Laparoscopic partial nephrectomy for tumours >4 cm compared with smaller tumours: perioperative results

Objective  

The use of laparoscopic partial nephrectomy (LPN) in patients with tumours >4 cm remains to be further evaluated. We report our experience with LPN in tumours >4 cm compared with tumours ≤4 cm.     

Robot-assisted partial nephrectomy for renal tumors larger than 4?cm: results of a multicenter, international series

Backgrounds

Limited data are available for the use of robot-assisted partial nephrectomy (RAPN) in tumors >4?cm. The objectives of this study were to report the perioperative outcomes of a series of patients who underwent RAPN for suspicious >4?cm renal tumors and to compare these results with those observed in a group of patients with ≤4?cm tumors.

Methods

We analyzed retrospectively the clinical records of 49 patients who underwent RAPN for suspicious of renal cell carcinoma (RCC) >4?cm in size at four centers from September 2008 to September 2010. All patients underwent da Vinci RAPN. The results were compared with those observed in a group of patients undergoing RAPN for ≤4?cm renal tumors.

Results

The median warm ischemia time (WIT) was 22?min (Interquartile range [IQR] 18–28). The median console time was 145?min (median IQR 112–177). The median blood loss was 120?mL (IQR 62–237). In two cases, we observed intraoperative renal vein injury (4?%). Postoperative complications were reported in 13 (26.5?%) patients. Major complications were observed in 4 (8.2?%) cases. Patients with large tumors showed perioperative outcomes worse than those received the RAPN for ≤4?cm tumors. Conversely, no significant difference was observed in positive surgical margin (PSM) rates.

Conclusions

These outcomes support the use of RAPN as possible alternative to open PN for the treatment for patients with suspicious renal masses >4?cm. Positive surgical margin rates demonstrated RAPN is an oncologically safe procedure for tumors >4?cm.     

Partial nephrectomy for renal masses ≥ 7 cm: technical, oncological and functional outcomes

What's known on the subject? and What does the study add? Partial nephrectomy for the pT1 renal mass has demonstrated acceptable oncological outcomes in addition to improved overall long‐term survival when compared with radical nephrectomy. Previous reports for lesions ≥7 cm have shown mixed data concerning oncological outcomes and technological success. We demonstrate that partial nephrectomy for renal masses ≥7 cm has acceptable oncological, technical, and functional outcomes. As such, partial nephrectomy should be a surgical option when feasible regardless of tumour size. Study Type – Therapy (case series) Level of Evidence 4

OBJECTIVE

• ? To present outcomes for patients with renal masses ≥7 cm in size who are treated with partial nephrectomy (PN) at our institution and to summarize the cumulative published experience.

PATIENTS AND METHODS

• ? We reviewed our prospectively maintained institutional kidney cancer database and identified patients undergoing PN for tumours >7 cm in size.
• ? Technical, oncological and renal functional data were analyzed and compared with the existing published experience of PNs for tumours >7 cm in size.

RESULTS

• ? In total, 46 patients with 49 renal tumours >7 cm in size who underwent PN were identified.
• ? With a median (range) follow‐up of 13.1 (0.2–170.0) months, there were 16 complications, including four (8.2%) blood transfusions and six (12.2%) urinary fistulae.
• ? The 5‐ and 10‐year overall and renal cell carcinoma (RCC)‐specific survivals were 94.5% and 70.9%. There were five (10.9%) patients who had an upward migration in their chronic kidney disease status after PN.
• ? There were six previous series totalling 280 tumours encompassing the published experience of PN for tumours >7 cm in size. The incidence of urinary fistulae and postoperative haemorrhage, respectively, was in the range 3.3–18.8% and 0–3%.
• ? Although oncological outcomes showed cancer‐specific survival in the range 66–97.0%, series matching PN and RN in patients with T2 RCC show equivalency in RCC‐specific and overall survivals. When reported, PN for tumours >7 cm in size was associated with better renal functional preservation.

CONCLUSION

• ? The findings of the present study show that PN can safely be performed in tumours ≥7 cm in size with acceptable technical, oncological and functional outcomes. Further studies are warranted.

     

Short-term functional and oncologic outcomes of nephron-sparing surgery for renal tumours ≥ 7 cm

Background

Nephron-sparing surgery (NSS) for renal tumours preserves renal function and has become the standard approach for small renal tumours. Little is known about perioperative and oncologic outcomes of patients following NSS in renal tumours ≥7 cm in the presence of a healthy contralateral kidney.

Objective

To analyse oncologic outcomes and perioperative morbidity in patients treated by NSS for renal tumours ≥7 cm.

Design, setting, and participants

In total, 5767 patients were treated for renal tumours at two institutions from 1984 to 2009. In 91 patients, elective NSS was performed for renal tumours ≥7 cm.

Measurements

Complication rates were assessed in detail and stratified using the Clavien-Dindo score (CDS). Oncologic outcomes for overall survival (OS), cancer-specific survival (CSS), and progression-free survival (PFS) were estimated using the Kaplan-Meier method. Logistic regression analysis was used to identify clinical risk factors for complications and prognosticators that have an oncologic impact on OS.

Results and limitations

The median follow-up was 28 mo (range: 1–247 mo). Twenty-seven patients (29.6%) had perioperative complications and, of these, 89.1% had CDS grade 1 and 2.Twenty-seven percent of the 91 patients had benign lesions. Seven patients (10.6%) died from cancer-related causes. The 5- and 10-yr rates for OS, CSS, and PFS were 88% and 64%, 97% and 83%, and 91% and 78%, respectively. None of the analysed parameters had an impact on morbidity or OS in the univariate analysis. Limitations of this study were its retrospective nature and the relatively short follow-up period for oncologic outcome.

Conclusions

NSS for renal tumours ≥7 cm can be performed with acceptable complication rates and with oncologic outcomes comparable to radical nephrectomy studies. Our findings support NSS whenever technically feasible to reduce the loss of renal function.     

Does pure robotic partial nephrectomy provide similar perioperative outcomes when compared to the combined laparoscopic–robotic approach?

Laparoscopic and robotic partial nephrectomy have become the preferred option for surgical management of incidentally discovered small renal tumors. Currently there is no consensus on which aspects of the procedure should be performed laparoscopically versus robotically. We believe that combining a laparoscopic exposure and hilar dissection followed by tumor extirpation and renorrhaphy with robotic assistance provides improved perioperative outcomes compared to a pure robotic approach alone. We performed a comparison of perioperative outcomes between combined laparoscopic–robotic partial nephrectomy—or hybrid procedure—and pure robotic partial nephrectomy (RPN). A multi-center retrospective analysis of patients undergoing RPN and hybrid PN using the da Vinci S system^® was performed. Patient data were reviewed for demographic and perioperative variables. Statistical analysis was performed using the Welch t test and linear regression, and nonparametric tests with similar significance results. Thirty-one patients underwent RPN while 77 patients underwent hybrid PN between 2007 and 2011. Preoperative variables were comparable in both groups with the exception of lesion size and nephrometry score which were significantly higher in patients undergoing hybrid PN. Length of surgery, estimated blood loss and morphine used were significantly less in the hybrid group, while warm ischemia time was significantly longer. The difference in WIT was accounted for in this data by adjusting for nephrometry score. In our multi-center series, the hybrid approach was associated with a shorter operative time, reduced blood loss and lower narcotic usage. We believe this approach is a valid alternative to RPN.     

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   

Evaluation of renal function in patients with a main renal stone larger than 1 cm and perioperative renal functional change in minimally invasive renal stone surgery: a prospective,observational study

Purpose

To compare the perioperative relative renal function and determine predictors of deterioration and recovery of separate renal function in patients with renal stones >10 mm and who underwent mini-percutaneous nephrolithotomy or retrograde intra-renal surgery.

Patients and methods

A main stone >10 mm or stones growing, high-risk stone formers and extracorporeal shock-wave lithotripsy-resistant stones were prospectively included in 148 patients. Patients with bilateral renal stones and anatomical deformities were excluded. Renal function was evaluated by estimated glomerular filtration rate, 99m-technetium dimercaptosuccinic acid and 99m-technetium diethylenetriamine pentaacetate prior to intervention and at postoperative 3 months. Logistic regression analyses were performed to find predictors of functional deterioration and recovery.

Results

The overall stone-free rate was 85.1 %. A third of patients (53/148, 35.8 %) with renal stones >10 mm showed deterioration of separate renal function. Mean renal function of operative sites showed 58.2 % (36.8 %/63.2 %) of that of contralateral sites in these patients. Abnormal separate renal function showed postoperative recovery in 31 patients (58.5 %). Three cases (5.7 %) showed deterioration of separate renal function despite no presence of remnant stones. Improvement rates of the abnormal separate renal function did not differ according to the type of surgery. The presence of hydronephrosis and three or more stones were significant predictors for renal function deterioration. Female gender and three or more stones were significantly correlated with postoperative recovery.

Conclusions

Mini-percutaneous nephrolithotomy or retrograde intra-renal surgery was effective and safe for renal function preservation. Patients with multiple large stones should be considered for candidates of active surgical removal.

     

Laparoscopic partial nephrectomy: how far have we gone?

PURPOSE OF REVIEW: Several technical modifications of laparoscopic partial nephrectomy have resulted in a reduction of complications and warm ischemia time. The most recent results are reviewed with a focus on oncologic outcome and postoperative renal function. RECENT FINDINGS: The indications for laparoscopic partial nephrectomy are the same as for open surgery. All tumors up to 4 cm should be included and selected tumors up to 7 cm may be considered as well. In experienced hands, the complication rate is considerably low. Oncologic outcome is comparable with open partial nephrectomy and 5-year survival data have been published recently. Long warm ischemia time may be of some concern. The published functional results are excellent. Cost should not be the main argument in favor of a method. Laparoscopic partial nephrectomy, however, combines advantages for the patient with lower cost as shown by two studies. SUMMARY: Laparoscopic partial nephrectomy duplicates the principles of open surgery and has been standardized to a great extent. It is technically difficult and is being performed by a small number of centers only; however, the interest of the urologists and patient demand is growing quickly. At the present time, laparoscopic partial nephrectomy cannot be considered a standard of care, but excellent results have been reported when performed by experienced laparoscopists.     

Laparoscopic pyelolithotomy versus percutaneous nephrolithotomy for a solitary renal pelvis stone larger than 3 cm: a prospective cohort study

To prospectively compare the outcome of laparoscopic pyelolithotomy (LP) versus percutaneous nephrolithotomy (PCNL) in patients with a solitary renal pelvis stone larger than 30 mm. We analyzed demographic and perioperative parameters and intermediate outcome in 30 adults who underwent transperitoneal LP for solitary renal pelvis stone larger than 30 mm (Group I) and compared the results with 30 patients who underwent PCNL (Group II). The two groups were matched for age, sex and stone size (Group I 35.3 ± 7.33 mm, Group II 36.6 ± 7.0 mm; P = 0.47). Mean operative time was significantly longer in LP group (120.5 ± 39.94 min versus 98.1 ± 23.28 min; P = 0.01, 95 % CI 5.43–39.23). Stone-free rate after LP was significantly higher than after PCNL (100 % versus 76.7 %; P = 0.01). On the discharge day, no residual stone was found in LP group, and significant residual stone (mean size 9.8 mm, range 7–15 mm) was found in seven patients (23.3 %) in PCNL group. After the ancillary procedures, the stone-free rates were 100 % in LP and 96.6 % in PCNL group at the end of follow-up. The average overall treatment cost was significantly lower in LP (683.9 USD versus 815.9 USD; P < 0.001). Mean postoperative decreases in hemoglobin was similar in both groups. Given adequate laparoscopic experience, for patients with a solitary renal pelvis stone larger than 3 cm, LP can be considered as an appropriate second choice to PCNL. It can be a potentially cost-effective treatment option in terms of one-session stone-free rate and postoperative complications. However, the potential benefits of LP need to be weighed against the more invasive nature of this procedure.