Conservative surgery of renal cell carcinoma

From 1967 to 1985 conservative surgery (enucleation, n = 49; partial resection, n = 7) was performed for renal tumors in 57 patients (age 31-77, mean 54.8 years). Imperative indications for conservative surgery (n = 29) were chronic renal failure, benign pathology of contralateral kidney, functional or anatomical solitary kidney, and bilateral tumors. Elective conservative surgery (n = 28) was done for small, peripherally located lesions, in cases of uncertain malignancy and in one tumor detected by chance during stone surgery. Tumors removed for imperative indications were 2-11 cm (mean 5.8 cm) in size. In the elective group, tumor size ranged from 1 to 7 cm (mean 3.3 cm). Follow-up was 6-103 months (mean 35.8 months). In the group with imperative indications, there was 1 postoperative mortality; 18 of 29 patients are alive without evidence of disease, 2 with metastases, and 2 were reoperated conservatively for local recurrences; 1 was lost to follow-up, 2 died of metastases, and 3 died due to unrelated reasons. In the elective group all 28 patients are living free of cancer.     

Conservative surgery for transitional cell carcinoma of the renal pelvis

From 1972 to 1986, 14 patients underwent a conservative operation for transitional cell carcinoma of the renal pelvis. Most of these patients had low grade (12), noninvasive (10) tumors involving a solitary functioning kidney (12). The operations performed were open pyelotomy with tumor excision and fulguration (8 patients), partial nephrectomy (5) and percutaneous nephroscopic fulguration (1). There was 1 operative death. Of the 13 surviving patients 8 (62 per cent) remained free of transitional cell carcinoma postoperatively, while 5 (38 per cent) had recurrent disease. Six patients (46 per cent) presently are free of tumor 6 months to 5 years postoperatively. Conservative surgical techniques can provide satisfactory treatment for selected patients with renal pelvic transitional cell carcinoma when preservation of functioning renal parenchyma is necessary to avoid kidney failure.     

保留肾单位肾癌切除术的疗效与随访

目的 探讨保留肾单位的肾癌手术疗效。方法 26例行保留肾单位的肾癌切除术患者，男16例，女10例，平均年龄47岁。肿瘤直径1．1～4．0cm，平均2．8cm。T1 21例，T2 5例。透明细胞癌22例．颗粒细胞癌3例，囊性肾癌1例。10例有腰痛、血尿、低热等症状，无症状16例。单侧24例，双侧1例，术后孤立肾癌1例。对侧肾功能正常22例，对侧肾有病变或潜在病变4例。术后定期行腹部CT、超声及尿常规检查，复查肾功能。结果 26例手术均成功。术后平均随访41个月，除1例肾转移癌术后16个月因肺癌广泛转移死亡外，余25例肿瘤无复发，无瘤生存至今。结论 保留肾单位的肾癌剜除术安全有效。适用于对侧肾功能正常肿瘤直径≤4．0cm的局限性肾癌，对于对侧肾脏有病变或孤立肾癌是必要的选择。     

Conservative surgery for renal cell carcinoma: a single-center experience with 100 patients

From January 1956 to March 1987, 100 patients underwent a conservative (parenchyma-sparing) operation as curative treatment for renal cell carcinoma at our clinic. This series includes 56 patients with bilateral (28 synchronous and 28 asynchronous) and 44 with unilateral renal cell carcinoma; in the latter category the contralateral kidney was either absent or nonfunctioning (17 patients), functionally impaired (17), involved with a benign disease process (6) or normal (4). The pathological tumor stage was I in 75 patients, II in 9, III in 10 and IV in 6. A nephron-sparing operation was performed in situ in 86 patients and ex vivo in 14. Postoperatively, 93 patients experienced immediate function of the operated kidney, while 7 required dialysis (4 temporary and 3 permanent). The incidence of dialysis was greater after ex vivo than in situ surgery (p equals 0.0005). The mean postoperative serum creatinine level in 97 patients with renal function was 1.7 mg. per dl. (range 0.9 to 4.6 mg. per dl.). The over-all actuarial 5-year patient survival rate in this series is 67 per cent including death of any cause and 84 per cent including only deaths of renal cell carcinoma. Survival was improved in patients with stage I renal cell carcinoma (p less than 0.05). Survival also was improved in patients with unilateral renal cell carcinoma (p less than 0.05) and fewer patients in this category had recurrent disease postoperatively (p less than 0.0005). Nine patients (9 per cent) had local tumor recurrence postoperatively and 5 of these were rendered free of tumor by secondary surgical excision. Conservative surgery provides effective therapy for patients with localized renal cell carcinoma in whom preservation of renal function is a relevant clinical consideration.     

Conservative surgery for low rectal carcinoma after high-dose radiation. Functional and oncologic results.

OBJECTIVE: Using a prospective, nonrandomized study, the authors evaluated the morbidity and functional and oncologic results of conservative surgery for cancer of the lower third of the rectum after high-dose radiation. SUMMARY BACKGROUND DATA: Colo-anal anastomosis has made sphincter conservation for low rectal carcinoma technically feasible. The limits to conservative surgery currently are oncologic rather than technical. Adjuvant radiotherapy has proven its benefit in terms of regional control, with a dose relationship. METHODS: Since June 1990, 27 patients with distal rectal adenocarcinoma were treated by preoperative radiotherapy (40 + 20 Gy delivered with three fields) and curative surgery. The mean distance from the anal verge was 47 mm (27-57 mm), and none of the tumors were fixed (15 T2, 12 T3). RESULTS: Mortality and morbidity were not increased by high-dose preoperative radiation. Twenty-one patients underwent conservative surgery (78%-17 total proctectomies and colo-anal anastomoses, 4 trans-anal resections). After colo-anal anastomosis, all patients with colonic pouch had good results; two patients had moderate results and one patient had poor results after straight colo-anal anastomosis. With a mean follow-up of 24 months, the authors noted 1 postoperative death, 2 disease-linked deaths, 1 controlled regional recurrence, 2 evolutive patients with pulmonary metastases, and 21 disease-free patients. CONCLUSIONS: These first results confirm the possibility of conservative surgery for low rectal carcinoma after high-dose radiation. A prospective, randomized trial could be induced to determine the real role of the 20 Gy boost on the sphincter-saving decision.     

Radical extensive surgery for renal cell carcinoma: long-term results and prognostic factors

We studied 200 consecutive patients with renal cell carcinoma who underwent radical nephrectomy and extensive lymphadenectomy. Of the patients 25% already had distant metastasis at operation. Higher T stages tended to be associated with positive nodes (p less than 0.01) and distant metastasis (p less than 0.001). However, in patients with stage N0M0V0 tumors we found no statistically significant difference in survival in relationship to the T stage of the disease (5-year survival: stage T1 80%, stage T2 68% and stage T3 70%). Of all patients 10% had positive nodes without distant metastases and no venous spread of the tumor, and the 5-year survival rate was 52%. The 5-year survival rate of patients with distant metastases was 7%. Patient survival in the presence of a vena caval tumor thrombus is similar to that of patients with distant metastases. Based on our results the different stages in disease progression may be classified as having a good prognosis--intracapsular tumors (stages T1 to T2, N0M0V0) and tumors with involvement of perirenal fat (stage T3N0M0V0), an intermediate prognosis--tumors with nodal metastases alone (stages T1 to T3, N1 to 2, M0V0) and a poor prognosis--tumors with venous invasion and/or distant metastases. Histological grading and size of tumor can be used to assess prognosis but are not more accurate than pathological staging.     

保留肾单位手术治疗肾癌(附46例报告)

目的:探讨保留肾单位手术治疗肾癌的安全性和疗效。方法:对1993年2月～2006年10月共46例采用保留肾单位手术的肾癌患者的临床资料进行回顾性分析,其中双侧肾癌4例,孤立肾癌3例,对侧肾有病变或潜在功能受损的肾癌25例,对侧肾正常的肾癌14例。结果:46例患者术前均未发现转移灶。术后组织病理学结果示肾透明细胞癌36例,颗粒细胞癌6例,混合性细胞癌4例。术后42例(91%)获随访,随访时间6～160个月,平均随访65个月。5、10年生存率分别为94%、86%。3例术后出现局部复发和远处转移。结论:保留肾单位手术治疗肾癌安全有效,手术指征可扩展至对侧肾脏正常的患者。     

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.     

小肾癌的保留肾单位手术治疗

目的 探讨保留肾单位的肾部分切除手术治疗小肾癌的安全性和合理性。方法 对48例小肾癌患者行保留肾单位的肾部分切除术。男29例，女19例。平均年龄42岁（24～61岁）。平均肿瘤直径2．4cm（1．0～4．0cm）。病理分期T1N0M047例，双侧肾癌1例。评估肾蒂阻断时间、术后并发症及局部复发情况。结果 48例手术均顺利完成，肾蒂阻断时间平均18min（12～26min）。术后出血3例、漏尿1例。平均随访21个月，1例术后6个月局部复发行根治性手术，1例出现远处转移而死亡，余未见复发或远处转移。结论 保留肾单位的肾部分切除治疗小肾癌安全有效，手术指征可扩展至对侧肾脏正常的患者。     

保留肾组织手术治疗肾癌

１９８９年１２月～１９９７年４月行保留肾组织手术治疗肾癌１４例，其中双侧肾癌５例，对侧肾有病变或潜在功能受损的肾癌３例，对侧肾正常肾癌６例。肿瘤平均直径２９ｃｍ，病理分期为Ｔ１、Ｔ２。１４例中５例行剜出术，９例行肾部分切除术。本组术后无外科并发症，平均随访４６６个月，无瘤存活１２例，无局部复发。存活时间超过７年者２例，５年者４例，３年者１例，１年者２例，半年者３例。保留肾组织手术是早期局限性肾癌的有效治疗方法，可用于对侧肾正常、肿瘤体积较小的早期肾癌的治疗     

Anatomical background for nephron-sparing surgery in renal cell carcinoma.

3-Dimensional endocasts of intrarenal structures were analyzed on the basis of their importance for performing nephron-sparing surgery. In 86.6% of the endocasts the superior pole was related to 3 arteries involved in its resection. Management of the superior (apical) segmental artery as well as ligature of the artery related to the anterior surface of the upper infundibulum are generally not difficult. Ligature of the posterior segmental artery branch related to the superior pole is critical due to the risk of injuring this segmental artery and loss of a great portion of renal parenchyma. In 62.2% of the endocasts the inferior pole resection involved ligature of the inferior segmental artery with no risk to the posterior segmental artery. A deep anatomical knowledge is mandatory to perform mid kidney resection. In 36.4% of the endocasts this region received subdivision branches of arteries from superior and inferior poles, and in 62.2% the mid kidney resection involved amputation of calices that are dependent on polar calices. The middle branch of the posterior segmental artery also is involved in mid kidney resection and its ligature demands much care to avoid injury to the posterior segmental artery itself. In the dorsal kidney the posterior segmental artery is involved and must be safeguarded in all cases of either superior pole or mid kidney resection. In 37.8% of the cases the posterior segmental artery also may be involved in inferior pole resection. When present (69.2%), the retropelvic vein must be previously ligated to provide safe management of the posterior segmental artery.     

Typical renal metanephric adenoma. Conservative surgery

Metanephric Adenoma is uncommon renal tumor included in the complex group of the embryologics or nefroblastics renal tumors. Generally occurs in young females and usually has excellent prognosis. It's important to differentiate of malignant variants, particularly renal cell papillary carcinoma, metanephric adenosarcoma and adult Wilms tumor. The suspicion and intraoperative analysis of the tumor can to facilitate the use of conservative renal surgery in order to avoid unnecessary radical and aggressive surgery. To exist cases of metastatic metanephric adenoma, and the totally benign characteristic of the metanephric adenoma and the malignant potential isn't totally clarify.     

Conservative surgery of renal cell carcinoma associated with renal (artery) aneurysm in solitary kidney--a case report

A rare case of renal cell carcinoma associated with renal artery aneurysm in solitary kidney is reported. The patient is a 63-year-old woman with asymptomatic macrohematuria as CC, who previously received left nephrectomy (for which underlying disease is unknown). Excretory pyelography, abdominal CT and right renoarteriography revealed a 6 X 6 cm-tumor at the center of the right kidney, comprising the middle calices and a 16 X 18 mm-saccular aneurysm at the first bifurcation of the renal artery. No remote metastasis was revealed. Aneurysmectomy and partial nephrectomy (three-quarter of right middle and lower calices) were simultaneously performed in situ. The renal cell carcinoma was pT2b, of clear cell subtype and grade 1, and no calcification of the aneurysmal wall was observed. Anuria lasted for 21 postoperative days, but thereafter diuresis appeared. Renal function after 3 post-operative months remains kept as follows: BUN, 26 +/- 7 mg/dl; serum creatinine, 26 +/- 0.6 mg/dl; creatinine clearance, 20.1 ml/min. Now, after 18 postoperative months, the patient is already returning to work, with neither relapse nor need of dialysis.     

保留肾单位的肾癌切除术探讨

目的 探讨保留肾单位的肾癌切除术的适应证及术中处理。方法 肾癌患者53例。男32例，女21例。年龄21～76岁。病程1周～13个月。均经B超检查发现为单侧肾脏肿瘤，均除外对侧肾病变。肿瘤位于肾上极和下极者38例行肾部分切除术，肿瘤位于肾中部者15例行肾楔形切除术。术中肾血管全阻断，10～15min放松肾蒂钳，肾创面采用止血纱布填塞加可吸收线涤纶布外固定缝合。术后行干扰素治疗（500万U皮下注射，隔日1次，共3个月），每3个月复查。结果 肿瘤切除时间7～21min，平均12min。53例患者均经术中冰冻切片及术后病理学检查确诊为肾细胞癌，切缘阴性。肾癌最大直径6cm者1例，余均〈4cm。临床分期均为T1N0M0。术后随访6．48个月，肿瘤无复发，术侧肾脏功能良好。结论肾癌的快速切除可缩短肾血管全阻断时间，手术效果满意。对于直径〈4cm单发肿瘤或肿瘤直径〉4cm但位于肾浅表呈外凸性生长的T1肾癌，保留肾单位的肾癌切除术是值得积极尝试的治疗方式之一。     

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.     

Immunotherapy for renal cell carcinoma: recent results

Summary Advanced renal cell carcinoma (RCC) is refractory to all traditional therapies and has been the subject of intense investigation using newer therapeutic modalities, including monoclonal antibodies, lymphokine-activated killer cells and vaccines. We review these newer immunotherapies and summarize our results with radioimmune imaging and radioimmunotherapy using mouse xenografts of human RCC and one of our RCC-preferential monoclonal antibodies (A6H). We have consistently been able to image RCC xenografts without background subtraction. Radioimmunotherapy caused tumor shrinkage, and dosimetry results were consistent with xenograft cure. Phase I clinical trials are now underway at this institution.     

Long-term results of nephron sparing surgery for localized renal cell carcinoma: 10-year followup

PURPOSE: Partial nephrectomy is effective for renal cell carcinoma when preservation of renal function is a concern. We present the 10-year followup of patients treated with nephron sparing surgery at our institution. MATERIALS AND METHODS: Partial nephrectomy was performed in 107 patients with localized sporadic renal cell carcinoma before December 1988. Tumors were symptomatic in 73 patients (68%) and indications for surgery were imperative in 96 (90%). Of the patients 42 (39%) had renal insufficiency preoperatively. All patients were followed a minimum of 10 years or until death. RESULTS: At the end of the followup interval 32 patients (30%) had no evidence of recurrence, 28 (26%) died of metastatic renal cell carcinoma and 46 (42%) died of unrelated causes. Cancer specific survival was 88.2% at 5 and 73% at 10 years, and was significantly affected by tumor stage, symptoms, tumor laterality and tumor size. Long-term renal function was stable in 52 patients (49%). CONCLUSIONS: Partial nephrectomy is effective for localized renal cell carcinoma, providing long-term tumor control with preservation of renal function.