Mini-flank supra-11th rib incision for open partial or radical nephrectomy

OBJECTIVE: To report our approach to partial (PN) or radical nephrectomy (RN) using a supra-11th mini-flank incision, as the widespread availability of advanced imaging has increased the detection of incidental, lower-stage renal tumours that are generally amenable to resection using smaller incisions. PATIENTS AND METHODS: The study included 167 consecutive patients undergoing PN/RN for renal tumours treated between February 2000 and March 2003 using the supra-11th rib mini-flank approach. Variables analysed were age, gender, nephrectomy type (PN vs RN), operative duration, estimated blood loss (EBL), hospital stay, tumour size and location, pathological stage and histology, perioperative transfusions, and complications. Patients undergoing PN were examined for ischaemia type (cold, warm, none) and duration of renal artery clamping. The interval after surgery to initiate solid diet and discontinue patient-controlled analgesia, and overall pain control, were analysed and compared between PN and RN. RESULTS: In all, 133 patients (80%) underwent PN and 34 (20%) RN, at a median age of 61.7 years. The median operative duration was 2.9 h, the EBL 400 mL, tumour size 3.2 cm and median hospital stay 5 days. At a median follow-up of 18.2 months, there were seven (4%) late complications: six patients had a flank bulge and one had a reducible hernia. Surgical margins were negative in 164 (98%) patients. CONCLUSIONS: The supra-11th rib mini-flank incision offers a practical alternative to traditional open or laparoscopic PN or RN. Using a small (8 cm) incision with no rib resection, this approach affords optimum exposure without compromising cancer control, with excellent cosmetic results and a lower risk of late complications at the wound site.     

Small Renal Mass: To Treat or Not To Treat

An increasing number of small renal masses (SRMs) are being detected with modern cross-sectional imaging. The natural history of SRMs is mostly unknown. Initial active surveillance (AS) is a reasonable treatment option for small renal masses (SRMs) <?4 cm in the infirm patient with major comorbidities. Partial nephrectomy (PN) is the established treatment for T1a tumors, provided that the operation is technically feasible and the tumor can be completely removed. Laparoscopic and, most recently, robotic PN have functional and oncologic outcomes comparable to open PN, but are technically demanding procedures. Radical nephrectomy (RN) should be limited to those cases where the tumor is not amenable to PN. Percutaneous needle biopsy of SRMs can be safely performed and has the potential to characterize SRMs histologically. It is best utilized in conjunction with ablative technologies. However, ablative therapies should be reserved for carefully selected patients who are poor surgical candidates.     

Evolving practice patterns for the management of small renal masses in the USA

Study Type – Therapy (trend analysis) Level of Evidence 2b What's known on the subject? and What does the study add? Treatment options for small renal masses include radical nephrectomy (RN), partial nephrectomy (PN), ablation, and surveillance. PN provides equivalent oncological as RN for small tumours, but long‐term outcomes for ablation and surveillance are poorly defined. Due to changing techniques and technology, treatment patterns for small renal masses are rapidly developing. Prior studies had analysed utilisation trends for PN and RN to 2006, revealing a relative rise in the rate of PN. However, overall treatment trends including surveillance and ablation had not been studied using a population‐based cohort. It has become increasingly clear that RN is associated with greater renal and cardiovascular deterioration than nephron‐sparing treatments. Thus, it is important to understand current population‐based practice patterns for the treatment of small renal masses to assess whether practitioners are adhering to ever‐changing principles in this field. The present study provides up‐to‐date treatment trends in the USA using a large population‐based cohort.

OBJECTIVE

• ? To describe the changing practice patterns in the management of small renal masses, including the use of surveillance and ablative techniques.

PATIENTS AND METHODS

• ? All patients in the Surveillance, Epidemiology and End Results (SEER) registry treated for renal masses of ≤7 cm in diameter, from 1998 to 2008, were included for analysis.
• ? Annual trends in the use of surveillance, ablation, partial nephrectomy (PN), and radical nephrectomy (RN) were calculated.
• ? Multinomial logistic regression was used to determine the association of demographic and clinical characteristics with treatment method.

RESULTS

• ? In all, 48 148 patients from 17 registry sites with a mean age of 63.4 years were included for analysis.
• ? Between 1998 and 2008, for masses of <2 cm and 2.1–4 cm, there was a dramatic increase in the proportion of patients undergoing PN (31% vs 50%, 16% vs 33%, respectively) and ablation (1% vs 11%, 2% vs 9%, respectively).
• ? In multivariable analysis, later year of diagnosis, male gender, being married, clinically localised disease, and smaller tumours were associated with increased use of PN vs RN. Later year of diagnosis, male gender, being unmarried, smaller tumour, and the presence of bilateral masses were associated with increased use of ablation and surveillance vs RN.

CONCLUSIONS

• ? PN is now used in half of all patients with the smallest renal masses, and its use continues to increase over time.
• ? Ablation and surveillance are less common overall, but there is increased usage over time in select populations.

     

Trends in the incidence of benign pathological lesions at partial nephrectomy for presumed renal cell carcinoma in renal masses on preoperative computed tomography imaging: A single institute experience with 290 consecutive patients

Objective: The aim of this study was to determine trends in the incidence of benign lesions in patients undergoing surgery for suspicious renal masses on preoperative computed tomography scan. Methods: The records of 1065 patients who underwent open consecutive partial nephrectomy (PN) or radical nephrectomy (RN) between January 2001 and December 2008 were reviewed. Patients who underwent PN during the periods 2001–2002, 2003–2004, 2005–2006, and 2007–2008 were assigned to groups 1, 2, 3 and 4, respectively. The frequencies of benign and malignant lesions in these groups were assessed according to size and histology subtypes. Results: The ratio of PN to RN was 12.4%, 18.3%, 24.3% and 37.2% in groups 1, 2, 3 and 4, respectively (P < 0.05). The mean size of resected lesions was 2.6 cm (range 0.8–6.2 cm). Of the 290 cases, histopathology revealed benign findings in 52 (17.9%). Benign pathology was found in three of 18 cases (16.7%) in group 1, seven of 36 cases (19.4%) in group 2, 12 of 63 cases (19.0%) in group 3 and 30 of 173 cases (17.3%) in group 4. There was no significant difference in the frequency of benign histology among groups. Conclusion: PN, as opposed to RN, has shown a rising tendency over time. The frequency of benign pathology findings after PN for suspicious renal masses on preoperative computed tomography imaging has not decreased. Proper management should favor nephron‐sparing surgery for renal lesions if such lesions can be removed satisfactorily with PN.     

Does laparoscopy beget underuse of partial nephrectomy for T(1) renal masses? Competing treatment decision pathways may influence utilization

BACKGROUND AND PURPOSE: It has been suggested that renal laparoscopy has resulted in an underuse of partial nephrectomy (PN) for small renal masses in the U.S. In the absence of evidence-based medicine (EBM) guide-lines, multiple-perspective reasoning is required where complete v partial nephrectomy and the laparoscopic v the open surgical approach must be considered. We report on the PN rate in a contemporary laparoscopicera series of patients with T(1) renal masses and examine the potential influence of the management decision tree on the PN rate. PATIENTS AND METHODS: An actively managed database of referred patients with T(1) renal masses was utilized retrospectively. All patients were evaluated by a single fellowship-trained urologic oncologist with formal laparoscopic training. Patients were presented with a management decision tree in which PN v total nephrectomy (TN) was the first decision node, laparoscopy v open surgery was the second decision node, and the actual PN rate was reported. We then constructed a hypothetical decision tree in which the first and second decision nodes were reversed and the criteria for performing laparoscopic nephrectomy remained constant. RESULTS: Seventy consecutive patients were entered during a 36-month period (July 2002-June 2005). The actual PN rate was 60%: 91% for lesions <2.0 cm, 68% for lesions 2.1 to 4.0 cm, and 33% for lesions 4.1 to 7.0 cm; and 62% of patients were treated laparoscopically. When the first and second decision nodes were reversed and this hypothetical model was applied to the study cohort, the projected PN rate was 23%, and 96% of the patients were treated laparoscopically. In the hypothetical model, the PN rate fell when patients who chose laparoscopy at the first decision node were excluded from PN at the second decision node if the criteria for laparoscopic PN were not met. CONCLUSION: Laparoscopy did not appear to result in underuse of PN. We explain this by suggesting that the PN rate may be influenced by variation in the decision tree itself. Such variation is inherent in complex clinical decision making where EBM guidelines are lacking.     

Overall Survival and Development of Stage IV Chronic Kidney Disease in Patients Undergoing Partial and Radical Nephrectomy for Benign Renal Tumors

Background

Although partial nephrectomy (PN) has been associated with improved renal function compared with radical nephrectomy (RN) for renal cell carcinoma, the impact on overall survival (OS) remains controversial.

Objective

To evaluate comparative OS and renal function in patients following PN and RN for a renal mass where malignancy was not a confounding factor.

Design, setting, and participants

Using the Mayo Clinic Nephrectomy Registry, we retrospectively identified 442 patients with unilateral sporadic benign renal masses treated surgically with PN or RN between 1980 and 2008.

Outcome measurements and statistical analysis

The primary outcome measures were OS and the incidence of new-onset stage IV chronic kidney disease (CKD), determined using the Kaplan-Meier method. Cox models were used to test the association of nephrectomy type with these outcomes.

Results and limitations

Overall, 206 and 236 patients with benign renal masses were surgically treated with RN and PN, respectively. Patients who underwent RN were older (median age: 67 vs 64 yr; p = 0.02) and had larger tumors (median size: 5.0 vs 2.7 cm; p < 0.001). Median follow-up for patients still alive at last follow-up was 8.3 yr (range: 0.1–27.9 yr). Estimated OS (95% confidence interval [CI]) rates at 10 and 15 yr were 69% (62–76%) and 53% (45–62%) for RN compared with 80% (73–87%) and 74% (65–83%) following PN (p = 0.032). After adjusting for covariates of interest, patients treated with RN were significantly more likely to die from any cause (hazard ratio [HR]: 1.75; 95% CI, 1.08–2.83; p = 0.023) or develop stage IV CKD (HR: 4.23; 95% CI, 1.80–9.93; p < 0.001) compared with patients who underwent PN. Limitations include the retrospective design, selection bias for surgical approach, and referral bias to a tertiary care facility.

Conclusions

Our data suggest that PN may confer a clinical benefit for improved renal function and better OS compared with RN after excluding the confounding effect of malignancy.     

Partial Nephrectomy Is Associated with Improved Overall Survival Compared to Radical Nephrectomy in Patients with Unanticipated Benign Renal Tumours

Background

Partial nephrectomy (PN) has been associated with improved overall survival (OS) in select cohorts with localised renal masses when compared to radical nephrectomy (RN). The driving forces behind these differences have been difficult to elucidate given the heterogeneity of previously compared cohorts.

Objective

Compare OS in a subset of patients with unanticipated benign renal masses to minimise the confounding effect of cancer.

Design, setting, and participants

We retrospectively evaluated 2608 consecutive clinical T1 enhancing renal masses that were treated with extirpative surgery at our institution between 1999 and 2006. Of these, 499 tumours (19%) were found to be benign on final pathology. Preoperative data and renal functional data were used to generate a propensity model that was then plugged into a multivariate model of survival. Median follow-up for the entire cohort was 50 mo (interquartile range [IQR]: 32–73).

Intervention

All patients underwent PN or RN.

Measurements

We measured OS and cardiac-specific survival.

Results and limitations

Five-year OS estimates for the PN (n = 388) and RN (n = 111) cohorts were 95% (95% confidence interval [CI], 93–98) versus 83% (95% CI, 74–90), respectively (P < 0.0001). On multivariate analysis, controlling for both comorbidity and age, RN was associated with a 2.5-fold increased risk of death compared to PN (hazard ratio [HR]: 2.5; 95% CI, 1.3–5.1). Postoperative estimated glomerular filtration rate (eGFR) was also an independent predictor of OS and cardiac-specific survival (HR: 0.97; 95% CI, 0.95–0.99 and HR: 0.96; 95% CI, 0.93–0.99, respectively). The retrospective nature of this analysis limits the strength of the conclusions.

Conclusions

PN was associated with better OS when compared to RN in patients with unanticipated benign tumours. This observed survival advantage appears partly to be the result of better preservation of eGFR, but other kidney functions or unmeasured factors may also play a role. These data indicate that PN should be aggressively pursued in any patient where PN is technically feasible.     

Renal surgery in the elderly: morbidity in patients aged >75 years in a contemporary series

OBJECTIVES

To evaluate the surgical complications in a contemporary group of elderly patients with renal masses, as almost a quarter of patients with newly diagnosed renal mass are aged >74 years, with the potential for significant comorbidity.

PATIENTS AND METHODS

From April 2004 to June 2007, of 379 surgical resections of renal tumours, we assessed 117 consecutive patients aged ≥75 years, who had either radical nephrectomy (RN) or partial nephrectomy (PN) for assumed renal cell carcinoma. Also elderly patients who had nephroureterectomy (NU) for upper urothelial cancer were followed.

RESULTS

Fifty patients had RN, 57 PN and 10 had NU; the median (range) age of all patients was 78.1 (72.7–92.5) years and was similar in all groups. No patient died during surgery and only one died within 90 days. The complication rates during and after surgery RN, PN and NU were 12%, 15% and 20%, respectively; the major complications within 30 days were 4%, 7% and 10%; major complications included bleeding during surgery and one acute bleeding event after surgery in the PN group.

CONCLUSIONS

Open renal surgery in elderly patients can be done safely; there was no difference in morbidity among RN, PN and NU. Renal surgery in the elderly patient is safe if done at a specialized centre. Mortality and morbidity can be very low, rendering this a feasible approach in the treatment of renal masses even if the prognosis is not determined by the oncological situation but by comorbidity.     

Partial nephrectomy for renal masses ≥ 7 cm: technical, oncological and functional outcomes

What's known on the subject? and What does the study add? Partial nephrectomy for the pT1 renal mass has demonstrated acceptable oncological outcomes in addition to improved overall long‐term survival when compared with radical nephrectomy. Previous reports for lesions ≥7 cm have shown mixed data concerning oncological outcomes and technological success. We demonstrate that partial nephrectomy for renal masses ≥7 cm has acceptable oncological, technical, and functional outcomes. As such, partial nephrectomy should be a surgical option when feasible regardless of tumour size. Study Type – Therapy (case series) Level of Evidence 4

OBJECTIVE

• ? To present outcomes for patients with renal masses ≥7 cm in size who are treated with partial nephrectomy (PN) at our institution and to summarize the cumulative published experience.

PATIENTS AND METHODS

• ? We reviewed our prospectively maintained institutional kidney cancer database and identified patients undergoing PN for tumours >7 cm in size.
• ? Technical, oncological and renal functional data were analyzed and compared with the existing published experience of PNs for tumours >7 cm in size.

RESULTS

• ? In total, 46 patients with 49 renal tumours >7 cm in size who underwent PN were identified.
• ? With a median (range) follow‐up of 13.1 (0.2–170.0) months, there were 16 complications, including four (8.2%) blood transfusions and six (12.2%) urinary fistulae.
• ? The 5‐ and 10‐year overall and renal cell carcinoma (RCC)‐specific survivals were 94.5% and 70.9%. There were five (10.9%) patients who had an upward migration in their chronic kidney disease status after PN.
• ? There were six previous series totalling 280 tumours encompassing the published experience of PN for tumours >7 cm in size. The incidence of urinary fistulae and postoperative haemorrhage, respectively, was in the range 3.3–18.8% and 0–3%.
• ? Although oncological outcomes showed cancer‐specific survival in the range 66–97.0%, series matching PN and RN in patients with T2 RCC show equivalency in RCC‐specific and overall survivals. When reported, PN for tumours >7 cm in size was associated with better renal functional preservation.

CONCLUSION

• ? The findings of the present study show that PN can safely be performed in tumours ≥7 cm in size with acceptable technical, oncological and functional outcomes. Further studies are warranted.

     

Intermediate comparison of partial nephrectomy and radiofrequency ablation for clinical T1a renal tumours

OBJECTIVE: To compare the intermediate-term outcomes of patients with clinical T1a renal tumours who were treated with nephron-sparing surgery by partial nephrectomy (PN), the preferred approach for small (cT1a) renal tumours, or radiofrequency ablation (RFA), recently offered to selected patients as an alternative, less morbid technique. PATIENTS AND METHODS: We identified patients with stage T1a renal masses who had > or = 2 years of follow-up; those with bilateral synchronous or metachronous tumours, metastatic disease at presentation, or a family history of renal cell carcinoma were excluded. From July 1996 to January 2004 110 PNs were identified in our database; 37 patients who fulfilled the inclusion criteria had either open (30) or laparoscopic PN (seven) and 40 had either percutaneous (26) or laparoscopic (14) RFA. RESULTS: The mean (range) follow-up for the RFA and PN groups was 30 (18-42) and 47 (24-93) months, respectively; the respective mean tumour size was 2.41 and 2.43 cm. There was one incomplete ablation and two local recurrences in the RFA group, and two recurrences in the PN group (one local and one in the contralateral kidney). There were no disease-specific deaths. The overall actuarial disease-free probability for the PN and RFA groups, respectively, was 95.8% and 93.4% (P = 0.67). CONCLUSIONS: This initial 3-year actuarial analysis showed that RFA for cT1a renal tumours has comparable oncological outcomes to PN; however, longer term data are still needed.     

A preoperative prognostic nomogram for solid enhancing renal tumors 7 cm or less amenable to partial nephrectomy

PURPOSE: Small renal masses are increasing in incidence. Most tumors 7 cm or less are treated with radical or partial nephrectomy but clinicians are increasingly relying on ablative therapies and observation for some small renal masses. We present novel nomograms that predict the likelihood of benign, likely indolent or potentially aggressive pathological findings based only on readily identifiable preoperative factors. MATERIALS AND METHODS: Information on all partial nephrectomies performed at a single institution was collected in an institutional review board approved registry. Using retrospectively collected data on all 862 patients who underwent partial nephrectomy for a single, solid, enhancing, clinical T1 (7 cm or less) tumor between 1999 and 2005 tumors were classified as benign or malignant. Grade 3 clear cell renal cell carcinoma, grade 4 renal cell carcinoma of any type and any renal cell carcinoma with vascular, fat or collecting system invasion were considered potentially aggressive. The likelihood of benign, likely indolent or potentially aggressive pathological findings was modeled using multivariable logistic regression models based on age, gender, radiographic tumor size, symptoms at presentation and smoking history. RESULTS: Of 862 small renal masses 20% were benign and 80% were malignant but only 30% of cancers (24% of small renal masses) were potentially aggressive. All 11 patients with systemic symptoms had cancer. The remaining 851 patients underwent further analysis. Factors that were most strongly associated with the likelihood of benign pathology were age, gender, tumor size and smoking history. A nomogram constructed to predict benign histology proved to be relatively accurate and discriminating (bootstrap corrected concordance index 0.644) and calibrated. Small renal masses in older men and younger women were more likely to be benign. With regard to differentiating indolent from potentially aggressive cancers, only advanced age was independently significant on multivariate analysis (p <0.005). The nomogram for this outcome performed with limited ability (concordance index 0.557). CONCLUSIONS: Clinical factors provide substantial predictive ability to predict benign vs malignant pathology for small renal masses amenable to partial nephrectomy. Although most of these small renal masses are benign or indolent, our ability to predict potentially aggressive cancer in this population remains limited.     

Comparison of outcomes in elective partial vs radical nephrectomy for clear cell renal cell carcinoma of 4-7 cm

OBJECTIVE: To compare the outcomes of patients who had a elective partial nephrectomy (PN) or radical nephrectomy (RN) for clear cell renal cell carcinoma (RCC) of 4-7 cm. PATIENTS AND METHODS: From March 1998 to July 2004, 45 and 151 patients underwent PN and RN, respectively, for clear cell RCC. A multivariate Cox model was constructed for disease-free survival with adjustment for markers of disease severity, and a propensity-score approach used as a confirmatory analysis. RESULTS: In the PN and RN cohorts the treatment failed in one and 20 patients, respectively; the median follow-up was 21 months. The hazard ratio (95% confidence interval) for PN after adjusting for disease severity was 0.36 (0.05-2.82; P = 0.3). Using planned PN as a predictor (intent-to-treat analysis) the hazard ratio was 1.06 (0.32-3.53; P = 0.9). In the propensity-score model, planned PN was associated with a hazard ratio of 1.75 (0.50-6.14; P = 0.4). The serum creatinine level 3 months after surgery was significantly lower in patients who had PN, with a difference between the means of 0.36 (0.23-0.48; P < 0.001). CONCLUSIONS: Renal function was preserved after PN for 4-7 cm clear cell RCC tumours. When comparing the outcomes of PN and RN it is important to consider the intended operation as an independent variable. There was no clear evidence that PN was associated with worse cancer control, although a continued follow-up of this and other cohorts is warranted.     

Organ intact retrieval via umbilical incision after simultaneous bilateral laparoscopic radical nephrectomy for renal masses

PURPOSE: We report on two cases of laparoscopic bilateral nephrectomy for renal-cell carcinoma (RCC) in patients with end-stage renal disease. PATIENTS AND METHODS: Bilateral renal masses were detected in two patients with acquired renal cystic disease. They underwent bilateral laparoscopic nephrectomy. The specimens were removed intact via an umbilical incision. RESULTS: The operative times were 8 hours and 6 hours and the estimated blood loss was 154 mL and 120 mL. Both patients resumed oral intake on postoperative day 1 and were discharged on postoperative day 6. No intraoperative and postoperative complications occurred. The pathology report revealed bilateral RCC. The original length of the umbilical incision was 4 cm which shrank to 3 cm by 2 months after the operation. CONCLUSIONS: Bilateral laparoscopic radical nephrectomy including intact organ retrieval for bilateral renal masses via a small umbilical incision is feasible.     

Active surveillance of small renal masses offers short‐term oncological efficacy equivalent to radical and partial nephrectomy

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Active surveillance of small renal masses has traditionally been reserved for elderly patients deemed unfit for surgery or ablation. There is increasing evidence showing the safety of active surveillance in the management of small renal masses. In this retrospective study we compared outcomes for patients with small renal masses managed with active surveillance, radical nephrectomy and partial nephrectomy. We showed that active surveillance was safe and appeared as effective as immediate surgery in the management of small renal tumours.

OBJECTIVE

• ? To compare the oncological outcomes of active surveillance (AS), radical nephrectomy (RN) and partial nephrectomy (PN) in the management of T1a small renal masses (SRMs).

PATIENTS AND METHODS

• ? At present AS is used in the treatment of SRMs in elderly patients with multiple co‐morbidities or in those who decline surgery.
• ? We identified all patients with T1a SRMs managed with RN, PN or AS.
• ? Retrospective data were collected from patient case records with survival data and cause of death cross‐referenced with the Oxford Cancer Intelligence Unit.

RESULTS

• ? A total of 202 patients with 234 T1a SRMs (solid or Bosniak IV) were identified; 71 patients were managed with AS, 41 with an RN and 90 by PN.
• ? Over a median follow‐up of 34 months the mean growth rate on AS was 0.21 cm/year with 53% of SRMs managed with AS showing negative or zero growth.
• ? No statistically significant difference was observed in overall (OS) and cancer‐specific (CSS) survival for AS, RN and PN (AS‐CSS 98.6%, AS‐OS 83%; RN‐CSS 92.6%, RN‐OS 80.4%; PN‐CSS 96.6%, PN‐OS 90.0%).

CONCLUSIONS

• ? Active surveillance of SRMs offers oncological efficacy equivalent to surgery in the short/intermediate term.
• ? The results of this study support a multicentre prospective randomized controlled trial designed to compare the oncological efficacy of AS and surgery.

     

Trends in the operative management of renal tumors over a 14-year period

OBJECTIVE: To review the trends in the operative management of renal tumours over a 14-year period at a university hospital, as the therapeutic options available for treating renal tumours have increased over the past decade. PATIENTS AND METHODS: The study was a retrospective chart review of 1621 consecutive patients undergoing treatment for renal tumours from January 1991 to March 2005. The characteristics assessed included patient demographics, tumour size, operative duration and treatment. RESULTS: During the study period, 624 (38.6%) open, 883 (54.6%) laparoscopic and 111 (6.7%) percutaneous approaches were performed. The number of renal tumours treated increased annually, as did the use of minimally invasive techniques (93.4% in 2005). Conversely, the number of open surgical treatments used declined both absolutely and proportionally. Over the study period, for tumours of 7 cm, open radical nephrectomy (ORN) was the most common method of treatment over all years. However, since 2002, laparoscopic radical nephrectomy (LRN) surgery has been increasingly used over ORN for treating this tumour group (73% LRN vs 19.2% ORN in 2004). CONCLUSION: The available treatment options for renal tumours have increased significantly since the early 1990s. At a university hospital in which there are physicians with a specific interest in minimally invasive surgery and ablative treatments, minimally invasive approaches have become the standard treatment.     

Treatment of localised renal cell carcinoma

Context

The increasing incidence of localised renal cell carcinoma (RCC) over the last 3 decades and controversy over mortality rates have prompted reassessment of current treatment.

Objective

To critically review the recent data on the management of localised RCC to arrive at a general consensus.

Evidence acquisition

A Medline search was performed from January 1, 2004, to May 3, 2011, using renal cell carcinoma, nephrectomy (Medical Subject Heading [MeSH] major topic), surgical procedures, minimally invasive (MeSH major topic), nephron-sparing surgery, cryoablation, radiofrequency ablation, surveillance, and watchful waiting.

Evidence synthesis

Initial active surveillance (AS) should be a first treatment option for small renal masses (SRMs) <4 cm in unfit patients or those with limited life expectancy. SRMs that show fast growth or reach 4 cm in diameter while on AS should be considered for treatment. Partial nephrectomy (PN) is the established treatment for T1a tumours (<4 cm) and an emerging standard treatment for T1b tumours (4-7 cm) provided that the operation is technically feasible and the tumour can be completely removed. Radical nephrectomy (RN) should be limited to those cases where the tumour is not amenable to nephron-sparing surgery (NSS). Laparoscopic radical nephrectomy (LRN) has benefits over open RN in terms of morbidity and should be the standard of care for T1 and T2 tumours, provided that it is performed in an advanced laparoscopic centre and NSS is not applicable. Open PN, not LRN, should be performed if minimally invasive expertise is not available. At this time, there is insufficient long-term data available to adequately compare ablative techniques with surgical options. Therefore ablative therapies should be reserved for carefully selected high surgical risk patients with SRMs <4 cm.

Conclusions

The choice of treatment for the patient with localised RCC needs to be individualised. Preservation of renal function without compromising the oncologic outcome should be the most important goal in the decision-making process.     

Functional preservation in patients with renal cortical tumors: The rationale for partial nephrectomy

Renal cortical tumors (RCT) are a family of neoplasms with diverse histology and metastatic potentials. Conventional clear cell tumors account for 54% of all RCT and 90% of those that metastasize. Liberal use of abdominal imaging detects 70% of RCT incidentally and at a small size (< 4 cm in diameter). Emerging evidence strongly favors partial nephrectomy (PN) as the primary treatment when technically possible for tumors 7 cm or smaller. This approach provides local tumor control equivalent to radical nephrectomy (RN) and prevents or delays chronic kidney disease (CKD) onset. CKD is present in 26% of apparently well patients with such small renal tumors and is an independent risk factor for cardiovascular disease, hospitalization, and death. The likelihood of freedom from an estimated glomerular filtration rate lower than 45 mL/min/1.73m², a level of significant CKD, is 95% after PN, but only 64% after RN. RN should be reserved for patients with massive renal tumors in whom PN is not an option. Increased training in PN and its wider application is essential.     

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 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.     

Adherence to guideline recommendations for management of clinical T1 renal cancers in the Netherlands: a population-based study

Purpose

For decades, small renal cancers are treated by radical nephrectomy (RN). Current guidelines recommend partial nephrectomy (PN) to preserve renal function and minimize cardiovascular comorbidity. As adherence to guidelines is largely unknown and international comparison to evaluate quality of health care is lacking, an pre-specified guideline evaluation of quality indicators concerning management of cT1 renal cancers was performed.

Methods

We performed a cohort study including patients with cT1 renal cancer between 2010 and 2014, identified through the Netherlands Cancer Registry. Time trends and variation in treatment were described. Factors associated with PN in cT1a and laparoscopic RN in cT1b were evaluated with logistic regression analyses.

Results

An increase in nephron-sparing treatment strategies (NSS) of cT1a patients (N _total = 2436) was observed; in 2014, 67 % underwent NSS (62 % PN and 5 % thermal ablation). Age, a non-central tumor localization and being treated in a high-volume hospital were associated with PN. Although NSS were applied more frequently over time, the majority (70 %) of cT1b patients (N _total = 2205) underwent RN in 2014, mainly performed laparoscopically. Increasing tumor size, tumor localization in the right kidney and being treated in a university hospital were associated with a lower probability of a laparoscopic RN versus open. Treatment in a high-volume hospital was associated with a higher probability of laparoscopic RN.

Conclusions

Dutch patients with cT1 renal cancer are predominantly treated according to current guidelines. Data of this pre-specified quality indicator analysis of a urological national guideline may serve as a model for international comparison of treatment of cT1 renal cancers.