Laparoscopic radical adrenalectomy for malignancy in 31 patients

PURPOSE: Laparoscopic adrenalectomy for malignancy is controversial. We analyzed our experience with laparoscopic radical adrenalectomy for cancer with an emphasis on predictors of surgical outcome and oncological followup data. MATERIALS AND METHODS: Since July 1997, 31 patients have undergone a total of 33 laparoscopic adrenalectomies for malignancy. Mean adrenal tumor size was 5 cm (range 1.8 to 9). The laparoscopic approach was transperitoneal in 17 cases, retroperitoneal in 15 and transthoracic in 1. Data were obtained from patient charts, radiographic reports and direct telephone calls to patient families. RESULTS: Associated organ resection (radical nephrectomy) was performed in 3 patients. One case was electively converted to open surgery. There was no operative mortality. The pathological diagnoses were metastatic cancer in 26 cases and primary adrenal malignancy in 7. Current median followup, available on 30 patients, was 26 months (range 1 to 69). Overall 15 patients (48%) died and 16 (52%) were alive, of whom 13 (42%) showed no evidence of disease. Cancer specific survival at a median followup of 42 months was 53% and 5-year actuarial survival was 40%. Local recurrence was noted in 7 patients (23%). There were no port site metastases. Survival was similar in patients with tumors less than 5 cm vs 5 cm or greater. Survival was not associated with patient age, tumor size, operative time or surgical approach. Survival was compromised in patients with local recurrence (p = 0.016). CONCLUSIONS: Laparoscopic radical adrenalectomy can be performed with acceptable outcomes in the carefully selected patient with a small, organ confined, solitary adrenal metastasis or primary adrenal carcinoma. To our knowledge the largest series in the literature to date is presented.     

Renal cell carcinoma with renal vein and inferior vena caval involvement: clinicopathological features, surgical techniques and outcomes

PURPOSE: We present a contemporary review of patients with renal cell carcinoma (RCC) in whom renal vein/inferior vena caval thrombus was treated with radical nephrectomy and thrombectomy. MATERIALS AND METHODS: A total of 220 patients underwent radical nephrectomy for RCC at our institution from 1998 to 2002. Of them 49 patients with renal vein/inferior vena caval involvement (T3b/c) were selected for review. We evaluated demographics, presenting symptoms, imaging modalities, clinical staging, pathological features, adjuvant treatment and clinical outcomes. We also evaluated surgical incisions, liver mobilization procedures, blood loss, transfusion requirements and perioperative mortality/morbidity. RESULTS: Gross hematuria was the most common presenting symptom, seen in 22 patients (45%), followed by constitutional symptoms in 8 (16%). Stage T3b/c was clinically diagnosed in 44 patients, while 2 had T2 and 2 had T4 disease. A subcostal incision was made in 30 patients, a chevron incision was made in 18, and a sternotomy and flank incision were made in 1. Liver mobilization was necessary in 13 patients and 2 required a Pringle maneuver. Cardiopulmonary bypass was performed in a single patient. Lymph node involvement was seen in 4 patients (8%) and distant metastases were present in 10 (20%). Median tumor size was 10 cm. Clear cell carcinoma was most common, as seen in 42 patients. Early (30-day) mortality in this series was 8%. At a median followup of 15 months 21 patients (43%) were without evidence of disease, 14 (29%) had disease, 8 (16%) had died of disease and 2 (4%) had died of other causes. None of the patients with lymph node involvement survived beyond 8 months after surgery. Tumor grade and T stage were found to be significant negative predictors of survival on univariate analysis. CONCLUSION: Most patients with RCC and tumor thrombus are symptomatic at presentation and metastatic disease at presentation is not uncommon. These results support the role of aggressive surgical treatment as the best initial management of these tumors. The majority of tumors can be approached and safely controlled without the need for a thoracoabdominal incision. While surgery provides modest disease-free survival, most patients should be offered immunotherapy, particularly those with advanced stage, grade, nodal involvement or metastases.     

pT2 classification for renal cell carcinoma. Can its accuracy be improved?

PURPOSE: The 2002 tumor classification for renal cell carcinoma (RCC) classifies pT2 tumors as more than 7 cm in greatest dimension, limited to the kidney. In this study we determined whether a size cutoff point exists within pT2 tumors and whether such subclassification would further improve the accuracy of the current tumor classification. MATERIALS AND METHODS: We studied 544 patients with unilateral, sporadic pT2 RCC treated with radical nephrectomy or nephron sparing surgery between 1970 and 2000. The association of tumor size with death from RCC was examined using martingale residuals from a Cox proportional hazards regression model to determine the optimal size cutoff point. RESULTS: There were 204 deaths from RCC a median of 3.8 years following nephrectomy. Univariately tumor size was significantly associated with death from RCC (risk ratio 1.08, 95% CI 1.04 to 1.13, p <0.001). A scatterplot of tumor size vs expected risk of death per patient suggested that a cutoff point between 9 and 10 cm was appropriate. When adjusted for regional lymph node involvement and distant metastases, the 10 cm cutoff point performed better than the 9 cm point (risk ratio 1.42, 95% CI 1.07 to 1.90, p = 0.017 vs 1.22, 95% 0.86 to 1.72, p = 0.268). Therefore, we propose using a 10 cm cutoff point to subclassify patients into pT2a and pT2b. CONCLUSIONS: Our data suggest that the prognostic accuracy of the 2002 pT2 tumor classification can be further improved by subclassifying patients with tumors greater than 7 and less than 10 cm into a pT2a category, and those with tumors 10 cm or greater into a pT2b category.     

Retroperitoneal laparoscopic radical nephrectomy: the Cleveland clinic experience

PURPOSE: Laparoscopic radical nephrectomy is usually performed by the transperitoneal approach. At our institution the retroperitoneoscopic approach is preferred. We confirm the technical feasibility of retroperitoneoscopic radical nephrectomy, even for large specimens, and compare its results with open surgery in a contemporary cohort. MATERIALS AND METHODS: A total of 47 patients underwent 53 retroperitoneoscopic radical nephrectomies. Data from the most recent 34 laparoscopic cases were retrospectively compared with 34 contemporary cases treated with open radical nephrectomy. RESULTS: For the 53 retroperitoneoscopic radical nephrectomies mean tumor size was 4.6 cm. (range 2 to 12), surgical time was 2.9 hours (range 1.2 to 4.5) and blood loss was 128 cc. Mean specimen weight was 484 gm. (range 52 to 1,328), and concomitant adrenalectomy was performed in 72% of patients. Mean analgesic requirement was 31 mg. morphine sulfate equivalent. Average hospital stay was 1.6 days, with 68% of patients discharged from the hospital within 23 hours of the procedure. Minor complications occurred in 8 patients (17%) and major complications occurred in 2 (4%) who required conversion to open surgery. Various parameters, including patient age, body mass index, American Society of Anesthesiologists status, tumor size (5 versus 6.1 cm.), specimen weight (605 versus 638 gm.) and surgical time (3.1 versus 3.1 hours), were comparable between patients undergoing laparoscopic (34) and open (34) radical nephrectomy. However, laparoscopy resulted in decreased blood loss (p <0.001), hospital stay (p <0.001), analgesic requirements (p <0.001) and convalescence (p = 0.005). Complications occurred in 13% of patients in the laparoscopic group and 24% in the open group. CONCLUSIONS: Retroperitoneoscopy is a reliable, effective and, in our hands, the preferred technique of laparoscopic radical nephrectomy. At our institution retroperitoneoscopy has emerged as an attractive alternative to open radical nephrectomy in patients with T1-T2N0M0 renal tumors.     

IS FROZEN SECTION ANALYSIS IN NEPHRON SPARING SURGERY NECESSARY? A CLINICOPATHOLOGICAL STUDY OF 301 CASES

PURPOSE: One of the basic principles of nephron sparing surgery for renal cell carcinoma is resection of the tumor with normal tissue margins verified by frozen section analysis. In cases of positive tumor margins the surgeon is committed to complete the local resection or to perform radical nephrectomy. In this study we retrospectively evaluated the yield of frozen section analysis performed during nephron sparing surgeries, especially concerning compatibility with the final histological report and the long-term oncological outcome. MATERIALS AND METHODS: Between 1988 and 2003, 172 men and 129 women with a mean age of 59 years (range 16 to 83) underwent nephron sparing surgery due to suspected renal tumors. Mean tumor size was 3.56 cm (range 1 to 12.5). Frozen section analysis was routinely performed during surgery. RESULTS: Positive tumor margins in frozen section analysis were found in 2 cases (0.7%). In both cases the tumor was centrally located. Those 2 patients underwent immediate radical nephrectomy but no residual tumor was subsequently found in the radical nephrectomy specimens. Paraffin sections disclosed positive tumor margins in 4 other cases (1.3%) in whom the frozen section analysis had shown tumor negative margins. Of the 4 patients 1 underwent radical nephrectomy for tumor recurrence after 9 months. The other 3 patients showed no evidence of disease recurrence after 26, 59 and 120 months of followup. CONCLUSIONS: Our results suggest that frozen section analysis during nephron sparing surgery has minimal clinical significance and hence routine incorporation in urological practice should be reconsidered.     

Renal cell carcinoma: evaluation of the 1997 TNM system and recommendations for follow-up after surgery.

OBJECTIVE: We evaluated the tumor recurrence pattern after radical or nephron-sparing surgery for localized renal cell carcinoma. Based on this pattern, we suggest a surveillance protocol after surgery. METHODS: The outcome of 200 consecutive patients with localized renal cell carcinoma (RCC) that were operated on between January 1982 and December 1997 was evaluated retrospectively. Radical nephrectomy was performed in 155 patients (77.5%), and nephron-sparing surgery in 45 patients (22.5%). The timing and site of disease recurrence were correlated with parameters of the primary tumor. RESULTS: One hundred and twenty-four patients (62%) had pathological stage T1, 26 (13%) had stage T2, and 50 (25%) had stage T3 (41 stage T3a, 8 stage T3b, and 1 stage T3c). The mean follow-up was 47 months (range 6--169 months). Four patients (3.2%) with stage T1, 6 patients (23%) with T2, and 13 patients (26%) with T3 developed recurrent disease. None of the patients with a stage T1 tumor, smaller than 4 cm, had tumor recurrence. There were no recurrences after nephron-sparing surgery compared to 23 recurrences (14.8%) among patients after radical nephrectomy (p = 0.01). Only 1 patient who underwent pulmonary lobectomy for asymptomatic metastases smaller than 2.5 cm, found by routine chest CT, attained long-term survival. CONCLUSIONS: The prognosis of patients after radical nephrectomy for renal cell carcinoma, smaller than 4 cm, is excellent and they do not need radiological follow-up. Patients with larger T1 tumors, 4--7 cm in diameter, or a higher stage should be followed with CT of the chest and abdomen done every 6 months for 5 years and then annually. Following partial nephrectomy of small renal tumors periodic renal ultrasonography should be done to rule out local recurrence in the operated kidney.     

Retroperitoneoscopic radical and partial nephrectomy in the patient with cirrhosis

PURPOSE: In patients with cirrhosis and a renal mass options may be limited by medical disease and the surgical difficulties associated with portal hypertension. We describe a retrospective review of patients with cirrhosis with renal masses who underwent radical or partial nephrectomy through a retroperitoneoscopic approach. MATERIALS AND METHODS: Ten consecutive patients, including 4 men and 6 women, with cirrhosis, of whom 2 had undergone liver transplantation, underwent radical (7) or partial (3) nephrectomy for a total of 5 right and 5 left renal neoplasms via the retroperitoneoscopic approach at our institution from March 2002 to February 2004. Recovery data were prospectively obtained and other information was gathered retrospectively from the medical record. RESULTS: Average patient age was 58 years and average American Society of Anesthesiology score was 2.8. Average renal tumor size for radical and partial nephrectomy was 4.6 (range 2.9 to 7) and 1.8 cm (range 1.3 to 2.3), respectively. Operative time was 140 to 315 minutes (median 172) and estimated blood loss was 100 to 5,000 ml (median 225). One patient required open conversion due to hemorrhage from left portosystemic venous communications. Mean postoperative hospitalization was 1.5 days (range 1 to 6). CONCLUSIONS: Although retroperitoneoscopic surgery avoids many surgical dangers associated with portal hypertension and it is our preferred approach to renal surgery in patients with cirrhosis, significant portosystemic venous communications exist in the retroperitoneum, especially on the left side, and they still lead to substantial blood loss in some patients.     

The accuracy of 250 fine needle biopsies of renal tumors

PURPOSE: In some cases of uncertain lesions in the kidney it would be helpful to perform biopsies for preoperative histopathological evaluation. In this study we evaluated the accuracy of and the impact on tumor management of core biopsy for histopathological evaluation of small solid renal masses. MATERIALS AND METHODS: After radical or partial nephrectomy 250 renal tumor biopsies were performed in 50 patients. All biopsies were performed by 1 urologist after preparation of the kidney ex situ on back table visually guided. Formalin fixed paraffin embedded biopsies were evaluated by 1 pathologist. RESULTS: In 49 of 50 cases (98%) we could define the malignant behavior of the tumor when performing 1 central and 4 peripheral biopsies of each tumor. In 85.2% the grading was correctly defined. A benign lesion was revealed in 4 cases (8%, all oncocytoma). In renal tumors 4 cm or smaller in diameter the accuracy of 1 central and 1 peripheral biopsy each regarding definition of tumor origin, tumor grading and cell type/growth pattern was 96% and 95.5%, 84% and 84.4%, and 87.5% and 89.5%, respectively. In renal tumors more than 4 cm in diameter the accuracy was 100% and 98.1%, 85% and 94.3%, and 71.4% and 88.7%, respectively. CONCLUSIONS: Core biopsy of renal lesions is accurate enough for histopathological evaluation and determination of therapeutic procedure. Additionally, biopsy could be used for identifying benign renal lesion for observation.     

Impact of clinicopathological parameters in patients treated for renal cell carcinoma

PURPOSE: We determined the impact of clinical and pathological factors in the outcome of patients with renal cell carcinoma treated surgically. MATERIALS AND METHODS: We retrospectively reviewed the records of 230 consecutive patients after radical or partial nephrectomy. We analyzed clinical (incidental or symptomatic disease) and pathological (tumor size, histological type, Fuhrman nuclear grade, microvascular invasion and lymph node involvement) parameters. Disease-free and cancer specific survival curves were individualized for each parameter and on multivariate analysis. RESULTS: Median postoperative followup was 34.3 months, median time to recurrence was 22 months and mean overall survival was 130 months. A total of 40 patients (17.3%) presented with local and/or metastatic recurrence and 32 (13.9%) died of the disease. Five-year disease-free and cancer specific survival rates on univariate analysis were 56.7% and 64% for symptomatic tumors, 76.6% and 68% for clear cell carcinoma, 26.9% and 39% for sarcomatoid tumors, 34.7% and 47.5% for high grade tumors, 26.7% and 39.7% for microvascular invasion, 37.5% and 49.1% for tumors larger than 7 cm, and 11% and 32% for lymph node involvement, respectively. On univariate analysis patients with lymph node involvement and microvascular invasion had a poor prognosis. Multivariate analysis showed that the single independent prognostic factor was microvascular invasion. CONCLUSIONS: This study points out different clinical and pathological prognostic factors of survival in patients treated for renal cell carcinoma. Microvascular invasion was the only independent prognostic factor on multivariate analysis.     

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   

A preoperative prognostic nomogram for solid enhancing renal tumors 7 cm or less amenable to partial nephrectomy

PURPOSE: Small renal masses are increasing in incidence. Most tumors 7 cm or less are treated with radical or partial nephrectomy but clinicians are increasingly relying on ablative therapies and observation for some small renal masses. We present novel nomograms that predict the likelihood of benign, likely indolent or potentially aggressive pathological findings based only on readily identifiable preoperative factors. MATERIALS AND METHODS: Information on all partial nephrectomies performed at a single institution was collected in an institutional review board approved registry. Using retrospectively collected data on all 862 patients who underwent partial nephrectomy for a single, solid, enhancing, clinical T1 (7 cm or less) tumor between 1999 and 2005 tumors were classified as benign or malignant. Grade 3 clear cell renal cell carcinoma, grade 4 renal cell carcinoma of any type and any renal cell carcinoma with vascular, fat or collecting system invasion were considered potentially aggressive. The likelihood of benign, likely indolent or potentially aggressive pathological findings was modeled using multivariable logistic regression models based on age, gender, radiographic tumor size, symptoms at presentation and smoking history. RESULTS: Of 862 small renal masses 20% were benign and 80% were malignant but only 30% of cancers (24% of small renal masses) were potentially aggressive. All 11 patients with systemic symptoms had cancer. The remaining 851 patients underwent further analysis. Factors that were most strongly associated with the likelihood of benign pathology were age, gender, tumor size and smoking history. A nomogram constructed to predict benign histology proved to be relatively accurate and discriminating (bootstrap corrected concordance index 0.644) and calibrated. Small renal masses in older men and younger women were more likely to be benign. With regard to differentiating indolent from potentially aggressive cancers, only advanced age was independently significant on multivariate analysis (p <0.005). The nomogram for this outcome performed with limited ability (concordance index 0.557). CONCLUSIONS: Clinical factors provide substantial predictive ability to predict benign vs malignant pathology for small renal masses amenable to partial nephrectomy. Although most of these small renal masses are benign or indolent, our ability to predict potentially aggressive cancer in this population remains limited.     

肾癌肾部分切除术的临床价值及合适的手术切缘的探讨

目的：探讨肾癌肾部分切除术(保留肾单位手术)的临床价值及合适的手术切缘。方法：回顾性分析15例行肾部分切除术的肾癌患者临床资料．其中双侧异时性肾癌且一侧为多发肿瘤2例，单发肿瘤13例。肿瘤直径2～6cm．均为T1期(1997年TNM分期标准)。对15例肾癌患者行肾部分切除术．手术切缘位于肿瘤外1cm。另取肾癌根治性手术标本21例．于体外沿假包膜行肾肿瘤剜除术．并随机切取肿瘤边缘0．3cm、0．5cm及1cm处肾实质及肾蒂处淋巴脂肪组织行病理检查。结果：15冽患者随访12～72个月．平均41个月．未见并发症及残肾内肿瘤复发。21例标本于体外行肿瘤剜除后肉眼下均无肿瘤组织残留，送检组织均无肿瘤细胞浸润。结论：肾部分切除术能安全有效地治疗局限的早期肾癌患者．而手术切缘为肿瘤边缘1cm处较为合适。     

Partial nephrectomy for renal tumors

We performed partial nephrectomy in 5 patients with renal tumors. In 1 patient with synchronous bilateral renal cell carcinoma, radical nephrectomy was conducted simultaneously for the contralateral kidney. The second patient had a transitional cell carcinoma of the renal pelvis of the contralateral side, for which the pelvis was resected simultaneously. In the remaining 3 patients the contralateral kidney was normal. In these patients the tumor was less than 3.0 cm in size and localized in either the upper pole or peripheral region, for which partial nephrectomy was performed. The weight of the resected kidney ranged 6 to 35 g with a mean of 18.2 g. The tumor size was 1.8 to 4.0 cm, the mean being 2.4 cm. Tumor grading was renal cell carcinoma grade 1 in 2 patients, grade 2 in 2 patients and oncocytoma in one patient. In all patients the tumor was encapsulated with a pseudocapsule with no involvement of the perinephric fat, venous or regional lymph nodes, and the tumor was diagnosed as pT2V0N0M0, stage I. In none of the patients intraoperative or postoperative complications developed with renal function of the operated kidney normal. The follow up interval after the operation was 5 years in 1 patients and 6 months to 1 year and 2 months in the remaining 4 patients. All patients have survived without metastasis or local recurrence in the operated kidney. We believe that partial nephrectomy is worth performing in selected patients with renal cell carcinoma not only in those having lesion in solitary kidney or bilateral kidneys but also in those whose function of the contralateral kidney is normal.     

The impact of a 4 cm. cutoff point for stratification of T1N0M0 renal cell carcinoma after radical nephrectomy

PURPOSE: The 1997 TNM classification defines T1 tumors as those smaller than 7 cm. Recently, a cutoff point of 4 cm. has been proposed to create a subclass of T1 tumors. We evaluated the validity of this cutoff point by assessing the pathological findings and prognoses of patients with T1N0M0 renal cell carcinoma following radical nephrectomy. MATERIALS AND METHODS: We reviewed the hospital charts of 333 patients with T1N0M0 tumors, followed as long as 282 months (median 63) after radical nephrectomy. The validity of tumor size cutoff point for predicting survival outcome was tested in relation to other prognostic factors, including patient age, tumor position, nuclear grade, tumor histopathology and degree of microscopic venous invasion. RESULTS: During followup 32 patients (9.6%) had tumor recurrence and 21 (6.3%) died of renal cell carcinoma. A 5 cm. cutoff point maximized the differences in cancer specific survival rates and a 4 cm. cutoff point maximized the differences in disease-free survival rates. Tumor size was directly related to microscopic venous invasion and nuclear grade, which are significant prognostic factors, and a 4 cm. cutoff point enhanced these relationships. CONCLUSIONS: Tumor size is an important prognostic factor for patients with T1N0M0 renal cell carcinoma. A cutoff point of 4 cm. is practical for dividing the T1N0M0 classification into T1a and T1b subclasses.     

Robotic partial nephrectomy for complex renal tumors: surgical technique

OBJECTIVES: Laparoscopic partial nephrectomy requires advanced training to accomplish tumor resection and renal reconstruction while minimizing warm ischemia times. Complex renal tumors add an additional challenge to a minimally invasive approach to nephron-sparing surgery. We describe our technique, illustrated with video, of robotic partial nephrectomy for complex renal tumors, including hilar, endophytic, and multiple tumors. METHODS: Robotic assistance was used to resect 14 tumors in eight patients (mean age: 50.3 yr; range: 30-68 yr). Three patients had hereditary kidney cancer. All patients had complex tumor features, including hilar tumors (n=5), endophytic tumors (n=4), and/or multiple tumors (n=3). RESULTS: Robotic partial nephrectomy procedures were performed successfully without complications. Hilar clamping was used with a mean warm ischemia time of 31 min (range: 24-45 min). Mean blood loss was 230 ml (range: 100-450 ml). Histopathology confirmed clear-cell renal cell carcinoma (n=3), hybrid oncocytic tumor (n=2), chromophobe renal cell carcinoma (n=2), and oncocytoma (n=1). All patients had negative surgical margins. Mean index tumor size was 3.6 cm (range: 2.6-6.4 cm). Mean hospital stay was 2.6 d. At 3-mo follow-up, no patients experienced a statistically significant change in serum creatinine or estimated glomerular filtration rate and there was no evidence of tumor recurrence. CONCLUSIONS: Robotic partial nephrectomy is safe and feasible for select patients with complex renal tumors, including hilar, endophytic, and multiple tumors. Robotic assistance may facilitate a minimally invasive, nephron-sparing approach for select patients with complex renal tumors who might otherwise require open surgery or total nephrectomy.     

Intermediate results of laparoscopic cryoablation in 59 patients at the Medical College of Wisconsin

PURPOSE: We report our experience with LC for small renal tumors. MATERIALS AND METHODS: Patients who underwent LC at our institution between February 2000 and September 2004 were included in the study. A retrospective chart review was done for perioperative and postoperative parameters as well as clinical outcomes. RESULTS: A total of 65 LCs were performed in 59 patients during the period reviewed. Overall 81 renal tumors were cryoablated. Median patient age was 62 years. Median tumor size was 2.5 cm. Median operative time was 190 minutes. Median estimated blood loss was 50 ml. Median hospital stay was 2 days. Conversion to open surgery occurred in 2 patients. Nephrectomy for bleeding occurred in 1 patient. Median followup was 26.8 months. Two recurrences were identified after LC. CONCLUSIONS: LC is an alterative modality to laparoscopic partial nephrectomy or open partial nephrectomy for small renal tumors. Tumor recurrence rates in the studies published to date are comparable to those of partial nephrectomy, although longer followup is needed.     

Bilateral adrenal masses from renal cell carcinoma: a case report

We report a case of bilateral adrenal metastasis from renal cell carcinoma. A 65-year-old man was referred to our hospital for a right renal mass. A computed tomography revealed a 9 cm right renal tumor and bilateral adrenal masses (3.5 cm on the right side and 4.5 cm on the left). A right radical nephrectomy and bilateral adrenalectomy demonstrated renal cell carcinoma with metastasis to bilateral adrenal glands. The pathological findings of the right renal tumor showed clear cell carcinoma, G3 > G2 and both adrenal tumors showed the same pathology as the right renal tumor. The patient is alive with lung metastasis after 15 months postoperatively treated with interferon-alpha.     

Parenchymal sparing surgery in patients with hereditary renal cell carcinoma: 10-year experience

PURPOSE: von Hippel-Lindau disease, hereditary papillary renal cell carcinoma, the Birt-Hogg-Dubé syndrome and familial renal oncocytoma are familial renal tumor syndromes. These hereditary disorders are noteworthy for the development of multiple bilateral renal tumors and the risk of new tumors throughout life. One management strategy is observation of solid renal tumors until reaching 3 cm, then performing parenchymal sparing surgery. We present a 5-year update on our experience. MATERIALS AND METHODS: From May 1988 to October 1998, 49 patients with hereditary renal cell carcinoma, including von Hippel-Lindau disease in 44, hereditary papillary renal cell carcinoma in 4 and the Birt-Hogg-Dubé syndrome in 1, and 1 with familial renal oncocytoma underwent exploration to attempt renal parenchymal sparing surgery. Patients were followed prospectively with periodic screening for recurrence, metastasis and loss of renal function. Median followup was 79.5 months (range 0.7 to 205). RESULTS: A total of 50 patients underwent 71 operations resulting in unilateral nephrectomy in 6, bilateral nephrectomy in 1 and partial nephrectomy in 65, with 1 to 51 tumors removed from each kidney (mean 14.7). Mean patient age was 39.5 years (range 18 to 70). Of the 65 (40%) partial nephrectomies 26 were performed with cold renal ischemia. Mean blood loss was 2.9 +/- 0.5 l (range 0.15 to 23). Postoperative complications included renal atrophy in 3 patients. Mean preoperative serum creatinine was 1.05 +/- 0.03 mg/dl (range 0.6 to 1.8), and postoperative creatinine was 1.06 +/- 0.04 mg/dl (range 0.6 to 2.0). No patient who underwent renal parenchymal sparing surgery required renal replacement therapy. Metastatic disease developed in 1 patient with a 4.5 cm renal tumor. CONCLUSIONS: Parenchymal sparing surgery with a 3 cm threshold in patients with hereditary renal cancer appears to be an effective therapeutic option to maximize renal function while minimizing the risk of metastatic disease.     

Laparoscopic partial nephrectomy with "on-demand" clamping reduces warm ischemia time

OBJECTIVES: To investigate the impact of "on-demand" clamping during laparoscopic partial nephrectomy on warm ischemia time. METHODS: We retrospectively reviewed 39 consecutive patients with renal tumors who had undergone transperitoneal laparoscopic partial nephrectomy from April 2002 to May 2006. Median tumor size was 2.3 cm. In all cases, the hilum was dissected early and extracorporeal clamping performed. The pedicle was clamped only in case of excessive bleeding, and it was released immediately after the closure of the renal defect with knot-tying sutures over Surgicel bolsters. RESULTS: Median operative time was 120 min. Renal clamping was required in 31 of 39 patients and in this subgroup the median warm ischemia time was 9 min. Median operative blood loss was 150 ml. Eight patients required blood transfusion and among these two were converted to open surgery. Positive surgical margin was observed in one case. Renal cell carcinoma was present in 22 (54.4%) specimens. No recurrence was observed after a median follow-up of 15 mo. CONCLUSIONS: This novel technique using extracorporeal clamping significantly decreases warm ischemia time, avoiding clamping of the pedicle in selected cases. Our study underlines the feasibility of performing laparoscopic partial nephrectomy with extracorporeal hilar clamping, allowing the shortest ischemia time ever published.     

A scoring algorithm to predict survival for patients with metastatic clear cell renal cell carcinoma: a stratification tool for prospective clinical trials

PURPOSE: We developed a clinically useful scoring algorithm to predict cancer specific survival for patients with clear cell metastatic renal cell carcinoma (RCC). MATERIALS AND METHODS: We studied 727 patients treated with radical nephrectomy for clear cell RCC from 1970 to 2000 who had distant metastases at nephrectomy (285) or in whom metastases subsequently developed (442). A scoring algorithm to predict cancer specific survival was developed using the regression coefficients from a Cox proportional hazards model. RESULTS: There were 606 deaths from clear cell RCC at a median of 1.0 years (range 0 to 14) following metastatic RCC. Constitutional symptoms at nephrectomy (+2), metastases to the bone (+2) or liver (+4), metastases in multiple simultaneous sites (+2), metastases at nephrectomy (+1) or within 2 years of nephrectomy (+3), complete resection of all metastatic sites (-5), tumor thrombus level I to IV (+3), and the primary pathological features of nuclear grade 4 (+3) and histological tumor necrosis (+2) were significantly associated with death from RCC. All patients started with a score of 0 and points were added or subtracted as indicated in parentheses. Cancer specific survival rates at 1 year were 85.1%, 72.1%, 58.8%, 39.0%, and 25.1%, respectively, for patients with scores of -5 to -1, scores of 0 to 2, scores of 3 to 6, scores of 7 or 8, and scores of 9 or more. CONCLUSIONS: This scoring algorithm can be used to predict cancer specific survival for patients with metastatic clear cell RCC.