Multiple ipsilateral renal tumors discovered at planned nephron sparing surgery: importance of tumor histology and risk of metachronous recurrence

PURPOSE: Unrecognized sporadic multifocality at planned nephron sparing surgery (NSS) presents a surgical dilemma. We report a single institution experience with patients presenting with multiple ipsilateral renal tumors, of which at least 1 was renal cell carcinoma (RCC). We determined the outcome for patients treated with NSS or radical nephrectomy (RN). MATERIALS AND METHODS: A total of 118 patients underwent surgery between 1970 and 2000 for sporadic multiple ipsilateral renal tumors, of which at least 1 was RCC. The patients were treated with RN (102) and NSS (16). Clinical features recorded included age at surgery, sex, history of smoking, a preexisting solitary kidney and symptomatic disease at presentation. Pathological features included histological subtype, nuclear grade, tumor stage (2003 TNM) and tumor size. Cancer specific survival was estimated using the Kaplan-Meier method. RESULTS: A greater proportion of patients treated with NSS had a solitary kidney compared with patients treated with RN (6 or 38% versus 0, p <0.001). Of the 102 patients treated with RN for multiple tumors 12 died of RCC at a median time to death of 3.3 years (range 3 months to 9.5 years). Estimated cancer specific survival at 5 years was 90.1%. There was metachronous contralateral recurrence in 5 patients a median of 8.1 years following RN (range 3 months to 14 years). Two of the 16 patients treated with NSS died of RCC 6 and 11 years following NSS, respectively, for a cancer specific survival rate of 100% at 5 years. Two patients had local renal recurrence 1.7 and 2.8 years following NSS, respectively, and a metachronous contralateral renal tumor was found in 1 patient 7 months following NSS. Of the 102 patients treated with RN 63 (62%) and 9 of the 16 (56%) treated with NSS had at least 1 clear cell RCC. In 23 of the 102 patients (23%) treated with RN only 1 tumor was RCC, while the remainder were benign, suggesting that these patients were potential candidates for NSS. CONCLUSIONS: Patients undergoing RN or NSS for multiple ipsilateral renal tumors, of which at least 1 is RCC, have favorable cancer specific survival. The metachronous contralateral recurrence rate for patients with sporadic multifocal lesions is approximately 5%. Planned NSS may not be abandoned if satellite lesions are benign.     

Long-term outcome of multiple ipsilateral renal tumours found at the time of planned nephron-sparing surgery

OBJECTIVE

To evaluate patients with multiple ipsilateral renal tumours and to determine outcomes of nephron‐sparing surgery (NSS) and radical nephrectomy (RN), as the treatment of unrecognized sporadic multifocal tumours at NSS presents a surgical dilemma.

PATIENTS AND METHODS

In all, 104 patients had surgery between 1970 and 2003 for sporadic multiple ipsilateral renal tumours, at least one of which was renal cell carcinoma (RCC); 114 were treated with RN and 26 with NSS. Cancer‐specific survival (CSS) was estimated using the Kaplan‐Meier method.

RESULTS

More patients treated with NSS had a solitary kidney than those undergoing RN (six, 23%, vs none, P < 0.001). Seventeen of the 114 having RN died from RCC at a median (range) of 3.4 (0.25–10.3) years after RN. The estimated 5‐year CSS was 90.5%. There was metachronous recurrence in nine patients at a median of 5.6 (1–14 ) years after. Two of the 26 patients having NSS died from RCC at 1 and 6 years after NSS; the 5‐year CSS was 95.8%. There was local or metachronous recurrence in three patients at 7 months to 6 years after surgery; all three were alive at the last follow‐up. In 26 (23%) of the 114 patients treated with RN, only one tumour was RCC.

CONCLUSION

Patients undergoing either RN or NSS for multiple ipsilateral renal tumours have a favourable CSS. A planned NSS is safe if small satellite lesions are resectable.     

Nephron sparing surgery for renal cell carcinoma with normal contralateral kidney: 25 years of experience

PURPOSE: We report the long-term results of our consecutive series of 504 patients who underwent NSS for cancer suspicious, solid renal tumors in the presence of a normal opposite kidney at our institution since 1979. MATERIALS AND METHODS: A total of 715 patients underwent NSS since 1969, including 504 for an elective indication, that is with a normal opposite kidney. Of these patients 381 (75.6%) had RCC, 123 (24.4%) had cancer suspicious benign lesions, including 53 (10.5%) with oncocytoma, 33 (6.5%) with angiomyo(lipo)ma, 23 (4.6%) with a complicated cyst and 13 (2.8%) with other benign lesions. Of the 381 patients with RCC 283 (74.3%) had clear cell, 68 (17.8%) had papillary and 30 (7.9%) had chromophobic RCC. Mean tumor diameter was 3.0 cm (range 0.5 to 11.0). Mean followup was 6.77 years (range 0.2 to 24.1). The oncological outcome was studied, including pathological features associated with tumor progression. RESULTS: Estimated cancer specific survival rates at 5 and 10 years were 98.5% and 96.7%, respectively. Estimated survival rates free of distant metastasis at 5 and 10 years were 97.5% and 95.1%, respectively. Nine patients with localized RCC experienced local recurrence after NSS. Estimated survival rates free of local recurrence at 5 and 10 years were 98.3% and 95.7%, respectively. CONCLUSIONS: The long-term results of our series support the concept of organ sparing surgery for RCC in the presence of a normal opposite kidney with excellent long-term survival and a low tumor recurrence rate.     

Long-term outcome of conservative surgery for kidney cancer: survival,blood pressure,and renal function

PURPOSE: Nephron-sparing surgery (NSS) for renal cell carcinoma (RCC) remains controversial for elective indications (low stage RCC in the presence of a normal contralateral kidney). In this single center study survival rate and, as novel aspects, the frequency of postoperative arterial hypertension and renal function parameters were investigated to evaluate safety and efficacy of NSS. PATIENTS AND METHODS: The complete data of 248 patients operated nephron-sparing for RCC between 1975 and 1995 were evaluated. One hundred and seventy-five patients were treated for elective indication (95% with tumor stage T1 or T2), 73 patients for mandatory indication (bilateral tumors, solitary kidney, renal insufficiency). The mean follow-up was 75 months (maximum 23 years). RESULTS: Mean tumor-size was lower under elective (3.8 cm) than under mandatory (4.7 cm) indication. Overall tumor-specific survival after 5 years for both indications was 88%. Comparing preoperative vs. follow-up values, arterial blood pressure and serum-creatinine values remained unchanged for both indications. The incidence of postoperative proteinuria (19% imperative, 11% elective indication) was strongly related to hypertension. CONCLUSIONS: NSS for RCC under elective indication achieves patient survival comparable to the results of radical nephrectomy. The presented data do not indicate significant longterm complications such as arterial hypertension, proteinuria or deterioration of renal function as a result of glomerulosclerosis or hyperfiltration. This gives further argument for the concept of NSS in RCC as an alternative to radical nephrectomy in the presence of a healthy contralateral kidney.     

Partial nephrectomy for renal tumors using selective parenchymal clamping

Purpose To describe our experience with partial nephrectomy using selective parenchymal clamping for the treatment of renal tumors. Patients and methods Between 2003 and 2005, seven patients with solid renal tumors underwent partial nephrectomy with selective parenchymal clamping at our Institution. In five, the tumor was in the right kidney and in two the tumor was in the left. Only one patient had a tumor within a solitary kidney. The tumor was located in the upper pole in 2 patients and in the lower pole in 5. Partial nephrectomy was performed with the DeBakey aortic clamp without occlusion of renal vessels. Results Mean operative time was 236 min (range 175–298 min). Mean intraoperative blood loss was 485 ml with only one patient requiring blood transfusion. There were no major complications. Mean preoperative serum creatinine level was 0.74 mg/dl (range 0.58–1.26 mg/dl) and mean postoperative serum creatinine level was 0.81 mg/dl (range 0.69–1.21 mg/dl) with no patient requiring dialysis. Mean hospital postoperative stay was 5 days (range 4–7 days). Mean tumor size was 2.9 cm (range 1.3–4.0 cm). Pathologic analysis detected renal cell carcinoma in 5 patients, angiomyolipoma in 1 and fibrosis with chronic hemorrhage in 1, all with negative surgical margins. After a mean follow-up of 18 months (range 3–32 months), all patients are free of disease recurrence. Conclusion Partial nephrectomy with selective parenchymal clamping allows resection of solid masses without damage to normal renal tissue, avoids the risk of renal failure and offers an excellent local cancer control.     

Matched comparison of radical nephrectomy vs. nephron-sparing surgery in patients with unilateral renal cell carcinoma and a normal contralateral kidney.

Objective: To report the long-term follow-up of a matched comparison of radical nephrectomy (RN) and nephron-sparing surgery (NSS) in patients with single unilateral renal cell carcinoma (RCC) and a normal contralateral kidney.Patients and Methods: Between August 1966 and March 1999, 1492 and 189 patients with unilateral RCC and a normal contralateral kidney underwent RN and NSS, respectively. Patients with renal impairment, previous nephrectomy, bilateral or multiple RCCs, metastasis, and familial cancer syndromes were excluded. A total 164 patients in each cohort were matched according to pathological grade, pathological T stage, size of tumor, age, sex, and year of surgery. The Kaplan-Meier method and stratified Cox proportional hazards model were used to estimate and compare overall, cancer-specific, local recurrence-free, and metastasis-free survival and survival free of chronic renal insufficiency. The 2 groups were evaluated for early (⩽30 days) complications and proteinuria at last follow-up.Results: At last follow-up, 126 RN patients (77%) and 130 NSS patients (79%) were alive with no evidence of disease. There was no significant difference observed between patients who had RN and those who had NSS with respect to overall survival (risk ratio, 0.96; 95% confidence interval [CI], 0.52–1.74; P = .88) or cancer-specific survival (risk ratio, 1.33; 95% CI, 0.30–5.95; P = .71). At 10 years, similar rates of contralateral recurrence (0.9% for RN vs 1% for NSS) and metastasis (4.9% for RN vs 4.3% for NSS) were seen in each group, whereas the rate of ipsilateral local recurrence for patients who underwent RN and NSS was 0.8% and 5.4%, respectively (P = .18). There was no significant difference in the early complications between the RN and NSS groups. However, patients who underwent RN had a significantly higher risk for proteinuria as defined by a protein/osmolality ratio of 0.12 or higher (55.2% vs 34.5%; P = .01). At 10 years, the cumulative incidence of chronic renal insufficiency (creatinine > 2.0 mg/dL at least 30 days after surgery) was 22.4% and 11.6%, respectively, for the RN and NSS groups (risk ratio, 3.7; 95% CI, 1.2–11.2; P = .01).Conclusions: This retrospective study of patients with unilateral RCC and a normal contralateral kidney suggests that NSS is as effective as RN for the treatment of RCC on long-term follow-up. The increased risk of chronic renal insufficiency and proteinuria after RN supports use of NSS.CommentaryData from several studies have shown that nephron-sparing surgery (NSS) and radical nephrectomy provide equally effective curative treatment for patients with a single, small (⩽ 4 cm), unilateral, localized renal cell carcinoma (RCC) and a normal opposite kidney 1, 2. A recent study from Memorial Sloan Kettering reported a 10-year cancer free survival rate of 97% following elective partial nephrectomy in 70 such patients [3]. Other studies have further shown that the cost of NSS is equivalent to that of radical nephrectomy [4] and that quality of life is improved following NSS in this setting [5].Notwithstanding the above data, there has been controversy concerning the renal functional advantage of performing NSS when the contralateral kidney is anatomically and functionally normal. Long-term follow-up after live donor nephrectomy operations has failed to demonstrate any significant adverse sequela in terms of proteinuria, hypertension or renal failure. However, patients undergoing surgical treatment for localized RCC represent a different population who are generally older and often have co-morbid medical conditions. This is the likely explanation for the findings in this important study from the Mayo Clinic which suggest an increased risk of chronic renal insufficiency and proteinuria after radical nephrectomy (compared to NSS) in patients with a normal contralateral kidney. A similar observation was recently reported in a study from Memorial Sloan Kettering presented at the 2001 annual AUA meeting. These emerging beneficial renal functional data enhance the argument in favor of elective NSS in patients with a solitary small (⩽ 4 cm) RCC and a normal contralateral kidney.Andrew C. Novick, M.D.     

Bilateral synchronous sporadic renal cell carcinoma: surgical management, oncological and functional outcomes

OBJECTIVE: To analyse the functional and oncological outcomes of surgical treatment of bilateral synchronous sporadic renal cell carcinoma (RCC). PATIENTS AND METHODS: Between 1969 and 2006, 57 patients with bilateral synchronous sporadic RCC were identified from our kidney database. The mean (range) follow-up was 4.8 (0.1-23.8) years; 28 patients (49%) had radical nephrectomy (RN) and contralateral nephron-sparing surgery (NSS), and 22 (39%) had bilateral NSS. The oncological outcome and long-term renal function were analysed. RESULTS: After excluding four patients (7%) with bilateral benign renal tumours, six (11%) with metastatic bilateral RCC and three (5%) who had bilateral RN, the cancer-specific outcome was analysed. For 44 patients with bilateral RCC who had surgery with intent to cure and avoid dialysis, 13 (30%) had stage pT1a, 10 (23%) pT1b, nine (17%) pT2 and 12 (27%) pT3 disease. At 5 and 10 years, the cancer-specific survival rates were 86% and 75%, and the local recurrence-free survival rates were 87% and 80%. The median serum creatinine level at the latest follow-up was 1.18 mg/dL in patients after bilateral NSS and 1.40 mg/dL after unilateral NSS and contralateral RN (P < 0.05). CONCLUSIONS: These long-term data support the concept that NSS, whenever possible bilateral, is the treatment of choice for bilateral synchronous sporadic RCC. NSS provides adequate local tumour control and cancer-specific survival. Preservation of renal function is more efficient with bilateral NSS than with unilateral NSS and contralateral RN.     

Surgical treatment of stage pT3b renal cell carcinoma in solitary kidneys: a case series

OBJECTIVE: To describe the surgical management of patients with renal cell carcinoma (RCC) in a solitary kidney (managed preferentially by nephron-sparing surgery, NSS, to avoid dialysis) and extending into the renal vein or inferior vena cava (T3b). PATIENTS AND METHODS: We identified 13 patients treated surgically between 1977 and 2002 for stage T3b RCC in a solitary kidney; their charts were reviewed to ascertain details of management, pathology and outcomes. RESULTS: NSS was successful in seven patients (four in situ and three extracorporeally). Five patients had radical nephrectomy (RN), four after failed NSS. The mean (sem) operative duration was longer for NSS, at 5.8 (0.7) h, than RN, at 3.3 (0.6) h. There was one death during surgery before nephrectomy, and eight other complications in six patients. At a median (range) follow-up of 24 (0-204) months, eight patients had died, four from RCC (all having had NSS) at a median interval of 9.5 (7-16) months. Of the five patients alive at a median follow-up of 25 months, four had no identifiable disease, whilst one had systemic recurrence. CONCLUSIONS: NSS combined with venous tumour thrombectomy for treating T3b RCC involving a solitary kidney is feasible, albeit complicated. There was oncological success in a third of the patients. The treatment of these patients needs to be individualized, as alternatives to NSS (RN or observation) have obvious disadvantages.     

肾癌、肾错构瘤保留肾单位的手术治疗

目的探讨肾细胞癌（RCC）、肾错构瘤（AML）保留肾单位手术（NSS）的可能性和疗效。方法对30例肾癌15例肾AML患者行47人次保留肾单位的手术治疗，肾癌瘤体直径平均2．83cm，肾AML瘤体平均直径5．7cm。无症状22例，有症状23例。单侧肾癌28例，肾AML13例；双侧肾癌1例，肾AML2例，术后孤立肾肾癌1例。对侧肾功能正常37例，对侧肾有病变或潜在病变8例。全部通过电话对其随访。结果45例手术均成功。术后随访平均63个月，除1例肾癌术后16个月因肺癌广泛转移而死亡外，2例肾AML行选择性动脉栓塞（SAE），余均无瘤生存至今。结论肾癌、肾AML保留肾单位的手术治疗在适应证下是安全有效的。     

Laparoscopic partial nephrectomy in solitary kidney

PURPOSE: We report our experience with LPN for tumor in a solitary kidney. MATERIALS AND METHODS: Of 430 patients undergoing LPN since February 1999 at our institution 22 (5%) underwent LPN for tumor in a solitary kidney, as performed by a single surgeon. The laparoscopic technique that we used duplicated open principles, including hilar clamping, cold cut tumor excision and sutured renal reconstruction. RESULTS: Mean tumor size was 3.6 cm (range 1.4 to 8.3, median 3 cm), median blood loss was 200 cc (range 50 to 500), warm ischemia time was 29 minutes (range 14 to 55), total operative time was 3.3 hours (range 2.2 to 4.5) and hospital stay was 2.8 days (range 1.3 to 12). Two cases (9%) were electively converted to open surgery. Pathological findings confirmed renal cell carcinoma in 16 patients (73%) with negative surgical margins in all those with LPN. Major complications occurred in 3 patients (15%) and minor complications developed in 7 (32%). Median preoperative and postoperative serum creatinine (1.2 and 1.5 mg/dl) and estimated glomerular filtration rate (67.5 and 50 ml per minute per 1.73 m2) reflected a change of 33% and 27%, respectively, which appeared proportionate to the median amount of kidney parenchyma excised (23%). One patient (4.5%) required temporary hemodialysis. At a median followup of 2.5 years (range 0.5 to 4.5) cancer specific and overall survival was 100% and 91%, respectively. No patient with LPN had local or port site recurrence, or metastatic disease. CONCLUSIONS: LPN can be performed efficaciously and safely in select patients with tumor in a solitary kidney. To our knowledge we present the largest series in the literature. Advanced laparoscopic experience and expertise are necessary in this high risk population.     

Imperative indications for conservative surgery for renal cell carcinoma: 20 years' experience

INTRODUCTION: Radical nephrectomy is the treatment of first choice for unilateral renal cell carcinoma (RCC) with a healthy contralateral kidney; however, the current standard for dealing with RCC in patients with a solitary kidney, bilateral tumor and renal or systemic disease inducing a progressive impairment of renal function is nephron-sparing surgery. MATERIALS AND METHODS: Between January 1974 and July 1996, 62 patients (39 men and 23 women, 33-77 years old, mean age 60.6 years) with RCC underwent nephron-sparing surgery. The patients were divided in to two groups according to treatment indication: 46 patients with bilateral tumor (n = 21) or solitary kidney (n = 25) and 16 patients with renal or systemic disease that could damage the contralateral kidney. Survival curves were calculated according to the Kaplan-Meyer method. RESULTS: In the first group 3 patients died postoperatively, and 3 were lost to follow-up; 12 patients (27.9%) had malignant recurrence and 5 (11.6%) died of local recurrence or systemic diffusion. The probability of local or systemic tumor recurrence was 9.9% at 2 years, 20.2% at 5 years and 24.7% at 10 years; the probability of survival was 100% at 2 years, 91.9% at 5 years and 81.9% at 10 years. In the second group 3 patients died of unrelated causes and 1 was lost to follow-up; 4 patients (25%) had a malignant recurrence and 2 (12.5%) died of systemic diffusion of RCC. The probability of tumor recurrence was 13.0% at 2 years, 19.7% at 5 years and 26.4% at 10 years, the probability of survival was 100% at 2 years, 93.3% at 5 years and 86.1% at 10 years. CONCLUSIONS: In our experience nephron-sparing surgery seems justified in patients with a solitary kidney, bilateral tumor or a disease that potentially damages renal function. Tumor diameter and stage, incidental or symptomatic tumor presentation and specific indication for conservative surgery determine the prognosis.     

Population‐based comparative effectiveness of nephron‐sparing surgery vs ablation for small renal masses

Study Type – Prognosis (cohort) Level of Evidence 2a What's known on the subject? and What does the study add? Case series of patients undergoing various forms of ablation show that it is technically feasible and possible for ablation to achieve short‐ and intermediate‐term cancer‐specific survival rates similar to those of controls undergoing partial nephrectomy. This is the first well‐powered study with a controlled design to compare effectiveness between partial nephrectomy and ablation.

OBJECTIVE

• ? To determine, in a population‐based cohort, if disease‐specific survival (DSS) was equivalent in patients undergoing ablation vs nephron‐sparing surgery (NSS) for clinical stage T1a renal cell carcinoma (RCC).

PATIENTS AND METHODS

• ? A retrospective cohort study was performed using patients from the Surveillance, Epidemiology and End Results cancer registry with RCC < 4 cm and no evidence of distant metastases, who underwent ablation or NSS.
• ? Kaplan–Meier and Cox regression analyses were performed to determine if treatment type was independently associated with DSS.

RESULTS

• ? Between 1998 and 2007, a total of 8818 incident cases of RCC were treated with either NSS (7704) or ablation (1114).
• ? The median (interquartile range) follow‐up was 2.8 (1.2–4.7) years in the NSS group and 1.6 (0.7–2.9) years in the ablation group, although 10% of each cohort were followed up beyond 5 years.
• ? After multivariable adjustment, ablation was associated with a twofold greater risk of kidney cancer death than NSS (hazard ratio 1.9, 95% confidence interval 1.1–3.3, P= 0.02).
• ? Age, gender, marital status and tumour size were also significantly associated with outcome.
• ? The predicted probability of DSS at 5 years was 98.3% with NSS and 96.6% with ablation.

CONCLUSION

• ? After controlling for age, gender, marital status and tumour size, the typical patient presenting with clinical stage T1a RCC, who undergoes ablation rather than NSS, has a twofold increase in the risk of kidney cancer death; however, at 5 years the absolute difference is small, and may only be realized by patients with long life expectancies.

     

Nephron-sparing surgery for renal cell carcinoma--long-term results

OBJECTIVES: Renal cell carcinoma (RCC) is most often treated using radical nephrectomy. However, in patients with only one kidney or with bilateral RCC, nephron-sparing surgery (NSS) is mandatory. NSS may also be undertaken in patients with a normal contralateral kidney, providing that the tumour is fairly small and not unfavourably located. The aim of the present study was to determine the long-term results in patients treated with NSS for RCC. MATERIAL AND METHODS: We reviewed the records of 87 patients with RCC subjected to NSS between 1980 and 1999. The survival rate was determined, as well as the tumour grade (Skinner classification) and stage (1992 World Health Organisation classification). RESULTS: Cancer-specific survival, in patients with no demonstrable distant metastases and regardless of stage and grade, was 80% and 75% at 5 and 10 years, respectively. Long-term survival was significantly dependent on tumour stage and grade. CONCLUSION: In this patient series, long-term survival did not differ from the results obtained using radical nephrectomy, judging from the available literature. An exception was found in patients with high-stage RCC, where NSS appeared to be a less favourable procedure. We therefore recommend that NSS should be performed in cases with bilateral tumour disease or an absent/malfunctioning contralateral kidney. NSS may also be considered in cases of low-stage RCC with a normal contralateral kidney, especially in patients with local or systemic conditions that may adversely affect renal function in the future.     

Nephron sparing surgery for appropriately selected renal cell carcinoma between 4 and 7 cm results in outcome similar to radical nephrectomy

PURPOSE: We compared outcomes between patients treated with nephron sparing surgery (NSS) without imperative indications for renal preservation and radical nephrectomy (RN) for 4 to 7 cm renal cell carcinoma (RCC). MATERIALS AND METHODS: We identified 91 patients treated with NSS and 841 patients treated with RN for 4 to 7 cm RCC between 1970 and 2000. Cancer specific, distant metastases-free and recurrence-free survivals were estimated using the Kaplan-Meier method. RESULTS: Cancer specific survival rates at 5 years for patients treated with NSS and RN for 4 to 7 cm RCC were 98% and 86%, respectively. On univariate analysis patients treated with RN for 4 to 7 cm RCC were more likely to die of RCC compared to patients treated with NSS. However, after adjusting for features associated with death from RCC including stage, grade, histological tumor necrosis and histological subtype, this difference was no longer statistically significant (risk ratio 1.60, 95% CI 0.50-5.12, p = 0.430). Distant metastases-free survival rates at 5 years for patients treated with NSS and RN were 94% and 83%, respectively. On univariate analysis patients treated with RN were more likely to have tumors that metastasized compared to patients treated with NSS, although this difference was no longer significant after adjusting for the features listed previously (risk ratio 1.76, 95% CI 0.64-4.83, p = 0.273). Recurrence-free survival rates at 5 years for patients treated with NSS and RN were 94% and 98%, respectively. On univariate analysis patients treated with RN were less likely to have recurrence compared to patients treated with NSS (risk ratio 0.32, 95% CI 0.12-0.85, p = 0.022). CONCLUSIONS: There were no statistically significant differences in cancer specific survival and distant metastases-free survival between patients treated with NSS and RN for 4 to 7 cm RCC after adjusting for important pathological features. NSS for 4 to 7 cm RCC results in excellent outcome in appropriately selected patients.     

Surgical outcomes of nephron-sparing surgery for renal tumors

PURPOSE: We retrospectively assessed the surgical outcomes of nephron-sparing surgery (NSS) for patients with renal tumors. PATIENTS AND METHODS: From 1985 to March 2001, a total of 99 NSSs were performed on 94 patients with renal tumors. The patients were divided into three groups. Group I comprised of 22 patients who underwent imperative surgeries for renal cell carcinoma (RCC). The tumors were found in 18 patients bilaterally (including 8 patients with von Hippel-Lindau disease), in 3 with solitary kidney, and in 1 with chronic renal failure. The mean +/- standard deviation of patient age and tumor diameter was 46 +/- 23 years and 36 +/- 23 mm, respectively. Twenty-three in situ NSSs were performed on 18 patients in Group I, and the remaining 4 patients were treated with 3 simultaneous operations for bilateral renal tumors with or without 2 ex vivo surgeries. Group II consisted of 49 patients who had small RCCs with the normal contralateral kidney and underwent NSSs (elective indication). The mean age and tumor diameter was 54 +/- 10 years and 28 +/- 11 mm, respectively. Group III consisted of 23 patients with non-RCC tumor (10 angiomyolipomas, 8 cystic tumors, 2 adenomas, 2 metastatic tumors, and 1 degenerative lesion), all of whom were treated with NSS. The mean age and tumor diameter was 47 +/- 14 years and 41 +/- 29 mm, respectively. RESULTS: In Group I, 3 patients died of cancer including 2 patients who had had multiple lung metastases preoperatively. The five-year tumor specific survival rate was 87.3% with a postoperative follow-up of 49 +/- 36 months. In Group II, there were few peri-operative complications or no local recurrence at follow-up of 52 +/- 38 months. A patient developed lung metastasis, which was removed surgically with no evidence of recurrence at 159 months after NSS. Postoperative renal scintigraphy on 35 patients showed well-preserved renal function of the operated kidney. Improvement in surgical techniques resulted in less-invasive surgery in 22 operations during the last 4 years. The patients of Group III were also operated uneventfully, although 1 experienced postoperative bleeding. In 12 patients with solitary kidney (11 in Group I and 1 in Group III) serum creatinine level increased transiently, decreased to 1.3 times of preoperative values within 3 months, and almost recovered at 1-year follow-up. CONCLUSION: Excellent outcomes in cancer control and preservation of renal function support the validity of nephron-sparing surgery to treat renal tumors. The candidate patients may include those with bilateral kidney tumors, tumor occuring in the solitary kidney or small renal cell carcinomas with the normal contralateral kidney. Earlier detection of small lesions and less invasive surgical techniques will facilitate a wider indication of NSS.     

Nephron-sparing surgery and percutaneous biopsies in renal-cell carcinoma: a global impression among endourologists

BACKGROUND AND PURPOSE: On the one hand, nephron-sparing surgery (NSS) in small renal tumors is a safe and effective alternative to radical nephrectomy. On the other hand, the role of preoperative percutaneous needle biopsies (PNB) remains controversial. The purpose of this study was to evaluate the global current use of NSS in the treatment of renal-cell carcinoma (RCC) and the use of PNB among endourologists. MATERIALS AND METHODS: One thousand questionnaires were distributed during the 23rd World Congress of Endourology and SWL. Six questions regarding NSS and two questions regarding PNB were presented. Two hundred twenty-two questionnaires were returned. RESULTS: Of the respondents, 86.6% perform NSS for small renal tumors, whereas 13.4% perform only radical nephrectomies; 7.5% will consider NSS only in patients with a solitary kidney, and 0.5% will never consider NSS. The techniques for NSS, in descending order of preference, are partial nephrectomy, enucleation, cryoablation, radiofrequency ablation, and high-intensity focused ultrasound. The mean and maximum diameter of the tumor in patients with a normal contralateral kidney for which the urologists perform NSS is 4.0 cm. For a centrally located tumor, NSS is an option for 27.2% of the respondents. Regarding PNB in patients with suspicion of RCC, 55.9% of respondents never obtain renal biopsies in the preoperative assessment and 41.8% obtain them only in rare cases. The majority (90%) prefer histologic over cytologic biopsies. CONCLUSIONS: Nephron-sparing surgery is evolving to a global worldwide standard treatment for small renal tumors. Percutaneous needle biopsy remains a highly debated procedure.     

Surgeon's role in the management of solitary renal cell carcinoma metastases occurring subsequent to initial curative nephrectomy: An institutional review

Background: Solitary metastases from a primary renal cell carcinoma (RCC) occur in <10% of patients with metastatic RCC. To date, the benefit of surgically resecting such apparently solitary lesions has not been well documented. Materials and Methods: Forty-one patients (25 men, 16 women) with metastatic renal cell carcinoma treated by surgical excision of solitary metastases (1970–1990) were retrospectively reviewed. They comprised 9% of patients with metastatic hypernephroma seen during this period. All patients had undergone previous curative nephrectomy with a median disease-free interval of 27 months. Patients with skeletal, spinal cord, and lymph node metastases were excluded. Results: Mevtastases were intrathoracic (n=20), intracranial (n=7), and intraabdominal or in the extrapleural chest wall soft tissue (n=10). Three patients had metastases to the thyroid gland and one had a solitary metastasis to an index finger. Median follow-up was 3.2 years. Complete resection was possible in 36 patients (88%) with a single lesion excised in 23 of these 36 patients (64%). There was no operative mortality. Predicted survival from the date of complete resection of metastases was 77%, 59%, and 31% at 1, 3, and 5 years, respectively, with a median survival of 3.4 years. One patient is alive without evidence of recurrent tumor 93 months from the first of 12 complete surgical resections. Varying adjuvant therapy was used in 50% of the patients. An increased histological tumor grade of the metastatic lesion relative to the original RCC was the only significant prognostic indicator identified. Disease-free interval and number of resected lesions were not significantly associated with patient survival. Conclusion: A small fraction of renal cell carcinoma patients are candidates for potentially curative surgical resection of solitary metastatic lesions. Excision of such lesions may contribute to prolonged survival in selected instances. The results of this study were presented at the 46th Annual Cancer Symposium of The Society of Surgical Oncology, Los Angeles, California, March 18–21, 1993.     

Biopsy-confirmed de novo renal cell carcinoma (RCC) in renal grafts: a single-centre management experience in a 2396 recipient cohort

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? The renal cell carcinoma incidence among renal transplant recipients is approximately 0.5%; however, a significant increase in the number of RCC in renal grafts can be expected in the forthcoming years due to the increase in donor age and in renal graft survival. Our findings support evidence that radiological screening of kidney recipients allows the detection of small tumors for which a conservative management by nephron sparing surgery or nonsurgically destructive techniques can be proposed with mid‐term oncological safety. Systematic tumor biopsy may also help in the management and treatment decision.

OBJECTIVE

? To study the natural history of renal cell carcinoma (RCC) development in renal grafts and their management.

PATIENTS AND METHODS

? We report a single‐centre series of de novo RCC in allografts from a cohort of 2396 consecutive renal transplant recipients.

RESULTS

? In all, 17 RCCs were detected in 12 patients, representing 0.5% of kidney recipients. ? The mean patient age was 55 years and the time to RCC diagnosis since transplantation was 13 years. The mean diameter of the RCC was 23 mm. ? Biopsies were taken in all cases. Concordance between biopsy and surgical specimens was 100% for nuclear grade and pathological type. ? Four graft removals were performed and six patients underwent nephron‐sparing surgery (NSS). Two cryoablations were performed. ? Overall, nine papillary RCC, five clear cell carcinomas, and one chromophobe cell carcinoma were removed surgically. The mean follow‐up was 43 months. One local recurrence was reported in a patient treated by NSS.

CONCLUSIONS

? Our findings support evidence that radiological screening of kidney recipients allows the detection of small tumours for which a conservative management by NSS or non‐surgically destructive techniques can be proposed with mid‐term oncological safety. ? Systematic tumour biopsy may help in the management and treatment decision. ? Several questions remain unanswered such as the importance of mammalian target of rapamycin inhibitors in the chemoprevention of the recurrence and the genetic cell origin of RCC in renal grafts.     

Management of renal angiomyolipoma in complex clinical situations.

Renal angiomyolipoma (AML) is associated with complex clinical situations such as tumour in a solitary kidney, bilateral, large or multicentric tumours or those associated with tuberous sclerosis (TS) or pregnancy. Management in these situations may be challenging. Fifteen patients (20 kidneys) were admitted with symptomatic AML over last 10 years. Eleven patients had one or the other complicating factor. Ten patients had a tumour of >10 cm, 4 had TS, 5 had multiple and bilateral tumours, 1 patient was pregnant and 1 had a solitary functioning kidney. With the newer imaging modalities correct diagnosis was possible in 12 cases and renal cell carcinoma (RCC) was suspected in 3 cases. Selective angioembolization (SAE) was done in 3 patients, which successfully controlled bleeding in all. Nephron-sparing surgery (NSS) was performed in 5 patients. Total nephrectomy was done in 4 cases, in 3 due to suspicion of RCC and in 1 due to extensive involvement of the kidney. Three patients with multiple and bilateral tumours were chosen for conservative treatment and none developed recurrence of bleeding on strict follow-up. In a pregnant patient, bleeding was successfully controlled with angioembolization. However, 1 patient with a solitary functioning kidney with large-sized tumour (20 x 18 cm) underwent NSS. In conclusion, the basis of management of AML is preservation of renal tissue, which can be effectively achieved with SAE or NSS. In a solitary functioning kidney, NSS or SAE is the ideal treatment, if feasible. The patients in the TS group are usually more complicated and require life-long follow-up after initial management with NSS or SAE. Pregnant AML patients can be safely managed with SAE. Conservative treatment without any intervention and regular follow-up may be more helpful in some patients with multiple, bilateral extensive tumours.