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SURGICAL REMOVAL OF SMALL RENAL TUMORS—GOING, GOING, GONE?
0022-5347/05/1741-0009/0 THE JOURNAL OF UROLOGY® Copyright © 2005 by AMERICAN UROLOGICAL ASSOCIATION
Vol. 174, 9, July 2005 Printed in U.S.A.
DOI: 10.1097/01.ju.0000167236.90062.95
SURGICAL REMOVAL OF SMALL RENAL TUMORS—GOING, GOING, GONE? unrelated causes during the study period. These authors have extensive experience with percutaneous radio frequency ablation, and are to be applauded for continued accurate reporting of their results.9 These data further emphasize that patients with smaller, exophytic renal lesions may be suitable to percutaneous radio frequency ablation. These results widen the scope of treatments and “treatable” patients with renal cell carcinoma, as these procedures are performed under only intravenous sedation. This fact is particularly relevant since many of our patients with renal tumors have numerous comorbidities and are often poor surgical candidates. So what does the future hold for urologists treating renal tumors? Until urologists are able to identify which renal tumors should be followed, ablated or surgically excised based on novel serum or radiographic testing, treatment decisions will be made based on tumor size, location, patient age and comorbidities. Larger T1 and T2 tumors should be removed, and laparoscopic radical nephrectomy, with or without hand assistance, remains common practice in 2005. Smaller tumors may be ablated, in many cases under intravenous sedation on an outpatient basis, which will usher in collaboration between specialties in many centers. In fact, select reports have appeared in radiology journals, reflecting the fact that at certain institutions needle ablative therapy has been a multidisciplinary effort.9 Undoubtedly this is an area in evolution and, while it remains unclear which ablative techniques will be performed, it is imperative that urologists remain at the forefront of ablative technology to remain skillful providers for all patients with renal cancer.
There has been an undeniable paradigm shift in the surgical management of renal cell carcinoma in the last 2 decades. More specifically, research advancements have led to a heightened understanding of the natural history and biology of renal tumors, in parallel with broad technical advances in surgical and ablative treatments for small renal tumors. As a result, many urologists now offer patients laparoscopic procedures, and select urologists will consider needle ablative treatments or even conservative management for renal cancer. Since the report of the first laparoscopic radical nephrectomy in 1991, open radical nephrectomy has been under scrutiny.1 Following suit, Licht and Novick reported long-term outcomes using open partial nephrectomy for treating small renal tumors, which resulted in a change in accepted management for smaller polar renal lesions.2 Laparoscopic partial nephrectomy ushered in the era when most all renal tumors could be treated laparoscopically and, although arguably more complex than the open counterpart, laparoscopic partial nephrectomy seems to be taking hold in many advanced laparoscopic practices.3, 4 Further advancements, such as the introduction of hand assisted techniques, enabled more practicing urologists to embrace renal laparoscopy, and subsequently simplified even laparoscopic partial nephrectomy.5, 6 The retroperitoneal approach has also worked well for select urologists, and certainly created an effective approach to laparoscopic renal surgery, particularly when operating on patients after prior abdominal surgery.7 The most drastic paradigm shift has been to minimally invasive ablative therapies. The initial reports of cryoablation and radio frequency ablation, and subsequent reports by other centers represent a significant philosophical challenge to the strategy of traditional surgical excision.8–10 Taken together, these advances have changed the way urologists evaluate and treat renal cell carcinoma in 2005, and new advances in several avenues continue. In this issue of The Journal Sato et al (page 53) report on 20 consecutive patients who underwent a hybrid procedure, the retroperitoneal hand assisted radical nephrectomy with a mean operative time of 103 minutes and 1 open conversion. This unique approach uses retroperitoneal access and hand assistance to complete a rapid, minimally invasive procedure. It is interesting that the authors used pure laparoscopy to handle the hilum, as we believe hand assistance is beneficial in managing the renal hilum.11 Nonetheless, this series describes a reproducible, rapid technique that may interest more urologists in the retroperitoneal approach. This issue is relevant since evidence exists that even experienced laparoscopists can have difficulty with orientation using the retroperitoneal approach.12 Lapini et al (page 57) demonstrated that “less can be more” when excising renal tumors, at least in their series. Surgical enucleation offers maximal nephron sparing benefits and decreased morbidity compared to formal partial nephrectomy. From 1989 to 2000 these authors performed simple enucleation of renal tumors averaging 2.7 cm using an open approach and demonstrated a progression-free survival rate approaching 98% at an average of 88 months of followup, with a minimum followup of 44 months. This series demonstrates that surgical enucleation without margin resection can be effective and provides a local recurrence rate of 1.9% with an average followup approaching 8 years. The 4-year followup report in this issue on percutaneous radio frequency ablation of renal cell carcinoma by McDougal et al (page 61) is of great interest to many practitioners. Of 19 patients with a minimum of 4 years of followup 16 had biopsy proven renal cell carcinoma averaging 3.2 cm. Based on computerized tomography or magnetic resonance imaging findings all 12 cases of peripheral tumors were successfully ablated, and in only 1 case did a central tumor persist. Five patients died of
Stephen Y. Nakada The University of Wisconsin Hospital and Clinics Madison, Wisconsin REFERENCES
1. Clayman, R. V., Kavoussi, L. R., Soper, N. J., Dierks, S. M., Meretyk, S., Darey, M. D. et al: Laparoscopic nephrectomy: initial case report. J Urol, 146: 278, 1991 2. Licht, M. R. and Novick, A. C.: Nephron sparing surgery for renal cell carcinoma. J Urol, 149: 1, 1993 3. Winfield, H. N., Donovan, J. F., Godet, A. S. and Clayman, R. V.: Laparoscopic partial nephrectomy: initial case report for benign disease. J Endourol, 7: 521, 1993 4. Gill, I. S., Matin, S. F., Desai, M. M., Kaouk, J. H., Steinberg, A., Mascha, E. et al: Comparative analysis of laparoscopic versus open partial nephrectomy for renal tumors in 200 patients. J Urol, 170: 64, 2003 5. Stifelman, M. D., Sosa, R. E., Nakada, S. Y. and Shichman, S. J.: Hand-assisted laparoscopic partial nephrectomy. J Endourol, 15: 161, 2001 6. Nakada, S. Y., Moon, T. D., Gist, M. and Mahvi, D.: Use of the pneumo sleeve as an adjunct in laparoscopic nephrectomy. Urology, 49: 612, 1997 7. Gaur, D. D., Agarwal, D. K. and Purohit, K. C.: Retroperitoneal laparoscopic nephrectomy: initial case report. J Urol, 149: 103, 1993 8. Uchida, M., Imaide, Y., Sugimoto, K., Uehara, H. and Watanabe, H.: Percutaneous cryosurgery for renal tumors. Br J Urol, 75: 132, 1995 9. Gervais, D. A., McGovern, F. J., Arellano, R. S., McDougal, W. S. and Mueller, P. R.: Renal cell carcinoma: clinical experience and technical success with radio-frequency ablation of 42 tumors. Radiology, 226: 417, 2003 10. Shingleton, W. B. and Sewell, P. E., Jr.: Percutaneous renal tumor cryoablation with magnetic resonance imaging guidance. J Urol, 165: 773, 2001 11. Nakada, S. Y.: Hand-assisted laparoscopic nephrectomy. J Endourol, 13: 9, 1999 12. McAllister, M., Bhayani, S. B., Ong, A., Jaffe, W., Malkowicz, S. B., VanArsdalen, K. et al: Vena caval transection during retroperitoneoscopic nephrectomy: report of the complication and review of the literature. J Urol, 172: 183, 2004 9
Vol. 174, 9, July 2005 Printed in U.S.A.
DOI: 10.1097/01.ju.0000167236.90062.95
SURGICAL REMOVAL OF SMALL RENAL TUMORS—GOING, GOING, GONE? unrelated causes during the study period. These authors have extensive experience with percutaneous radio frequency ablation, and are to be applauded for continued accurate reporting of their results.9 These data further emphasize that patients with smaller, exophytic renal lesions may be suitable to percutaneous radio frequency ablation. These results widen the scope of treatments and “treatable” patients with renal cell carcinoma, as these procedures are performed under only intravenous sedation. This fact is particularly relevant since many of our patients with renal tumors have numerous comorbidities and are often poor surgical candidates. So what does the future hold for urologists treating renal tumors? Until urologists are able to identify which renal tumors should be followed, ablated or surgically excised based on novel serum or radiographic testing, treatment decisions will be made based on tumor size, location, patient age and comorbidities. Larger T1 and T2 tumors should be removed, and laparoscopic radical nephrectomy, with or without hand assistance, remains common practice in 2005. Smaller tumors may be ablated, in many cases under intravenous sedation on an outpatient basis, which will usher in collaboration between specialties in many centers. In fact, select reports have appeared in radiology journals, reflecting the fact that at certain institutions needle ablative therapy has been a multidisciplinary effort.9 Undoubtedly this is an area in evolution and, while it remains unclear which ablative techniques will be performed, it is imperative that urologists remain at the forefront of ablative technology to remain skillful providers for all patients with renal cancer.
There has been an undeniable paradigm shift in the surgical management of renal cell carcinoma in the last 2 decades. More specifically, research advancements have led to a heightened understanding of the natural history and biology of renal tumors, in parallel with broad technical advances in surgical and ablative treatments for small renal tumors. As a result, many urologists now offer patients laparoscopic procedures, and select urologists will consider needle ablative treatments or even conservative management for renal cancer. Since the report of the first laparoscopic radical nephrectomy in 1991, open radical nephrectomy has been under scrutiny.1 Following suit, Licht and Novick reported long-term outcomes using open partial nephrectomy for treating small renal tumors, which resulted in a change in accepted management for smaller polar renal lesions.2 Laparoscopic partial nephrectomy ushered in the era when most all renal tumors could be treated laparoscopically and, although arguably more complex than the open counterpart, laparoscopic partial nephrectomy seems to be taking hold in many advanced laparoscopic practices.3, 4 Further advancements, such as the introduction of hand assisted techniques, enabled more practicing urologists to embrace renal laparoscopy, and subsequently simplified even laparoscopic partial nephrectomy.5, 6 The retroperitoneal approach has also worked well for select urologists, and certainly created an effective approach to laparoscopic renal surgery, particularly when operating on patients after prior abdominal surgery.7 The most drastic paradigm shift has been to minimally invasive ablative therapies. The initial reports of cryoablation and radio frequency ablation, and subsequent reports by other centers represent a significant philosophical challenge to the strategy of traditional surgical excision.8–10 Taken together, these advances have changed the way urologists evaluate and treat renal cell carcinoma in 2005, and new advances in several avenues continue. In this issue of The Journal Sato et al (page 53) report on 20 consecutive patients who underwent a hybrid procedure, the retroperitoneal hand assisted radical nephrectomy with a mean operative time of 103 minutes and 1 open conversion. This unique approach uses retroperitoneal access and hand assistance to complete a rapid, minimally invasive procedure. It is interesting that the authors used pure laparoscopy to handle the hilum, as we believe hand assistance is beneficial in managing the renal hilum.11 Nonetheless, this series describes a reproducible, rapid technique that may interest more urologists in the retroperitoneal approach. This issue is relevant since evidence exists that even experienced laparoscopists can have difficulty with orientation using the retroperitoneal approach.12 Lapini et al (page 57) demonstrated that “less can be more” when excising renal tumors, at least in their series. Surgical enucleation offers maximal nephron sparing benefits and decreased morbidity compared to formal partial nephrectomy. From 1989 to 2000 these authors performed simple enucleation of renal tumors averaging 2.7 cm using an open approach and demonstrated a progression-free survival rate approaching 98% at an average of 88 months of followup, with a minimum followup of 44 months. This series demonstrates that surgical enucleation without margin resection can be effective and provides a local recurrence rate of 1.9% with an average followup approaching 8 years. The 4-year followup report in this issue on percutaneous radio frequency ablation of renal cell carcinoma by McDougal et al (page 61) is of great interest to many practitioners. Of 19 patients with a minimum of 4 years of followup 16 had biopsy proven renal cell carcinoma averaging 3.2 cm. Based on computerized tomography or magnetic resonance imaging findings all 12 cases of peripheral tumors were successfully ablated, and in only 1 case did a central tumor persist. Five patients died of
Stephen Y. Nakada The University of Wisconsin Hospital and Clinics Madison, Wisconsin REFERENCES
1. Clayman, R. V., Kavoussi, L. R., Soper, N. J., Dierks, S. M., Meretyk, S., Darey, M. D. et al: Laparoscopic nephrectomy: initial case report. J Urol, 146: 278, 1991 2. Licht, M. R. and Novick, A. C.: Nephron sparing surgery for renal cell carcinoma. J Urol, 149: 1, 1993 3. Winfield, H. N., Donovan, J. F., Godet, A. S. and Clayman, R. V.: Laparoscopic partial nephrectomy: initial case report for benign disease. J Endourol, 7: 521, 1993 4. Gill, I. S., Matin, S. F., Desai, M. M., Kaouk, J. H., Steinberg, A., Mascha, E. et al: Comparative analysis of laparoscopic versus open partial nephrectomy for renal tumors in 200 patients. J Urol, 170: 64, 2003 5. Stifelman, M. D., Sosa, R. E., Nakada, S. Y. and Shichman, S. J.: Hand-assisted laparoscopic partial nephrectomy. J Endourol, 15: 161, 2001 6. Nakada, S. Y., Moon, T. D., Gist, M. and Mahvi, D.: Use of the pneumo sleeve as an adjunct in laparoscopic nephrectomy. Urology, 49: 612, 1997 7. Gaur, D. D., Agarwal, D. K. and Purohit, K. C.: Retroperitoneal laparoscopic nephrectomy: initial case report. J Urol, 149: 103, 1993 8. Uchida, M., Imaide, Y., Sugimoto, K., Uehara, H. and Watanabe, H.: Percutaneous cryosurgery for renal tumors. Br J Urol, 75: 132, 1995 9. Gervais, D. A., McGovern, F. J., Arellano, R. S., McDougal, W. S. and Mueller, P. R.: Renal cell carcinoma: clinical experience and technical success with radio-frequency ablation of 42 tumors. Radiology, 226: 417, 2003 10. Shingleton, W. B. and Sewell, P. E., Jr.: Percutaneous renal tumor cryoablation with magnetic resonance imaging guidance. J Urol, 165: 773, 2001 11. Nakada, S. Y.: Hand-assisted laparoscopic nephrectomy. J Endourol, 13: 9, 1999 12. McAllister, M., Bhayani, S. B., Ong, A., Jaffe, W., Malkowicz, S. B., VanArsdalen, K. et al: Vena caval transection during retroperitoneoscopic nephrectomy: report of the complication and review of the literature. J Urol, 172: 183, 2004 9