Renal cell carcinoma in the solitary kidney: an analysis of complications and outcome after nephron sparing surgery

PURPOSE: We evaluated surgical techniques, pathological features and extended outcomes in patients with renal cell carcinoma in a solitary kidney treated with surgical excision. MATERIALS AND METHODS: Between 1970 and 1998, 76 patients underwent nephron sparing surgery for sporadic renal cell carcinoma in a solitary kidney, including 63 with tissue specimens available for pathological review who comprised the cohort. Six (9.5%) patients had a congenitally absent kidney and 57 (90.5%) had previously undergone contralateral nephrectomy for renal cell carcinoma. The clinical and pathological features examined were patient age at nephron sparing surgery, sex, type of nephron sparing surgery (enucleation, partial nephrectomy or ex vivo resection), tumor size, nuclear grade, histological subtype and 1997 tumor stage. Overall cancer specific, local recurrence-free and metastasis-free survival as well as early (within 30 days of nephron sparing surgery) and late (30 days to 1 year after nephron sparing surgery) complications were assessed. Univariate and multivariate analyses were done to test for the associations of clinical and pathological features with outcome. RESULTS: Most patients were treated with enucleation (36.5%), standard partial nephrectomy (38.1%) or the 2 procedures (11.1%) and in 8 (12.7%) ex vivo tumor resection was done. The renal cell carcinoma histological subtypes were clear cell in 82.5% of cases, papillary in 15.9% and chromophobe in 1.6%. Grade was 1 to 3 in 10 (15.9%), 42 (66.7%) and 10 (15.9%) tumors, respectively. At 5 and 10 years the overall survival rate was 74.7% and 45.8%, the cancer specific survival rate was 80.7% and 63.7%, the local recurrence-free survival rate was 89.2% and 80.3%, and the metastasis-free survival rate was 69% and 50.4%, respectively. Tumor stage and nuclear grade were significantly associated with death from any cause, death from renal cell carcinoma and distant metastases on multivariate analysis. Notably no patient with papillary or chromophobe renal cell carcinoma died of renal cell carcinoma, or had recurrence or metastasis. The type of nephron sparing surgery was not significantly associated with outcome, although there were too few patients with recurrence to assess the association of the type of nephron sparing surgery with local recurrence. The most common early complication was acute renal failure in 12.7% of cases, while the most common late complications were proteinuria in 15.9% and renal insufficiency in 12.7%. CONCLUSIONS: The 1997 tumor stage and nuclear grade were significant predictors of death from any cause, death from renal cell carcinoma and distant metastases in patients treated with nephron sparing surgery for renal cell carcinoma involving a solitary kidney. Nephron sparing surgery in a solitary kidney can be performed safely and with minimal morbidity.     

肾癌患者治疗方法的选择

目的:探讨肾细胞癌的不同手术方式、术前肾动脉栓塞及免疫治疗的临床应用价值。方法:回顾性分析179例肾细胞癌患者的临床资料。对患者的临床资料分组进行对比,并对治疗效果和随访结果作进一步统计学分析。结果:小肾癌行肾癌根治术与保留肾组织手术效果比较,在手术时间、术后住院时间、术后5年生存率上差异均无统计学意义(P>0.05);78例术前行选择性肾动脉栓塞者,手术证实栓塞效果满意。结论:保肾单位手术是治疗局限性小肾癌的有效手段;较大的肾癌术前进行肾动脉栓塞术便于手术切除病灶,提高了肿瘤的切除率;免疫治疗是继手术治疗之后的又一种主要临床治疗方式,尤其肿瘤疫苗的出现,对于晚期肾癌及转移癌效果明显。     

保留肾单位手术治疗早期肾癌的长期疗效观察

目的：探讨保留肾单位手术治疗早期肾癌的临床应用价值。方法：对采取保留肾单位手术治疗的23例孤立肾或对侧肾功能不全的早期肾癌临床资料进行回顾性分析。结果：术后均未发生严重并发症，术后病理均为T1a期，其中透明细胞癌19例，嫌色细胞癌2例，乳头状肾癌1例，囊性肾癌1例。术后平均随访44．7个月，肿瘤复发1例，复发率为4．3％。1年、3年无瘤生存率分别为100％(23／23)、93．8％(15／16)。随访期间未出现肾功能衰竭而需透析治疗者。结论：孤立肾或对侧肾功能不全的早期肾癌，是施行保留肾单位手术的绝对指征，在最大限度保留肾功能的前提下可以获得与根治性肾切除相似的疗效。     

肾癌保留肾单位手术的临床价值(附17例报告)

目的　评价肾癌保留肾单位手术的临床价值。　方法　回顾性研究 17例行保留肾单位手术的肾癌患者临床资料 ,其中单侧 15例 ,双肾异时性肾癌且一侧为多发肿瘤 2例。绝对指征 2例 ,相对指征 6例 ,选择性指征 9例。肿瘤直径 2～ 6cm ,均为T1期 (1997年TNM标准 ) ;行改良肾肿瘤剜除术 (切缘于肾肿瘤外 1cm正常肾实质处 ) 15例 ,肾上极切除术 1例 ,楔形切除术 1例。 2 0例同期肾癌临床及分期相当但行根治性手术的患者资料作随访对照 ,并作生存率时序检验。　结果　 17例患者随访 3～ 6 3个月 ,平均 35 .2个月 ,未见并发症及残肾肿瘤复发。无瘤生存率与根治性手术者相近。　结论　肾癌保留肾单位手术安全、有效 ,适合于对侧肾功能正常、一侧局限的偶发肾肿瘤患者。     

Incidental renal cell carcinoma and nephron sparing surgery

The role of nephron sparing surgery in patients with a solitary kidney, bilateral kidney tumors or an impaired renal function has been widely accepted. Partial nephrectomy in patients with a normal contralateral kidney is still under discussion. Nevertheless, more and more surgeons perform nephron sparing surgery in these patients with good results. From historical comparisons there seems to be no statistically significant difference in five-year survival between radical nephrectomy and nephron sparing surgery when the tumor diameter is four centimeters or less. The most common problem is the risk of tumor recurrence due to the multifocality. However, multifocality is more frequent than kidney recurrence, questioning the spontaneous evolution of satellite lesions. Further investigations are necessary to optimize patient selection. Therefore, a randomized prospective multicenter study with long-term follow-up might add to the excellent results published by several authors during the last two years in order to confirm that nephron sparing surgery is an excellent alternative to radical nephrectomy in small asymptomatic renal cell carcinoma.     

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。     

小肾癌54例诊治分析

目的 提高小肾癌的诊断水平和治疗效果。方法 对54例直径小于3cm的小肾癌的诊断与治疗进行回顾性分析。结果 54例中因体检或其他疾病检查时发现者37例（68．5％）；腰痛9例（16．7％）；血尿5例（0．9％）；腰痛伴血尿3例。行根治性肾切除术43例．行保留肾单位手术11例。术后均经病理证实。术中快速冰冻切片证实5例。结论 小肾癌多为偶然发现。其早期诊断主要依靠B超、CT、MRI和DSA等影像学检查；手术视具体情况行根治性肾切除术或保留肾单位手术；小肾癌病理分期低。肿瘤体积小．预后较好，生存率高。     

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.     

Nephron-sparing surgery--strategies for partial nephrectomy in renal cell carcinoma.

The use of partial nephrectomy for renal cell carcinoma has continuously changed in the clinical practice. Previously it was mostly used in imperative cases, in patients with a solitary kidney or in patients with a risk of renal failure. An increased number of incidentally detected renal cell carcinomas are diagnosed due to the advances of the radiological methods. These tumours tend to be smaller and generally with a lower stage. The reported excellent results of partial nephrectomy have promoted the use of nephron-sparing surgery also in patients with a normal contralateral kidney and tumours smaller than 4-5 cm. The technical outcome is excellent with a low operative morbidity and a good oncologic control. Therefore partial nephrectomy has become a standard technique in the treatment of properly selected patients. Laparoscopy with its reduced postoperative pain and shorter rehabilitation time, has encouraged the interest in minimally invasive nephron sparing surgical techniques. Although low, the risk of local tumour recurrence and surgical complications are higher after nephron-sparing surgery compared with radical nephrectomy. Furthermore, long-term renal function remains adequate in most patients with a normally functioning contralateral kidney also after radical nephrectomy. Albeit these facts, there is convincing evidence justifying nephron-sparing surgery to be used routinely for patients with a small renal cell carcinoma and a normal functioning contralateral kidney.     

双侧肾细胞癌21例报告

目的 探讨双侧肾细胞癌手术治疗的疗效。方法 1990年1月至2005年1月收治双侧肾细胞癌患者21例。其中同时性10例，异时性11例。肿瘤位于肾上极15枚，中极19枚，下极20枚；左肾28枚，右肾26枚。肿瘤直径0．5～16．0cm，平均4．5cm。2例伴下腔静脉癌栓。17例经手术治疗。6例同时性肾癌中，5例行双侧一期手术，1例行分期手术。其中1例行双肾部分切除术；1例行双肾部分切除及左肾上腺切除术；3例行一侧肾癌根治术及对侧肾部分切除术；1例行一侧肾癌根治术，对侧肾部分切除术及下腔静脉切开取癌栓术。11例异时性肾癌均分期手术。其中3例行双肾部分切除术；1例行一侧肾癌根治术，对侧肾肿瘤剜出术；1例行一侧肾癌根治术，对侧肾部分切除术加下腔静脉切开取癌栓术；6例行一侧肾癌根治术，对侧肾部分切除术。未行手术治疗4例．其中行介入治疗1例，生物学治疗1例，保守治疗2例。结果 21例随访3个月～24年，平均3．4年。17例手术治疗者中，13例未见肿瘤复发和转移，术后肾功能均可；1例术后10个月出现左上肺转移，已带瘤存活9个月；1例术后1年出现残肾肿瘤复发，经生物学和中药治疗，已带瘤存活5个月；2例死于肿瘤转移。4例未手术者中，1例10个月后死于胰腺转移，1例4个月后死于肾衰竭，1例6个月后死于脑血管意外，1例伴腹膜后淋巴结转移者经化疗和生物学治疗，病情稳定，已带瘤存活7个月。异时性肾癌者的先发一侧行肾癌根治术，对侧肾出现肿瘤的时间为7个月～18年。结论 双侧肾癌并非手术禁忌，如果采取积极的治疗措施，仍可获得满意的手术效果。保肾手术是目前较为理想的治疗方法，如果保留足够的肾实质，患者仍可获得良好的生存状态。     

Disease Outcome in Patients With Low Stage Renal Cell Carcinoma Treated With Nephron Sparing or Radical Surgery

Purpose

We investigated the outcome of nephron sparing surgery in patients with low grade and low stage (Robson stage II or less) renal cell carcinoma.

Materials and Methods

We retrospectively reviewed the records of 185 patients treated with nephron sparing surgery and 209 matched for patient age and sex, and tumor stage and grade who were treated with radical nephrectomy. Kaplan-Meier survival curves were constructed for progression and survival end points. Multivariate analysis was performed to determine the tumor characteristics independently correlated with progression and cancer death.

Results

No significant difference was observed with respect to progression-free, crude or cancer specific survival between the nephron sparing surgery and radical nephrectomy groups. Less than 5 percent of the patients treated with conservative nephron sparing surgery had local recurrence. Tumor size was a strong independent predictor of outcome, whereas Robson stage was not. Patients treated with radical nephrectomy had a significant cancer specific and progression-free survival advantages when controlling for tumor diameter and grade. However, no difference was observed in patients with primary tumor diameters of 4 cm. or less.

Conclusions

Robson staging is inaccurate in predicting tumor behavior. Patients with tumors larger than 4 cm. and a normal contralateral kidney may be best served by radical nephrectomy rather than elective nephron sparing surgery. However, nephron sparing surgery may result in an outcome similar to that of radical nephrectomy for low grade, low stage renal cell carcinomas of 4 cm. or smaller.     

保存肾单位的肾癌切除术适应证及疗效观察：附17例报告

目的 探讨保存肾单位的肾部切除术适应证,观察其治疗效果。方法 对１９９０～１９９８年施行的保存肾单位的肾癌切除术１７例患者进行回顾性分析,其中１１例作肾肿瘤切除术,６例作肾上极或下极切除术。结果 术后随访１～６．５年,除１年术后５年死于肿瘤转移外,其余均正常,预后满意。结论 对双侧同时发生无症状性肾癌、孤立肾伴肾癌或需靠双侧肾维持功能的肾癌,可考虑行保存肾单位的肾癌切除术;保存肾单位的肾癌切除术效     

Nephron sparing surgery for renal tumors: indications, techniques and outcomes.

PURPOSE: A contemporary review of the indications, techniques and outcomes is presented for nephron sparing approaches to solid renal masses, emphasizing their role for the treatment of renal cell carcinoma. We also reviewed the evolving role of minimally invasive forms of parenchymal sparing renal surgery. MATERIALS AND METHODS: MEDLINE and CANCERLIT computerized literature searches, and manual bibliographic reviews were performed to identify published peer reviewed articles pertaining to nephron sparing surgery or partial nephrectomy from 1980 to 2000. Pertinent articles were collated and reviewed. RESULTS: Nephron sparing surgery is increasingly being used to treat patients with solid renal lesions. The technical success rate of nephron sparing surgery is excellent, and operative morbidity and mortality are low. For renal cell carcinoma long-term cancer-free survival is comparable to that after radical nephrectomy, particularly for low stage disease. The overall incidence of local recurrence is low at 0% to 10%. For tumors 4 cm. or less local recurrence rates are even less at 0% to 3%. The risk of local recurrence depends primarily on the initial local pathological tumor stage. The reported incidence of multifocal renal cell carcinoma is approximately 15% and it also depends on tumor size, histology and stage. The risk of multifocal disease is low at less than 5% when the maximal diameter of the primary tumor is 4 cm. or less. Recent advances in renal imaging limit the radiographic evaluation necessary when planning complex nephron sparing approaches. Three-dimensional, volume rendered computerized tomography integrates all of the necessary information previously obtained by conventional computerized tomography, angiography, venography and pyelography into a single preoperative test, allowing better operative planning with maximal preservation of unaffected parenchyma in the remnant kidney. Minimally invasive modalities of tumor resection or destruction should be reserved for highly select patients and await improvements in technology, standardization of technique and long-term outcomes data before they may be completely integrated options. CONCLUSIONS: Nephron sparing surgery provides effective therapy for patients in whom preservation of renal function is a relevant clinical consideration. The importance of meticulous operative technique for achieving acceptable oncological and functional outcomes is emphasized. Accumulating data in appropriately select patients suggest a long-term functional advantage gained by the maximal preservation of unaffected renal parenchyma without sacrificing cancer control.     

后腹腔镜下肾部分切除术在治疗肾脏肿瘤中的临床疗效

目的 探讨后腹腔镜下保留肾单位的肾部分切除术在治疗肾脏肿瘤的临床应用价值.方法 回顾性分析施行后腹腔镜保留肾单位的肾部分切除术的70例患者的临床资料,其中男42例,女28例,年龄平均(56±11.8)岁,肿瘤直径(3.4士1.3)cm.结果 70例患者均成功在后腹腔镜下实施手术,无1例术中中转为开放手术.手术时间100～180 min,平均(130±27)min.血管阻断时间20～40min,平均每例患者25 min.术中失血50～800mL.术后出血2例:1例发生在术后第4天,行选择性血管栓塞术后好转;另1例出现在术后第7天,经选择性血管栓塞后未见好转遂行患肾切除术.术后病检:肾透明细胞癌53例,肾乳头状癌12例,肾嫌色细胞癌2例,囊性肾癌2例,肾脏囊肿并出血1例.随访3～18个月无局部复发及远处转移.结论 后腹腔镜下保留肾单位的肾部分切除术治疗早期肾脏肿瘤安全、有效,兼有创伤小、康复快等优点,近期疗效满意,远期疗效有待进一步观察.     

肾细胞癌271例临床分析

目的 探讨肾细胞癌的诊治方法.方法 1993年1月至2000年12月共收治肾细胞癌患者271例,对诊断方法、治疗手段、随访及预后进行回顾性分析.结果 B超、CT仍为主要的诊断方法.手术治疗234例患者,其中行根治性肾切除术197例(72.6%),保留肾单位手术19例;转移瘤切除术6例;其他手术12例.病理结果:透明细胞癌137例,占61.4%(137/223)、颗粒细胞癌18例(8.1%)、混合细胞癌32例(14.3%)、乳头状腺癌23例(10.3%),其他13例.210例患者(77.5%)获得随访.1、3、5、10年生存率分别为95.3%(182/191)、88.7%(107/122)、74.7%(56/75)和32.1%(10/31).结论 B超是检测肾细胞癌的首选检查方法,CT为最有价值诊断方法.提高肾细胞癌远期生存率最关键的因素是早期发现、早期行肾癌根治术或保留肾单位的肾癌切除术.     

Renal cancer

Renal carcinoma is a reasonably common cancer in the UK. Fortunately, its diagnosis is nowadays much earlier due to the increased utilization of radiological imaging. Whilst surveillance is an option, particularly in older/comorbid patients, nephron sparing surgery remains the gold standard treatment for small renal masses. Laparoscopic, robotic or open partial nephrectomy have excellent cure rates. For larger tumours, radical nephrectomy may be required. This again can be performed laparoscopically, robotically or in an open manner. The classic presentation of renal mass, haematuria and loin pain is a late presentation – many of these patients will already have metastatic disease. Although non-curable, treatments are available for metastatic disease. Surgical options in the form of cytoreductive nephrectomy and metastasectomy can improve overall survival. Tyrosine kinase inhibitors and other targeted novel agents contribute the non-surgical treatments and have demonstrated increases in survival.     

保留肾单位手术治疗小肾癌的可行性与疗效评估

目的:探讨保留肾单位手术(NSS)治疗小肾癌的可行性和疗效.方法:报告20例行NSS治疗小肾癌患者(NSS组)和21例和根治性肾切除术(RN)治疗的同种患者(RN组)的临床资料,比较两组的手术时间、术中出血量、术后住院时间、并发症、复发情况及存活率.结果:两组手术均顺利完成.NSS组平均手术时间、术中出血量、并发症发生率大于RN组(P<0.05);但两组间术后住院时间、肿瘤复发率及长期存活率方面,差异无统计学意义.结论:NSS切除治疗小肾癌具有安全有效性.但要严格掌握适应证,对于大于4cm的肾癌,尽可能行RN.     

双侧原发性肾癌5例报告

目的:探讨双侧原发性肾癌的诊断、治疗和预后。方法:回顾性分析2001年3月~2005年6月诊治的5例双侧同期原发性肾癌患者的临床资料。5例均经B超、CT等检查确诊,施行保留肾单位手术联合对侧肾癌根治术。结果:术后恢复顺利,无外科并发症,4例为双侧肾透明细胞癌,1例为双侧肾乳头状腺癌。随访5~51个月(平均20.4个月),无局部复发、转移及肾功能不良。结论:双侧原发性肾癌早期无特殊临床表现,主要依靠影像学检查诊断。外科手术为主要治疗方法,保留肾单位手术联合对侧肾癌根治术既能有效治疗恶性肿瘤,又能确实保存肾功能,预后良好。     

56例肾细胞癌手术治疗的临床分析

目的：探讨肾细胞癌（肾癌）的手术方式,以进一步提高其疗效。方法：对56例肾癌手术治疗的临床资料进行回顾性分析,实施根治性肾切除术者48例,其中4例同时进行下腔静脉癌栓切除术;实施保留肾单位手术者3例;实施其他类型手术者5例。结果：病理类型为透明细胞癌40例,颗粒细胞癌10例,混合型癌6例。42例获得随访,其中3年、5年和10年生存率分别为71.4%(30/42) 、54.2%(13/24)和20.0%(2/10)。结论：根治性肾切除术仍是目前 肾癌最有效的治疗方法,保留肾单位手术应严格掌握手术适应证。     

The role of surgery in renal cell carcinoma

Renal cell carcinoma accounts about three percent of all adult neoplasms. This review provides a current status about the surgical management of renal cell carcinoma. In localised carcinomas radical nephrectomy is still the standard treatment and provides 5 Year survival rates up to 98 %. As nephron-sparing surgery in mandatory indications can achieve similar survival doubt can be expressed whether lymphadenectomy or adrenalectomy are necessary in every case. Nephron-sparing surgery is associated with a higher rate of operative complications up to 40 % and probably with a higher risk of local recurrence. However, parenchymal-sparing surgery in elective indications is possible for small tumors, if long term follow up is guaranteed. But there is no convincing advantage of nephron-sparing surgery to recommend this procedure as a general approach in patients with a normal contralateral kidney. Radical surgery in renal carcinomas invading to the vena cava still remains a challenging surgical intervention. Nevertheless, in selected patients surgery can realise long term survival in over a third of cases. Palliative nephrectomy in metastatic renal carcinomas is only justified in real palliative indications (bleeding, pain) or in clinical trials investigating cytoreductive surgery before immunotherapy. In highly selected patients with metastatic renal carcinoma a radical surgical approach including nephrectomy and complete metastasectomy can achieve long term survival.