The need for routine adrenalectomy during the surgical treatment of renal cell cancer - the Hannover experience

08

SURGICALTREATMENTOF RENALCELL CARCINOMA Monday, February 25,11.45-13.15 hrs, Room C

TRANSABDOMINAL

APPROACH

FOR LARGE RENAL TUMOURS

277

IN RADICAL

NEPHRECTOMY

OUR EXPERIENCE WITH AN ELECTIVE CARDIOPULMONARY BYPASS IN THE SURGICAL TREATMENT OF RENAL NEOPLASMS EXTENDING INTO THE RIGHT ATRIUM

WITH IVC EXTENSION

Dubev Deeoak’. Rix David’, Kelly J.D.K.’ , Neal D.E.’ . Manas Derek’ ‘Urology,

Freeman

Hospital,

Newcastle

Unit, Freeman Hospital, Newcastle INTRODUCTION tumours

cardiopulmonary

MATERIALS (median

Radical

& METHODS: underwent

radiate abdominal

for large renal with or without

the feasibility of radical nephrectomy incision.

1 I patients with large upper pole renal tumours

radical nephrectomy

(3-retrohepatic,

and vena cavotomy

incision. In all cases the liver was mobilised

medially to achieve suprahepatic of caval wall was performed

8-

through a trithen displaced

control of the IVC. Thrombectomy

after total vascular occlusion

or excision

of the IVC.

RESULTS: In all patients surgery was successful with a median (SD) blood loss and operating

time of 1250 (843) ml and 5.0 (0.84) respectively.

Three patients

were placed

on veno-venous

was extended

bypass,

The tri-radiate

incision

superiorly through the sternum in one patient. Median (SD) hospital stay was 14 (7.2) days. There were no perioperative developed

deaths, a superficial

wound infection

in 3 cases.

CONCLUSION:

A tri-radiate

incision enables the tranaabdominal

large renal tumours with caval extension and is associated Exposure for liver mobilisation

is excellent,

if necessary,

be accessed by extending the incision via sternotomy. is superior to thoracotomy

Giusepper , Ferrare

Paolo’ , Piccin

Carla*,

Fabbri

‘Department of Urology, S. Bortolo Hospital, Vicenza, Italy, ?Department Cardiovascular Surgery, S. Bortolo Hospital, Vicenza, Italy

nephrectomy

18.5-28 cm) and IVC thrombi

Abatang

2Liver

often requires thoractomy

through an abdominal

20.6 cm, range

infrahepatic)

upon Tyne, United Kingdom,

bypass. We demonstrate

and caval thrombectomy

Tasca A.‘, Alessandro’

upon Tyne, United Kingdom

& OBJECTIVES:

with vena caval extension

278

of

INTRODUCTION & OBJECTIVES: We evaluate the results of an elective CPB conceived to minimise the surgical risk related to the use of cardiopulmonary bypass (CPB) with temporary circulatory arrest and deep hypothermia in the treatment of patients with renal tumour extending into the right atrium (RA). MATERIALS & METHODS: From July 1996 to December 2000, I9 patients with renal neoplasm and venous involvement were admitted to our department. Three out of 4 patients aged 4,57 and 58 years with a right (2) and left (I) renal tumour extending into the right atrium underwent radical nephrectomy and tumour thrombus removal using a normothermic CPB. The CPB circuit was connected with a vacuum assisted venous drainage (VAVD) giving a negative pressure of 20-40 mmHg. Neither circulatory arrest nor hypothermia was used. Tumour thrombus was extracted through a longitudinal cavotomy and removed along with the kidney. RESULTS: The total CPB time was 14, 19 and 22 minutes, respectively. No intra- or postoperative complications due to the surgical technique were noted. No significant bleeding was observed at the time of cavotomy and neoplastic tissue was totally removed. Pathological examination documented renal cell carcinoma in 2 cases and Wilms tumour in I. Two patients are alive and diseasefree at 38 and 60 months, I is dead for metastatic disease I5 months after the operation.

excision of

with low morbidity. the thoracic cava can

We believe this approach

for the majority of complex renal cases.

CONCLUSION: Normothermic CPB with VAVD makes circulatory arrest and hypothermia unnecessary and avoids the potential complications associated with these procedures. With respect to veno-venous shunts this technique guarantees complete surgical control of the thrombus and avoids the need for extensive dissection of retro hepatic vena cava and the Pringle manoeuvre.

279

280

THE RISK OF IATROGENIC SPLENECTOMY MAY BE REDUCED BY A COLO-EPIPLOIC MOBILISATION DURING LEFT RADICAL NEPHRECTOMY FOR RENAL CELL CARCINOMA

THE NEED FOR ROUTINE ADRENALECTOMY DURING THE SURGICAL TREATMENT OF RENAL CELL CANCER - THE HANNOVER EXPERIENCE

Meiean Arnaud, Chretien Nicolas, Dufour Bertrand

Kuczvk Markus’, Munch Torsten’, Machtens Kondo Mashahiko I. Jonas Udoi

Yves, Cazin

Sebastien,

Balian

Chant,

Thiounn

Urology, Hopital Necker, Paris, France INTRODUCTION & OBJECTIVES: Radical nephrectomy is indicated for renal cell carcinoma (RCC) 40 mm or more and a majority of urologists is still using a open surgery either from a transperitoneal or from a retroperitoneal approach. In a previous study we have reported that the splenectomy is one of the main complications (8%) of left radical nephrectomy using the transperitoneal anterior subcostal incision (TASI). The greater omentum and the colon being closely attached to the spleen, we studied whether the coloepiploic mobilisation (CEM) is indicated to reduce the incidence of iatrogenic splenectomy during left radical nephrectomy for RCC. MATERIALS & METHODS: Between January 1995 and April 2001 a left radical nephrectomy was performed in 233 consecutive patients for RCC through a TASI. A CEM procedure was systematically performed with a complete detachment of the colic flexure. Pre, per and postoperative data were noted in a database. Mean age was 51.3 years (21.3-90.2) and mean tumour size was 58 mm (I 5-230). The phrenicocolic ligament was incised. The renal vessels were controlled after the incision of the peritoneum between the duodenum and the inferior mesenteric vein. The greater omentum was turned up and the dissection between the colonic epiploa and the colon was initiated on the middle part of the transverse colon. After opening of the omental bursa, the colon was detached following a non-vascular line. All the ligaments between the wall, the spleen and the left colon llexure were gently sectioned. The dissection of the kidney was facilitated and the incision of the parietal peritoneum at the level of the superior pole was not obscured by the splenic flexure. The radical nephrectomy was done without any traction on the spleen. RESULTS: A iatrogenic splenectomy was required in 3 patients and in one patient a splenic injury was treated conservatively. The incidence of iatrogenic splenectomy accompanying left radical nephrectomy was I .3%. The mean operative time was 120 minutes (80-240 minutes). The mean time of normal gut motility was 3.4 days (2-l I days) and to discharge from the hospital 9.3 days (6. I9 days). Regarding CEM we do not observe any significant abdominal complication. CONCLUSION: Using the technique of CEM during transabdominal radical nephrectomy might decrease the risk of iatrogenic splenic injury. European

Urology

Supplements

1 (2002)

No. 1, pp. 72

left

Stefan', Wefer Antje’,

‘Department of Urology and Diagnostic Radiology, IHannover University Medical School, Hannover, Germany, ‘FRG and Department of Urology. Nara University, Osaka. Japan INTRODUCTION AND OBJECTIVES: Since in the absence of clinically overt metastastatic disease tumorous lesions within the adrenal gland are found in only 2-10s of cases, the majority of renal cell cancer patients are overtreated by adrenelectomy as an integrated part of tumour nephrectomy. A long-lasting debate is ongoing about the need for the routine removal of the ipsilateral adrenal gland as part of perifascial nephrectomy. PATIENTS AND METHODS: The medical records of 847 patients undergoing adrenalectomy in combination with nephrectomy irrespective the local extension of the primary tumour or the clinical stage at first diagnosis were reviewed to determine the reliability of currently available imaging modalities regarding the prediction of adrenal gland metastases. More than 20 patients’ and tumour characteristics were correlated to the presence of intraadrenal metastases and their possibly independent prognostic value was determined by a multivariate logistic regression model. RESULTS: Metastatic spread into the adrenal gland was observed in 27 of 847 (3%) patients. In only 3 of 8 patients in whom the adrenal was identified as the only metastatic site, preoperative abdominal CT-scans were interpreted as false negative. During multivariate statistical analysis, only the presence of distant metastases, vascular invasion within the primary tumour and multifocal growth of renal cell cancer within the tumour-bearing kidney were identified to independently predict the likelihood for the presence of intraadrenal metastases. CONCLUSIONS: None of the patients’ or tumour characteristics evaluated reliably predicted the likelihood for the presence of adrenal metastases in patients without evidence of disseminated metastatic spread. However, the frequency of metachronous metatases within the contralateral kidney (2.4%) is significantly higher than the risk of a preoperatively undetected isolated adrenal metataais when currently available imaging modalities are applied. Therefore, routine adrenalectomy should not be recommended in case of preoperative normal radiological examinations.