Surgical Management Of Renal Tumors Research Articles

Surgical Management and Outcomes of Renal Tumors Arising from Horseshoe Kidneys: Results from an International Multicenter Collaboration

BackgroundDespite being the most frequent renal fusion anomaly, tumors arising from horseshoe kidneys (HSKs) are extremely rare and management guidance is lacking. ObjectiveTo evaluate the perioperative, oncological, and functional outcomes of surgically treated HSK tumors. Design, setting, and participantsA retrospective, multicenter cohort study of 43 HSK tumors in 40 patients was conducted, and technical description of the surgical approach has been provided. Surgical procedureSurgical resection of renal tumors arising from HSKs was performed either via open surgery or via minimally invasive surgery (MIS). MeasurementsWe analyzed patient and tumor characteristics as well as surgical technique, and functional and oncological outcomes. Results and limitationsEight patients were treated by MIS and 32 by open surgery. One patient (2.5%) experienced an intraoperative complication and 13 patients (32.5%) experienced postoperative complications, of which three (7.5%) were Clavien-Dindo ≥3 complications. Surgical margins were positive in two tumors (4.7%). The most frequent histology was clear-cell renal cell carcinoma (46.5%). The median follow-up was 51 (interquartile range [IQR] 17–73) mo. The 5-yr overall, cancer-specific, and recurrence-free survival rates were 81.2%, 86.8%, and 83.1%, respectively. The percent decreases in estimated glomerular filtration rate at discharge and the last follow-up were 15% (IQR 4–26%) and 17% (IQR 1–31%), respectively. Limitations include the cohort's retrospective nature, heterogeneity, and small sample size. ConclusionsSurgical management of tumors in HSKs can be approached via both open surgery and MIS, with maximal preservation of functional renal parenchyma. In this cohort, rates of complications, positive surgical margins, and renal functional decrease were acceptable, considering the anatomical complexity of these kidneys and tumors. These tumors display great variation in histological subtypes. Meticulous presurgical planning, taking advantage of advanced imaging techniques, can aid in achieving good outcomes. Patient summaryWe evaluated the surgical management of renal tumors in horseshoe kidneys, which are very rare. Although these procedures are highly complex, outcomes are acceptable. Modern imaging techniques are often required in presurgical planning.

Evolving trends in the surgical management of renal masses over the past two decades: A contemporary picture from a large prospectively-maintained database.

To investigate the trends in the presentation and surgical management of renal tumors at Singapore General Hospital, Singapore. We accessed our uro-oncological registry to extract the clinicopathological data of patients with renal tumors who underwent nephrectomy from 2000 to 2015. Binary logistic regression was used to identify predictors of nephron-sparing surgery utilization, Clavien-Dindo grade≥III complications and progression to stage≥3 chronic kidney disease. Cox regression models were created to evaluate the proportional hazards of the risk factors for overall survival and cancer-specific survival. A total of 1208 cases of nephrectomy were carried out between 2000 and 2015. The proportion of cT1a tumors increased from 2000-2004 to 2010-2015, which was accompanied by the doubling of utilization rates of nephron-sparing surgery and minimally invasive surgery. Charlson Comorbidity Index score <2, asymptomatic presentation, clinical T1a tumors and having an estimated glomerular filtration rate ≥30mL/min/1.73m2 were all independent predictors of nephron-sparing surgery utilization. Age, symptomatic presentation and nephron-sparing surgery utilization were all significantly associated with greater odds of having Clavien-Dindo grade≥III complications, whereas minimally invasive surgery was associated with decreased risk. The utilization of partial nephrectomy and minimally invasive surgery was significantly associated with a decreased risk of developing postoperative stage≥3 chronic kidney disease. Both overall survival and cancer-specific survival were not significantly affected by whether nephron-sparing surgery was utilized. There has been an increasing proportion of small renal masses diagnosed incidentally with a shift towards nephron-sparing surgery for clinically localized tumors. With the adoption of nephron-sparing surgery, progression to stage3 chronic kidney disease has decreased, without any compromise in oncological and survival outcomes.

Bone health and chronic kidney disease: another reason for partial nephrectomy?

To review the potential role of surgically induced nephron loss in calcium metabolism and its consequences on bone heath, and possible impact of surgical management of renal tumors on bone disorders. With long-term oncological equivalence to radical nephrectomy and renal functional benefit, partial nephrectomy is the reference standard for management of clinical T1 renal tumors. Impact of nephron preservation on reduction of cardiovascular sequelae of chronic kidney disease is controversial. Reports from preclinical models provide a mechanism for surgically induced nephron loss leading to vitamin D and calcium metabolism dysregulation, resulting in osteoporosis. Emerging retrospective data also suggest that nephron preservation in setting of surgical treatment of renal malignancy may reduce risk of chronic kidney disease and sequelae, including osteoporosis and fractures. The magnitude and broader impact is unclear as other reports suggest that surgically induced chronic kidney disease is more stable than its medical counterpart. Preclinical models and retrospective series suggest that surgically induced nephron loss is independently associated with development of osteopenia and fractures and biochemical events, which may lead to these subsequent events. Although prospective data is requisite, it is reasonable to prioritize nephron preservation when feasible in patients with preexisting disorders of bone metabolism, or to consider partial nephrectomy in patients with risk factors for osteoporosis.

Adapting Liver Transplantation Techniques in the Surgical Management of Renal Tumors with IVC Tumour Thrombus

Adapting Liver Transplantation Techniques in the Surgical Management of Renal Tumors with IVC Tumour Thrombus

Robotic Right Nephrectomy and Inferior Vena Cava Tumor Thrombectomy with Caval Patch Graft Reconstruction

Abstract Introduction: Despite the increasing popularity of laparoscopic and robotic approaches for renal tumors, open surgery is the standard approach for the surgical management of renal tumors with extension into the inferior vena cava (IVC).1 Abaza reported the first robot-assisted radical nephrectomy with IVC tumor thrombectomy in a series of five patients with good outcomes. Two patients necessitated cross-clamping of the IVC, and in all cases, the IVC cavotomy was closed using a two layer suture.2 We present our technique and perioperative results of the first robot-assisted radical nephrectomy and IVC tumor thrombectomy and reconstruction using a synthetic patch graft. Materials and Methods: A 61-year-old woman presented with an 8-cm right renal mass, bilateral pulmonary embolism, and IVC tumor thrombus extending into the subhepatic IVC. After counseling and discussion of all available treatment options, the patient opted for robotic-assisted surgical management. The procedure was performed by a s...

Practice Trends in the Surgical Management of Renal Tumors in an Academic Medical Center in the Past Decade

Objectives. To evaluate the trends of surgical treatment of the renal tumor in an academic medical center. Methods. Between 2001 and 2010, 505 were treated surgically at the Federal University of Sao Paulo for renal tumors. The following variables were observed and analyzed according to their evolution through time: frequency and types of surgeries performed, operative time, hospital stay, and warm ischemia time for partial nephrectomy. Results. An increase in the frequency of laparoscopic radical nephrectomies, open partial nephrectomies, and laparoscopic partial nephrectomies was observed when comparing the periods from 2001 to 2005 (4.3%, 2.6%, and 12.6%, resp.) and from 2006 to 2010 (13.2%, 18.6%, and 20.2%, resp.; ). The average of operative time, hospital stay, and tumor size diminished (from 211.7 to 177.17 minutes, from 5.52 to 4.22 days, and from 6.72 to 5.29 cm, resp.) when compared to the periods from 2001 to 2005 and from 2006 to 2010 (, , resp.). Conclusion. As time goes by, there has been a significant reduction in the hospital stay time, surgery time, and size of renal tumor in patients treated surgically. The frequencies of minimally invasive and nephron-sparing surgeries have increased over the last years.

Development of a surgical safety checklist for the performance of radical nephrectomy and tumor thrombectomy

BackgroundThe surgical management of renal cell carcinoma with invasion of the renal vein or inferior vena cava is associated with significant rates of perioperative morbidity and mortality. In this report we propose a surgical checklist aimed at reducing adverse events associated with the resection of these tumors.MethodsThis review describes the development of an evidence- and experience-based surgical checklist aimed at improving the perioperative safety of patients undergoing radical nephrectomy and tumor thrombectomy.ResultsReducing the risk of complications during the surgical management of renal tumors with venous invasion begins with appropriate pre-operative imaging aimed at defining the cranial extent of the tumor thrombus, thus facilitating accurate preoperative planning. Other key elements of the checklist are aimed at ensuring clear and precise pre-, intra- and postoperative communication between members of the multidisciplinary-care team.ConclusionA standardized surgical checklist may help to increase the perioperative safety of patients undergoing radical nephrectomy and tumor thrombectomy. Future validation studies are required to determine the clinical feasibility and post-implementation safety profile of this new checklist.

Comparative Effectiveness for Survival and Renal Function of Partial and Radical Nephrectomy for Localized Renal Tumors: A Systematic Review and Meta-Analysis

The relative effectiveness of partial vs radical nephrectomy remains unclear in light of the recent phase 3 European Organization for the Research and Treatment of Cancer trial. We performed a systematic review and meta-analysis of partial vs radical nephrectomy for localized renal tumors, considering all cause and cancer specific mortality, and severe chronic kidney disease. Cochrane Central Register of Controlled Trials, MEDLINE®, EMBASE®, Scopus and Web of Science® were searched for sporadic renal tumors that were surgically treated with partial or radical nephrectomy. Generic inverse variance with fixed effects models were used to determine the pooled HR for each outcome. Data from 21, 21 and 9 studies were pooled for all cause and cancer specific mortality, and severe chronic kidney disease, respectively. Overall 31,729 (77%) and 9,281 patients (23%) underwent radical and partial nephrectomy, respectively. According to pooled estimates partial nephrectomy correlated with a 19% risk reduction in all cause mortality (HR 0.81, p < 0.0001), a 29% risk reduction in cancer specific mortality (HR 0.71, p = 0.0002) and a 61% risk reduction in severe chronic kidney disease (HR 0.39, p < 0.0001). However, the pooled estimate of cancer specific mortality for partial nephrectomy was limited by the lack of robustness in consistent findings on sensitivity and subgroup analyses. Our findings suggest that partial nephrectomy confers a survival advantage and a lower risk of severe chronic kidney disease after surgery for localized renal tumors. However, the results should be evaluated in the context of the low quality of the existing evidence and the significant heterogeneity across studies. Future research should use higher quality evidence to clearly demonstrate that partial nephrectomy confers superior survival and renal function.

424 A POPULATION-BASED STUDY OF SURGEON CHARACTERISTICS ASSOCIATED WITH THE UPTAKE OF CONTEMPORARY TECHNIQUES IN RENAL SURGERY

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Practice Patterns, Cost Effectiveness III1 Apr 2012424 A POPULATION-BASED STUDY OF SURGEON CHARACTERISTICS ASSOCIATED WITH THE UPTAKE OF CONTEMPORARY TECHNIQUES IN RENAL SURGERY Stanley Yap, Shabbir Alibhai, David Margel, Robert Abouassaly, Narhari Timilshina, and Antonio Finelli Stanley YapStanley Yap Toronto, Canada More articles by this author , Shabbir AlibhaiShabbir Alibhai Toronto, Canada More articles by this author , David MargelDavid Margel Toronto, Canada More articles by this author , Robert AbouassalyRobert Abouassaly Cleveland, OH More articles by this author , Narhari TimilshinaNarhari Timilshina Toronto, Canada More articles by this author , and Antonio FinelliAntonio Finelli Toronto, Canada More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.490AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Current evidence supports new standards in the surgical management of renal tumors. Despite such evidence, we have witnessed a slow uptake of many of these contemporary techniques. Furthermore, we have a poor understanding of the factors involved in such uptake. We sought to evaluate surgeon-level characteristics associated with the uptake of laparoscopy, partial nephrectomy (PN), and adrenal-sparing approaches in the surgical management of renal tumors. METHODS Using the Ontario Cancer Registry, we identified surgeons treating renal cell carcinoma (RCC) in the province of Ontario, Canada between the years of 2002 to 2004. We then classified individuals within this cohort as either high or low utilizers of laparoscopy, PN, or adrenal-sparing approaches. Further variables analyzed included academic status, surgeon graduation year, and surgical volume status. We then utilized univariable and multivariable logistic regression models to assess predictors of uptake. RESULTS We evaluated 108 surgeons for their uptake of both laparoscopy and adrenal-sparing approaches and 94 surgeons for their uptake of PN. Regarding laparoscopy, we identified 32 surgeons (30%) as high users based on a cut-off of using laparoscopic approaches in at least 50% of their radical nephrectomies for tumors 7cm or smaller. Predictors of uptake of laparoscopy included graduation year after 1990 (OR 4.81, 95% CI 1.57-14.8) and high surgeon volume (OR 4.33, 1.60-10.4). We identified 41 surgeons (44%) as high users of PN based on a threshold of performing PN for >33% of their cases for T1a tumors. The only significant predictor of uptake of PN was academic status (OR 5.83, 1.96-17.3). We identified 69 surgeons (65%) as high users of adrenal-sparing approaches but did not identify any significant predictors for uptake in this group. CONCLUSIONS We identify unique factors contributing to the uptake of distinct surgical techniques in the management of RCC. This information sheds light on the underlying mechanisms and helps us understand how to further encourage the dissemination of these practices to achieve the highest quality of surgical care. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e174 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Stanley Yap Toronto, Canada More articles by this author Shabbir Alibhai Toronto, Canada More articles by this author David Margel Toronto, Canada More articles by this author Robert Abouassaly Cleveland, OH More articles by this author Narhari Timilshina Toronto, Canada More articles by this author Antonio Finelli Toronto, Canada More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Cold Intravascular Organ Perfusion for Renal Hypothermia During Laparoscopic Partial Nephrectomy

We report initial data on the safety and functional outcomes of renal hypothermia with arterial cold perfusion during partial nephrectomy. From June 2007 to June 2009, 31 consecutive patients underwent laparoscopic partial nephrectomy with hypothermia using renal arterial perfusion with cold, lactated Ringer's solution during renal ischemia. Doppler echography was done intraoperatively to evaluate renal perfusion. Complication data were reported prospectively. Median followup was 57 weeks (IQR 28, 83). The lowest recorded renal temperature during ischemia was 14C. Median tumor size was 4.0 cm (IQR 2.7, 6.2). Median estimated blood loss was 150 cc (IQR 100, 275). Median ischemia time was 35 minutes (IQR 26, 41). Doppler echography identified intrarenal arterial blood flow postoperatively in all cases. The median change in the estimated glomerular filtration rate from preoperatively to postoperative day 2 was 4 ml per minute (IQR -29, 19). Two months postoperative in 20 patients the median change was 3.5 ml per minute (IQR -6, 16.5). At last followup in 31 patients the overall change in the estimated glomerular filtration rate was -0.5 ml per minute (IQR -6, 6). Six complications developed in a total of 5 patients, of which 5 were grade 2 or less. One grade 3 postoperative hemorrhage from an arteriovenous fistula at the tumor resection site was treated with angiography and selective embolization. Cold intravascular perfusion during laparoscopic partial nephrectomy can achieve renal hypothermia below 15C. It is not associated with an immediate risk of renal vascular injury or thrombosis, as measured by Doppler echography in this series. Early changes in postoperative estimates of renal function appear minimal.

Limited Warm Ischemia During Elective Partial Nephrectomy has Only a Marginal Impact on Renal Functional Outcomes

Ischemic damage during partial nephrectomy increases with each minute of warm ischemia, leading some groups to advocate hypothermia in all cases or partial nephrectomy without vascular occlusion as a primary technique. The renal functional implications of these approaches have not been well studied in patients who undergo elective partial nephrectomy. We evaluated early and late renal functional outcomes in 1,132 patients with 2 functioning kidneys and normal preoperative serum creatinine who underwent partial nephrectomy without regional ischemia (58), with less than 30-minute warm ischemia (809) or with cold ischemia (265). The preoperative, postoperative and latest glomerular filtration rates were not significantly different in the 3 groups. At latest followup the relative decrease in renal function was less in cases without regional ischemia than in those with less than 30-minute warm ischemia and those with cold ischemia (0.5% vs 13% and 11%, respectively, p <0.001). In part this reflected selection bias since tumor size and the amount of parenchyma removed were lowest in that group (p <0.001). On multivariate analysis the percent of parenchyma preserved and the baseline glomerular filtration rate were strongly associated with the postoperative and latest glomerular filtration rates (p <0.001) but the partial nephrectomy approach was not (p >0.05). Adverse short or long-term renal functional outcomes were marginally increased in patients with 20 to 30-minute warm ischemia. However, such events were uncommon and renal failure developed in only 4 of 1,132 patients (less than 0.4%). During elective partial nephrectomy a warm ischemia time of less than 20 minutes is not associated with clinically relevant functional loss compared to that of alternative techniques. However, longer warm ischemia time may correlate with ischemic injury and should be avoided.

A History and Evolution of Laparoscopic Nephrectomy: Perspectives From the Past and Future Directions in the Surgical Management of Renal Tumors

June 25, 2010 marks the twentieth anniversary of the first clinical laparoscopic nephrectomy. Since the advent of this procedure a paradigm shift toward minimally invasive options for urological surgery has been witnessed, resulting in rapid technological innovations and improved patient outcomes. A history of the minimally invasive surgical management of renal masses is presented with a focus on laparoscopic nephrectomy.

7-Year Oncological Outcomes After Laparoscopic and Open Partial Nephrectomy

Open partial nephrectomy has proven long-term oncological efficacy. Long-term outcomes of laparoscopic partial nephrectomy are pending. We present the long-term outcomes of patients undergoing laparoscopic or open partial nephrectomy for a single cT1 renal cortical tumor 7 cm or less. Of 2,246 patients undergoing partial nephrectomy for a single cT1 tumor (1999 to 2008), minimum 7-year followup was available in 77 and 310, and minimum 1-year followup was available in 672 and 944 after laparoscopic and open partial nephrectomy, respectively. Survival and recurrence data obtained from medical records, radiographic reports and patient contact were analyzed retrospectively. Median followup after laparoscopic and open partial nephrectomy was 4.0 and 5.7 years, respectively. Oncological outcomes were excellent in both groups. On multivariable analysis predictors of all cause mortality included advancing age (p <0.0001), comorbidity (p <0.0001) and preoperative renal dysfunction (p = 0.0001) but not tumor size (p = 0.6) or operative approach (laparoscopic vs open partial nephrectomy, p = 0.06). Cancer recurred infrequently and only rarely caused mortality after laparoscopic or open partial nephrectomy. At 7 years metastasis-free survival was 97.5% and 97.3% (p = 0.47) after laparoscopic and open partial nephrectomy, respectively. After accounting for baseline differences between the cohorts using propensity score matching 7-year metastasis-free survival was similar after laparoscopic and open partial nephrectomy. Laparoscopic and open partial nephrectomy appear to provide similar long-term overall and cancer specific survival in patients undergoing partial nephrectomy for clinical stage T1 (7 cm or less) renal cortical tumors. Oncological outcomes at 7 years after laparoscopic and open partial nephrectomy are excellent with the majority (97%) of patients experiencing metastasis-free survival.

Contemporary Different Patterns of Indications and Outcomes for the Surgical Management of Renal Tumors in an Academic Center

Inconsistencies have been pointed out in the treatment of small renal tumors by laparoscopists, as many would remove the entire kidney unnecessarily, whereas open surgeons are more likely to perform partial nephrectomy. Thus, we compared the practice and outcomes between two groups of surgeons treating renal tumors. We reviewed the renal cancer database from our institution from January 2000 to October 2006 for data retrieval and analysis. The patients treated by the laparoscopy staff (LS) and the oncology staff (OS) were divided into two groups for comparison. Data were collected for age, gender, type of surgery performed, time of operation, length of stay in the hospital, complications, histological evaluation, operation room time, hospital stay time, complications rate, and overall survival. A total of 240 patients were evaluated, 149 in the LS group (62%) and 91 in the OS group (38%), and the results have been summarized. Fifty percent of all procedures were open; however, in the OS group 100% of the surgeries were open and in the LS group 19% of the cases were open. Interestingly, only 9% of the surgeries in the OS group were nephron sparing, whereas in the LS group 60% of the patients had their kidneys spared. OS treated a higher percentage of locally advanced tumors. Laparoscopists performed a more variety of surgical approaches including open procedures and performed much more nephron sparing surgeries than the oncologists. Open surgery still plays an important role for locally advanced disease and hilar tumors.

Deep Hypothermia and Circulatory Arrest in the Surgical Management of Renal Tumors with Cavoatrial Extension

The inferior vena cava (IVC) is involved in almost 5% to 10% of renal tumors. Their intraluminar extension to the cardiac cavities occurs with a tumor-thrombus formation at a percentage of 1%. The aim of this study is to present the principles of "radical" management that should be targeted to excision of the kidney together with the cavoatrial tumor-thrombus. From 2003 through 2008, we treated six patients with renal-cell carcinoma involving the IVC and/or the right cardiac chambers. The main symptoms leading to the diagnosis were hematuria, dyspnea, or lower limb edema. The extension of the tumor was type IV in three cases, type III in two, and type II in one case. Extracorporeal circulation combined with a short period of hypothermic circulatory arrest was the method used. Radical nephrectomy combined with cavotomy and atriotomy was performed to an "en-block" extirpation of the tumor-thrombus and allowed oncologic surgical clearance of the disease. There was no operative death. The mean postoperative course duration was 11 days, apart from one obese patient who presented postoperative pancreatitis and died on the 44th postoperative day due to respiratory failure. During the cumulative postoperative follow-up of 171 months the patients remain free of recurrence. The use of extracorporeal circulation and deep hypothermic circulatory arrest provides a good method for radical excision of renal carcinomas involving the IVC with satisfactory morbidity and long-term survival results. Cooperation of urologists and cardiac surgeons is necessary for this type of operation.

Guideline for Management of the Clinical T1 Renal Mass

Guideline for Management of the Clinical T1 Renal Mass

Management of the Adrenal Gland During Partial Nephrectomy

Nephron sparing surgery is an increasingly used alternative to Robson's radical nephroadrenalectomy. The indications for adrenalectomy in patients undergoing partial nephrectomy are not clearly defined and some surgeons perform it routinely for large and/or upper pole renal tumors. We analyzed initial management and oncological outcomes of adrenal glands after open partial nephrectomy. Institutional review board approval was obtained for this study. During partial nephrectomy the ipsilateral adrenal gland was resected if a suspicious adrenal nodule was noted on radiographic imaging, or if intraoperative findings indicated direct extension or metastasis. Concomitant adrenalectomy was performed in 48 of 2,065 partial nephrectomies (2.3%). Pathological analysis revealed direct invasion of the adrenal gland by renal cell carcinoma (1), renal cell carcinoma metastasis (2), other adrenal neoplasms (3) or benign tissue (42, 87%). During a median followup of 5.5 years only 15 patients underwent subsequent adrenalectomy (0.74%). Metachronous adrenalectomy was ipsilateral (10), contralateral (2) or bilateral (3), revealing metastatic renal cell carcinoma in 11 patients. Overall survival at 5 years in patients undergoing partial nephrectomy with or without adrenalectomy was 82% and 85%, respectively (p = 0.56). Adrenalectomy should not be routinely performed during partial nephrectomy, even for upper pole tumors. We propose concomitant adrenalectomy only if a suspicious adrenal lesion is identified radiographically or invasion of the adrenal gland is suspected intraoperatively. Using these criteria adrenalectomy was avoided in more than 97% of patients undergoing partial nephrectomy. Even using such strict criteria only 13% of these suspicious adrenal nodules contained cancer. The rarity of metachronous adrenal metastasis and the lack of an observable benefit to concomitant adrenalectomy support adrenal preservation during partial nephrectomy except as previously outlined.

Factors Predicting Renal Functional Outcome After Partial Nephrectomy

Compared to radical nephrectomy, partial nephrectomy better preserves renal parenchyma and function. Although several clinical factors may impact renal function after partial nephrectomy including preoperative function, age, gender and comorbidities, the contributions of tumor and surgical factors have not been well studied. We evaluate independent factors predicting functional outcomes after partial nephrectomy. Preoperative and all postoperative serum creatinine values for 1,169 patients undergoing partial nephrectomy were used to estimate glomerular filtration rate. Postoperative nadir glomerular filtration rate and ultimate glomerular filtration rate were analyzed using multiple pertinent covariates. Median preoperative, postoperative nadir and ultimate glomerular filtration rates were 77, 57 and 71 ml per minute per 1.73 m(2), respectively. Increasing age, gender, lower preoperative glomerular filtration rate, solitary kidney, tumor size, ischemia time and longer time to nadir glomerular filtration rate significantly predicted postoperative nadir glomerular filtration rate and ultimate glomerular filtration rate. Acute loss of renal function predicted lower ultimate glomerular filtration rate. In the entire cohort, in patients with normal preoperative renal function, and in those with baseline stage 3 and those with stage 4 chronic kidney disease the incidence of postoperative acute kidney injury after partial nephrectomy was 3.6%, 0.8%, 6.2% and 34%, and the incidence of chronic end stage renal disease after partial nephrectomy was 2.5%, 0.1%, 3.7% and 36%, respectively. Lower preoperative glomerular filtration rate, solitary kidney, older age, gender, tumor size and longer ischemic interval all predicted lower glomerular filtration rate after partial nephrectomy. Therefore, duration of renal ischemia is the strongest modifiable surgical risk factor for decreased renal function after partial nephrectomy, and efforts to limit ischemic time and injury should be pursued in open and laparoscopic partial nephrectomy.

Importance of surgical margins in the management of renal cell carcinoma

Surgical resection remains the standard treatment for clinically localized renal cell carcinoma. Pathological features of the surgical specimen, including the margin status, play an important part in determining the patient's prognosis. Negative surgical margins have traditionally been sought to maximize the efficacy of treatment. Initial concerns that partial nephrectomy might have high local recurrence rates compared with radical nephrectomy have now been minimized as a result of technological advances and refinements in surgical technique. Current concerns in relation to partial nephrectomy include the width of parenchymal tissue that should be removed to avoid positive surgical margins, effects of positive margins on recurrence-free survival, and the use of frozen-section analysis to determine margin status. Size of the surgical margin in partial nephrectomy does not seem to affect the risk of local tumor recurrence, and not all positive surgical margins lead to recurrent disease. Intraoperative frozen-section analysis is not definitive and its value in guiding the surgical management of renal tumors remains to be defined. Laparoscopic partial nephrectomy is emerging as an attractive approach for selected renal masses. Intraoperative use of ultrasound, cold-scissor parenchymal transection, embolization, and hilar clamping to achieve a bloodless operative field with clear visibility, may minimize the risk of positive margins during partial nephrectomy.

Comparison of Laparoscopic and Open Partial Nephrectomy for Tumor in a Solitary Kidney

We compared the postoperative and renal functional outcomes of patients undergoing open or laparoscopic partial nephrectomy for tumor in a solitary functioning kidney. Between 1999 and 2006, 169 open and 30 laparoscopic partial nephrectomies were performed for 7 cm or smaller tumors in a solitary functioning kidney. Data were collected in an institutional review board approved registry and median followup was 2.0 years. Preoperative and postoperative glomerular filtration rates were estimated with the abbreviated Modification of Diet in Renal Disease equation. By 3 months after open or laparoscopic partial nephrectomy, the glomerular filtration rate decreased by 21% or 28%, respectively (p = 0.24). Postoperative dialysis was required acutely after 1 open partial nephrectomy (0.6%) and 3 laparoscopic partial nephrectomies (10%, p = 0.01), and dialysis dependent end stage renal failure within 1 year occurred after 1 open partial nephrectomy (0.6%) and 2 laparoscopic partial nephrectomies (6.6%, p = 0.06). In multivariate analysis warm ischemia time was 9 minutes longer (p <0.0001) and the chance of postoperative complications was 2.54-fold higher (p <0.05) with laparoscopic partial nephrectomy. Longer warm ischemia time (more than 20 minutes) and preoperative glomerular filtration rate were associated with poorer postoperative glomerular filtration rate in multivariate analysis. Notwithstanding the association with warm ischemia time, the surgical approach itself was not an independent predictor of postoperative glomerular filtration rate (p = 0.77). While laparoscopic partial nephrectomy is technically feasible for tumor in a solitary kidney, warm ischemia time was longer and complication rates higher compared with open partial nephrectomy. In addition, although average loss of renal function at 3 months is equivalent (after accounting for warm ischemia time), a greater proportion of patients required dialysis temporarily or permanently after laparoscopic partial nephrectomy in this initial series. Therefore, open partial nephrectomy may be the preferred nephron sparing approach at this time for these patients at high risk for chronic kidney disease.