Recent advances in localized RCC: A focus on VEGF and immuno-oncology therapies

Recent advances in advanced renal cell cancer (RCC) research have produced new drugs and therapies for patients with metastatic disease leading to higher response rates, improvements in progression-free survival, and longer overall survival. These advances have yet to be realized in patients with early-stage kidney cancer, and to date, no drug has been approved for the adjuvant treatment of localized kidney cancer. The current standard of care for localized high-risk kidney cancers is resection of the primary tumor. Here, we review the results of recently completed adjuvant vascular endothelial growth factor receptor 2 (VEGFR2) tyrosine kinase inhibitor (TKI) trials in RCC that have been reported, or are awaiting results. Further, we discuss the new immune checkpoint inhibitor adjuvant trials planned. There is hope that these trials may lead to new options and longer survival for patients with localized high-risk kidney cancer.     

Sarcomatoid renal cell carcinoma: Biology and treatment advances

Sarcomatoid transformation in renal cell carcinoma, so called sacromatoid RCC (sRCC), is associated with an aggressive behavior and a poor prognosis. Current therapeutic approaches are largely ineffective. Recent studies looking into the genomic and molecular characterization of sRCCs have provided insights into the biology and pathogenesis of this entity. These advances in molecular signatures may help development of effective treatment strategies. We herein present a review of recent developments in the pathology, biology, and treatment modalities in sRCC.     

Documento nacional de recomendaciones sobre el seguimiento del paciente con carcinoma de células renales

Objectives

This document was developed to establish directives for the follow-up of patients with renal cell carcinoma (RCC) based on the best available scientific evidence and on expert opinions, which can help urologists in the decision-making process and standardise the criteria at the national level.

Incidencia de infección de herida quirúrgica en cirugía renal. Efecto de la adecuación de la profilaxis antibiótica. Estudio de cohortes prospectivo

Objective

To assess compliance with the antibiotic prophylaxis protocol for patients who underwent renal surgery and its effect on the incidence of surgical wound infection.

Perioperative Morbidity of Lymph Node Dissection for Renal Cell Carcinoma: A Propensity Score–based Analysis

Background

There are little data regarding the morbidity of lymph node dissection (LND) for renal cell carcinoma (RCC) to assess its risk–benefit ratio.

原位肾低温灌注腹腔镜下肾部分切除术

目的 探讨一种改进的原位肾低温灌注方法在腹腔镜下肾部分切除术中的临床价值.方法 2009年3-5月,对5例解剖性或功能性孤立肾患者行原位肾低温灌注腹腔镜下肾部分切除术.男3例,女2例;平均年龄49(39～63)岁;肿瘤位于左侧2例,右侧3侧;肿瘤直径平均5.6(3.8～7.0)cm.慢性肾功能不全2例,孤立肾1例,对侧肾萎缩1例,较大良性肿瘤1例.术前经皮穿刺经股动脉介入方法在患侧肾动脉留置带球囊契压导管1根,术中契压导管的球囊注水以阻断患侧肾动脉,并通过契压导管在加压泵下持续向肾动脉内灌注4℃冰盐水约200 ml,以实现患侧肾脏低温原位灌注,同时行腹腔镜下肾部分切除术,术后抽出球囊水以解除肾动脉阻断.结果 5例均成功施行原位肾低温灌注腹腔镜下肾部分切除术,手术时间平均102(80～120)min,肾动脉阻断时间平均35(29～39)min,术中出血量平均190(50～300)ml.低温灌注后皮肤温度平均降低0.6℃,肾脏表面温度降低10.0℃,肿瘤表面温度平均降低9.8℃.术前、术后第1、3、5和10天患者肌酐清除率分别为(64.7±16.9),(48.9±14.5)、(52.1±12.4)、(54.5±13.8)和(54.6±11.7)ml/min,多个相关样本检验显示,各组之间肌酐清除率比较差异有统计学意义(P=0.001).术后第5天和第10天比较差异无统计学意义(P=0.125),其余组间比较差异有统计学意义(P=0.043),术后第5天肌酐清除率基本稳定.结论 原位肾低温灌注腹腔镜下肾部分切除术安全可行,同时解决了腹腔镜下动脉阻断和低温灌注难题,有利于延长肾缺血时间、保护肾功能.     

Every Minute Counts When the Renal Hilum Is Clamped During Partial Nephrectomy

Background

The safe duration of warm ischemia during partial nephrectomy remains controversial.

Objective

Our aim was to evaluate the short- and long-term renal effects of warm ischemia in patients with a solitary kidney.

Design, setting, and participants

Using the Cleveland Clinic and Mayo Clinic databases, we identified 362 patients with a solitary kidney who underwent open (n = 319) or laparoscopic (n = 43) partial nephrectomy using warm ischemia with hilar clamping.

Measurements

Associations of warm ischemia time with renal function were evaluated using logistic or Cox regression models first as a continuous variable and then in 5-min increments.

Results and limitations

Median tumor size was 3.4 cm (range: 0.7–18.0 cm), and median ischemia time was 21 min (range: 4–55 min). Postoperative acute renal failure (ARF) occurred in 70 patients (19%) including 58 (16%) who had a glomerular filtration rate (GFR) <15 ml/min per 1.73 m² within 30 d of surgery. Among the 226 patients with a preoperative GFR ≥ 30 ml/min per 1.73 m² and followed ≥30 d, 38 (17%) developed new-onset stage IV chronic kidney disease during follow-up. As a continuous variable, longer warm ischemia time was associated with ARF (odds ratio: 1.05 for each 1-min increase; p < 0.001) and a GFR < 15 (odds ratio: 1.06; p < 0.001) in the postoperative period, and it was associated with new-onset stage IV chronic kidney disease (hazard ratio: 1.06; p < 0.001) during follow-up. Similar results were obtained adjusting for preoperative GFR, tumor size, and type of partial nephrectomy in a multivariable analysis. Evaluating warm ischemia in 5-min increments, a cut point of 25 min provided the best distinction between patients with and without all three of the previously mentioned end points. Limitations include the retrospective nature of the study.

Conclusions

Longer warm ischemia time is associated with short- and long-term renal consequences. These results suggest that every minute counts when the renal hilum is clamped.     

Robot-Assisted Partial Nephrectomy: An International Experience

Background

Robot-assisted partial nephrectomy (RAPN) is emerging as a viable approach for nephron-sparing surgery (NSS), though many reports to date have been limited by evaluation of a relatively small number of patients.

Objective

We present the largest multicenter RAPN experience to date, culling data from four high-volume centers, with focus upon functional and oncologic outcomes.

Design, setting, and participants

A retrospective chart review was performed for 183 patients who underwent RAPN at four centers between 2006 and 2008.

Surgical procedure

RAPN was performed using methods outlined in the supplemental video material. Though operative technique was similar across all institutions, there were minor variations in trocar placement and hilar control.

Measurements

Perioperative parameters, including operative time, warm ischemic time, blood loss, and perioperative complications were recorded. In addition, we reviewed functional and oncologic outcomes.

Results and limitations

Mean age at treatment was 59.3 yr. Mean tumor size was 2.87 cm. Mean total operative time was 210 min while mean ischemic time was 23.9 min. Calyceal repair was required in 52.1% of procedures. Mean estimated blood loss was 131.5 ml. Sixty-nine percent of excised tumors were malignant, of which 2.7% exhibited positive surgical margins. The incidence of major complications was 8.2%. At up to 26 mo follow-up, there have been no documented recurrences and no significant change in serum creatinine (1.03 vs 1.04 mg/dl, p = 0.84) or estimated glomerular filtration rate (eGFR) from baseline (82.2 vs 79.4 mg/ml per square meter, p = 0.74). The study is limited by its retrospective nature, and the outcomes are likely influenced by the robust prior laparoscopic renal experience of each of the surgeons included in this study.

Conclusions

RAPN is a safe and efficacious approach for NSS, offering short ischemic times, as well as perioperative morbidity equivalent to other standard approaches. Moreover, RAPN is capable of providing patients with excellent functional and oncologic outcomes.     

Robotic Laparoendoscopic Single-Site Surgery Using GelPort as the Access Platform

Background

Laparoendoscopic single-site surgery (LESS) allows for the performance of major urologic procedures with a single small incision and minimal scarring. The da Vinci Surgical System provides advantages of easy articulation and improved ergonomics; however, an ideal platform for these procedures has not been identified.

Objective

To evaluate the GelPort laparoscopic system as an access platform for robotic LESS (R-LESS) procedures.

Design, setting, and participants

Since April 2008, 11 R-LESS procedures have been completed successfully in a single institutional referral center. For the last four consecutive cases, the GelPort has been used as an access platform through a 2.5–5-cm umbilical incision.

Intervention

R-LESS cases performed with the GelPort included pyeloplasty (n = 2), radical nephrectomy (n = 1), and partial nephrectomy (n = 1).

Measurements

Perioperative data were obtained for all patients including demographic data, operative indications, operative records, length of stay, complications, and pathologic analysis.

Results and limitations

For both pyeloplasty cases, average operative time (OR time) was 235 min and estimated blood loss (EBL) was 38 cm³. For the patient undergoing radical nephrectomy for a 5.1-cm renal tumor, OR time was 200 min and EBL was 250 cm³. The final patient underwent partial nephrectomy without renal hilar clamping for an 11-cm angiomyolipoma with OR time of 180 min and EBL of 600 cm³. All R-LESS procedures attempted with the GelPort were completed successfully and without complication. Average length of hospital stay was 1.75 d (range: 1–2). The partial nephrectomy patient required transfusion of 1 U of packed red blood cells.

Conclusions

Use of the GelPort as an access platform for R-LESS procedures provides adequate spacing and flexibility of port placement and acceptable access to the surgical field for the assistant, especially during procedures that require a specimen extraction incision. Additional platform and instrumentation development will likely simplify R-LESS procedures further as experience grows.     

后腹腔镜下肾切除术

目的 探讨后腹腔镜下肾切除术的临床应用价值.方法 回顾性分析我院自2008年5月至2009年9月68例后腹腔镜下肾切除术患者的临床资料.首先清除腹膜外脂肪,打开肾周筋膜,沿腰大肌方向分离至肾蒂,游离肾动脉、肾静脉及输尿管,并用Hem-o-lok夹闭后离断之,继续游离肾脏.延长腰部切口,将患肾取出.结果 所有患者除1例因肾蒂周围粘连较严重,无法分离中转开放外,均获成功,未发生周围脏器及大血管损伤等严重并发症.手术时间60～120 min,平均90 min,失血量50～150 ml,平均100 ml.术后2～3 d拔除创腔引流管.术后平均住院时间8～10 d,平均9 d.平均随访5个月,对侧肾功能正常.结论 后腹腔镜肾切除术损伤小,住院时间短,患者恢复快. Abstract： Objective To investigate the clinical efficacy of retroperitoneal laparoscopic surgery in nephrectomy. Methods The way was retrospective analysis of 68 patients who were our in-patients and took the operation of retroperitoneal laparoscopic nephrectomy from May 2008 to September 2009. First of all, cleaning the extraperitoneal fat and then open the perirenal fascia,freeing the tissue along with psoas to renal pedicle and next freeing renal artery,renal vein and ureter,occlusing them with Hem-o-lock and then disconnected them,continuing freeing the kidney. Elongating the incision in the waist,taking out the kidney with tuberculosis. Results Only one case in all patients changed the operation type into opening since the adhesion around the renal pedicle was so serious that the target couldn't be freed clearly. All operations turned out to be successful and had no serious complications like the injury of large vessels and important organs around. Operation times are among 60 mins to 120 mins, 90 mins on average and blood losses are between 50 ml and 150 ml, 100 ml on average. Taking off the drainage tube 2 to 3 days after operations. The hospital stays after operations were 8-10 days, 9 days on average. The average follow-up period was 5 months and the function of the kidney in the other side was normal in this period. Conclusions Retroperitoneal laparoscopic nephrectomy has advantages of minimal invasion,short hospital stay and rapid recovery.