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.     

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.     

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.     

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.     

Elective nephron sparing surgery should become standard treatment for small unilateral renal cell carcinoma: Long-term survival data of 216 patients

OBJECTIVES: Our experiences with elective nephron-sparing surgery (NSS) for renal cell carcinoma (RCC) in a consecutive series of 216 patients are presented. Clinicopathological features and long-term oncological outcome is compared to patients treated with radical nephrectomy (RN). METHODS: Between 1975 and 2002, NSS was performed in 488 patients; 311 of these patients had elective indications. Renal cell carcinoma was found in 241/311 patients (77.5%). Long-term follow up data could be obtained in 216/311 patients. Cancer-specific survival was estimated using the Kaplan-Meier method. Cox's regression analysis and log-rank tests were used to evaluate independent predictive values of different clinicopathological features. Survival data of the 216 patients after NSS surgery were compared to 369 patients with small RCC treated with RN. RESULTS: After a mean follow up of 66 months (median 64 months) 29 (13.4%) of 216 patients treated with NSS had died, 4 of them (1.8%) tumour-related. Tumour recurrence was detected in 12 patients (5.6%). 204 patients (94.4%) were free of tumour at last follow-up. Cancer specific survival rates at 5 and 10 years for patients treated with NSS (RN) were 97.8% (95.5%) and 95.8% (84.4%). CONCLUSIONS: Elective NSS surgery provides optimal long-term outcome in patients with small localized RCC. Compared to RN, renal parenchyma is preserved without any disadvantage in survival rates. Consequently elective NSS should be accepted as gold standard for small renal tumours.     

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.     

A prospective randomized EORTC intergroup phase 3 study comparing the complications of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma

OBJECTIVES: This study compared the complications and the cancer control of elective nephron-sparing surgery (NSS) and radical nephrectomy (RN) in patients with a small (相似文献   

Excellent long-term cancer control with elective nephron-sparing surgery for selected renal cell carcinomas measuring more than 4 cm

OBJECTIVES: Elective nephron-sparing surgery (NSS) for renal cell carcinoma (RCC) < 4 cm has been accepted as alternative to radical nephrectomy (RN). However, NSS for tumours > 4 cm is controversial. We present our experiences and long-term oncologic outcome of RCC > 4 cm treated with NSS in a retrospective single-institutional analysis of 69 patients. METHODS: Between 1975 and 2004, elective NSS was performed in 368 patients at our institution, including 69 patients with sporadic, nonmetastatic RCC > 4 cm. Overall and cancer-specific survivals were estimated using the Kaplan-Meier method. RESULTS: Complications were seen in nine patients (13.0%). After a mean follow-up of 6.2 yr (median, 5.8 yr) seven patients (10.1%) had died, none of them of tumour-related causes. Tumour recurrence was detected in four patients (5.8%). The 5-yr overall survival probability was 94.9%. The 10-yr and 15-yr overall survival rates were both 86.7%. Cancer-specific survival was 100% after 5, 10, and 15 yr. CONCLUSIONS: Selected patients with localized RCC even > 4 cm can be treated with elective NSS providing optimal long-term outcome. The surgeon's decision for organ-preserving surgery should depend on tumour localisation and technical feasibility rather than on tumour size.     

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.     

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.     

A prospective, randomised EORTC intergroup phase 3 study comparing the oncologic outcome of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma

Background

Nephron-sparing surgery (NSS) can safely be performed with slightly higher complication rates than radical nephrectomy (RN), but proof of oncologic effectiveness is lacking.

Objective

To compare overall survival (OS) and time to progression.

Design, setting, and participants

From March 1992 to January 2003, when the study was prematurely closed because of poor accrual, 541 patients with small (≤5 cm), solitary, T1–T2 N0 M0 (Union Internationale Contre le Cancer [UICC] 1978) tumours suspicious for renal cell carcinoma (RCC) and a normal contralateral kidney were randomised to NSS or RN in European Organisation for Research and Treatment of Cancer Genito-Urinary Group (EORTC-GU) noninferiority phase 3 trial 30904.

Intervention

Patients were randomised to NSS (n = 268) or RN (n = 273) together with limited lymph node dissection (LND).

Measurements

Time to event end points was compared with log-rank test results.

Results and limitations

Median follow-up was 9.3 yr. The intention-to-treat (ITT) analysis showed 10-yr OS rates of 81.1% for RN and 75.7% for NSS. With a hazard ratio (HR) of 1.50 (95% confidence interval [CI], 1.03–2.16), the test for noninferiority is not significant (p = 0.77), and test for superiority is significant (p = 0.03). In RCC patients and clinically and pathologically eligible patients, the difference is less pronounced (HR = 1.43 and HR = 1.34, respectively), and the superiority test is no longer significant (p = 0.07 and p = 0.17, respectively). Only 12 of 117 deaths were the result of renal cancer (four RN and eight NSS). Twenty-one patients progressed (9 after RN and 12 after NSS). Quality of life and renal function outcomes have not been addressed.

Conclusions

Both methods provide excellent oncologic results. In the ITT population, NSS seems to be significantly less effective than RN in terms of OS. However, in the targeted population of RCC patients, the trend in favour of RN is no longer significant. The small number of progressions and deaths from renal cancer cannot explain any possible OS differences between treatment types.     

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.     

T1b期肾癌保留肾单位手术的适应证选择与疗效分析

目的 探讨T1b期肾癌行NSS的适应证选择、安全性及其临床效果.方法 对47例T1b期肾癌患者实施肾部分切除术.结果 OPN及LPN的热缺血时间分别为（15.3±5.8）min,（22.1±7.2）min.术后并发症：迟发性肾脏出血1例,术后肾动脉瘤1例,下肢深静脉血栓1例,分别予二次手术、选择性肾动脉栓塞术、抗凝等治疗.术后随访时间5个月～10年,5例失访,14例肿瘤转移.结论 T1b期肾癌选择肾部分切除术是安全可行的.需要综合考虑患者意愿、主要脏器功能状况、肿瘤与肾血管的解剖关系、残留肾单位的比例及术者擅长的术式等多种因素.因此,NSS有望成为T1b期肾癌的标准术式之一.     

Nephron sparing surgery for renal cell carcinoma in a solitary kidney

To determine functional and oncological outcomes of nephron sparing surgery (NSS) for renal cell carcinoma (RCC). We identified from our kidney database 103 consecutive patients undergoing NSS for solid renal tumors in a solitary kidney. After excluding 17 patients (16.5%) undergoing NSS with palliative intent in presence of preoperatively diagnosed metastatic disease (n = 15) or positive lymph nodes (n = 2) and 6 patients (5.8%) who turned out to have benign tumors, the remaining 80 patients with RCC were analyzed. Mean follow-up is 8.0 years (range: 0.1–25.8). Mean tumor size was 4.2 cm (range 1.2–11 cm). Chronic renal failure requiring hemodialysis developed after NSS in nine patients (11.2%). In the remainder, serum creatinine was 1.72 mg/dl (range: 0.45–4.6 mg/dl) at latest follow-up. The cancer specific survival rates at 1, 5 and 10 years were 97.2, 89.6 and 76%, respectively. The estimated local recurrence free survival rates at 1, 5 and 10 years were 97.8, 89.4 and 79.9%, respectively. Univariate analysis of correlation between clinical and pathologic features with death from RCC showed significant associations for grading and tumor size. The long-term data of our series support the concept of organ-sparing surgery for RCC in a solitary kidney since it provides excellent local tumor control and cancer specific survival and preserves renal function renal function so that 89% of patients remained free of dialysis in the long-run.     

Nephron‐sparing surgery for pathological stage T3b renal cell carcinoma confined to the renal vein

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

To report the functional and oncological outcome of nephron‐sparing surgery (NSS) for pathological stage pT3bNxMx (2002 Tumour‐Node‐Metastasis staging) renal cell carcinoma (RCC) with tumour thrombus confined to the renal vein.

PATIENTS AND METHODS

Of the 305 patients who underwent NSS at our institute from October 2004 to July 2009, seven (2%) were found to have stage T3bNxMx RCC on final pathology. Their charts were reviewed to identify demographic, operative and pathology details of these patients, in addition to obtaining functional and oncological outcome data.

RESULTS

All seven patients had centrally located endophytic tumours. There were absolute indications for NSS in six patients (solitary kidney in five, renal insufficiency in one). The clinical stage was T1a in five and T3b in two patients; in those with cT1a, thrombus was first identified with intraoperative ultrasonography in two and by palpation of the renal vein or during the NSS in the remaining three. Renal surface hypothermia was applied in four cases (mean 77 min) and warm ischaemia in three (mean 38 min). The mean (range) tumour size was 3.9 (2.5–6) cm and all the tumours were clear cell RCC on histology, and all had negative surgical margins. The mean estimated glomerular filtration rate (eGFR) decreased by 24% after surgery. One patient developed new‐onset renal failure (eGFR <30 mL/min/1.73 m²). Postoperative urine leak occurred in one patient successfully managed with a JJ stent. One patient developed a local recurrence with level III inferior vena caval (IVC) tumour thrombus 9 months after NSS and was managed with radical excision and IVC thrombectomy followed by postoperative dialysis. Six other patients were free of recurrence with no need for dialysis at a mean follow‐up of 30 months.

CONCLUSIONS

In selected patients with pathological stage T3b RCC and tumour thrombus confined to the renal vein, NSS is a feasible treatment option with acceptable oncological and renal functional outcomes.     

Solitary, isolated metastatic disease to the kidney: Memorial Sloan-Kettering Cancer Center experience

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Usually malignant disease involving the kidneys is characterized by bilateral and multiple lesions in association with widespread dissemination of the primary tumour. Metastasis to the kidney as a solitary, isolated renal mass is an extremely rare event and little is known about its characteristics and outcomes. Our study shows that kidney involvement by other tumours can occur as isolated solitary lesions and the kidney can be the first and only site of metastatic involvement. Of the 14 patients included in the study, 8 were alive at the last follow‐up and 4 without evidence of disease after nephrectomy. In this highly selected group of patients nephrectomy can be offered as a therapeutic option.

OBJECTIVE

? To analyse the clinical characteristics and outcomes of patients who underwent nephrectomy for solitary, isolated metastatic disease to the kidney.

PATIENTS AND METHODS

? From July 1989 to July 2009, we identified 13 patients who underwent nephrectomy for solitary metastasis to the kidney. Patients’ demographics, intra‐operative variables and outcomes are reported.

RESULTS

? The median age at nephrectomy was 52 years (range 33–79). Eleven patients (85%) had an incidentally discovered renal mass, whereas two patients (15%) presented with gross haematuria. ? Median time from initial surgery at the primary site to development of metastatic disease to the kidney was 63 months (range 9–136). No patient had evidence of disease at other sites at the time of nephrectomy. In seven patients (54%), the kidney was the first site of recurrence. ? The most common primary site was the lung in five patients (38%), followed by the colon in two (15%), chest wall in two (15%) and bone, brain, breast and salivary gland in one patient each (8%). ? Of the 14 procedures performed, eight (57%) were partial nephrectomy (PN) and six (43%) were radical nephrectomy (RN). ? Four patients died after progression from the primary tumour, all within 2 years of nephrectomy. One patient with a primary chondrosarcoma had no evidence of disease at last follow‐up and died from other causes 50 months after nephrectomy. The median follow‐up for the eight patients who were alive at last follow‐up was 30 months after nephrectomy. Four of these patients had no evidence of disease and four patients were alive with metastatic disease.

CONCLUSION

? Kidney involvement by metastatic disease can occur as isolated solitary lesions. Some patients will also have the kidney as the first and only site of metastatic involvement. The presence of an isolated renal metastasis should not be considered an end‐stage disease, and nephrectomy can be offered for highly selected patients as a therapeutic option.     

Pancreatic Resection for Metastatic Renal Cell Carcinoma: Presentation,Treatment, and Outcome

Background: The diverse natural history of renal cell carcinoma (RCC) includes metastases to the pancreas, a very unusual site for distant spread of other cancers. Considering the relatively indolent behavior of some cases of metastatic RCC, pancreatic resection is offered to select patients.Methods: We reviewed the records of patients at three affiliated university hospital centers who had prior nephrectomy for RCC and subsequent pancreatic resection of metastases.Results: Fourteen patients—9 women and 5 men with a median age of 63.8 years—underwent a total of 15 pancreatic resections for metastatic RCC. Nine (64%) had solitary metastases. The median interval from nephrectomy to diagnosis of pancreatic metastases was 83 months. The median size of metastases was 4.6 cm. There was one perioperative death. Pancreatic recurrence occurred in five patients (36%), and one patient underwent repeat resection. At a median follow-up of 32 months, seven patients (50%) are alive without evidence of disease, and four patients (28%) are alive with recurrent disease.Conclusions: Resection of pancreatic metastases from RCC is associated with long-term survival and should be considered for patients in whom complete resection is possible.     

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.     

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.