Most kidney cancers are primary renal cell carcinomas (RCC) of clear cell histology. RCC is unique in its ability to invade into contiguous veins - a phenomenon terms venous tumor thrombus. Surgical ...resection is indicated for most patients with RCC and an inferior vena cava (IVC) thrombus in the absence of metastatic disease. Resection also has an important role in selected patients with metastatic disease. In this review, we discuss the comprehensive management of the patient with RCC with IVC tumor thrombus, emphasizing a multidisciplinary approach to the surgical techniques and perioperative management.
Abstract Context Partial nephrectomy (PN) is the current gold standard treatment for small localized renal tumors.; however, the impact of duration and type of intraoperative ischemia on renal ...function (RF) after PN is a subject of significant debate. Objective To review the current evidence on the relationship of intraoperative ischemia and RF after PN. Evidence acquisition A review of English-language publications on renal ischemia and RF after PN was performed from 2005 to 2014 using the Medline, Embase, and Web of Science databases. Ninety-one articles were selected with the consensus of all authors and analyzed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. Evidence synthesis The vast majority of reviewed studies were retrospective, nonrandomized observations. Based on the current literature, RF recovery after PN is strongly associated with preoperative RF and the amount of healthy kidney parenchyma preserved. Warm ischemia time (WIT) is modifiable and prolonged warm ischemia is significantly associated with adverse postoperative RF. Available data suggest a benefit of keeping WIT <25 min, although the level of evidence to support this threshold is limited. Cold ischemia safely facilitates longer durations of ischemia. Surgical techniques that minimize or avoid global ischemia may be associated with improved RF outcomes. Conclusions Although RF recovery after PN is strongly associated with quality and quantity of preserved kidney, efforts should be made to limit prolonged WIT. Cold ischemia should be preferred when longer ischemia is expected, especially in presence of imperative indications for PN. Additional research with higher levels of evidence is needed to clarify the optimal use of renal ischemia during PN. Patient summary In this review of the literature, we looked at predictors of renal function after surgical resection of renal tumors. There is a strong association between the quality and quantity of renal tissue that is preserved after surgery and long-term renal function. The time of interruption of renal blood flow during surgery is an important, modifiable predictor of postoperative renal function.
What's known on the subject? and What does the study add?
Given that percutaneous cryoablation (PCA) is a relatively new procedure, there are few studies published on this treatment with almost no ...long‐term follow‐up. The percutaneous approach, while not the first choice treatment for RCC, may be most appropriate for older patients with several comorbidities as it offers less invasive outpatient management of small renal masses (SRMs). It is therefore important to measure procedural outcomes noting rates of complications and reasons for treatment failure or recurrence.
To our knowledge, this is the first paper applying the R.E.N.A.L nephrometry scoring system to PCA of SRMs. The study adds insight into procedural outcomes from this treatment. Little has been published on this treatment strategy, but it has been increasingly considered for patients who are not candidates for traditional surgical approach. It is important to study and establish the outcomes of all treatments used by physicians. It is also necessary to understand treatment complications – how and why they occur – and seek reasons for treatment failure and recurrence. This allows physicians to choose the best management for each individual patient to improve outcomes.
OBJECTIVE
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To investigate the value of the R.E.N.A.L nephrometry scoring system in predicting treatment success for image‐guided percutaneous cryoablation (PCA).
PATIENTS AND METHODS
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The study included 139 patients with renal masses treated with PCA.
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Preoperative computed tomography or magnetic resonance images were reviewed by a urology resident.
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The primary endpoint variable was incomplete treatment or tumour recurrence.
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R.E.N.A.L. scores were categorized into low (4–6), moderate (7–9), and high (10–12).
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Logistic regression analysis was conducted to predict tumour recurrence. Additional variables collected included age at surgery, American Society of Anesthesiologists score, lesion size, skin‐to‐tumour distance, skin‐to‐hilum distance, and number of treatment cryoprobes.
RESULTS
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At a median follow‐up of 24 months, there were 10 tumour recurrences (six moderate and four high R.E.N.A.L. score categories). Nephrometry score and number of probes used were not associated with recurrence (odds ratio OR 1.02, P= 0.9 and P= 0.53, respectively).
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The tumour distances for patients with recurrence and no recurrence were 10.8 cm and 8.5 cm, respectively (P≤ 0.05), the skin‐to‐tumour distance was associated with treatment failure (OR 1.24, P= 0.015); for each unit increase in the mean value, patients were 1.5 times more likely to have a tumour recurrence (95% confidence interval CI 1.04–1.72).
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The model that best predicted complications included the number of probes used (P= 0.002) and R.E.N.A.L. score (OR 1.35, P= 0.027). For each additional probe used, patients were twice as likely to have complications (OR 1.98, 95% CI 1.28–3.05). With each unit increase in R.E.N.A.L. score, patients were 1.5 times more likely to experience a complication (OR 1.49, 95% CI 1.05–2.11).
CONCLUSIONS
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An increased skin‐to‐tumour distance is associated with a higher risk of treatment failure after PCA.
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Furthermore, an increase in both R.E.N.A.L nephrometry score and number of probes used was associated with an increased risk of complications after PCA.
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The R.E.N.A.L. nephrometry score as a measure of tumour complexity was not associated with tumour recurrence.
Abstract Background The safe duration of warm ischemia during partial nephrectomy remains controversial. Objective Our aim was to evaluate the short- and long-term renal effects of warm ischemia in ...patients with a solitary kidney. Design, setting, and participants Using the Cleveland Clinic and Mayo Clinic databases, we identified 362 patients with a solitary kidney who underwent open ( n = 319) or laparoscopic ( n = 43) partial nephrectomy using warm ischemia with hilar clamping. Measurements Associations of warm ischemia time with renal function were evaluated using logistic or Cox regression models first as a continuous variable and then in 5-min increments. Results and limitations Median tumor size was 3.4 cm (range: 0.7–18.0 cm), and median ischemia time was 21 min (range: 4–55 min). Postoperative acute renal failure (ARF) occurred in 70 patients (19%) including 58 (16%) who had a glomerular filtration rate (GFR) <15 ml/min per 1.73 m2 within 30 d of surgery. Among the 226 patients with a preoperative GFR ≥ 30 ml/min per 1.73 m2 and followed ≥30 d, 38 (17%) developed new-onset stage IV chronic kidney disease during follow-up. As a continuous variable, longer warm ischemia time was associated with ARF (odds ratio: 1.05 for each 1-min increase; p < 0.001) and a GFR < 15 (odds ratio: 1.06; p < 0.001) in the postoperative period, and it was associated with new-onset stage IV chronic kidney disease (hazard ratio: 1.06; p < 0.001) during follow-up. Similar results were obtained adjusting for preoperative GFR, tumor size, and type of partial nephrectomy in a multivariable analysis. Evaluating warm ischemia in 5-min increments, a cut point of 25 min provided the best distinction between patients with and without all three of the previously mentioned end points. Limitations include the retrospective nature of the study. Conclusions Longer warm ischemia time is associated with short- and long-term renal consequences. These results suggest that every minute counts when the renal hilum is clamped.
Androgen deprivation therapy (ADT) commonly leads to incomplete cell death and the fate of persistent cells involves, in part, a senescent phenotype. Senescence is terminal growth arrest in response ...to cell stress that is characterized by increased lysosomal-β-galactosidase (GLB1) the origin of senescence associated-β-gal activity (SA-β-gal). In the current study senescence is examined in vivo after ADT use in a neoadjuvant trial.
Tissue microarrays were generated from prostate cancer specimens (n = 126) from a multicenter neoadjuvant ADT trial. Arrays were subjected to multiplexed immunofluorescent staining for GLB1, Ki67, cleaved caspase 3 (CC3) and E-cadherin. Automated quantitative imaging was performed using Vectra™ and expression correlated with clinicopathologic features.
Tissue was analyzed from 59 patients treated with neoadjuvant ADT and 67 receiving no therapy preoperatively. Median follow-up was 85.3 mo and median ADT treatment was 5 mo. In PC treated with neoadjuvant ADT, GLB1 expression increased in intermediate Gleason score (GS 6-7; p = 0.001), but not high grade (GS 8-10) cancer. Significantly higher levels of GLB1 were seen in tissues undergoing neoadjuvant ADT longer than 5 months compared to untreated tissues (p = 0.002). In contrast, apoptosis significantly increased earlier (1-4 mo) after ADT treatment (p<0.5).
Increased GLB1 after neoadjuvant ADT occurs primarily among more clinically favorable intermediate grade cancers and enrichment of the phenotype occurs in a temporally prolonged fashion. Senescence may explain the persistence of PCa cells after ADT. Given concerns for the detrimental longer term presence of senescent cells, targeting these cells for removal may improve outcomes.
Objective To evaluate the effects of warm ischemia time (WIT) and quantity and quality of kidney preserved on renal functional recovery after partial nephrectomy (PN). The effect of WIT relative to ...these other parameters has recently been challenged. Methods We identified 362 consecutive patients with a solitary kidney who had undergone PN using warm ischemia. Multivariate models with multiple imputations were used to evaluate the associations with acute renal failure and new-onset stage IV chronic kidney disease (CKD). Results The median WIT was 21 minutes (range 4-55), the median percentage of kidney preserved was 80% (range 25%-98%), and the median preoperative glomerular filtration rate (GFR) was 61 mL/min/1.73 m2 (range 11-133). Postoperative acute renal failure occurred in 70 patients (19%). Of the 226 patients with a preoperative GFR >30 mL/min/1.73 m2 , 38 (17%) developed new-onset stage IV CKD during follow-up. On multivariate analysis, the WIT ( P = .021), percentage of kidney preserved ( P = .009), and preoperative GFR ( P < .001) were significantly associated with acute renal failure, and only the percentage of kidney preserved ( P < .001) and preoperative GFR ( P < .001) were significantly associated with new-onset stage IV CKD during follow-up. Using our previously published cutpoint of 25 minutes, a WIT of >25 minutes remained significantly associated with new-onset stage IV CKD in a multivariate analysis adjusting for the quantity and quality factors (hazard ratio 2.27, P = .049). Conclusion Our results have validated that the quality and quantity of kidney are the most important determinants of renal function after PN. In addition, we have also demonstrated that the WIT remains an important modifiable feature associated with short- and long-term renal function. The precision of surgery, maximizing the amount of preserved, vascularized parenchyma, should be a focus of study for optimizing the PN procedure.
Case 5-2017 Blute, Michael L; Abramson, Jeremy S; Cronin, Kevin C ...
The New England journal of medicine,
02/2017, Letnik:
376, Številka:
7
Journal Article, Conference Proceeding
Recenzirano
A 19-year-old man presented with a 2-day history of hematuria, without pain, after hiking. Imaging revealed a well-circumscribed 4.6-cm retroperitoneal mass. A procedure was performed.
Presentation ...of Case
Dr. Jed-Sian Cheng
(Urology): A 19-year-old man was seen in the urology outpatient clinic of this hospital because of a retroperitoneal mass and a history of transient hematuria.
The patient had been in excellent health until approximately 1 month before this evaluation, when, after hiking, he noted a small degree of hematuria, without pain, for 2 days.
Dr. Kevin C. Cronin:
On evaluation at a hospital near the patient’s home in South America, transabdominal and scrotal Doppler ultrasonography (Figure 1) revealed a heterogeneous, well-circumscribed mass anterior to the right common iliac artery that had prominent internal vascularity. . . .
We examined the relationship between tumor size and malignancy among solid renal tumors, and the relationship between tumor size and RCC subtype within tumors with renal cell carcinoma (RCC).
We ...identified 2,770 adult patients who underwent radical nephrectomy or nephron sparing surgery for sporadic unilateral nonmetastatic solid renal tumors between 1970 and 2000. All pathology specimens were reviewed by a urological pathologist for diagnosis, and in RCC tumors, for histological subtype and nuclear grade.
There were 376 benign (12.8%) and 2,559 (87.2%) malignant tumors. The percentage of benign tumors decreased from 46.3% for those less than 1 cm to 6.3% for those 7 cm or greater. Among RCC tumors the percentage that were clear cell increased from 25.6% for those less than 1 cm to 83.0% for tumors 7 cm or greater, while the percentage that were papillary decreased from 74.4% for those less than 1 cm to 10.0% for tumors 7 cm or greater. No RCC tumors less than 1 cm were chromophobe compared to 7.0% of tumors 7 cm or greater. The percentage of malignant tumors that were high grade RCC increased from 2.3% for those less than 1 cm to 57.7% for RCC tumors 7 cm or greater. Only 1% of all tumors less than 1 cm and 9.2% of all tumors less than 2 cm were high grade malignancies.
As tumor size increased there was a significant increase in the odds of having a malignant compared to a benign tumor, clear cell compared to papillary RCC and high grade compared to low grade malignancy.
Purpose Laparoscopic partial nephrectomy is an increasingly performed, minimally invasive alternative to open partial nephrectomy. We compared early postoperative outcomes in 1,800 patients ...undergoing open partial nephrectomy by experienced surgeons with the initial experience with laparoscopic partial nephrectomy in patients with a single renal tumor 7 cm or less. Materials and Methods Data on 1,800 consecutive open or laparoscopic partial nephrectomies were collected prospectively or retrospectively in tumor registries at 3 large referral centers. Demographic, intraoperative, postoperative and followup data were compared between the 2 groups. Results Compared to the laparoscopic partial nephrectomy group of 771 patients the 1,028 undergoing open partial nephrectomy were a higher risk group with a greater percent presenting symptomatically with decreased performance status, impaired renal function and tumor in a solitary functioning kidney (p <0.0001). More tumors in the open partial nephrectomy group were more than 4 cm and centrally located and more proved to be malignant (p <0.0001 and 0.0003, respectively). Based on multivariate analysis laparoscopic partial nephrectomy was associated with shorter operative time (p <0.0001), decreased operative blood loss (p <0.0001) and shorter hospital stay (p <0.0001). The chance of intraoperative complications was comparable in the 2 groups. However, laparoscopic partial nephrectomy was associated with longer ischemia time (p <0.0001), more postoperative complications, particularly urological (p <0.0001), and an increased number of subsequent procedures (p <0.0001). Renal functional outcomes were similar 3 months after laparoscopic and open partial nephrectomy with 97.9% and 99.6% of renal units retaining function, respectively. Three-year cancer specific survival for patients with a single cT1N0M0 renal cell carcinoma was 99.3% and 99.2% after laparoscopic and open partial nephrectomy, respectively. Conclusions Early experience with laparoscopic partial nephrectomy is promising. Laparoscopic partial nephrectomy offered the advantages of less operative time, decreased operative blood loss and a shorter hospital stay. When applied to patients with a single renal tumor 7 cm or less, laparoscopic partial nephrectomy was associated with additional postoperative morbidity compared to open partial nephrectomy. However, equivalent functional and early oncological outcomes were achieved.
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