Efficacy and safety of nephron‐sparing surgery

To analyse the current evidence of efficacy and safety of nephron‐sparing surgery (NSS) that encompasses open partial nephrectomy (OPN), laparoscopic partial nephrectomy (LPN) and robotic partial nephrectomy in the management of localized renal cell carcinoma (RCC). Oncological data, complications and postoperative renal function were reviewed for the most important series of partial nephrectomy. Partial nephrectomy (PN) provides similar oncological control as radical nephrectomy (RN) and is superior to RN with respect to preserving renal function and preventing chronic kidney disease. OPN remains the first treatment option for T1 renal tumors in centers without advanced laparoscopic expertise. Indications for LPN have expanded as such that LPN is suited for most renal tumors provided that the procedure is carried out in selected patients by an experienced laparoscopic surgeon. Warm ischemia time should be kept within 20 min, which is currently recommended regardless of surgical approach. In experienced hands, LPN yields intermediate oncological efficacy and renal function outcome comparable to open surgery in the treatment of pT1 renal tumors. Positive surgical margin rates are comparable after LPN and OPN. In contemporary series, the morbidity of LPN is decreasing to become similar to that of OPN. Preliminary results with robotic PN are comparable to results obtained with LPN. Additional studies are required to validate these results and compare with other current methods, such as thermal ablation. NSS is effective and safe for the management of localized RCC and is the gold standard to which new ablative techniques need to be compared.     

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

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

A Critical Analysis of the Actual Role of Minimally Invasive Surgery and Active Surveillance for Kidney Cancer

Context

The incidence of renal cell carcinomas (RCCs) has increased steadily—most rapidly for small renal masses (SRMs). Paralleling the changing face of RCC in the past 2 decades, new, less invasive surgical options have been developed. Laparoscopic radical nephrectomy (LRN) is an established procedure for the treatment of RCC. Treatment of SRMs includes open partial nephrectomy (OPN), laparoscopic partial nephrectomy (LPN), thermal ablation, and active surveillance.

Objective

To present an overview of minimally invasive treatment options and data on surveillance for kidney cancer.

Evidence acquisition

Literature and meeting abstracts were searched using the terms renal cell carcinoma, minimally invasive surgery, laparoscopic surgery, thermal ablation, surveillance, and robotic surgery. The articles with the highest level of evidence were identified with the consensus of all the collaborative authors and reviewed.

Evidence synthesis

Renal insufficiency, as measured by the glomerular filtration rate, occurs more often after radical nephrectomy than partial nephrectomy (PN). OPN and LPN show comparable results in long-term oncologic outcomes. The treatment modality for SRMs should therefore be nephron-sparing surgery (NSS). In select patients, thermal ablation or active surveillance of SRMs is an alternative.

Conclusions

LRN has become the standard of care for most organ-confined tumours not amenable to NSS. Amongst NSS options, PN is the treatment of choice, yet remains underutilised in the community. Initial data during its learning curve revealed that LPN had higher urologic morbidity. However, current emerging data indicate that in experienced hands, LPN has shorter ischaemia times, a lower complication rate, and equivalent long-term oncologic and renal functional outcomes, yet with decreased patient morbidity compared to OPN. Robotic partial nephrectomy is being explored at select centres, and cryotherapy and radiofrequency ablation are options for carefully selected tumours. Active surveillance is an option for selected high-risk patients. Percutaneous needle biopsy is likely to gain increasing relevance in the management of small renal tumours.     

The medical and oncological rationale for partial nephrectomy for the treatment of T1 renal cortical tumors

This article presents the oncological and medical rationale for partial nephrectomy as the treatment of choice whenever possible for T1 renal tumors. The value of partial nephrectomy in the management of small renal cortical tumors is gaining wider recognition thanks to (1) enhanced understanding of the biology of renal cortical tumors; (2) better knowledge about tumor size and stage migration to small tumors at the time of presentation; (3) studies indicating the oncologic efficacy of kidney-sparing surgery, and (4) increasing awareness of the wide prevalence of chronic kidney disease. The overzealous use of radical nephrectomy for small renal tumors must now be considered detrimental to the long-term health and safety of the patient with a small renal cortical tumor.     

Partial nephrectomy: contemporary outcomes, candidate selection, and surgical approach

Localized kidney cancer is ideally managed with surgical extirpation. Historically renal cell carcinoma has been treated with radical nephrectomy, but partial nephrectomy has become increasingly used because of a growing body of evidence demonstrating equivalent oncologic control and a potential benefit in overall survival. In this article, the authors demonstrate that partial nephrectomy carries excellent oncologic efficacy. They additionally review the growing indications for partial nephrectomy and factors influencing candidate selection. The authors also compare the relative outcomes of open and minimally invasive techniques. Several factors influence outcome, and surgeon experience should dictate the choice of technique.     

Laparoscopic partial nephrectomy

PURPOSE OF REVIEW: This review defines the current role, indications, contraindications, advances, complications, and outcomes of laparoscopic partial nephrectomy in the management of renal tumors. RECENT FINDINGS: Recent publications have widened the scope for the application of this technology. The new advances in the management of renal tumors and the tools for tumor excision, renal parenchymal reconstruction, hemostasis, renal vascular control to establish renal ischemia, and the ability to avoid positive surgical margins have made the procedure safe and feasible in the hands of an experienced laparoscopist. SUMMARY: The trend toward nephron-sparing surgery has become stronger even in the presence of normal contralateral functioning kidney. Data on oncologic efficacy are promising, and partial nephrectomy is becoming a standard therapy for renal tumors less than 4 cm in size in many centers. Laparoscopic partial nephrectomy has evolved significantly during the past 10 years in our experience as well as that of others. It cannot be considered as a standard yet, but it is being performed in rapidly increasing numbers with good surgical efficiency and oncologic efficacy parallel to that of open surgery.     

Importance of surgical margins in the management of renal cell carcinoma

Surgical resection remains the standard treatment for clinically localized renal cell carcinoma. Pathological features of the surgical specimen, including the margin status, play an important part in determining the patient's prognosis. Negative surgical margins have traditionally been sought to maximize the efficacy of treatment. Initial concerns that partial nephrectomy might have high local recurrence rates compared with radical nephrectomy have now been minimized as a result of technological advances and refinements in surgical technique. Current concerns in relation to partial nephrectomy include the width of parenchymal tissue that should be removed to avoid positive surgical margins, effects of positive margins on recurrence-free survival, and the use of frozen-section analysis to determine margin status. Size of the surgical margin in partial nephrectomy does not seem to affect the risk of local tumor recurrence, and not all positive surgical margins lead to recurrent disease. Intraoperative frozen-section analysis is not definitive and its value in guiding the surgical management of renal tumors remains to be defined. Laparoscopic partial nephrectomy is emerging as an attractive approach for selected renal masses. Intraoperative use of ultrasound, cold-scissor parenchymal transection, embolization, and hilar clamping to achieve a bloodless operative field with clear visibility, may minimize the risk of positive margins during partial nephrectomy.     

Expanding the indications for laparoscopic radical nephrectomy

PURPOSE OF REVIEW: Laparoscopic radical nephrectomy is an established treatment for patients with clinical T1 renal cell carcinoma who are unsuitable for nephron-sparing surgery. In this review we summarize the expanding indications for laparoscopic nephrectomy, including large tumors, locally advanced disease, venous thrombi and cytoreductive surgery. RECENT FINDINGS: Laparoscopic nephrectomy remains the foremost conventional laparoscopic procedure in urologic surgery. Multiple studies have demonstrated the feasibility of laparoscopic radical nephrectomy for stage T2 tumors, showing less morbidity and earlier return to activity compared to the open approach. Confirmation of durable oncologic control requires randomized prospective trials with longer follow-up. With growing experience, laparoscopic surgery has been extended to patients with renal cell carcinoma associated with limited local invasion and lymph node metastases. Experimental studies demonstrate the technical feasibility of laparoscopic radical nephrectomy in the presence of renal vein and inferior vena cava thrombi. In well-selected patients with metastatic renal cell carcinoma, laparoscopic cytoreductive nephrectomy can be performed safely, with less morbidity than open nephrectomy. SUMMARY: Minimally invasive surgery results in significantly less postoperative morbidity than does open surgery. The intermediate oncologic outcomes of laparoscopic radical nephrectomy for advanced renal cell carcinoma are comparable to those historically achieved with open radical nephrectomy. Longer follow-up is needed to confirm survival equivalence.     

Intraoperative renal ultrasonography: a useful adjunct to partial nephrectomy

Several evolutionary changes in ultrasonographic instrumentation, including miniaturization of transducers and marked improvement in resolution, have made intraoperative renal ultrasonography a valuable adjunct for intrarenal surgery. We investigated its use in 6 patients undergoing partial nephrectomy for treatment of renal cell carcinoma. In addition, 14 kidneys with renal tumors were scanned immediately after radical nephrectomy and the specimens were subjected to simulated partial nephrectomy. Transverse and longitudinal real-time sonographic images were obtained with a 5 MHz. sector scanner or a 7.5 MHz. convex array transducer. With ultrasonography to define tumor extent and location, negative surgical margins were obtained in all 6 individuals undergoing partial nephrectomy. A negative surgical margin was obtained in 13 of the 14 radical nephrectomy specimens subjected to simulated partial nephrectomy. A small satellite lesion was not identified and not resected in 1 of the radical nephrectomy specimens. We found that intraoperative renal ultrasonography helps to identify the location and extent of deep intraparenchymal lesions. It also provides a guide for a more accurate nephrotomy, which facilitates the attainment of negative resection margins during partial nephrectomy.     

双侧肾癌的诊治与预后（附6例报告）

目的：探讨双侧肾癌（Bilateral renal cell carcinoma,BRCC）患者的诊治与预后。方法：1999年1月～2006年1月我院共诊治BRCC患者6例,平均发病年龄53（35～74）岁。其中双侧同时性肾癌3例,异时性肾癌3例。肿瘤位于肾上极6枚,中极7枚,下极1枚;左肾6枚,右肾8枚;肿瘤平均直径4．6（3～7）cm。3例同时性肾癌患者,2例行双侧同期手术,1例行分期手术。其中2例行一侧肾癌根治术,对侧保留肾单位手术（NSS）;1例一侧先行NSS,2周后再行对侧肾癌根治术。3例异时性肾癌患者均行分期手术治疗,均行一侧肾癌根治术,对侧NSS术。结果：6例随访12～156个月,平均84．5个月。肿瘤转移2例,分别死于肺转移和骨转移;肿瘤局部复发2例;无瘤生存2例。结论：NSS是目前较为理想的双侧肾癌治疗方法。治疗双侧肾癌的原则为尽可能切除肿瘤和最大限度保存。肾功能。     

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.     

The feasibility of surgical enucleation for renal cell carcinoma

Although partial nephrectomy for renal cell carcinoma has been recommended for tumors in solitary kidneys, surgical enucleation has been suggested as an alternative form of surgical management in highly selected patients. To verify the efficacy of surgical enucleation the surgical specimens from 16 standard radical nephrectomies were dissected carefully. The tumors were enucleated ex vivo and carefully investigated pathologically. It was possible to enucleate successfully some well circumscribed, low grade tumors but venous invasion, tumor heterogeneity, occult metastatic disease in lymph nodes, satellite tumor nodules in the kidney and extrinsic spread through the renal capsule were features that may not have been appreciated fully in the operating room. Computerized tomography could not always predict which patients were possible enucleation candidates. Partial nephrectomy remains the preferred surgical treatment in a parenchymal-sparing operation rather than simple enucleation.     

Laparoscopic and Image-guided Radiofrequency Ablation of Renal Tumors: Patient Selection and Outcomes

Multiple modalities exist for the management of small renal tumors, including active surveillance, extirpation (radical nephrectomy and partial nephrectomy), and ablative therapies. Radiofrequency ablation (RFA) is an alternative to extirpative surgery for renal tumors. This article presents the current literature on RFA for renal tumors. We reviewed 28 RFA series in the English literature from 2003 to 2010 to assess patient selection, biopsy, renal outcomes, and oncologic outcomes.     

Surgical Treatment of Localised Renal Cancer

The management of localised renal cancer has been revolutionised with the introduction of laparoscopy and minimally invasive techniques, achieving comparable oncologic results and reduced morbidity. With the detection rate of small renal lesions increasing, the diagnostic approach and surgical treatment shift to nephron-sparing surgery and less invasive techniques.Today, open partial nephrectomy (OPN), laparoscopic partial nephrectomy (LPN), radiofrequency ablation, and cryotherapy are treatment options. Comparing OPN and LPN, multicentre studies have shown equivalent cancer-specific survival rates. Robot-assisted partial nephrectomy seems to have an advantage with regard to decreased ischemia time compared to conventional laparoscopy.OPN and LPN are now preferred treatment options for the surgical treatment of smaller renal lesions (<7 cm). With increasing experience in minimally invasive techniques, the laparoscopic and robotic approaches are becoming the preferred techniques in specialised centres. Promising novel augmented reality tracking systems may further improve the surgical and oncologic outcome of laparoscopic and robotic procedures.     

Nephron-sparing surgery

The curative management of renal cell carcinoma remains surgical. Recent advances in imaging and increased use of cross-sectional imaging modalities have led to an increased detection of incidental renal cell carcinomas. There is little debate regarding the role of nephron-sparing surgery (NSS) when absolutely indicated. Radical nephrectomy is still considered by many as the treatment of choice for localized renal cell carcinoma in the setting of a normal contralateral kidney. However, there is growing evidence that in the correct patient, the use of NSS in this setting is justified. Therefore, the indications of NSS have evolved in the past decade. Recent data indicate that radical nephrectomy and NSS provide effective and equivalent curative treatment for most renal cell carcinomas, especially those 4 cm or smaller. These data, along with new, refined surgical techniques, new studies regarding the biology of renal cell carcinoma and true incidence of occult multifocality, and earlier diagnosis make NSS an attractive consideration for the practicing urologist.     

Complications of Laparoscopic Surgery for Renal Masses: Prevention,Management, and Comparison with the Open Experience

Context

The initial excitement about the laparoscopic treatment of renal masses has been tempered by concerns related to increased operative time, technical complexity, and the suitability of laparoscopic approaches to oncologic surgery.

Objective

To provide a comprehensive review of intraoperative and postoperative complications and their prevention and management during laparoscopic surgery of renal tumors.

Evidence acquisition

A literature review of the Medline and Google Scholar databases was performed, searching for renal cell carcinoma, renal mass, laparoscopy, laparoscopic radical nephrectomy, open radical nephrectomy, laparoscopic partial nephrectomy, open partial nephrectomy, laparoscopic cryoablation, laparoscopic radiofrequency ablation, complications, intra-operative, and post-operative. English-language articles published between 1990 and 2008 were reviewed.

Evidence synthesis

Laparoscopic radical nephrectomy (LRN), whether transperitoneal or retroperitoneal, can be performed safely. The overall complication rate is low and does not significantly differ from that of the open experience. Laparoscopic partial nephrectomy (LPN), in contrast, is a technically challenging procedure. Although the intermediate oncologic outcomes are comparable to those of the open experience, there are concerns related to warm ischemia time, and there is a risk of major complications such as urinary leakage and hemorrhage requiring transfusion. Laparoscopic-assisted ablative therapies (cryotherapy and radiofrequency) are being performed more commonly for the treatment of small exophytic renal lesions with a low complication rate and intermediate oncologic outcomes similar to LRN and LPN.

Conclusions

Complications associated with the laparoscopic management of renal masses vary among the different procedures and with surgeon experience. The rate of complication appears to be similar to that of open surgery.     

Cost comparison of nephron-sparing treatments for cT1a renal masses

ObjectivesTreatment options for small renal tumors have evolved from radical nephrectomy (RN) to partial nephrectomy (PN), thermal ablation, or active surveillance. With the advancement of techniques, costs differences are unclear. The objective of this study is to compare the 6-month costs associated with nephron-sparing procedures for cT1a renal tumors.Materials and methodsWe performed a review of patients diagnosed with a solitary cT1a renal mass who underwent surgical treatment from June 2008 to May 2011. Open partial nephrectomy (OPN), robot-assisted partial nephrectomy (RLPN), laparoscopic radio-frequency ablation (LRFA), or computed tomography guided radio frequency ablation (CTRFA) was performed on 173 patients. Cost data were collected for surgical costs, associated hospital stay, and the 6-month postoperative period.ResultsPatients underwent surgery, including 52 OPN, 48 RLPN, 44 LRFA, and 29 CTRFA. Median total costs associated were $17,018, $20,314, $13,965, and $6,475, for OPN, RLPN, LRFA, and CTRFA, respectively. When stratified by approach differences were noted for total cost (P < 0.001), operating room (OR) time (P < 0.001), surgical supply (P < 0.001), and room and board (P < 0.001) in univariable analysis. Multivariable linear regression (R² = 0.966) showed surgical approach (P = 0.007), length of stay (P < 0.001), and OR time (P < 0.001) to be significant predictors of total cost. However, tumor size (P = 0.175), and Charlson comorbidity index (P = 0.078) were not statistically significant.ConclusionsSix-month cost of nephron-sparing surgery is lowest with radio frequency ablation (RFA) by either laparoscopic or computed tomography (CT)-guided approach compared to RLPN and OPN. As oncologic and safety outcomes improve and become comparable in all nephron-sparing surgery (NSS) approaches, cost of each procedure will start to play a stronger role in the clinical and healthcare policy setting.     

Routine frozen-section biopsy from the surgical bed should be performed during nephron-sparing surgery for renal cell carcinoma

OBJECTIVE: It has been reported in recent studies that nephron-sparing surgery (NSS) is as effective as radical nephrectomy (RN) for pT1a and pT1b renal cell carcinoma (RCC). In order to decrease the rate of tumor recurrence, resection of a small amount of normal parenchyma surrounding the tumor is widely recommended. Although a 0.5-1.5-cm wide resection margin is recommended no agreement has been reached concerning the thickness of the surgical margin. In this study we tried to determine whether routine frozen-section biopsy from the surgical bed is mandatory during NSS for RCC. MATERIAL AND METHODS: The study involved 19 renal units of 18 patients who underwent partial nephrectomy for solid renal tumors (<7 cm) at different centers in Ankara. Hypothermic ischemia was instituted after placing the kidney in an intestinal bag full of ice slush and cross-clamping the renal artery. In all cases an approximately 1-cm margin of normal tissue was removed with the tumor. Then, intraoperatively, at least three frozen-section biopsies were taken from the surgical bed to determine the surgical margin. If the biopsy was positive, RN was performed. RESULTS: All patients were staged as pT1a or pT1b according to the 2002 TNM classification. The average tumor size was 3.8 cm. In three cases we performed RN due to positive surgical margins. Surgical margins were negative in 16 tumors, with a mean negative margin size of 5 mm (range 2-11 mm). One patient died of a non-cancer-related cause. The mean distance to the renal capsule was 7 mm (range 1-11 mm). Seventeen patients were followed up for 18 months with no local or systemic recurrence. CONCLUSION: In some cases an approximately 1-cm margin is not sufficient to ensure a negative margin and frozen-section biopsies must be taken from the tumor bed, even if it seems normal macroscopically.     

局限性肾癌保留肾单位手术20例分析

目的探讨保留肾单位手术（nephrom-sparing surgery,NSS）治疗局限性肾癌的安全性和疗效。方法回顾性分析20例行NSS肾癌患者的临床资料,其中双侧肾癌1例,孤立肾肾癌1例,对侧肾有病变或潜在功能损害的肾癌3例,对侧肾正常的肾癌15例。肿瘤直径平均3.9（1.3-7.4）cm。行肿瘤剜除术13例,肾部分切除术4例,肾楔形切除术3例。结果 20例患者手术均成功。术后平均随访29（15-37）个月,1例双侧肾癌患者术后14月出现远处转移死亡,1例术后12个月因局部复发改行根治性肾切除术,2例术后出现暂时性肾功能不全。结论 NSS治疗肾癌安全有效,尤其适用于局限性肾癌患者。