated operative outcome and feasibility in patients with renal cell carcinoma in a solitary kidney treated with laparoscopic partial nephrectomy. Materials and Methods: Between September 2003 and September 2008, 59 patients with renal tumors underwent laparoscopic partial nephrectomy. Among them, 4 patients with a solitary kidney were enrolled in the study. The mean age of the 2 male and 2 female patients was 66.8 years old, and their mean body mass index was 24.7. The mean size of the tumor was 3.5 cm. Results: The mean operative time was 138.5 minutes, and estimated blood loss was 163.8 ml. In 2 patients, warm ischemic times were 25 and 55 minutes. Initiation of postoperative oral intake and ambulation were at 1.0 and 1.5 days. The mean hospital stay was 15.0 days. One patient had a complication of urinary leakage. Pathologic examination revealed renal cell carcinomas with negative surgical margins in all patients. The mean serum creatinine level of preoperative and postoperative day 1 was 1.04 and 1.73 mg/dl, respectively. One patient required temporary hemodialysis. At the mean follow-up of 21.3 months, there was no recurrence of tumors. The mean serum creatinine level at the final visit was 1.36 mg/dl. Conclusions: Laparoscopic partial nephrectomy for renal tumors in solitary kidneys can be performed safely. Although it is a possible modality with excellent outcome, long-term follow-up for cancer control, along with advanced laparoscopic technique and experience, is necessary. (Korean J Urol 2009;50:463-467) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏

UP.16: Nephron-Sparing Surgery for Renal Tumors: Laparoscopic-Assisted Radio Frequency Ablation with Curative Intent

Laparoscopic-assisted radiofrequency ablation is a minimally-invasive treatment option for the preservation of renal parenchyma, particularly in patients with increased co-morbidity. We present our short-term results of patients treated by this novel technique.

Minimally invasive nephron-sparing surgery

To review the evolution and current status of minimally invasive nephron-sparing surgery for renal tumors. Minimally invasive nephron-sparing surgery for renal tumors encompasses extirpative laparoscopic partial nephrectomy and ablative procedures such as cryoablation, radiofrequency ablation, and recently radiosurgery. Minimally invasive nephron-sparing surgery modalities are associated with decreased morbidity when compared with open partial nephrectomy. Recent multicenter study comparing laparoscopic partial nephrectomy and open partial nephrectomy demonstrated that equivalent cancer-specific survival was similar between the two modalities. Encouraging long-term data are available for laparoscopic partial nephrectomy and cryoablation. However, some concerns remain about incomplete tumor cell kill after radiofrequency ablation. Radiosurgery is a promising new technology, but is still experimental. In 2008, open partial nephrectomy and laparoscopic partial nephrectomy are the reference standards for treating the small renal mass, with laparoscopic partial nephrectomy increasingly becoming the preferred option at major tertiary referral centers. Encouraging long-term data for ablative technologies are emerging.

Nephron-Sparing Surgery for Renal Tumours: Acceleration and Facilitation of the Laparoscopic Technique

ObjectivePresent our surgical technique for and experience with laparoscopic partial nephrectomy (LPN) for renal tumours during warm ischaemia. MethodsTwenty-five patients underwent LPN during warm ischaemia via a transperitoneal four-trocar approach. Mean tumour size was 26.2±7.3mm (range: 11–39mm). Sixteen tumours were exophytic, 7 endophytic, and 2 central. The renal vessels were secured by an umbilical tape and occluded by a self-made Rumel tourniquet. Tumours were excised with a cold Endo-shear. The interstitial tissue and collecting system was closed using a running suture secured by two resorbable clips. Parenchymal edges were approximated using a running suture over a haemostatic bolster. The threads were secured by non-resorbable clips. During follow-up, renal function was evaluated by determination of serum creatinine, 99mTc-mercaptoacetyltriglycine scintigraphy, and parenchymal transit time. ResultsMean ischaemia time was 28.9±5.2min (range: 19–40min) and the mean blood loss was 177.4±285.5ml (range: 50–1500ml). No intraoperative complications occurred and no patient needed conversion to open surgery. Surgical margins were negative in all patients. One postoperative surgical-related perirenal haematoma occurred, which was treated conservatively (no transfusions required). None of the patients had a urinary leak. During a mean follow-up of 6.2 mo (range: 1–15 mo), none of the patients had local or port-site recurrence or distant metastasis. Parenchymal transit time was increased in 1 of 10 investigated patients (ischaemia time: 26min), indicating ischaemic parenchymal damage. ConclusionOur technical refinements for LPN during warm ischaemia have widened indications to more complex tumours. The use of clips rather than knot tying made the procedure easier and faster and allowed completion of the suturing during an acceptable warm ischaemia time. The self-made Rumel tourniquet is safe and efficient for vessel control and occlusion. These improvements increase feasibility so that LPN can be used by more laparoscopic urologic surgeons.

Nephron-Sparing Surgery for Renal Tumor: A Choice of Treatment in an Allograft Kidney

The incidence of de novo malignancies is an accepted complication of organ transplantation. Renal cell carcinoma (RCC) was 4.6% of cancers occurring de novo in organ allograft recipients compared with 3% in the general population. Less than 10% of these renal cancers affected the renal allograft. Among patients developing a renal tumor in the kidney allograft, transplant nephrectomy reduced the quality of life. For these patients for whom preservation of renal function is a relevant clinical consideration, partial nephrectomy may be considered the choice for treatment. Fifteen cases have been reported regarding conservative surgery on kidney transplant tumors. Herein we have reported three cases of renal masses in well-functioning kidney transplants that were successfully treated with nephon-sparing surgery. Our experience demonstrated that in selected patients, nephron-sparing surgery on a renal allograft represents a feasible approach for tumor removal with preservation of graft function.

Partial nephrectomy with perfusion cooling for imperative indications: a 24‐year experience

To report our 24-year experience with open nephron-sparing surgery for renal tumours, using cold ischaemia achieved by renal artery perfusion, as partial nephrectomy for imperative indications is a surgical challenge. From 1980 to 2004, open partial nephrectomy was performed in 717 patients; of these, 65 (9.1%) with a solitary kidney, synchronous bilateral tumours or renal failure in the opposite kidney (imperative indication) had surgery under cold ischaemia, achieved by continuous perfusion of Ringer's lactate at 4 degrees C through the renal artery, which was clamped and cannulated. The tumour was resected in a bloodless field, with biopsies taken from the tumour bed. Focusing on patients with an imperative indication and cold perfusion, we report our perfusion technique, and the ischaemia time, complication rate and cancer-specific survival rate of these patients. The mean (SD, range) operative duration was 132 (103, 91-252) min and ischaemia time 49 (37, 31-71) min. The most common complications were postoperative haemorrhage in 19%, urinary fistula in 8% and acute renal failure in 6% of patients. There were no specific complications related to the perfusion technique (renal artery stenosis, renal artery or vein thrombosis). The mean (SD, range) long-term follow-up of 95 (71, 4.3-231) months showed increased but constant creatinine values (95 micromol/L before, 182 micromol/L after surgery; P < 0.05) with no need for long-term dialysis. The tumour-specific survival rate was 94%, 76% and 76% after 1, 5 and 10 years, respectively. Partial nephrectomy under cold ischaemia remains reserved for selected patients with renal tumours with an imperative indication. The technique provides excellent intraoperative visibility in an absolutely bloodless field, allows surgery with no pressure of time, and makes ex vivo workbench surgery with autotransplantation unnecessary. Perfusion cooling allows good tumour-specific long-term results, with stable residual kidney function sufficient to prevent dialysis.