The role of adjunctive nephrectomy in patients with metastatic renal cell carcinoma.

The results of therapy for 78 patients with disseminated renal cell carcinoma are evaluated. Symptoms related to the primary tumor were noted in only 28 per cent of the patients and were not difficult to manage in those patients not undergoing nephrectomy. Adjuctive nephrectomy, therefore, is a more appropriate term than palliative nephrectomy when referring to removal of the primary tumor as part of an aggresive combined therapeutic approach. Of patients receiving an adjunctive nephrectomy those with osseous metastases only had a better 1-year survival rate (36 per cent) than those with metastases to other sites (18 per cent). Complete regression of metastases was noted in 12 per cent of patients treated with medroxyprogesterone acetate and adjunctive nephrectomy. The role of adjunctive nephrectomy combined with embolic infarction, hormonal therapy, chemotherapy and/or immunotherapy is discussed.     

Cranial irradiation after surgical excision of brain metastases in melanoma patients

Background: Brain metastases account for 20–54% of reported deaths from melanoma. Duration and quality of survival depend on the extent of metastatic disease and response to treatment. Treatment goals are palliation of symptoms and prolongation of life. No studies have directly compared surgery alone and surgery with adjunctive cranial irradiation in patients with solitary brain metastases. Methods: We evaluated postoperative adjunctive cranial irradiation in 34 patients with solitary brain metastases. Results: Overall survival was significantly improved in the 22 patients who received adjunctive cranial irradiation versus that in the 12 patients who had surgery alone. Twenty-eight patients subsequently relapsed. Nine of 10 patients with surgery alone had brain recurrence as a component of failure. Six of 10 patients not receiving irradiation had brain recurrences as a component of relapse at multiple sites whereas only 1 of 18 patients receiving irradiation relapsed with the brain. Conclusions: Adjunctive cranial irradiation is justified for melanoma patients who undergo surgical therapy for solitary brain metastases. Survival in patients presenting with solitary brain metastases was improved by a reduction of relapse in the brain as a component of failure by combined surgery and irradiation.     

The natural history of metastatic renal cell carcinoma: a computer analysis.

Survival factors of 86 patients with metastatic renal cell carcinoma were studied by computer analysis. Cumulative survival was 53 per cent at 6 months, 43 per cent at 1 year, 26 per cent at 2 years and 13 per cent at 5 years. Survival was influenced favorably by confinement of metastases to the lungs, by the absence of local recurrence or persistence of tumor and by a longer interval free of disease after removal of the primary tumor. Medical therapy improved survival during the first year after diagnosis of metastases but no objective regression of tumor was observed. Excision of metastatic foci significantly improved survival for up to 5 years (p less than 0.05 and p less than 0.02) after which most patients died of recurrence. Palliative or adjunctive nephrectomy in patients with metastases was associated with a 6 per cent mortality rate but it increases survival over other patients with metastases at the time of diagnosis of renal carcinoma who did not undergo nephrectomy. This difference was owing to patient selection and survival of those who had adjunctive nephrectomy was no greater than that of the study population as a whole. However, based on the factors that were associated with improved survival palliative nephrectomy may be beneficial when a limited number of metastases treatable by excision or radiation therapy are present, when effective systemic therapy exists or when the primary tumor produces severe symptoms.     

Synchronous nephrectomy and right hepatectomy for metastatic chromophobe renal cell carcinoma: report of a case and review of the literature

The prognosis of metastatic renal cell carcinoma is poor, since non-operative modalities for advanced renal carcinoma have failed to yield effective results. In fact, there is no indication for radiotherapy, except for palliative treatment of symptomatic bone metastases, and systemic chemotherapy is not effective. Despite the promising early results with immunotherapy, a complete response occurs in less than 15% of patients and is rarely lasting. Surgery, when indicated, seems to be the only therapeutic option possible. Liver metastases occur in 20% of cases and are often multiple. Experience with hepatectomy for metastatic renal tumours has rarely been reported. Not only does a small group of patients have isolated liver metastases that may be treated with radical surgery, but also extrahepatic metastases ordinarily coexist at the time of diagnosis. We report a case of a 55-year-old man with a chromophobe renal cell carcinoma with a single synchronous hepatic metastasis that were treated simultaneously with radical nephrectomy and right hepatectomy. To the best of our knowledge this is the first case of a single metastasis of a chromophobe renal cell carcinoma treated with synchronous kidney and hepatic resection.     

Adjunctive nephrectomy at post-chemotherapy retroperitoneal lymph node dissection for nonseminomatous germ cell testicular cancer

PURPOSE: Patients with metastatic testicular cancer with residual masses encasing the renal hilum or kidney after platin based chemotherapy may require adjunctive nephrectomy to achieve complete resection at post-chemotherapy retroperitoneal lymph node dissection. We reviewed our experience with adjunctive nephrectomy to assess the impact on cancer control and renal function. MATERIALS AND METHODS: Of 647 post-chemotherapy retroperitoneal lymph node dissection procedures performed at our institution since 1989 adjunctive nephrectomy has been performed in 32 patients (5%). Patient information was obtained from a prospective database. Median followup was 31 months. RESULTS: Of the adjunctive nephrectomy procedures 17 (53%) were performed in high risk settings such as post-salvage chemotherapy, desperation retroperitoneal lymph node dissection, late relapse and reoperative retroperitoneal lymph node dissection. Disease was present in the adjunctive nephrectomy specimen in 21 patients (66%). Following post-chemotherapy retroperitoneal lymph node dissection 7 patients had disease relapse and 5-year disease-free survival was 66%. No case of relapse required substitution for cisplatin due to compromised renal function. Progression to chronic renal insufficiency occurred in 3 patients, 1 of whom required hemodialysis. The calculated creatinine clearance after adjunctive nephrectomy was more than 30% below the age specific norm in 14 patients (50%) and median patient age was 40 years. CONCLUSIONS: Adjunctive nephrectomy at post-chemotherapy retroperitoneal lymph node dissection is most frequently performed in patients with high risk features to ensure the completeness of resection. When indicated, adjunctive nephrectomy should be performed because residual cancer is frequently present and long-term cancer control can be achieved in 66% of patients. Although adjunctive nephrectomy did not interfere with subsequent chemotherapy, the renal reserve in these patients was substantially reduced in 50%, emphasizing the importance of preventative measures to preserve long-term renal function.     

Parenchyma-sparing surgery for renal tumors

Summary Between 1969 und 1989 conservative surgery for kidney tumors was performed in 123 patients. In 49 patients there was an imperative indication for a parenchyma-sparing operation because nephrectomy would have made dialysis obligatory. Thirty-five of these 49 patients show no signs of tumor progression after a mean follow-up of 4.5 years. Known metastases were present in 3 of 6 patients who died as a result of their tumors. In two patients there was a recurrence after 1 and 5 years, respectively, requiring a second organ-preserving operation. In one further patient we suspect that multiple small tumor lesions may be present 2 years after the first operation. In 74 patients with a healthy contralateral kidney the tumor was enucleated by choice (elective indication). Sixty-eight of these 74 patients show no signs of tumor progression after a mean follow-up period of 3.3 years. One patient died from tumor metastases. Two patients had tumor recurrence, requiring nephrectomy and enucleation, respectively. Fifty-seven enucleated tumors were available for image analysis DNA cytometry. Only the two patients with a hypertriploid tumor died from their cancer.     

Tratamiento quirúrgico de las metástasis del cáncer renal

Complete removal of metastatic lesions can contribute to improve clinical prognosis of renal cáncer. Nowadays, it is accepted that surgical extirpation of solitary metastases for patients with renal cancer is the only potential for long-term survival. Provided that the metastases could be technical and functionally resected. This review addresses the current evidence about resecable renal cancer metastases at lung, liver, bone, kidney and other organs.The criteria to consider a patient as candidate for resection of metastases are: control of primary tumor, surgical extirpation feasibility and lack of systemic disease. In patients with synchronous metastases, the surgical extirpation should be performed at the same time than nephrectomy. The clinical prognosis is worse when metastases are asynchronous. After the introduction of novel anti-angiogenic agents, surgery is also justified in patients with good responses. Although, this approach remains in the field of investigation.     

Native Nephrectomy in Patients With Autosomal Dominant Polycystic Kidney Disease Evaluated for Kidney Transplantation

Native nephrectomy (NN) in patients with autosomal dominant polycystic kidney disease (ADPKD) is indicated in cases of recurrent urinary tract infections and hematuria, neoplastic degeneration, and encumbrance. Timing, indication, and surgical approach of NN depends on the symptoms or policy of the center. The aim of our study is to evaluate our experience.In our retrospective study, we included 130 patients with a diagnosis of ADPKD from 530 patients evaluated for renal transplantation from 2011 to 2017. We analyzed the etiologic indication, the timing, and the complications of NN.In our cohort, 53 patients underwent open NN, 85% pre-kidney transplantation (KT), 13% post-KT, and only 1 case simultaneous with KT. In the pre-KT group, indications included: major indication was encumbrance in the. In the post-KT group, the major indication was infection followed by encumbrance, which developed after KT. Complications were: 3 cases of bleeding (1 required relaparotomy, 2 evolved into hematoma and radiological derange); 1 iatrogenic iliac artery injury, which was contextually repaired, and 5 cases of incisional hernia. At 35 ± 7.2 months follow-up, patients’ survival was 96%; 1 patient died at the induction of anesthesia and 1 patient from sepsis after double NN and removal of nonfunctional transplanted kidney.NN is not without complications and should be performed when clearly indicated. In our experience, we preferred to perform NN before KT.     

Aspectos quirúrgicos actuales de la nefrectomía de donante vivo

ContextLiving donor renal transplant surgery has evolved from the classical nephrectomy by lumbotomy to less invasive surgery, the laparoscopic and robotic nephrectomy currently being the most important. It is important to know the available evidence on whether nephrectomy in patients with multiple arteries, right kidney and in obese patients can be performed safely when there is a correct indication.ObjectiveTo perform a review of the different surgical techniques in living donor nephrectomy, adapted to the current surgical evidence and other aspects related to the indication.Evidence acquisitionA systematic review was made in PubMed (1997-2011). This included previous reviews randomized controlled clinical studies, cohort studies, and meta-analyses of this surgical aspects of living donor nephrectomy.ConclusionsCurrently, there is sufficient evidence to consider living donor laparoscopic nephrectomy as the technique of choice, although the role of hand-assisted retroperitoneoscopic technique is still not totally clear. Open surgery techniques using mini-incision are an acceptable alternative for the sites that have not yet implemented laparoscopic surgery. Right kidney nephrectomy, of those cases that present multiple pedicles and in obese donors, is justified in selected cases.     

Should radical nephrectomy be performed in the face of surgically incurable disease?

The role of cytoreductive nephrectomy in the management of metastatic renal cancer remains controversial. Recent trials, like SWOG 8949 have suggested the usefulness of this approach at least in selected patients with good performance status and other favorable indicators. The timing of cytoreductive nephrectomy has also been controversial and remains so to this time.CommentaryAn estimated 30,000 new cases of renal cell carcinoma (RCC) are detected annually in the U.S. In approximately one-third of these cases, metastatic disease is diagnosed at presentation. Multi-modality treatment combines biologic response modifier (BRM) therapy with surgery in an attempt to improve survival with either form of treatment alone. The optimal timing of surgery relative to BRM therapy continues to be debated.Prior to the advent of multi-modality therapy, there were relatively few indications for nephrectomy in patients with metastatic RCC. The incidence of spontaneous regression of metastatic RCC following removal of the primary tumor is only 1–4% and, therefore, nephrectomy on this basis is not justified. There is a palliative role for nephrectomy in selected patients with metastatic RCC who are experiencing severe disability from associated local symptoms; however, some patients in this category can be managed with percutaneous renal angioinfarction. A small subset of patients with a solitary metastasis may benefit from nephrectomy and resection of the metastatic lesion based on reported 5-year survival rates of up to 30–35%.There has been controversy concerning the appropriate timing of adjuvant or cytoreductive nephrectomy in the multi-modality approach to treatment of metastatic RCC. Many protocols have involved preliminary removal of the primary tumor before the administration of BRM therapy. The rationale for this has been to enhance response rates to BRM therapy by reducing tumor volume and, in some cases, to provide immunoreactive cells for treatment. A drawback of this approach was that many patients underwent nephrectomy without subsequently receiving BRM therapy due to postoperative morbidity/mortality or rapid tumor progression. This prompted interest in an alternative approach of delayed adjuvant nephrectomy wherein BRM therapy was administered initially and nephrectomy was subsequently performed only in those patients who demonstrated a response to systemic therapy.The relative merits of initial versus delayed adjuvant nephrectomy in conjunction with BRM therapy for metastatic RCC have recently been clarified through two phase III prospective multicenter clinical trials conducted in Europe (EORTC) and the United States (SWOG). The results of both of these carefully done studies have indicated improved survival with initial nephrectomy followed by BRM therapy. The latter comprised interferon monotherapy in both studies, which opens the studies to criticism, however the essential observation of extended survival with preliminary nephrectomy appears to be valid. On this basis, there is now objective evidence to suggest that initial cytoreductive nephrectomy is the preferred approach in patients with metastatic RCC who are candidates for multi-modality therapy. The most appropriate candidates for such therapy remain patients with good performance status and low-volume (preferably pulmonary) metastatic disease. The ability to perform cytoreductive nephrectomy laparoscopically in some of these patients, with reduced morbidity, is a further development that has strengthened the argument in favor of initial nephrectomy.Andrew C. Novick, M.D.     

Skeletal metastases in 102 patients evaluated before surgery for renal cell carcinoma.

During a 3-year period a consecutive series of 102 patients were treated for renal cell carcinoma at one urological unit. Thirty-three patients (32.4%) had metastatic spread, but bone metastases were found in six patients only, i.e. 5.9% of the whole series and 18.2% of the patients with metastases preoperatively. The bone metastases had in all six patients given local symptoms first indicating radiography, and thereafter radionuclide scintigraphy of the entire skeleton. Bone scintigraphy performed merely by routine in 70 patients did not reveal one single case of bone metastasis. Only one patient had a solitary bone metastasis, and this metastasis was considered inoperable because of its location and size and the patient's age. The decision about nephrectomy was not in any case altered by the finding of bone metastases. Solitary bone metastasis must be diagnosed early since they may be radically removed. Routine scintigraphy of the skeleton in symptomless patients, however, has a low yield. Screening for skeletal metastases may therefore be best performed by careful physical examination and history-taking.     

Current features of malignant renal tumors in children]

The diagnosis of nephroblastoma is based on a postulate: any solid intrarenal tumour in a child between the ages of six months and six years is a nephroblastoma and therefore requires preoperative chemotherapy. Fine needle biopsy to obtain histological confirmation is only justified in doubtful cases. The prognosis is dominated by unfavourable, sarcomatous and anaplastic histological forms, which represent less than 10% of all nephroblastomas and are responsible for one half of deaths. Due to the better understanding of the therapeutic sequelae, particularly following radiotherapy, this modality is avoided whenever possible in young children. Radiotherapy is only indicated in stage II, with lymph node invasion, and stage III forms with favourable histology. It is indicated in all forms with unfavourable histology except for stage I anaplastic tumours. Surgery is indicated for metastases, especially lung metastases, once again to avoid irradiation. Lastly, bilateral partial nephrectomy is the best treatment for bilateral nephroblastoma.     

Natural History of Liver Metastasis of Gastroenteropancreatic Neuroendocrine Tumors: Place for Chemoembolization

Hepatic metastases of gastroenteropancreatic tumors are observed in at least 10% of cases at presentation and in 85% of cases after 20 years of follow-up. They are slow-growing; and there is a 5-year life expectancy that varies between 13% and 60% depending of the degree of differentiation, with occasional survival of more than 20 years. Curative liver resection is the best treatment, with a 4-year survival rate of 73%, but this is possible in only 10% of cases. Chemoembolization is indicated for nonresectable multiple bilobar metastases: 87% of patients respond, half with tumor reduction and the other half with diminution of the symptoms of hypersecretion. The mean survival is 2 years; complete remission of more than 2 years is exceptional. The technique can be repeated but is not without risks, with a possible postembolization syndrome lasting up to 10 days and subsiding spontaneously, without indication for operation. Therefore one lobe only should be embolized at a session. It is not impossible that chemoembolization increases the occurrence of lung metastases. It is only a palliative method but with great functional benefit for patients with hypersecreting tumors.     

The failure of infarction and/or nephrectomy in stage IV renal cell cancer to influence survival or metastatic regression

The success of cancer therapy depends on the destruction of all viable cancer cells in the primary site, as well as in metastatic areas. Surgery alone can do little for the patient whose tumor has produced distant involvement except in those situations where surgical excision, radiotherapy, chemotherapy, or immunotherapy can be relied on to eradicate metastatic disease. Because of the paucity of systemic therapy for renal cell carcinoma, an aggressive surgical approach to the primary tumor is justifiable when all metastatic lesions can be excised or otherwise definitively treated and in experimental protocols in which adjuvant therapy of possible benefit can be combined with palliative nephrectomy. There is no evidence, however, in reported studies to suggest that routine palliative nephrectomy in patients who will not be offered adjuvant systemic therapy or radiation is beneficial. Such practice is also associated with a higher incidence of complications and mortality than is expected for resection of localized renal cell carcinoma. For these reasons, it is reasonable to recommend adjunctive nephrectomy only in certain selected instances, which include (1) the control of a patient's current symptoms related to the primary disease, for example, flank pain, hematuria, fever and toxicity, anemia, erythrocytosis, and hypercalcemia; (2) nephrectomy with the excision of a solitary metastasis; and (3) the patient who is willing to undergo experimental therapy, part of which involves removal of the primary tumor.     

Simultaneous bilateral adrenal involvement by renal cell carcinoma: experience with 3 cases

We report 3 cases of renal cell carcinoma and synchronous bilateral adrenal metastases discovered preoperatively with computerized tomography and other imaging techniques. Surgical treatment consisted of radical nephrectomy through a transperitoneal approach, with adjunctive lower polar resection in a patient with bilateral renal tumors, and contralateral adrenalectomy. Subsequent steroid treatment was given.     

Treatment and prognosis of T 4 renal cell carcinoma]

BACKGROUND: We studied the cases with T 4 renal cell carcinoma (RCC) to characterize the factors associated with prolonged survival and to clarify the indication of extended nephrectomy. MATERIALS AND METHODS: The study population consisted of 53 patients (44 male and 9 female) with pT 4 RCC treated at the Yokohama City University Hospital and its affiliated hospitals from 1965 to 1994. Survival rates were analyzed with respect to clinicopathological factors (patient age, sex, symptom, tumor growing type, tumor size, histological grade, cell type, structural type, lymph node metastasis, vein invasion, distant metastasis and extended nephrectomy). RESULTS: One-year, 2-years, and 3-years survival rates of the cases with T 4 RCC were 30.4%, 16.4%, and 9.4% respectively. In univariate analysis, improved survival were correlated with no extra-urinary symptom (Logrank: p = 0.0048, Wilcoxon: p = 0.0423), no lymphnode metastasis (Logrank: p = 0.1045, Wilcoxon: p = 0.0199), no distant metastases (Logrank: p = 0.0007, Wilcoxon: p = 0.0006), and enforcement of extended nephrectomy (Logrank: p = 0.0018, Wilcoxon: p = 0.0008). In 28 cases with extended nephrectomy, improved survival was correlated with no extra-urinary symptom, no abdominal wall invasion and no distant metastases. In 5 cases with more than 3 year survival after extended nephrectomy, 4 cases were found to have no distant metastases at the time of operation. Non-operative therapy including interferon for 20 cases without extended nephrectomy were almost ineffective. CONCLUSIONS: These results indicate that if curative excision for T 4 RCC cases without distant metastases could be done, some patients might be appropriate candidates for extended nephrectomy.     

Experience with partial nephrectomy for renal cell carcinoma

From Sept. 1991 to Jan. 1999, we performed partial nephrectomy on 7 patients with renal cell carcinoma. The indication was imperative for 3 patients, and elective for 4 patients. The 3 imperative cases consisted of bilateral renal cell carcinomas, a polycystic kidney disease and a contralateral atrophic kidney. All 4 patients with elective indication revealed renal cell carcinoma with a normal functioning contralateral kidney. The tumor size ranged from 1.3 cm to 6.0 cm (2.7 cm on average). The mean clamping time of renal artery was 22 minutes and mean blood loss was 400 ml. The pathological stage was pT1a in 6 patients and pT1b in one patient. Postoperative follow-up ranged from 4 months to 92 months (mean: 43 months). One patient with bilateral renal cell carcinoma died of metastases to the lungs and brain at 25 months postoperatively. The remaining 6 patients are alive without recurrence and metastasis. We obtained a good postoperative course in our selected patients with low stage. Thus it was considered that partial nephrectomy is effective against small renal cell carcinoma.     

Nephrectomy for renal cell carcinoma with metastases

The percentage of patients with renal cell carcinoma who also have identifiable metastases when first seen is increasing. In the past metastases were considered justification for excluding nephrectomy in the management of the patient. However, numerous opportunities for therapy which are abetted by removal of the primary tumor are presented. It is concluded, depending on several variables, that the advantages of nephrectomy usually justify the procedure.     

Real indications for adrenalectomy in renal cell carcinoma

OBJECTIVES: Adrenalectomy is a part of radical nephrectomy because of the surgical oncology principle of a 'wide margin beyond the malignancy' and due to concern over possible metastases to the ipsilateral adrenal gland, especially in upper pole tumors. But, neither the frequency, predisposing factors of the renal cell carcinoma nor mechanisms of involvement of the adrenal gland are well defined. We assessed the ipsilateral adrenal involvement in renal cell carcinoma to determine whether ipsilateral adrenalectomy during radical nephrectomy is essential. MATERIAL AND METHOD: In a series of 15,347 autopsies in Jena from 1985 through 1996, 272 renal cell carcinoma with 24 adrenal metastases were found. In the same period 9 adrenal metastases were found in 639 radical nephrectomies. Contralateral and bilateral metastases were seen in 15 cases of the autopsy series and in 2 cases of the operative series. RESULTS: The risk of adrenal metastases correlated with multifocal tumors, pleomorphic cell type, anaplastic growth pattern and tumors that were larger than 2.5 cm. Of the 24 renal cell carcinomas with adrenal metastases in the autopsy series, 23 had evidence of widespread disease and 22 had lymph node metastases. A preoperative abdominal computerized tomography was performed in all 9 patients of the operative series with renal cell carcinoma and adrenal involvement. The adrenal gland was considered abnormal in 8 of the 9 cases (88.9%). Only in 1 patient was the computerized tomography incorrectly interpreted as negative. CONCLUSION: We think adrenalectomy should only be performed if there is radiographic evidence of metastases in the adrenal gland or adrenal infiltration by a large upper-pole tumor is possible. Macroscopically normal adrenal glands should not be removed during tumor nephrectomy because the need and benefit of routine adrenalectomy are extremely limited.     

Outcome of nephron-sparing surgery: elective versus imperative indications

INTRODUCTION: The increase in the detection of renal tumors incidentally in earlier stages has enhanced the enthusiasm for nephron-sparing surgery (NSS). PATIENTS AND METHODS: We performed NSS in 76 patients (53 male, 23 female) with a mean age 52.3 between December 1988 and September 2001. Patients were sub-classified into 2 groups as elective or imperative indication group. They were compared regarding surgical technique, time of surgery, pathological analysis, complications, and disease free status. RESULTS: Elective indication group (group I) with a normal contralateral kidney consisted of 50 patients, whereas there were 26 patients in the imperative indication group (group II). Tumors were incidentally detected in 63%; 74% in group I and 42% in group II. Although the mean diameter of the tumor was slightly higher in group II (39.1 vs. 36.3 mm), this difference did not reach statistical significance (p > 0.05). The partial nephrectomy was performed more frequently compared to enucleation in group I (90 vs. 69%, p = 0.050). However, the mean operation time as well as the mean clamping time did not differ significantly between the two groups (p > 0.05). In the histological evaluation tumors were benign in 16 (21%) and malignant in 60 patients. All of the patients but one with renal cell carcinoma had stage T1-T2 disease. Major complications were observed in 14 (18%) and 12 were from group II. Complication rate was significantly higher in group II (p = 0.000). Of 60 patients with renal cell carcinoma, 2 died of unrelated causes. One patient died with multiple visceral metastases. One patient was lost to follow-up. In the remaining 56 patients with a mean follow-up of 37.1 months (1-152), local recurrence or distant metastases were not detected. Serum creatinine levels have remained almost the same compared to preoperative levels (1.2 +/- 0.6 vs. 1.5 +/- 0.9). Overall and cancer-specific survivals were 100 and 100% in group I, 85 and 95% in group II, and 94 and 98% for the entire patient population, respectively. CONCLUSION: NSS is an effective and reliable treatment in low stage renal tumors. It prevents unnecessary nephrectomy in benign lesions that could not be diagnosed preoperatively. However, the patients who underwent NSS with elective indication outcome with better results, compared to those with imperative indication.