The role of nephron sparing surgery for metastatic (pM1) renal cell carcinoma

PURPOSE: Studies have demonstrated increased time to progression when cytoreductive nephrectomy is performed for metastatic renal cell carcinoma. We evaluated the role of nephron sparing surgery in these patients. MATERIALS AND METHODS: We selected all patients with pM1 renal cell carcinoma treated with nephron sparing surgery or radical nephrectomy, and all patients with pM0 renal cell carcinoma undergoing nephron sparing surgery for solitary kidney from 1970 to 2002 from the Mayo Clinic Nephrectomy Registry. RESULTS: We identified 16 patients who underwent nephron sparing surgery for pM1 renal cell carcinoma. Solitary kidney was present in 12, 3 had bilateral synchronous disease and 1 had elective nephron sparing surgery. Cancer specific survival rates at 1, 3 and 5 years were 81%, 49% and 49%, respectively. We identified 404 patients who underwent radical nephrectomy for pM1 renal cell carcinoma. Cancer specific survival rates at 1, 3 and 5 years were 51%, 21% and 13%, respectively. The pM1 nephron sparing surgery for solitary kidney cases were more likely to have early (33% vs 10%, p = 0.009) or late (50% vs 19%, p = 0.018) complications compared with pM1 radical nephrectomy cases. There were no significant differences in early (p = 0.475) or late (p = 0.350) complications between pM1 nephron sparing surgery cases and 139 pM0 nephron sparing surgery cases. CONCLUSIONS: Cancer specific survival rates in pM1 nephron sparing surgery cases were comparable to pM1 radical nephrectomy cases. Although there were differences in early and late complications between the pM1 nephron sparing surgery and pM1 radical nephrectomy groups, there were no differences when compared with imperative pM0 nephron sparing surgery cases. This study demonstrates that nephron sparing surgery can achieve adequate cytoreductive therapy while preserving renal function, with postoperative complication rates similar to those of pM0 nephron sparing surgery cases.     

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     

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。     

腹腔镜超声在微小肾癌保留肾单位手术中的临床应用

目的:探讨腹腔镜超声(LUS)在微小肾癌保留肾单位手术中的临床应用价值。方法:对5例肿瘤直径均小于1.5 cm的微小肾癌患者施行后腹腔镜保留肾单位手术,术前行超声造影及增强CT检查提示瘤体包埋于肾实质内,术中应用LUS探查肿瘤的具体位置,了解瘤体与正常肾组织的界限,协助完成保留肾单位肾部分切除手术。结果:5例患者均成功施行保留肾单位手术,手术平均出血量150 ml,术后无并发症。结论:LUS在微小肾癌保留肾单位手术中能够准确定位肿瘤位置,指导手术,提高对早发小肾癌施行保留肾单位手术的可能性。     

Von Hippel-Lindau disease and renal cell carcinoma in a 16-year-old boy.

Von Hippel-Lindau disease is a rare autosomal dominant disorder. Kidney lesions occur in the majority of cases, with renal cell carcinoma noted in 40% and renal cysts in 60%. Renal cell carcinoma in von Hippel-Lindau disease is usually bilateral and occurs at an earlier age than in patients with sporadic renal cell carcinoma. We report on a 16-year-old boy who, to our knowledge, is the youngest patient to present with von Hippel-Lindau disease and renal cell carcinoma. Controversy currently exists regarding the nature of renal cysts in von Hippel-Lindau disease and the optimal therapeutic approach (that is radical versus parenchymal sparing surgery). We review the histology of renal cysts and carcinoma, and discuss the rationale for selecting parenchymal sparing surgery.     

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.     

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.     

Long-term followup after nephron sparing surgery for renal cell carcinoma in von Hippel-Lindau disease.

We reviewed the long-term outcome of nephron sparing surgery in 9 patients with localized bilateral renal cell carcinoma and von Hippel-Lindau disease. One patient died of metastatic renal cell carcinoma 43 months postoperatively. One patient has not had recurrent tumor and was alive at 74 months postoperatively. The remaining 7 patients (mean followup 88 months) had local recurrence of tumor in the operated kidney and a secondary renal operation was done in 6 of them. Overall, 6 patients are free of tumor but only 3 of them retain functioning native renal parenchyma. We conclude that the results of nephron sparing surgery in patients with renal cell carcinoma and von Hippel-Lindau disease are less satisfactory than in patients with sporadic renal cell carcinoma.     

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。     

腹腔镜保留肾单位手术治疗小肾癌18例报告

目的探讨腹腔镜保留肾单位手术治疗小肾癌的方法和疗效。方法选择小肾癌患者18例,肿瘤直径1．5～3．0cm,经后腹腔途径腹腔镜保留肾单位肿瘤切除11例,经腹腔途径手术7例。术中距瘤体0．5～1cm用超声刀切除肿瘤,肿瘤床多处活检送快速病理。结果幅例手术均获成功,无中转开放。手术时间85—140rain,平均110min;术中出血量50～600ml,平均145ml;术后住院时间8～13天,平均9．6天。术后随访8～30个月,未见肿瘤局部复发,未见转移,切口未见种植。结论腹腔镜保留肾单位手术治疗小肾癌,创伤小、临床效果肯定,可作为小肾癌首选治疗方法。     

小肾癌25例的诊治体会

目的 探讨直径小于4cm的小肾癌的诊治效果。方法 对25例直径小于4cm的小肾癌的诊治进行回顾性总结。结果 25例均行B超、CT检查，B超明确诊断16例，准确率64％(16／25)；CT明确22例，准确率88％(22／25)。16例行根治性肾切除术，9例行保留肾单位手术。随访10-102个月，平均56．6个月。9例行保留肾单位手术中，发生术后出血1例，局部复发1例。结论 小肾癌的诊断主要依据B超、CT等影像学检查综合分析作出，其中CT是最有价值的检查万法。根治性肾切除术治疗小肾癌疗效可靠、安全，仍是首选手术方式。     

Treatment of Renal Cell Carcinoma in Von Hippel-Lindau Disease: A Multicenter Study

A total of 65 patients with von Hippel-Lindau disease underwent surgery for renal cell carcinoma (54 bilaterally and 11 unilaterally) at 8 medical centers. Only 1 patient presented with metastatic disease. Radical nephrectomy and nephron sparing surgery were performed in 16 and 49 patients, respectively. Mean posttreatment followup was 68 months.

The 5 and 10-year cancer-specific survival rates for all patients were 95 percent and 77 percent, respectively. The corresponding rates for patients treated with nephron sparing surgery were 100 percent and 81 percent, respectively. Of the latter patients 25 (51 percent) had postoperative local tumor recurrence but only 2 had concomitant metastatic disease. Survival free of local recurrence was 71 percent at 5 years but only 15 percent at 10 years. End stage renal failure occurred in 15 patients (23 percent): 6 underwent renal transplantation (5 are alive with satisfactory renal function and no evidence of malignancy) and 9 were treated with chronic dialysis (6 are free of tumor).

Our results indicate that nephron sparing surgery can provide effective initial treatment for patients with renal cell carcinoma and von Hippel-Lindau disease. These patients must be followed closely, since most will eventually have locally recurrent recurrent renal cell carcinoma. When removal of all renal tissue is necessary to achieve control of malignancy, renal transplantation can provide satisfactory replacement therapy for end stage renal disease.     

术中超声辅助下行孤立肾肾癌保留肾单位手术效果观察

目的：探讨术中超声辅助下孤立肾肾癌保留肾单位手术对选择性肾动脉阻断以及确定肿瘤切缘的作用。方法：回顾2004-2011年先天性或获得性孤立肾肾细胞癌行保留肾单位手术患者资料,共7例术中采用超声多普勒确认肾段动脉阻断效果,并对肿瘤包膜边缘行超声检测从而进一步确定肿瘤切缘。术后1个月、6个月以及1年随访对比术前肾功能变化,并规律随访患者预后至今。结果：7例手术均成功行保留肾单位手术,超声引导检测下行选择性肾段动脉阻断5例,另2例采用单纯肾动脉于阻断下手术,术中超声发现肿瘤可疑卫星灶2例并指导切缘。术后6个月及1年随访肾功能与术前相比无明显下降,所有患者随访至今,平均随访45．4个月,均未见肿瘤复发或转移。结论：术中超声辅助下行保留肾单位手术是治疗孤立肾肾癌的理想方法,有助于肿瘤的准确切除和肾功能保护。     

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。     

Nephron Sparing Surgery for De Novo Renal Cell Carcinoma in an Allograft Kidney: A Case Report

De novo renal cell carcinoma in a renal allograft is rare and has special implications in renal transplant recipients. We describe a patient with a renal allograft who developed a de novo renal cell carcinoma in the functioning renal allograft 258 months after transplantation. The patient underwent enucleation of the tumor because preoperative MRI showed it was well-encapsulated. A DNA banding study showed that the tumor originated from the donor. Indications for conservative renal surgery in renal cell carcinoma have been increasing. Accordingly, 1 option in the treatment of de novo renal cell carcinoma in a functioning renal allograft is enucleation as a method of nephron sparing surgery.     

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.     

Nephron sparing surgery for renal cell carcinoma using selective renal parenchymal clamping.

PURPOSE: We describe a technical artifice facilitating nephron sparing surgery for renal cell carcinoma without clamping the renal pedicle. MATERIALS AND METHODS: Selective renal parenchymal clamping was performed using a large curved DeBakey aortic clamp placed around and sufficiently far from the tumor. The lesion was resected with a surrounding margin of normal renal parenchyma. The intrarenal vessels were suture ligated and the collecting system was closed as necessary. Time was not limited since the artery was not clamped. RESULTS: Ten patients with renal cell carcinoma in whom nephron sparing surgery was indicated underwent selective renal parenchymal clamping. The indication was elective in 8 patients and urgent in 2. The tumor was at the renal pole in 3 cases and peripheral in 7. Mean tumor size was 32 mm. (range 19 to 52). Blood loss was insignificant. Operative time was 81 minutes (range 61 to 125) and there were no perioperative or postoperative complications. CONCLUSIONS: Selective renal parenchymal clamping is a simple and efficient technical maneuver for facilitating nephron sparing surgery without pedicle dissection and clamping for renal peripheral or pole tumors. Neoplasm location and size are the limiting factors of this technique.     

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

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

Oxidized regenerated cellulose granuloma mimicking recurrent mass lesion after laparoscopic nephron sparing surgery

INTRODUCTIONAchieving hemostasis in laparoscopic nephron sparing surgery (LNSS), a technically demanding procedure, is challenging. Absorbable hemostatic agents, such as oxidized regenerated cellulose (ORC) are frequently used for hemostasis in laparoscopic nephron sparing surgery. Retention of this material is a very rare situation.PRESENTATION OF THE CASEWe are presenting a case of ORC granuloma after nephron sparing surgery for renal cell carcinoma (RCC) mimicking recurrent renal mass. A 50-year-old woman diagnosed with upper pole renal mass underwent laparoscopic nephron sparing surgery. Oxidized regenerated cellulose was used to achieve hemostasis for an oozing from the perirenal tissue. Resection confirmed RCC. Imaging at 6th month follow-up revealed a lesion with contrast enhancement at the location of the adrenal gland. Positron emission tomography suggested inflammation or metastasis. Histopathological evaluation of the mass revealed foreign body granuloma.DISCUSSIONLaparoscopic nephron sparing surgery is becoming a standardized treatment of select renal tumors. Hemostatic agents, such as ORC, are frequently used to minimize complications in LNSS. In case of ORC application, which is completely absorbed in 8 weeks, to or to a location with close proximity to the primary resection site, surgical granuloma formation should be considered. However its use should not be discouraged and biopsy may be considered for definitive diagnosis.CONCLUSIONOxidized regenerated cellulose granuloma may mimic different entities such as including invasive carcinoma. Thus it is of utmost importance, if ORC was used during LNSS, the location and use of this material should be noted precisely.     

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。