Surgical Management Of Renal Tumors Research Articles

Radical Nephrectomy for pT1a Renal Masses May be Associated With Decreased Overall Survival Compared With Partial Nephrectomy

We reviewed our surgical experience with small renal tumors, comparing overall survival in patients treated with radical and partial nephrectomy. Using our nephrectomy registry we identified patients with sporadic, unilateral, solitary and localized renal masses 4 cm or less who underwent radical or partial nephrectomy between 1989 and 2003. Patients with a solitary kidney or impaired renal function at presentation were excluded, leaving 648 available for analysis. Overall survival was estimated using the Kaplan-Meier method and associations with death were evaluated using Cox proportional hazards regression. At last followup 146 patients had died of any cause and 502 were alive at a median of 7.1 years. Radical and partial nephrectomy was performed in 290 and 358 patients, respectively. In all patients radical nephrectomy was not significantly associated with death from any cause compared with partial nephrectomy (RR 1.12, p = 0.52). However, there was a significant interaction with age, leading us to stratify our analysis at the median age of 65 years. In 327 patients younger than 65 years radical nephrectomy was significantly associated with death from any cause compared with partial nephrectomy (RR 2.16, p = 0.02). The increased risk of death persisted after adjusting for year of surgery (p = 0.02), preoperative creatinine (p = 0.03), Charlson-Romano index (p = 0.04), symptoms at presentation (p = 0.02), diabetes at presentation (p = 0.03) and histology (p = 0.02). Our results suggest that, compared with partial nephrectomy, radical nephrectomy is associated with decreased overall survival in younger patients with small renal masses.

5-Year Outcomes of Laparoscopic Partial Nephrectomy

Laparoscopic partial nephrectomy is increasingly a definitive therapeutic option in patients with a small renal mass. Intermediate term oncological outcomes after laparoscopic partial nephrectomy are excellent up to a mean followup of 3 years. We present outcomes in 56 patients, each of whom has now completed a minimum of 5 years of followup after laparoscopic partial nephrectomy. Of the 557 laparoscopic partial nephrectomies performed at our institution 58 patients with a localized tumor have completed more than 5 years since surgery. Clinical and renal functional data on 56 patients (97%) were obtained from medical records, radiographic reports and patient contact via telephone. Average patient age was 64 years and 9% were symptomatic at presentation. Average tumor size was 2.9 cm. On histopathology renal cell carcinoma was confirmed in 37 cases (66%) and pathological tumor stage was pT1a in 32 (86%). Final surgical margin was positive for cancer in 1 patient. Median serum creatinine preoperatively and postoperatively was 0.9 and 1.0 mg/dl, respectively. No patient with normal baseline serum creatinine undergoing elective laparoscopic partial nephrectomy had postoperative chronic renal insufficiency (serum creatinine more than 2 mg/dl). At a median followup of 5.7 years (range 5.0 to 6.9) no distant recurrence (0%) and a single local recurrence (2.7%) were detected. Overall and cancer specific survival was 86% and 100%, respectively, at 5 years. To our knowledge this is the initial report in the literature of oncological and renal functional outcomes 5 years after laparoscopic partial nephrectomy with excellent results comparable to those of open nephron sparing surgery. At our center laparoscopic partial nephrectomy is an established alternative to open partial nephrectomy.

RENAL CRYOABLATION AND RADIO FREQUENCY ABLATION: AN EVALUATION OF WORST CASE SCENARIOS IN A PORCINE MODEL

Although ablative technologies, including radio frequency (RF) ablation (RFA) and cryoablation (CA), are being used to treat renal masses, complications associated with injury to vital renal structures are not well understood. We investigated these worst case scenarios by deliberately targeting vital renal structures with CA or RFA in a porcine model. Following surgical exposure of the right kidney in female pigs a cryoneedle or an RF probe was deliberately placed under visual and ultrasound guidance in the renal pelvis (CA in 5 pigs and RFA in 7), major calix (CA and RFA in 5 each) or subsegmental renal vessels (CA in 5 pigs and RFA in 7). Cryo-energy or RF energy was then applied to create a 3 cm lesion. After 10 days the kidneys underwent gross and histological examination for urine and blood extravasation, cell death and injury. Ex vivo retrograde pyelography was performed to evaluate for urinary fistulas. All pigs tolerated the treatment and no procedure related deaths occurred. No significant bleeding was noted. RFA and CA created reproducible lesions and areas of cell death and necrosis. Despite significant intentional injury to the collecting system no urinary fistulas were demonstrated in CA specimens (0 of 15). In contrast, damage to the renal pelvis (4 of 7) by dry (3 of 4) or wet (1 of 3) RFA was associated with a high likelihood of urinary extravasation. This short-term study demonstrates that CA is safe, effective and not associated with urinary extravasation. In contrast, RFA to the renal pelvis is associated with urinary extravasation. Further studies are needed to support these findings.

Conservative Surgery of Renal Cell Tumors in 140 Patients: 21 Years of Experience

Operative method, course and complications were analyzed retrospectively in 140 patients who underwent a conservative operation for renal tumor between June 1969 and December 1990. In 53 patients (20 women and 33 men, mean age 61.2 years, range 38 to 77 years, with 49 renal cell carcinomas and 4 benign renal tumors) there was an imperative indication for an organ preserving operation because nephrectomy would have made dialysis obligatory. In 87 patients (29 women and 58 men, mean age 53.7 years, range 27 to 74 years, with 72 renal cell carcinomas and 15 benign renal tumors) the tumor was conservatively resected in the presence of a normal contralateral unit (elective indication) and 68 of these patients (78%) were symptom-free. In the imperative group 32 of 49 patients (65.3%) with renal cell carcinoma had no evidence of disease after a mean followup of 4.6 years. Known metastases were present in 4 of 7 patients who died of the tumors in this group. In 3 patients with an imperative indication for conservative surgery a second tumor occurred in the kidney: 2 were treated with further parenchyma sparing operations, while in 1 with poor physical condition no further measures were possible. Of 72 patients with renal cell carcinoma who underwent an elective operation 68 (94.4%) had no signs of tumor progression after a mean followup of 3.3 years. One patient died of tumor metastases, and 2 (2.7%) had tumor recurrence in the kidney requiring nephrectomy and enucleation, respectively. The 5-year cause-specific survival rates for the imperative and elective groups were 84% and 96%, respectively. Patients with a local stage T3 tumor were characterized by a significantly worse survival curve than those with a stage T1 or T2 tumor but no significant difference was noted among the various grades of differentiation.