Partial nephrectomy for renal cell carcinoma: indications, results and implications

Of 52 patients who underwent partial nephrectomy for tumor 44 were found to have renal cell carcinoma. The indications for this parenchyma-sparing procedure were categorized according to the initial status of the contralateral kidney and included bilateral tumors or tumor in a solitary kidney in 16 patients (mandatory indications), unilateral carcinoma with compromise of the contralateral kidney by a benign disease process in 9 (relative indications) and small peripheral tumor with a normal contralateral kidney in 19 (elective indications). There were 4 recurrences that accounted for 3 deaths, all in patients with mandatory indications. All patients who underwent partial nephrectomy for relative or elective indications were without definite evidence of recurrent disease at last followup (over-all mean 36 months). Our results suggest that conservative surgery can often provide effective and advantageous therapy for renal cancer and we encourage further consideration of the role of partial nephrectomy as an alternative to radical nephrectomy in selected patients with small peripheral tumors and normal contralateral kidneys.     

Open surgical partial nephrectomy for upper tract urothelial carcinoma

We aimed to determine the ability of partial nephrectomy to prevent end‐stage renal disease and tumor recurrence or progression in patients with upper tract urothelial carcinoma. Retrospectively, eight patients undergoing partial nephrectomy for upper tract urothelial carcinoma were identified and their medical records reviewed. All patients had imperative indications for nephron sparing, and diagnosis of upper tract urothelial carcinoma not adequately amenable to endoscopic management. Although three patients suffered acute tubular necrosis, only one required postoperative hemodialysis. During the follow‐up period 25% (2/8) developed end‐stage renal disease, including the one patient who had received postoperative hemodialysis. Recurrences occurred in five of seven patients with adequate oncological surveillance. Recurrences were successfully treated endoscopically in 80% (4/5) patients, and one patient had metastases. Of the eight patients, four have died. Death occurred 4 months, 1 year, 1.2 years and 3.5 years after partial nephrectomy. Of these patients, one succumbed to metastatic disease; the exact cause of death is unknown in the other three, but there was no documentation of metastatic cancer. The mean duration of follow up in the remaining four patients, all without evidence of metastatic urothelial cancer, is 71 months (range 22–108 months). In summary, partial nephrectomy for upper tract urothelial carcinoma in patients with imperative indications averts end‐stage renal disease in most patients, and appears to be associated with acceptable disease‐specific survival. Partial nephrectomy is a sparingly used option in patients with upper tract urothelial carcinoma refractory to endoscopic management who have imperative indications for nephron sparing.     

Should elective partial nephrectomy be performed for renal cell carcinoma >4 cm in size?

This Practice Point discusses the study of Pahernik and colleagues, which compared outcomes of partial nephrectomy between 102 patients with renal cell carcinoma >4 cm in size and 372 patients with tumors 相似文献   

Partial nephrectomy for renal cell carcinoma using a microwave tissue coagulator--postoperative recurrence and renal function

Nowadays, partial nephrectomy is often selected for treatment of small renal cell carcinoma (RCC) because T1a RCC shows a favorable prognosis with a 5-year overall-survival rate exceeding 90%. To determine the methodological usefulness and treatment outcome of partial nephrectomy using microwave tissue coagulator (MTC), we evaluated our series of 121 patients (124 kidneys) with T1 RCC who underwent this procedure. Ninety-nine patients were elective and 22 patients were imperative cases. This procedure was indicated for asymptomatic solitary RCC; < or =4 cm in diameter in elective cases or < or =5 cm in imperative cases, expanding outward with a clear capsule, and showing neither renal pelvis nor renal sinus invasion. The median operation time was 150 minutes and the median blood loss was 217 ml. Eight patients needed transfusion, and conservative therapy cured 4 patients of postoperative urine leakage successfully. Three patients underwent early secondary nephrectomy due to multiple RCCs, invasive spindle cell carcinoma, or prolongation of urine leakage. No significant deterioration of renal function by creatinine clearance (Ccr) was observed, and postoperative Ccr could be precisely predicted from preoperative serum creatinine value and the renal parenchymal volume estimated with 3-dimensinal image reconstruction. Five-year overall-survival rate was 91% at the mean follow-up of up to 37.9 months and 107 patients were alive without disease. One patient showed local recurrence 2 years later and underwent radical nephrectomy. We believe that non-ischemic partial nephrectmy using MTC is a simple and reliable nephron-sparing surgery for small RCC in respect of postoperative recurrence and preservation of renal function.     

Results of conservative treatment of upper urinary tract transitional cell carcinoma

BACKGROUND: The treatment preserving the kidney for upper urinary tract tumor is still controversial. The indications and results of conservative treatment remain to be elucidated. Experiences of this type of treatment are reported. METHODS: Between April 1981 and March 1998, 14 patients with upper urinary tract transitional cell carcinoma were treated with renal preserving methods. Five were elective and nine were imperative cases. Treatments performed were partial nephrectomy, partial ureterctomy with or without adjuvant chemotherapy, endoscopic tumor resection and topical bacillus Calmette-Guerin instillation in one, 10, two and one patient, respectively. RESULTS: Crude and cause-specific 5 year-survival rates were 91.7 and 100%, respectively. Of 14 patients, five had bladder recurrences, but ipsilateral local recurrence developed in only one patient. Two patients died from metastasis of transitional cell carcinoma 61 and 89 months after initial treatment. The lesions of carcinoma in situ were well controlled with topical bacillus Calmette-Guerin therapy. CONCLUSION: The results of conservative treatment for upper urinary tract tumor were satisfactory and local excision can be indicated for low grade, solitary tumors located in the distal ureter.     

Non-ischemic partial nephrectomy using microwave tissue coagulator

PURPOSE: The indications and the safety of non-ischemic partial nephrectomy using a microwave tissue coagulator were studied. MATERIALS AND METHODS: Non-ischemic partial nephrectomy was performed on 17 kidneys of 16 patients using a microwave tissue coagulator. The diagnosis was renal tumor and renal stones in eleven and five patients, respectively. Renal tumors were less than 4 centimeters in diameter, while the stones were associated with a caliceal diverticulum or secondary cortical atrophy. Excision of the tumors was done via the retroperitoneal approach through an oblique lumbar incision. The needle of the microwave tissue coagulator was inserted around the tumor (stone) 10 to 20 times, and the coagulator was activated. Then the tumor (stone) was excised with a sharp knife or scissors. Patients were encouraged to walk on the first postoperative day. RESULTS: Vascular clamping was necessary in one patient to reduce bleeding. Nephrectomy was done after partial nephrectomy in one patient because it was difficult to close the urinary collecting system after it was widely exposed. Although urine leakage was seen postoperatively in two patients, it ceased spontaneously at 14 and 23 days after surgery. Postoperative complications developed in one of seven patients (14%) with protruding renal tumor, in three of five patients (60%) with non-protruding renal tumor and in two patients with renal stone. Allogenic or autologous blood transfusion was not necessary, nor was any bleeding noticed post-operatively. In one patient, atrophy of the renal parenchyma occurred gradually after surgery and function was eventually lost. However, renal function was well preserved and recurrence of the problem was not observed in the other 15 patients, excluding one who died of esophageal cancer. CONCLUSIONS: The microwave tissue coagulator is a useful surgical instrument for non-ischemic partial nephrectomy, not only in patients with renal tumors but also in patients with complicated kidney stones. However, non-protruding renal tumor in a patient with solitary kidney should be avoided for this surgery. Thermal injury to the renal parenchyma or large vessels should be avoided and urine leakage from the collecting system should be meticulously treated during the operation.     

单孔腹腔镜肾癌保肾手术68例经验总结

目的:总结单孔腹腔镜肾癌保肾手术临床应用经验,分析其适应证、安全性、手术方式的选择及治疗效果.方法:回顾性分析2010年12月-2021年6月笔者分别在上海长海医院(22例)、上海第九人民医院(46例)主刀完成的单孔腹腔镜肾部分切除术(13例)、单孔腹腔镜肾癌冷冻消融术(33例)和单孔腹腔镜免缝合肾部分切除术(22例)...     

Imperative organerhaltende Nierentumorchirugie bei Einzelniere bzw. bilateralen Tumoren

Renal cell carcinoma is the most lethal amongst urological malignancies. Only surgical excision of the tumor offers the chance of curative therapy for patients with localized disease. Nephron-sparing surgery is mandatory for patients with renal tumors in both kidneys or in a solitary kidney in order to preserve renal function (imperative indication). Evaluation of patients with renal tumors in both kidneys or in a solitary kidney must weigh the surgical and oncological risks of nephron-sparing surgery against the morbidity of radical nephrectomy followed by hemodialysis and possibly renal transplantation. Herein we report our oncological and functional long-term results of nephron-sparing surgery in patients with an imperative indication and review the literature.     

Tumours in End-Stage Kidney

Objective

Patients with end-stage kidney disease (ESKD) show a greater risk for renal cell carcinoma (RCC), which tends to be multifocal and bilateral. The malignant potential is unclear. The question is whether to remove both kidneys in patients with a tumor on one side only diagnosed by computed tomography (CT).

Materials and Methods

Kidney tumors were found in 14 patients with ESKD from January 2002 to December 2006. One was unfit for surgery. Thirteen patients underwent nephrectomy and 6 a bilateral procedure of whom only 2 had bilateral tumors on CT, 3 multiple tumors on the contralateral side, and 1 uncontrollable hypertension with tumors as an incidental finding. Tumors were found in all 19 specimens.

Results

In 13 kidneys (68.4%), the tumors were multiple; in 6 (31.6%), solitary. The types of tumor were: 13 (68.4%) papillary RCCs (PRCC), 9 (47.4%) clear RCCs (CRCC), a combination of PRCC and CRCC in 4 (21.0%), and myxoid liposarcoma (with solitary PRCC contralaterally). The mean follow-up was short (19 ± 15 months; maximum, 54 months). Only 1 patient died due to a tumor at 16 months after operation.

Conclusions

There is a high risk for bilateral involvement. Patients who undergo unilateral nephrectomy must be regularly followed and contralateral nephrectomy carefully considered, mainly in transplanted patients on immunosuppression. Further studies are needed to give a definitive answer about the indications for surgery and the indications for contralateral nephrectomy as well. To date, prophylactic contralateral nephrectomy should not be a therapeutic standard.     

Organ preserving surgery in kidney tumors

Between 1967 and 1989 102 patients underwent conservative surgery for renal tumors at the Department of Urology, Mainz Medical School. In 39 patients the indication for organ preserving surgery was imperative because of single kidney, bilateral tumors, benign pathology of the contralateral kidney or chronic renal failure. In the elective group 63 patients underwent tumor enucleation for small, peripheral lesions of uncertain dignity. Tumors removed for imperative indications varied in diameter from 2-11 cm (mean 5.5 cm) whereas those which were electively resected ranged from 1-7 cm (mean 3.2 cm). 74% of the electively enucleated tumors were detected in an early asymptomatic stage by routine ultrasound investigations. 58 of the 63 patients with elective indications are alive with no evidence of tumor after a mean follow-up of 35 months (5-90 months). One patient was lost to follow-up, 3 patients died of reasons unrelated to cancer, and only 1 patient died of progressive disease. These results indicate, that tumor enucleation is a safe and reliable technique in small, peripheral renal tumors and offers an adequate alternative to radical nephrectomy in selected patients.     

肾癌保留肾单位手术的临床价值(附17例报告)

目的　评价肾癌保留肾单位手术的临床价值。　方法　回顾性研究 17例行保留肾单位手术的肾癌患者临床资料 ,其中单侧 15例 ,双肾异时性肾癌且一侧为多发肿瘤 2例。绝对指征 2例 ,相对指征 6例 ,选择性指征 9例。肿瘤直径 2～ 6cm ,均为T1期 (1997年TNM标准 ) ;行改良肾肿瘤剜除术 (切缘于肾肿瘤外 1cm正常肾实质处 ) 15例 ,肾上极切除术 1例 ,楔形切除术 1例。 2 0例同期肾癌临床及分期相当但行根治性手术的患者资料作随访对照 ,并作生存率时序检验。　结果　 17例患者随访 3～ 6 3个月 ,平均 35 .2个月 ,未见并发症及残肾肿瘤复发。无瘤生存率与根治性手术者相近。　结论　肾癌保留肾单位手术安全、有效 ,适合于对侧肾功能正常、一侧局限的偶发肾肿瘤患者。     

Open partial nephrectomy for the treatment of renal cell carcinoma

Open partial nephrectomy, or nephron-sparing surgery (NSS), is now considered the standard of care for the treatment of small renal tumors. The oncologic efficacy and safety of NSS for the treatment of stage-T1a renal tumors has been repeatedly demonstrated to be equivalent to radical nephrectomy. NSS initially was reserved for patients with solitary kidneys, impaired renal function, hereditary tumor syndromes, bilateral renal tumors, and those with significant comorbidities predisposing to future renal failure. The indications have expanded recently to allow elective partial nephrectomy in the setting of a normal contralateral kidney. Furthermore, recent data demonstrate that partial nephrectomy for larger tumors (T1b), which have been historically treated with radical nephrectomy, is a viable option when surgical margins can safely be achieved. In the era of minimally invasive techniques, laparoscopic NSS is technically feasible, yet long-term studies are still needed to assess oncologic efficacy. New NSS ablative technologies, such as cryoablation and radiofrequency ablation, are on the horizon. In this article, we discuss the role of open NSS and surgical technique in the contemporary management of renal tumors.     

In situ management of renal tumors: renal cell carcinoma and transitional cell carcinoma

In the last 8 years 15 patients with malignant neoplasms in functionally solitary kidneys underwent in situ excision of the tumor with preservation of renal parenchyma. Of 10 patients with renal cell carcinoma 8 underwent partial nephrectomy, 1 had a central wedge resection and 1 had enucleation of 3 tumors. After followup of 6 months to 4.7 years 6 patients are free of disease. One patient died of metastatic cancer and 1 of cardiovascular disease. Of 5 patients with transitional cell carcinoma of the kidney (including 2 with parenchymal invasion) 2 underwent partial nephrectomy and 3 underwent extensive resection of renal pelvic lesions. After followup of 6 months to 7 years 2 patients are alive, 2 died of metastatic disease and 1 died of metastatic bladder carcinoma. Only 1 of the 5 patients had locally recurrent tumor. These data demonstrate the efficacy of in situ management of renal tumors in selected patients with solitary kidneys or compromised renal function.     

Partial nephrectomy: the rationale for expanding the indications

Background We report preliminary results of partial nephrectomy for renal tumors of ≥4 cm in 39 patients with the intent of extending the indications for kidney-sparing surgery. Methods From July 1989 to October 2001, 39 patients underwent a partial nephrectomy for renal cortical tumors >4 cm in maximum diameter. Fourteen (36%) had the procedure performed for essential reasons, and 25 (64%) had an elective kidney-sparing operation. We evaluated tumor location and histology, perioperative renal function, and postoperative complications. Results There were 20 conventional clear-cell (51%), 13 papillary (33%), 4 chromophobe (10%), and 3 oncocytomas (8%) with a median tumor size of 5 cm. After a median follow-up of 13 months, 36 patients had no evidence of disease, 1 patient had died as a result of other causes, and 2 patients who had essential operations were alive with disease. Twenty-three patients (70%) maintained normal postoperative renal function. Of six patients with moderate preoperative renal dysfunction, five (83%) had no change in postoperative renal function and only one patient required short-term dialysis. Conclusions With careful patient selection, partial nephrectomy can be effectively used to treat patients with renal cortical tumors >4 cm in diameter. The benefits of this approach include the effective local tumor control while at the same time preserving maximum renal function. Presented at the Society of Surgical Oncology Meeting, Washington, DC, March 17, 2001.     

Laparoscopic partial nephrectomy: a decade of evolution

The detection of renal tumors is increasing with the widespread use of ultrasonography and CT. Laparoscopic partial nephrectomy (LPN) offers less pain, smaller scars, and shorter convalescence. Expanded indications of LPN include larger and more complex tumors, including those in hilar or central locations, multiple tumors, solitary kidneys, and patients with previous renal surgery. This procedure is in constant evolution. We describe the technical nuances of LPN over the past decade of evolution.     

Conservative surgery in solitary and bilateral renal carcinoma: indications and technical considerations

Seven patients presented with solitary or bilateral renal carcinoma. All 4 patients treated by partial nephrectomy are well and 3 are free of disease (followup of 24 to 32 months). A survey of similar series reveals a survival of 78 per cent in patients with solitary renal tumors undergoing partial nephrectomy (mean followup of 52 months). Since the projected survival in patients undergoing chronic hemodialysis for the same interval is only 65 per cent partial nephrectomy, when technically feasible, would appear to be the treatment of choice in solitary renal carcinoma. In cases involving bilateral lesions the survival rate after partial nephrectomy seems to be similar to that of cases on hemodialysis.     

Parenchyma-sparing surgery for renal tumors

Summary Between 1969 und 1989 conservative surgery for kidney tumors was performed in 123 patients. In 49 patients there was an imperative indication for a parenchyma-sparing operation because nephrectomy would have made dialysis obligatory. Thirty-five of these 49 patients show no signs of tumor progression after a mean follow-up of 4.5 years. Known metastases were present in 3 of 6 patients who died as a result of their tumors. In two patients there was a recurrence after 1 and 5 years, respectively, requiring a second organ-preserving operation. In one further patient we suspect that multiple small tumor lesions may be present 2 years after the first operation. In 74 patients with a healthy contralateral kidney the tumor was enucleated by choice (elective indication). Sixty-eight of these 74 patients show no signs of tumor progression after a mean follow-up period of 3.3 years. One patient died from tumor metastases. Two patients had tumor recurrence, requiring nephrectomy and enucleation, respectively. Fifty-seven enucleated tumors were available for image analysis DNA cytometry. Only the two patients with a hypertriploid tumor died from their cancer.     

Bilateral renal oncocytoma: report of 2 cases and literature review

We report on 2 patients with bilateral renal oncocytoma treated in the last 5 years. One patient underwent bilateral partial nephrectomy for a solitary tumor in each kidney. Both tumors were confirmed to be renal oncocytomas by light and electron microscopic examination. After 4 years this patient had no evidence of local recurrence or distal metastasis. The second patient presented with bilateral multiple renal oncocytomas. Transabdominal bilateral renal exploration revealed 2 tumors in the right kidney and 3 tumors in the left kidney. Right radical nephrectomy and enucleation of the left renal tumors were performed. Examination by light and electron microscopy confirmed that all tumors from both kidneys were oncocytomas. Only 8 cases of bilateral renal oncocytoma have been reported in the literature, including our 2 cases. In 6 of these 8 cases the tumors were multicentric, which may be a characteristic of bilateral renal oncocytoma. Recognizing the coexistence of multicentricity and bilaterality is important because more conservative treatment is required. However, a favorable prognosis may still be anticipated.     

Indications and contraindications for the use of laparoscopic surgery for renal cell carcinoma

Surgery remains the only treatment with a chance of cure for renal cell carcinoma. Laparoscopic radical nephrectomy (LRN) has developed to be a standard treatment for the management of suspected renal malignancy in many centers worldwide, with oncologic efficacy equal to that of open radical nephrectomy. LRN has considerable advantages over open surgery, such as decreased postoperative morbidity, decreased analgesic requirements, and shorter hospital stay and convalescence. Current indications for LRN include all patients with localized stage T1-2 renal tumors. LRN for stage T3 renal tumors may be technically feasible in individual situations, but cannot be considered standard treatment. Open radical nephrectomy is reserved for advanced renal tumors, according to the surgeon's judgment. Partial nephrectomy is well established and considered to be the standard management for all organ-confined tumors of 相似文献   

Renal cell carcinoma in solitary kidneys

We report 10 cases of renal tumors in a solitary kidney that were treated surgically with efforts to spare renal function. Three patients were rendered anephric to excise completely the renal cancer and 2 remain without disease. The remaining 7 patients had complete tumor excision with the aid of partial nephrectomy. One patient had bilateral oncocytomas. Of the 6 partial nephrectomy patients with cancer 1 (18 per cent) remains free of metastatic disease. Concern is expressed for the role of partial nephrectomy as curative surgery for renal cancer.