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NEPHRON-SPARING SURGERY: EXPERIENCE IN 159 CONSECUTIVE CASES
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638
‘BENCH’ SURGERY WITH AUTOTRANSPLANTATION FOR HILAR KIDNEY TUMOURS: A NEPHRON-SPARING ALTERNATIVE IN PATIENTS WITH A SOLITARY KIDNEY
PROSPECTIVE STUDY OF SAFETY MARGINS IN PARTIAL NEPHRECTOMY: INTRA-OPERATIVE ASSESSMENT AND CONTRIBUTION OF FROZEN SECTIONS
Boormans J.1, Marchand W.1, IJzermans J.2, Mikisch G.3, Verhagen P.1
Timsit M.O., Bazin J.P., Thiounn N., Fontaine E., Chretien Y., Dufour B., Mejean A.
Erasmus MC, Department of Urology, Rotterdam, The Netherlands, 2Erasmus MC, Department of Surgery, Rotterdam, The Netherlands, 3Centrum Für Operatieve Urologie Bremen, Department of Urology, Bremen, Germany 1
INTRODUCTION & OBJECTIVES: Partial nephrectomy is the treatment of choice for small, peripheral lesions of renal cell carcinoma. However, in patients with a solitary functioning kidney nephron-sparing surgery is the only alternative for nephrectomy with postoperative dialysis or kidney transplantation. Hilar tumours complicate a resection in situ, which may contribute to an unacceptable great surgical risk. For that reason we treated 12 patients from 1992 – 2003 by ex vivo dissection of a renal tumour followed by autotransplantation of the kidney. MATERIAL & METHODS: Patients with a hilar renal tumour and an imperative indication for nephronsparing surgery underwent Bench-dissection. Histories revealed a contralateral nephrectomy in 9 (8 for malignant disease and 1 for nephrolithiasis), a congenital solitary kidney in 2 and a non-functioning contralateral kidney in 1. The surgical procedure started with a nephrectomy and careful dissection of the hilar vessels. During the ischemic period the kidney was perfused with Eurocollins and cooled on ice. Ex vivo, the tumour was excised followed by reconstruction of the vessels and the collecting duct system. Thereafter autotransplantation of the kidney was done in the iliacal fossa. Follow-up consisted of 6-monthly visits with serum creatinin, a kidney ultrasound or CT-abdomen and yearly an X-ray or CT-scan of the thorax. Retrospectively we collected data on the procedures, complication rate, serum creatinin, histology of the tumour and recurrence of disease. RESULTS: Twelve patients (11 men, 1 woman) were operated with a mean age of 56.5 yrs (range 38 – 73). Ten patients had solitary tumours and 2 patients had 3 and 4 respectively. Mean operating time was 500 min. Mean time of hospitalization was 19 days. Mean preoperative serum creatinin was 114 μmol/l. One week postoperative it was 323 μmol/l and it decreased to 197 and 165 μmol/l 1 month and 1 year respectively. Postoperative complications (< 30 days of surgery) were death due to myocardial infarction in 1 patient after 16 days, temporarily dialysis due to acute tubular necrosis in 3, urinary leakage in 4 for which in 2 patients a nephrostomy was placed and pleural effusion in 1 patient for which drainage was required. Pathology showed 11 pT1 and 1 pT2 renal cell carcinomas. Mean diameter was 3.7 (range 1.0– 8.0 cm). In 2 patients there were positive surgical margins. With a mean follow-up of 47,5 months 6 patients are disease-free. A local recurrence was not seen, however in 5 patients there were metastases, in 3 to lymph nodes, in 1 to the adrenal gland and in 1 to the lung. Two patients died after 40 and 59 months respectively due to disseminated disease. CONCLUSIONS: Bench surgery is a nephron-sparing alternative in a selected population of patients with a solitary kidney and a hilar localisation of renal cell carcinoma. This technique avoids dialysis and kidney transplantation with preservation of kidney function and acceptable oncological result.
Necker Hospital, Urology and Transplantation, Paris, France INTRODUCTION & OBJECTIVES: Most experienced teams advocate laparoscopic approach for nephron-sparing surgery. However, facing obvious technical difficulties, the common urologist still performs open surgery with a recurrent debate regarding safety margins and the use of frozen sections. We aimed to prospectively evaluate the healthy parenchymal safety margin during open conservative surgery for renal cell carcinoma to highlight the reality of margins’ width and the accuracy of surgeons’ macroscopic evaluation. MATERIAL & METHODS: Between 1997 and 2001, elective nephron-sparing surgery was performed through a flank incision in 61 consecutive patients (mean age 59.4 [34.2–78.5] years). The mean tumour size was 32 [12–50] mm. Tumour localisations were juxta hilar (n=10) or distant (n=51). Prospective margin assessment applied the following protocol: margins were evaluated macroscopically by the surgeon, controlled by frozen section and subsequently measured during histological examination. All patients were monitored with computed-tomography scans, with a mean follow-up of 72.5 [46–95] months. RESULTS: Histological types were: 42 clear cell, 17 papillary and 2 chromophobic cell tumours; at 1997 TNM stage pT1 (n=57) or pT2 (n=4); and Furhman grade: 16 G1, 35 G2 and 10 G3. No tumour margin was positive. Frozen-section and routine histological examinations yielded 53 complete and 8 incomplete margins, versus 51 and 10, respectively, assessed by the surgeons. Mean peritumoural margins were: 7 [4–10] mm for the cortex and 2 [0–5] mm for the deep part. No patient developed a local-regional or metastatic relapse. CONCLUSIONS: No apparent relationship was observed between peritumoural margin width for the cortex and for the deep part, and there were no relationship neither with the risk of disease progression, even for tumours abutting the hilum, rendering illusory a safety margin > 1 cm. Although the surgeons’ macroscopic margin evaluations were accurate, frozen sections are mandatory when margin status is in doubt. In all cases, margin negativity remains an ontological imperative.
639
640
A NATIONAL SURVEY ON THE PRACTICE OF NEPHRON-SPARING SURGERY IN FRANCE
NEPHRON-SPARING SURGERY: EXPERIENCE IN 159 CONSECUTIVE CASES
Patard J.J.1, Albouy B.2, Lopes D.3, De La Taille A.3, Salomon L.3, Crepel M.1, Lobel B.1, Guille F.1, Bellec L.4, Soulie M.4, Bernhard J.C.5, Ferriere J.M.5, Lacroix B.6, Tostain J.6, Pfister C.2, Colombel M.7
Joniau S., Van Poppel H.
Rennes University Hospital, Urology, Rennes, France, 2Chu Rouen, Urology, Rouen, France, 3Chu Creteil, Urology, Creteil, France, 4Toulouse University Hospital, Urology, Toulouse, France, 5Bordeaux University Hospital, Urology, Bordeaux, France, 6St Etienne University Hospital, Urology, St Etienne, France, 7 Chu Lyons, Urology, Lyons, France 1
INTRODUCTION & OBJECTIVES: To evaluate through 7 expert centres the practice of nephron sparing surgery (NSS) in France. MATERIAL & METHODS: 7 academic centres performing at least 30% conservative renal surgery a year agreed to participate to this study. A detailed file including 70 variables was completed for each procedure. Notably, all the following variables were completed in all cases: age, gender, tumour size, surgical technique, indication, medical or surgical complications, length of hospital stay, final pathology and outcome. RESULTS: 741 NSS procedures were analysed. Median tumour size was 3 cm (0.5- 18). Indication was non-elective in 30.1% of the cases. 12.3% of the NSS procedures were performed by laparoscopy. Renal vessels clamping was necessary in 48% of the cases for a median duration time of 17 minutes (5-90). Urinary collecting system was repaired in 35.1% of the cases. Median operative time was 120 minutes and mean blood loss was 420 ml. Medical and surgical complication rates were 15.2% and 14.7% respectively. Blood transfusion rate was 10%. An urinary fistula occurred in 3.5% of the cases. Median length of hospital stay was 10 days. 21% were benign tumours. Conventional clear cell, papillary and chromophobe carcinomas accounted for 75%, 19.7% and 5.3% of the cases respectively. Among malignant tumours at the end of follow-up, local recurrence and death from cancer rates were 4.4% and 4.7% respectively. CONCLUSIONS: A large percentage of malignant tumours, a good selection of patients, an acceptable morbidity and a favourable outcome fully justify the increasing role of NSS in the surgical management of renal tumours. Eur Urol Suppl 2006;5(2):182
University Hospital Leuven, Urology, Leuven, Belgium INTRODUCTION & OBJECTIVES: As a result of the widespread use of ultrasound, CAT scan and MRI, the majority of Renal Cell Cancer (RCC) is nowadays detected at an early stage. Nephron sparing surgery has become an accepted treatment for small RCC. We review our experience in nephron sparing surgery for T1 and T2 lesions over the last 5 years. The aim is to evaluate the feasibility and the safety of the technique and to assess oncological control. MATERIAL & METHODS: Between July 1998 and July 2003, 159 consecutive patients underwent nephron sparing surgery for T1 and T2 lesions at our institution. Mean age was 59 (2-82) years, mean tumour volume was 4 (1-11) cm, mean follow-up 32 (6-65) months. Clinical stage was T1a in 77.4%, T1b in 19.5% and T2 3.1% . 69% had a normal contralateral kidney, 23% a solitary kidney and 8% had bilateral tumours. Mean operating time was 91 minutes, mean blood loss 342 ml. Clamping was performed in 32.7% with a mean duration of 15 minutes. In 5% renal cooling was performed. There was an endorenal growth in 10.7%, a combined growth in 43.4%, and an exorenal growth in 45,9%. Resection was performed in 30.2%, enucleoresection in 49.7% and enucleation in 20.1%. RESULTS: At histopathology, RCC was found in 76.7% and 23.3% were benign lesions. Cancer free survival was 98.1%. Local tumour recurrence occurred in 1.3% and metastasis in 0.6%. Intra-operative complications were seen in 2 patients (1.2%). In one patient, a splenectomy was necessary for bleeding and in another patient, a radical nephrectomy was done for arterial bleeding. In 15.1%, an early (< 1 month) postoperative complication occurred : a postoperative haematoma was found in 5.7%, acute renal failure in 1.9%, wound problems in 1.3% and hematuria and urine leakage in 1 patient (0.6%). 5 patients (3.9%) developed pneumonia and 3 patients had cardiac problems. Late (> 1 month) postoperative complications occurred in 6.3%. Chronic renal failure occurred in 2.5% and woundherniation in 1,9%. One patient developed an arterial-venous fistula for which a super selective embolisation was performed. Local recurrence occurred in two patients (1.3%). One patient had a recurrence at the resection site, another patient had a kidney recurrence. CONCLUSIONS: We believe that nephron sparing surgery for T1 and T2 lesions is safe and reproducible with good oncological control at intermediate term follow-up.
638
‘BENCH’ SURGERY WITH AUTOTRANSPLANTATION FOR HILAR KIDNEY TUMOURS: A NEPHRON-SPARING ALTERNATIVE IN PATIENTS WITH A SOLITARY KIDNEY
PROSPECTIVE STUDY OF SAFETY MARGINS IN PARTIAL NEPHRECTOMY: INTRA-OPERATIVE ASSESSMENT AND CONTRIBUTION OF FROZEN SECTIONS
Boormans J.1, Marchand W.1, IJzermans J.2, Mikisch G.3, Verhagen P.1
Timsit M.O., Bazin J.P., Thiounn N., Fontaine E., Chretien Y., Dufour B., Mejean A.
Erasmus MC, Department of Urology, Rotterdam, The Netherlands, 2Erasmus MC, Department of Surgery, Rotterdam, The Netherlands, 3Centrum Für Operatieve Urologie Bremen, Department of Urology, Bremen, Germany 1
INTRODUCTION & OBJECTIVES: Partial nephrectomy is the treatment of choice for small, peripheral lesions of renal cell carcinoma. However, in patients with a solitary functioning kidney nephron-sparing surgery is the only alternative for nephrectomy with postoperative dialysis or kidney transplantation. Hilar tumours complicate a resection in situ, which may contribute to an unacceptable great surgical risk. For that reason we treated 12 patients from 1992 – 2003 by ex vivo dissection of a renal tumour followed by autotransplantation of the kidney. MATERIAL & METHODS: Patients with a hilar renal tumour and an imperative indication for nephronsparing surgery underwent Bench-dissection. Histories revealed a contralateral nephrectomy in 9 (8 for malignant disease and 1 for nephrolithiasis), a congenital solitary kidney in 2 and a non-functioning contralateral kidney in 1. The surgical procedure started with a nephrectomy and careful dissection of the hilar vessels. During the ischemic period the kidney was perfused with Eurocollins and cooled on ice. Ex vivo, the tumour was excised followed by reconstruction of the vessels and the collecting duct system. Thereafter autotransplantation of the kidney was done in the iliacal fossa. Follow-up consisted of 6-monthly visits with serum creatinin, a kidney ultrasound or CT-abdomen and yearly an X-ray or CT-scan of the thorax. Retrospectively we collected data on the procedures, complication rate, serum creatinin, histology of the tumour and recurrence of disease. RESULTS: Twelve patients (11 men, 1 woman) were operated with a mean age of 56.5 yrs (range 38 – 73). Ten patients had solitary tumours and 2 patients had 3 and 4 respectively. Mean operating time was 500 min. Mean time of hospitalization was 19 days. Mean preoperative serum creatinin was 114 μmol/l. One week postoperative it was 323 μmol/l and it decreased to 197 and 165 μmol/l 1 month and 1 year respectively. Postoperative complications (< 30 days of surgery) were death due to myocardial infarction in 1 patient after 16 days, temporarily dialysis due to acute tubular necrosis in 3, urinary leakage in 4 for which in 2 patients a nephrostomy was placed and pleural effusion in 1 patient for which drainage was required. Pathology showed 11 pT1 and 1 pT2 renal cell carcinomas. Mean diameter was 3.7 (range 1.0– 8.0 cm). In 2 patients there were positive surgical margins. With a mean follow-up of 47,5 months 6 patients are disease-free. A local recurrence was not seen, however in 5 patients there were metastases, in 3 to lymph nodes, in 1 to the adrenal gland and in 1 to the lung. Two patients died after 40 and 59 months respectively due to disseminated disease. CONCLUSIONS: Bench surgery is a nephron-sparing alternative in a selected population of patients with a solitary kidney and a hilar localisation of renal cell carcinoma. This technique avoids dialysis and kidney transplantation with preservation of kidney function and acceptable oncological result.
Necker Hospital, Urology and Transplantation, Paris, France INTRODUCTION & OBJECTIVES: Most experienced teams advocate laparoscopic approach for nephron-sparing surgery. However, facing obvious technical difficulties, the common urologist still performs open surgery with a recurrent debate regarding safety margins and the use of frozen sections. We aimed to prospectively evaluate the healthy parenchymal safety margin during open conservative surgery for renal cell carcinoma to highlight the reality of margins’ width and the accuracy of surgeons’ macroscopic evaluation. MATERIAL & METHODS: Between 1997 and 2001, elective nephron-sparing surgery was performed through a flank incision in 61 consecutive patients (mean age 59.4 [34.2–78.5] years). The mean tumour size was 32 [12–50] mm. Tumour localisations were juxta hilar (n=10) or distant (n=51). Prospective margin assessment applied the following protocol: margins were evaluated macroscopically by the surgeon, controlled by frozen section and subsequently measured during histological examination. All patients were monitored with computed-tomography scans, with a mean follow-up of 72.5 [46–95] months. RESULTS: Histological types were: 42 clear cell, 17 papillary and 2 chromophobic cell tumours; at 1997 TNM stage pT1 (n=57) or pT2 (n=4); and Furhman grade: 16 G1, 35 G2 and 10 G3. No tumour margin was positive. Frozen-section and routine histological examinations yielded 53 complete and 8 incomplete margins, versus 51 and 10, respectively, assessed by the surgeons. Mean peritumoural margins were: 7 [4–10] mm for the cortex and 2 [0–5] mm for the deep part. No patient developed a local-regional or metastatic relapse. CONCLUSIONS: No apparent relationship was observed between peritumoural margin width for the cortex and for the deep part, and there were no relationship neither with the risk of disease progression, even for tumours abutting the hilum, rendering illusory a safety margin > 1 cm. Although the surgeons’ macroscopic margin evaluations were accurate, frozen sections are mandatory when margin status is in doubt. In all cases, margin negativity remains an ontological imperative.
639
640
A NATIONAL SURVEY ON THE PRACTICE OF NEPHRON-SPARING SURGERY IN FRANCE
NEPHRON-SPARING SURGERY: EXPERIENCE IN 159 CONSECUTIVE CASES
Patard J.J.1, Albouy B.2, Lopes D.3, De La Taille A.3, Salomon L.3, Crepel M.1, Lobel B.1, Guille F.1, Bellec L.4, Soulie M.4, Bernhard J.C.5, Ferriere J.M.5, Lacroix B.6, Tostain J.6, Pfister C.2, Colombel M.7
Joniau S., Van Poppel H.
Rennes University Hospital, Urology, Rennes, France, 2Chu Rouen, Urology, Rouen, France, 3Chu Creteil, Urology, Creteil, France, 4Toulouse University Hospital, Urology, Toulouse, France, 5Bordeaux University Hospital, Urology, Bordeaux, France, 6St Etienne University Hospital, Urology, St Etienne, France, 7 Chu Lyons, Urology, Lyons, France 1
INTRODUCTION & OBJECTIVES: To evaluate through 7 expert centres the practice of nephron sparing surgery (NSS) in France. MATERIAL & METHODS: 7 academic centres performing at least 30% conservative renal surgery a year agreed to participate to this study. A detailed file including 70 variables was completed for each procedure. Notably, all the following variables were completed in all cases: age, gender, tumour size, surgical technique, indication, medical or surgical complications, length of hospital stay, final pathology and outcome. RESULTS: 741 NSS procedures were analysed. Median tumour size was 3 cm (0.5- 18). Indication was non-elective in 30.1% of the cases. 12.3% of the NSS procedures were performed by laparoscopy. Renal vessels clamping was necessary in 48% of the cases for a median duration time of 17 minutes (5-90). Urinary collecting system was repaired in 35.1% of the cases. Median operative time was 120 minutes and mean blood loss was 420 ml. Medical and surgical complication rates were 15.2% and 14.7% respectively. Blood transfusion rate was 10%. An urinary fistula occurred in 3.5% of the cases. Median length of hospital stay was 10 days. 21% were benign tumours. Conventional clear cell, papillary and chromophobe carcinomas accounted for 75%, 19.7% and 5.3% of the cases respectively. Among malignant tumours at the end of follow-up, local recurrence and death from cancer rates were 4.4% and 4.7% respectively. CONCLUSIONS: A large percentage of malignant tumours, a good selection of patients, an acceptable morbidity and a favourable outcome fully justify the increasing role of NSS in the surgical management of renal tumours. Eur Urol Suppl 2006;5(2):182
University Hospital Leuven, Urology, Leuven, Belgium INTRODUCTION & OBJECTIVES: As a result of the widespread use of ultrasound, CAT scan and MRI, the majority of Renal Cell Cancer (RCC) is nowadays detected at an early stage. Nephron sparing surgery has become an accepted treatment for small RCC. We review our experience in nephron sparing surgery for T1 and T2 lesions over the last 5 years. The aim is to evaluate the feasibility and the safety of the technique and to assess oncological control. MATERIAL & METHODS: Between July 1998 and July 2003, 159 consecutive patients underwent nephron sparing surgery for T1 and T2 lesions at our institution. Mean age was 59 (2-82) years, mean tumour volume was 4 (1-11) cm, mean follow-up 32 (6-65) months. Clinical stage was T1a in 77.4%, T1b in 19.5% and T2 3.1% . 69% had a normal contralateral kidney, 23% a solitary kidney and 8% had bilateral tumours. Mean operating time was 91 minutes, mean blood loss 342 ml. Clamping was performed in 32.7% with a mean duration of 15 minutes. In 5% renal cooling was performed. There was an endorenal growth in 10.7%, a combined growth in 43.4%, and an exorenal growth in 45,9%. Resection was performed in 30.2%, enucleoresection in 49.7% and enucleation in 20.1%. RESULTS: At histopathology, RCC was found in 76.7% and 23.3% were benign lesions. Cancer free survival was 98.1%. Local tumour recurrence occurred in 1.3% and metastasis in 0.6%. Intra-operative complications were seen in 2 patients (1.2%). In one patient, a splenectomy was necessary for bleeding and in another patient, a radical nephrectomy was done for arterial bleeding. In 15.1%, an early (< 1 month) postoperative complication occurred : a postoperative haematoma was found in 5.7%, acute renal failure in 1.9%, wound problems in 1.3% and hematuria and urine leakage in 1 patient (0.6%). 5 patients (3.9%) developed pneumonia and 3 patients had cardiac problems. Late (> 1 month) postoperative complications occurred in 6.3%. Chronic renal failure occurred in 2.5% and woundherniation in 1,9%. One patient developed an arterial-venous fistula for which a super selective embolisation was performed. Local recurrence occurred in two patients (1.3%). One patient had a recurrence at the resection site, another patient had a kidney recurrence. CONCLUSIONS: We believe that nephron sparing surgery for T1 and T2 lesions is safe and reproducible with good oncological control at intermediate term follow-up.