Surgical Treatment For Renal Tumors Research Articles

Radiomics and machine learning for renal tumor subtype assessment using multiphase computed tomography in a multicenter setting

ObjectivesTo distinguish histological subtypes of renal tumors using radiomic features and machine learning (ML) based on multiphase computed tomography (CT).Material and methodsPatients who underwent surgical treatment for renal tumors at two tertiary centers from 2012 to 2022 were included retrospectively. Preoperative arterial (corticomedullary) and venous (nephrogenic) phase CT scans from these centers, as well as from external imaging facilities, were manually segmented, and standardized radiomic features were extracted. Following preprocessing and addressing the class imbalance, a ML algorithm based on extreme gradient boosting trees (XGB) was employed to predict renal tumor subtypes using 10-fold cross-validation. The evaluation was conducted using the multiclass area under the receiver operating characteristic curve (AUC). Algorithms were trained on data from one center and independently tested on data from the other center.ResultsThe training cohort comprised n = 297 patients (64.3% clear cell renal cell cancer [RCC], 13.5% papillary renal cell carcinoma (pRCC), 7.4% chromophobe RCC, 9.4% oncocytomas, and 5.4% angiomyolipomas (AML)), and the testing cohort n = 121 patients (56.2%/16.5%/3.3%/21.5%/2.5%).The XGB algorithm demonstrated a diagnostic performance of AUC = 0.81/0.64/0.8 for venous/arterial/combined contrast phase CT in the training cohort, and AUC = 0.75/0.67/0.75 in the independent testing cohort. In pairwise comparisons, the lowest diagnostic accuracy was evident for the identification of oncocytomas (AUC = 0.57–0.69), and the highest for the identification of AMLs (AUC = 0.9–0.94)ConclusionRadiomic feature analyses can distinguish renal tumor subtypes on routinely acquired CTs, with oncocytomas being the hardest subtype to identify.Clinical relevance statementRadiomic feature analyses yield robust results for renal tumor assessment on routine CTs. Although radiologists routinely rely on arterial phase CT for renal tumor assessment and operative planning, radiomic features derived from arterial phase did not improve the accuracy of renal tumor subtype identification in our cohort.

PD08-04 VIRTUAL RENAL MASS BIOPSY: PREDICTING RENAL TUMOR HISTOLOGY ON ABDOMINAL CT IMAGES USING MACHINE LEARNING

You have accessJournal of UrologyCME1 Apr 2023PD08-04 VIRTUAL RENAL MASS BIOPSY: PREDICTING RENAL TUMOR HISTOLOGY ON ABDOMINAL CT IMAGES USING MACHINE LEARNING Abhinav Khanna, Vidit Sharma, Adriana Gregory, H. Chase Gottlich, Cole J. Cook, Jason Klug, Christine Lohse, Theodora Potretzke, Aaron Potretzke, Stephen A. Boorjian, R. Houston Thompson, Naoki Takahashi, Bradley Erickson, John Cheville, Timothy Kline, and Bradley Leibovich Abhinav KhannaAbhinav Khanna More articles by this author , Vidit SharmaVidit Sharma More articles by this author , Adriana GregoryAdriana Gregory More articles by this author , H. Chase GottlichH. Chase Gottlich More articles by this author , Cole J. CookCole J. Cook More articles by this author , Jason KlugJason Klug More articles by this author , Christine LohseChristine Lohse More articles by this author , Theodora PotretzkeTheodora Potretzke More articles by this author , Aaron PotretzkeAaron Potretzke 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 , Naoki TakahashiNaoki Takahashi More articles by this author , Bradley EricksonBradley Erickson More articles by this author , John ChevilleJohn Cheville More articles by this author , Timothy KlineTimothy Kline More articles by this author , and Bradley LeibovichBradley Leibovich More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003239.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Up to 20% of renal tumors are benign and may not require treatment. However, benign versus malignant renal tumors cannot be distinguished using cross-sectional imaging. Renal mass biopsy is a possible solution, but biopsy is invasive and has notable non-diagnostic and false negative rates. As a result, many patients proceed directly to treatment, including some who undergo extirpative surgery for benign tumors. We aim to develop a radiomics and machine learning model for distinguishing between oncocytoma versus malignant renal neoplasms based on abdominal CT images. METHODS: Our institutional registry was queried for patients who underwent surgical treatment of renal tumors from 2000-2018. All surgical specimens underwent pathology re-review by an expert genitourinary pathologist. A total of 843 images from 609 patients (434 images of oncocytoma and 409 images of malignant renal tumor) were included. A previously developed artificial intelligence algorithm for segmentation of kidney, cyst, and tumor area was applied. Images were preprocessed by resampling via linear interpolation to 0.8 mm x 0.8 mm x 5 mm, window/level=440/40, and intensity normalized [0 255]. Features were extracted for the tumor region using PyRadiomics with a fixed bin width of 16. Both unsupervised (PCA, tSNE) and supervised (LR, SVM) machine learning approaches were explored. Data was split 80:20, and cross validation was used in the training/validation set parameters. The best performing model based on F1 macro was then calibrated using an isotonic calibration approach. RESULTS: Dimensionality reduction showed adequate class separation (Figure 1A). The top 10 radiomic features showed a mixture of first and second order features (Figure 1B). The final model reached an accuracy of 0.90 (Figure 1C). Of the 168 images in the testing set, only 2 benign cases were predicted to be malignant, and 15 malignant cases were predicted to be benign. The AUC for oncocytoma versus malignant histology prediction was 0.96 with CI [0.93 0.98] (Figure 1D). CONCLUSIONS: We developed a machine learning model for accurately distinguishing benign oncocytoma versus malignant renal tumors based on CT images alone. This may provide an opportunity for non-invasive risk stratification of solid renal neoplasms, which could potentially reduce overtreatment of renal tumors. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e233 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Abhinav Khanna More articles by this author Vidit Sharma More articles by this author Adriana Gregory More articles by this author H. Chase Gottlich More articles by this author Cole J. Cook More articles by this author Jason Klug More articles by this author Christine Lohse More articles by this author Theodora Potretzke More articles by this author Aaron Potretzke More articles by this author Stephen A. Boorjian More articles by this author R. Houston Thompson More articles by this author Naoki Takahashi More articles by this author Bradley Erickson More articles by this author John Cheville More articles by this author Timothy Kline More articles by this author Bradley Leibovich More articles by this author Expand All Advertisement PDF downloadLoading ...

Nephrometric score based on 3D modeling (3D nephrometry score) for the probability prediction of intra- and postoperative complications for kidney surgery.

The purpose of the study is the development and evaluation of the informativeness of the author's 3D nephrometric score application to predict the probability of intraoperative and postoperative complications in kidney operations. The study includes 264 patients who underwent surgical treatment of renal tumors, before that CT and 3D modeling were carried out. All patients underwent an analysis of the surgical intervention complexity on the C-index, PADUA, R.E.N.A.L., and developed 3D nephrometric score. To determine the set of variables that allow to classify patients, the method of discriminant analysis was used to predict the nature, volume of blood loss, duration of ischemia, and the number of complications. The sensitivity and specificity of the predictors were estimated with the help of ROC analysis. Indicators have been established to classify patients according to the probability of complications, the amount of blood loss and the duration of ischemia during surgery for kidney cancer. We have created linear models that predict the development of bleeding during surgery, the volume of blood loss of more than 200 ml and the duration of ischemia more than 20 min, as well as the likelihood of complications using discriminant functions. The proposed author's nephrometric score exceeds the capabilities of C-index, PADUA, R.E.N.A.L in many ways in blood loss and time of ischemia predicting, which allows us to recommend it for the assessment of resectability in kidney operations.

Abordaje laparoscópico vs abierto para el tratamiento quirúrgico de los tumores renales: Experiencia en el Centro Médico ISSEMyM Toluca, México

Objetivo: Describir la experiencia en el tratamiento quirúrgico convencional y laparoscópico de los tumores renales en nuestro centro médico.
 Metodología: Estudio retrospectivo y descriptivo. Se analizó la base de datos de pacientes con tumores renales tratados mediante nefrectomía radical laparoscópica y abierta entre enero de 2013 y abril de 2019 y se analizaron variables clínicas, bioquímicas e histopatológicas, así como el tiempo de seguimiento.
 Resultados: Se realizaron 50 nefrectomías laparoscópicas y 44 abiertas. En general la mediana de edad fue 60 años, el sexo masculino y el riñón derecho fueron los más intervenidos (58.5% y 57.4%), el tamaño promedio del tumor fue menor para el abordaje laparoscópico que para el abierto (5.1 cm vs 6 cm), en ambos procedimientos el estadio clínico más frecuente fue el I y la estadificación pT1 representó el 60.6%, el sangrado promedio y los días de estancia intrahospitalaria fueron menores para el procedimiento laparoscópico que para el abierto (372ml vs 419ml y 1.9 vs 3.7 días) y el tiempo quirúrgico fue mayor en la nefrectomía laparoscópica que en la abierta (164 vs 133 minutos).
 Conclusiones: El tratamiento quirúrgico radical para los tumores renales sigue siendo el estándar de oro. Como opciones de este tratamiento se tiene al procedimiento laparoscópico y al convencional, obteniendo resultados oncológicos similares.

Predicting positive surgical margins in partial nephrectomy: A prospective multicentre observational study (the RECORd 2 project)

Purposeto evaluate clinical predictors of positive surgical margins (PSMs) in a large multicenter prospective observational study and to develop a clinic nomogram to predict the likelihood of PSMs after partial nephrectomy (PN). Materials and methodsWe prospectively evaluated 4308 patients who had surgical treatment for renal tumors between January 2013 and December 2016 at 26 urological Italian Centers (RECORd 2 project). Two multivariable logistic models were evaluated to predict the likelihood of PSMs. Center caseload was dichotomized using a visual assessment adjusted for several predictors of PSMs. A nomogram predicting PSMs was developed. ResultsOverall, 2076 patients treated with PN were evaluated. pT1a, pT1b, pT2 and pT3a were recorded in 68.7%, 22.6%, 2.1% and 6.6% of the patients, respectively. PSMs were recorded in 342 (16.5%) patients. From a null multivariable model against number of PN/year, 60 PN/year were identified as the best cut-off to define a high-volume centre. At multivariable analysis, clinical stage (cT1a vs. cT2 [OR 1.94]; p = 0.03), volume centre (≤60 PN/year) (OR 2.22; p < 0.0001), imperative vs elective indication (OR 2.10; p = 0.04), surgical technique (laparoscopic vs. open [OR 1.62; p = 0.002), lymphovascular invasion (OR 2.27; p = 0.01) and upstaging to pT3a (OR 2.81; p < 0.0001) were independent predictors of PSMs. The final nomogram included age, ASA score, Charlson score, clinical tumor stage, surgical indication, surgical approach, surgical technique, PADUA score, clamp procedure and volume centre. ConclusionsPSMs after PN were significantly more likely in patients with lower clinical stage, higher PADUA score, in individuals referred to laparoscopic PN and in those treated at lower volume centers. We used these data to develop a nomogram to predict such risk.

Modified Makuuchi incision in the surgical treatment of renal tumors: Initial results.

To evaluate the modified Makuuchi incision in the surgical treatment of renal tumors. A total of 29 patients with renal tumors were operated using the modified Makuuchi incision. Patients' age ranged from 48 to 72 years. Twenty-three patients were male, and 6 patients were female. Renal tumors affected the right side in 22 patients and the left side in 7 patients. Twenty-six patients underwent radical nephrectomy, while 3 patients underwent partial nephrectomy. A perfect exposure was achieved with this incision in the surgical field. No serious complications such as bleeding or other organ injuries happened during the surgery. Blood transfusion during surgery was unnecessary. Additional use of analgesics due to wound pain during the postoperative period was not required. Incision-related complications, such as wound infection and wound dehiscence, did not occur in the early postoperative period. Patients had no complaints about the cosmetic appearance of their abdomen due to the incision. Incisional hernia was not observed in patients. This type of incision provided a perfect exposure of the field in the surgical treatment of renal tumors.

Evolution of Robot-assisted Partial Nephrectomy: Techniques and Outcomes from the Transatlantic Robotic Nephron-sparing Surgery Study Group

BackgroundRobot-assisted partial nephrectomy (RAPN) is considered a feasible minimally invasive alternative to open partial nephrectomy (OPN) for the surgical treatment of renal tumors. ObjectiveTo provide further evidence supporting the effectiveness of RAPN in a contemporary patient population treated at one of three tertiary care centers for robotic surgery and to describe the evolution of RAPN-based technical improvements. Design, setting, and participantsThe Transatlantic Robotic Nephron-sparing Surgery (TRoNeS) study group prospectively collected data from 635 patients subjected to RAPN for clinically localized kidney cancer between 2010 and 2016 at three high-volume tertiary care centers. Surgical procedureRAPN was performed using methods outlined in the supplementary video using either the da Vinci Si or Xi surgical system (Intuitive Surgical, Sunnyvale, CA, USA). MeasurementsClinical data were collected within a prospectively maintained multi-institutional database. Intra- and postoperative data as well as surgical outcomes were assessed. Descriptive statistical analysis was performed and multivariable logistic regression models were fitted to determine the predictors of surgical outcomes. Results and limitationsMean patient age was 60.7yr and mean preoperative tumor size was 33mm. According to the PADUA score, 202 (31.8%) patients had a low-, 235 (37.0%) had an intermediate-, and 198 (31.2%) had a high-complexity tumor. In the majority of patients, a transperitoneal approach was used (n=447; 70.4%). Mean operative time was 156.3min and mean estimated blood loss was 171ml. Overall, 25 (3.9%) patients experienced a significant (Clavien-Dindo >2) complication after surgery. No statistically significant differences between pre- and postoperative creatinine values were observed (p≤0.823). Finally, optimal surgical outcomes defined according to the margin, ischemia, and complication score were achieved in 459 (72.3%) individuals. At a mean follow-up of 26mo, only two local and two distant recurrences of the disease were observed. Finally, in multivariable logistic regression models, tumor complexity was associated with the risk of not achieving optimal surgical outcomes. ConclusionsRAPN represents an effective minimally invasive alternative to OPN in the treatment of clinically localized renal tumors. Patient summaryWe reported contemporary experience with RAPN for the treatment of kidney cancer. RAPN appears to be a safe and effective procedure, resulting in optimal outcomes in the majority of individuals despite tumor complexity.

Practical aspects of treatment of kidney cancer in a modern hospital: the evolution of surgical approaches

Objective: analysis of results of the outcomes of surgical treatment for renal tumors in the Saint Petersburg City Hospital No. 40 over the last 5 years and determination the trends.Materials and methods. The study included 293 patients that underwent 296 surgeries for renal tumors. The majority of patients (87.84 %) were diagnosed with localized cancer, whereas locally advanced and metastatic forms were detected in 4.39 and 7.77 % of cases respectively. We performed radical nephrectomy (RNE) or nephron sparing (NS) via open or minimally invasive route (videoendoscopic or robot-assisted surgery using the da Vinci Surgical System).Results. Organ-preserving surgeries were performed in 52.36 % of patients, RNE – in 47.64 % of patients; minimally invasive and open surgeries were conducted in 95.95 and 4.05 % respectively. In individuals with stage cT1a cancer, NS and RNE were performed in 87 and 13 % of cases respectively; in patients with stage cT1b cancer, NS and RNE were performed in 50.82 and 49.18 % of cases respectively. The majority (90.2 %) of patients with renal tumors &gt;7 cm underwent minimally invasive surgeries, primarily RNE. The incidence of severe postoperative complications after NS and RNE was comparable: 5.75–8.06 and 1.67–15.38 % respectively (р = 0.64).Conclusion. Minimally invasive NS is the method of choice for stage сT1 tumors; however, in some cases, we should also consider it for tumors &gt;7 cm. Videoendoscopic surgery is the most preferable option for these patients, whereas robot-assisted techniques should be used for organpreserving surgeries and RNE in difficult cases.

Risk of Nephrectomy in Previous Living Kidney Donors.

For patients with a solitary kidney, such as living kidney donors, the surgical treatment of renal tumors may result in loss of function of the remaining kidney. We conducted a retrospective, matched cohort study to determine the long-term risk of partial or total nephrectomy in previous living kidney donors compared to healthy nondonors. We reviewed the predonation charts for all living kidney donors in Ontario, Canada between 1992 and 2010 and linked this information to provincial healthcare databases. We matched 2119 donors to 21190 nondonors from the general population with similar baseline health. The median length of follow-up was 9.5 years (maximum 21.7 years). The rate of nephrectomy in follow-up was lower in donors versus nondonors (0 vs. 1.78 per 10000 person years; P = 0.037). In a subset of 1773 donors matched to 1773 healthy nondonors with renal imaging (median follow-up 7.6 years, maximum 21.0 years), the rate of nephrectomy was not statistically different in donors versus nondonors (0 vs. ≤5 per 10000 person years; P > 0.08). No living kidney donor in our cohort received a partial or total nephrectomy of their remaining kidney during our follow-up period. Although we will continue to follow people in this study, these interim results are reassuring for the safety of kidney donation.

Renal tumors presentation: Changing trends over two decades

We have analyzed the changing trends in surgical treatment of renal tumors over the last 2 decades with regard to age incidence, presentation, incidental detection, and histopathology. Records of renal tumors were analyzed from January 1, 1988 to December 31, 2007. Data were split into 4 parts based on a 5-year time period, 1 for each cohort of patients: cohort 1 (1988-1992)-103 patients, cohort 2 (1993-1997)-161 patients, cohort 3 (1998-2002)-243 patients, and cohort 4 (2003-2007)-304 patients. A comparative study was performed with regard to age incidence, presentation, incidentallomas, histopathology, and management with statistical analysis. Out of 811 renal tumors, 17.63% cases were benign and 82.37% were malignant. In the first cohort, 34.95% cases were detected in the seventh decade as compared with cohort 4 in which these were detected in the sixth (34.86%) and fifth decades (21.38%). Incidentallomas increased from 11 (10.67%) in cohort 1 to 84 (27.63%) in cohort 4 (P = 0.001). The cases of surgically treated tumors increased in number from 103 to 304 in cohort 4. Among the presenting features, incidence of weight loss, flank pain, and lump decreased while other clinical syndromes were constant. Only open radical nephrectomy was performed in the first 2 consecutive timeperiods. Laparoscopic radical nephrectomy was increasingly used in cohort 4 as compared with cohort 3 (121 vs 32, respectively). Similarly, open nephron sparing surgery (NSS) was increasingly used in cohort 4 as compared with cohort 3. Among the histopathologies, clear cell carcinoma was most common (73.35 %), but Fuhrman grading showed a trend toward more cases detected with grade 1 and 2 in cohort 4; 23.73% and 61.86%, respectively, as compared with 15.85% and 45.12% in cohort 1 (P = 0.001); more T1 tumors were detected (63.42% in cohort 4 as compared with 41.46% in cohort 1). A majority of renal tumors presented as symptomatic tumors. Recently, tumors are being detected at an early stage and grade; in the younger patients, with an increasing trend of laparoscopic and open NSS.

Commentary on Factors predicting health-related quality of life recovery in patients undergoing surgical treatment for renal tumors: Prospective evaluation using the RAND SF-36 health survey: Novara G, Secco S, Botteri M, De Marco V, Artibani W, Ficarra V, Department of Oncological and Surgical Sciences, Urologic Clinic, University of Padua, Padua, Italy

Most newly diagnosed kidney cancers present at localized stages. With appropriate treatments, the cancer-specific survival rates of such patients are extremely high, which makes patients' health-related quality of life (HRQOL) a relevant issue. To date, most of the available studies on HRQOL have been biased by the absence of baseline HRQOL assessments and by retrospective designs. To evaluate the baseline HRQOL of patients with kidney cancer, comparative HRQOL during the first year after surgery, and the prognostic factors predictive of HRQoL recovery. We prospectively collected the data of all patients undergoing surgery for kidney tumors at a tertiary academic referral center from February 2006 to September 2007. Patients underwent nephron-sparing surgery (NSS) or radical nephrectomy (RN). Patients were invited to self-complete the validated, Italian version of the RAND 36-Item Health Survey 1.0 (SF-36) before surgery, 6 months after surgery, and 12 months after surgery. Overall, 129 consecutive patients were evaluated. No significant differences were found between the baseline scores of our patients and age- and sex-matched normative data for the Italian general population. Comparing the baseline SF-36 scores to those at 6 months and 12 months, there was statistically significant worsening in the physical domains and improvement in the emotional domains (all P < 0.05). About 50%- to 80% of patients returned to baseline scores 6 months and 12 months after surgery. Age, body mass index (BMI), educational level, occupational status, New York Heart Association (NYHA) functional class, tumor mode of presentation, pathologic stage, size, and histologic subtype were associated with 6-month and 12-month return to the baseline HRQOL scores. The main limitation of the study was the lack of a disease-specific questionnaire. Most patients returned to preoperative HRQoL within 12 months after RN or NSS. Several patient features, clinical variables, and pathologic tumor variables predict the return of HRQOL.

Factors Predicting Health-Related Quality of Life Recovery in Patients Undergoing Surgical Treatment for Renal Tumors: Prospective Evaluation Using the RAND SF-36 Health Survey

BackgroundMost newly diagnosed kidney cancers present at localized stages. With appropriate treatments, the cancer-specific survival rates of such patients are extremely high, which makes patients’ health-related quality of life (HRQoL) a relevant issue. To date, most of the available studies on HRQoL have been biased by the absence of baseline HRQoL assessments and by retrospective designs. ObjectiveTo evaluate the baseline HRQoL of patients with kidney cancer, comparative HRQoL during the first year after surgery, and the prognostic factors predictive of HRQoL recovery. Design, setting, and participantsWe prospectively collected the data of all patients undergoing surgery for kidney tumors at a tertiary academic referral center from February 2006 to September 2007. InterventionsPatients underwent nephron-sparing surgery (NSS) or radical nephrectomy (RN). MeasurementsPatients were invited to self-complete the validated, Italian version of the RAND 36-Item Health Survey 1.0 (SF-36) before surgery, 6 mo after surgery, and 12 mo after surgery. Results and limitationsOverall, 129 consecutive patients were evaluated. No significant differences were found between the baseline scores of our patients and age- and sex-matched normative data for the Italian general population. Comparing the baseline SF-36 scores to those at 6 mo and 12 mo, there was statistically significant worsening in the physical domains and improvement in the emotional domains (all p<0.05). About 50–80% of patients returned to baseline scores 6 mo and 12 mo after surgery. Age, body mass index (BMI), educational level, occupational status, New York Heart Association (NYHA) functional class, tumor mode of presentation, pathologic stage, size, and histologic subtype were associated with 6-mo and 12-mo return to the baseline HRQoL scores. The main limitation of the study was the lack of a disease-specific questionnaire. ConclusionsMost patients returned to preoperative HRQoL within 12 mo after RN or NSS. Several patient features, clinical variables, and pathologic tumor variables predict the return of HRQoL.

Editorial Comment on: Factors Predicting Health-Related Quality of Life Recovery in Patients Undergoing Surgical Treatment for Renal Tumors: Prospective Evaluation Using the RAND SF-36 Health Survey

Editorial Comment on: Factors Predicting Health-Related Quality of Life Recovery in Patients Undergoing Surgical Treatment for Renal Tumors: Prospective Evaluation Using the RAND SF-36 Health Survey

Editorial Comment on: Factors Predicting Health-Related Quality of Life Recovery in Patients Undergoing Surgical Treatment for Renal Tumors: Prospective Evaluation Using the RAND SF-36 Health Survey

Editorial Comment on: Factors Predicting Health-Related Quality of Life Recovery in Patients Undergoing Surgical Treatment for Renal Tumors: Prospective Evaluation Using the RAND SF-36 Health Survey

Simplified Cardiopulmonary Bypass Technique for the Surgical Treatment of Renal Tumors with Intracaval and Intracardiac Extensions

The authors report four cases of renal tumors with intracaval and intracardiac extensions that can be removed successfully during cardiopulmonary bypass surgery. The management was relatively simple: mild hypothermia, empty heartbeat, monocaval cannulation, and no circulatory arrest. Bleeding from the hepatic or renal veins was controlled by temporary occlusion of the hepatic artery, the portal vein, and the renal artery for a short duration. The authors also advocate thrombectomy of the hepatic vein using direct observation to relieve hepatic congestion. No complications were experienced postoperatively. One patient died of systemic metastasis 9 months after the operation. Another died of cytomegalovirus infection 3 months postoperatively. The remaining 2 are leading normal lives. Although the surgical indication for these advanced tumors is controversial, the patients' quality of life may be improved by this aggressive yet simple and safe approach.