Nephron-sparing surgery

reported that elective NSS can be performed with equiva- lent direct hospital costs and length of stay when com- pared with patients undergoing radical nephrectomy for small solitary RCCs. Another article reported that nephron-sparing surgery was the standard of care for small RCC [27]. Thus, the comparison of efficacy be- tween NSS and RN with regards to other indicators still requires further evaluation.

Renal carcinoma is a common malignancy in the urinary system, which imposes a great threat to the patients. Radical nephrectomy is currently a generally accepted treatment meth- od for possible cure of localized renal carcino- ma [1, 2]. With the development in minimally invasive techniques, laparoscopy has now replaced open surgery to become the main- stream procedure for treating renal carcinoma due to smaller surgical trauma. For T1a stage renal carcinoma (tumor size ≤4 cm), the effica- cy of laparoscopic nephron sparing surgery (LNSS) is comparable to radical nephrectomy,

The increased use of nephron-sparing surgery to treat localized renal cell carcinoma (RCC) lends weight to the question of the value of microscopically positive surgical margins (PSM) in cases with a tumor bed macroscopically free of residual tumor. The aim of this article is to highlight the data available on risk factors for PSM, their clinical relevance, and possible therapeutic consequences. For this purpose, publications on the incidence and relevance of PSM after partial nephrectomy from the last 15 years were examined and evaluated. We summarize that PSM are generally rare, regardless of the surgical procedure, and are seen more often in connection with an imperative indication for nephron-sparing surgery as well as a central tumor location. Most studies describe that PSM lead to a moderate increase in the rate of local relapses, but no study has thus far been able to demonstrate an association with shorter tumor-specific overall survival. Intraoperative frozen section analysis had no positive influence on the risk of definite PSM in most trials. Therefore, we conclude that PSM should definitely be avoided. However, in cases with a macroscopically tumor-free intraoperative resection bed, they should lead to close surveillance of the affected kidney and not to immediate (re)intervention.

Methods: This study was a retrospective review of 51 patients who underwent open nephron-sparing surgery. The mean age of the patients (39 men, 12 women) was 54.2 ± 13.9 years, range 32 to 71 years. The glomerular filtration rate (GFR) was measured preoperatively and 6th months after the operation. Univariate analysis was used to screen indicators with significant differences in different levels of renal function damage. All variables found to be significant on univariate analysis were entered into a multiple logistic regression model to predict risk factors for renal function damage.

sue Graft, COOK Biotech, West-Lafayette, Ind, USA) is a natural acellular biomaterial based on collagen from the porcine submucosa. SIS does not induce major adverse reactions when surgically implanted and is gradually remodeled, leaving behind autologous tissue. The mem- brane is used for different purposes in urology, obstetrics and gynaecology, general surgery and wound care [4,5]. We describe our experience with SIS in optimizing the outcome in nephron-sparing surgery.

Abstract: This study aimed to evaluate the effect of nephron-sparing surgery (NSS) along with preoperative selective arterial embolization (SAE) on the treatment of giant renal angiomyolipomas (AML). Between July 2010 and October 2014, 3 men and 8 women with 11 sporadic giant renal AMLs were treated by NSS along with preoperative SAE in our center. The tumor size ranged from 10.4 to 24.2 cm. The medical data were collected. Of the 11 giant AMLs, 8 were completely devascularized by SAE, and the other 3 were mostly devascularized. The rate of post-embolization syndrome was 27.2% (3/11). NSS was successfully performed after SAE in all patients. The operating time was 70- 155 min (mean, 115 min). Blood loss was 50-150 ml (mean, 70 ml). The warm ischemia time was 8-25 min (mean, 15 min). The incidence of perioperative complications was 18.2% (2/11), and no severe complications occurred after NSS. The hospitalization time after NSS was 5-10 d (mean, 6.6 d). There was no statistical difference in kidney function pre- and post-surgery. No evidence of recurrence was found during the follow-up period. NSS with preopera- tive SAE can be considered a viable and effective treatment option for giant renal AMLs, for it avoids excess blood loss and shortens warm ischemia time during NSS.

Copyright © 2012 Ahmet Tefekli et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Hereditary kidney cancer patients with bilateral multiple kidney tumors represent challenges in the era of rapidly growing minimal invasive treatment techniques. Birt-Hogg-Dub´e Syndrome (BHDS) is an autosomal dominant genodermatosis characterized by a triad of benign skin tumors (fibrofolliculomas, trichodiscomas, acrochordons) together with an increased risk of developing malignant renal tumors and pulmonary disease such as pneumothoraces and multiple lung cysts. The morbidity and mortality of the affected patients is determined by the presence of the kidney tumors, which tend to be multifocal and bilateral, as observed in other hereditary kidney cancer syndromes like von Hippel-Lindau disease, familial leiomyomatosis, and hereditary papillary renal cell carcinoma. Herein, a patient with BHDS, presenting with synchronous bilateral multiple kidney tumors, is reported. The report describes the management of kidney tumors with two-stage open nephron-sparing surgery in which the nonvascular clamping technique was utilized.

Abstract: Objective: To compare the efficacy of robot-assisted laparoscopic nephron-sparing surgery (RALNSS) with conventional laparoscopic nephron-sparing surgery (LNSS) in patients with early-stage renal cell carcinoma (RCC). Methods: Seventy-five patients with early-stage (T1-T2N0M0) RCC who underwent RALNSS or LNSS from January 2015 to July 2016 were randomly divided into RALNSS group (n=38) or LNSS group (n=37). Measurements includ- ing operation time (OT), intraoperative blood loss (IOBL) and renal warm ischemia time (RWIT) were recorded in all surgeries. The patients in each operative group were divided into low-risk, moderate-risk and high-risk groups according to the RENAL nephrometry score, followed by comparation in OT, IOBL and RWIT between corresponding risk groups. All patients were given 2-year follow-up for renal function evaluation. Results: There were no significant differences between the two groups in OT, RWIT and postoperative renal function (all P>0.05). The RALNSS group had less IOBL than the LNSS group (P<0.05). There was no significant difference in OT, IOBL and RWIT between the two low-risk groups (all P>0.05). The OT, IOBL and RWIT in patients with moderate or high risk were better in the RALNSS group than those in the LNSS group with statistical differences (all P<0.05). As to 2-year follow-up of renal function, the RALNSS group was superior to the LNSS group (P<0.05). Conclusion: In the treatment of complex RCC surgery, RALNSS has shorter RWIT and OT, less IOBL, and better protection for renal function compared to LNSS, suggesting that RALNSS for RCC is worthy of application in clinical practice.

Open nephron-sparing surgery (ONSS) was performed using the intercostal (between 11 th and 12 th ribs) extra- peritoneal flank approach, as previously described [9]. Briefly, after adequate exposure of the kidney, Gerota’s fascia was opened and perinephritic fatty tissue was dissected off the renal surface. Ureter and the vascular pedicle were marked with vessel loops. The decision about hilar clamping was given perioperatively according to in-situ findings and preoperative radiologic data. We did not implement cold-ischemia in any of these open NSS’s. Tumors were removed via enucleoresection [10]. Bleeding from the tumor bed was controlled with 3/0 polyglactin interrupted sutures and parenchyma was adapted with 2/0 monofilament running sutures, over a surgical bolster.

tumors and imperative indications for nephron-sparing surgery, These patients underwent nephrectomy, work bench tumor resection, and kidney autotransplantation. The patients’ characteristics and surgical results are de- scribed in Tables 1 and 2. The comorbidity index ranged from 2 to 6 and ASA scoring from 1 to 3. A child of 5 years of age with a nephroblastoma in a single kidney was also included. In all cases, anatomically highly com- plex malignant renal masses or complex upper tract urothelial carcinomas (UTUC) were identified in single kidneys. In ten cases, the tumors were located centrally or in the renal pelvis, including the five cases of UTUC. In two cases, large tumors of the upper or lower pole with in- filtration of the renal hilum were indications for KAT.

Recently, Villavicencio et al. reported on the use of an off- clamp technique in 19 cases of retroperitoneoscopic partial nephrectomy for localized renal tumors. Those authors reported a mean blood loss of 414 ml (range 100-1600 ml), mean WIT of 4.9 minutes (range 0-28), mean surgical procedure time of 182 minutes (range 110-285 minutes) and mean hospitalization of 4.5 days (range 3-11 days) [14]. These results are in agreement with our own statistics, making it reasonable to speculate that our technique has consistently proven to be comparable to the minimally invasive procedures, which are only feasible by experienced hands in a referral institute. Positive surgical margins are present in up to 7% of cases of open PN, with fewer results in laparoscopic or robot-assisted surgery [21]. In the present study, only one case (1.6%) was managed conservatively due to prior chronic renal disease, showing no signs of metastasis or local recurrence during follow-up.

None of the patients developed metastatic progression, with only one case of in situ recurrence detected, which was connected with NSMs (Table 1). On the basis of the analytical obser[r]

bare the kidney and ureterogonadal pedicle. The ureterogo- nadal pocket was dissected up to the iliac vessels without disturbing the vascularity of the ureter. Dissection was con- tinued outside the Gerota’s fascia to mobilize the kidney all around. Hilar dissection was performed to achieve control over renal vessels. Ureter was disconnected at the level of iliac vessels and diuresis was confirmed followed by liga- tion and disconnection of renal artery and vein sequentially. On the right side, the cuff of the vena cava was included in the renal vein. Each kidney weighed about 2500 g. Bench surgery was performed to excise the tumour completely and to reconstruct the kidney meticulously. Autotransplantation was performed extending the incision to the iliac fossa as described earlier.

Our findings are helpful for surgical planning, and they suggest either the application of a clampless NSS technique or at least the shortest possible IT to reduce the risk of short-term impairment of the renal function, which might prevent AKI, particularly regarding patients with baseline eGFR category ≥G3, and might reduce long-term impair- ment of renal function. The reason for the beneficial effects of LNSS on short-term renal function remains unclear, but different techniques of clamping of the renal artery (e.g., bulldog clamps in LNSS or Satinsky clamps in ONSS, like in or study), different renal/cortical reconstruction tech- niques, assuming tighter cortical renorrhaphy in ONSS [64], or a selection bias of higher tumour complexity in the open cases performed, may have influenced the worse short-term renal outcome observed in ONSS. Future inves- tigations and strategies are needed to reduce ischaemia/re- perfusion injury. Well-designed high quality prospective studies are needed to evaluate both the impact of nephro- metric scores and renal ischemia/zero-ischemia on the renal functional outcomes in patients undergoing NSS for renal tumours (e.g. trial NTC02287987, [65]. Furthermore, studies evaluating renal function preservation after NSS should control for reconstructive renal injury. In addition, a modified definition of AKI in terms of surgery-related kidney injury that uses specific markers for renal tubular injury independently from a varying blood creatinine level, e.g. urinary biomarkers [66, 67], might help to better describe the postoperative short-term renal function and to predict the long-term renal function.

Methods and Results This paper provides an overview of in- dications, surgical techniques and results of L-NSS; explains the incidence, risk factors and manifestations of postoperative complications; discusses the preferred multidetector comput- ed tomography (CT) acquisition techniques; illustrates the ap- pearance of normal postoperative images following L-NSS; and reviews, with example images, the most common and unusual iatrogenic complications. These include haematuria, haemorrhage, vascular injuries, infections and urinary leaks. Most emphasis is placed on CT, which provides rapid, reliable triage and follow-up of iatrogenic complications after L-NSS, identifying occurrences that require transarterial embolisation or repeated surgery.

gone nephron−sparing surgery and were finally cured. The authors mentioned above emphasize the role of preoperative chemotherapy, which con− siderably diminished the volume of the tumor and facilitated the surgery. The conclusion is that chil− dren with stage I Wilms’ tumor which was signif− icantly reduced (13–23%) after preoperative chemotherapy should be selected for a nephron− sparing operation. In the case of these five children aged 1 to 5 years, nephron−sparing surgery was found technically feasible in the course of the operation. The diameter of the tumor was below 4 cm, the tumor was restricted to one renal pole, and the spared part of the kidney constituted more than 50% of the parenchyma. All the children sur− vived for five years without any symptoms of dis− ease. They can thus be regarded as cured, and rad− ical nephrectomy was not necessary.

10. Van Poppel H, Da Pazzo L, Albrecht W, et al. A prospective, randomised EORTC intergroup phase 3 study comparing the oncological outcome of elective nephron-sparing surgery and radical nephrectomy for low- stage renal cell carcinoma. Eur Urol 2010;59:543-52. http://dx.doi.org/10.1016/j.eururo.2010.12.013 11. Tan HJ, Norton EC, Ye Z, et al. Long-term survival following partial vs radical nephrectomy among older patients with early-stage kidney cancer. JAMA 2012;307:1629-35. http://dx.doi.org/10.1001/jama.2012.475 12. Miller DC, Ruterbusch J, Colt JS, et al. Contemporary clinical epidemiology of renal cell carcinoma: insight from a

Conventional nephron sparing surgery includes clamping the renal vessels which is followed by ischaemia in the remnant renal tissue. Especially predamaged organs often fail to compensate the caused hypoxia which leads to an increased morbidity regarding acute and renal failure [10]. Within the first 5–8 min oxidative radicals are formed in the hypoxic tissue leading to damage [15,16]. Therefore, ischaemia should be avoided. Studies indicate that ischae- mia free tumor exstirpation result in a better clinical out- come [8,12,17]. Laparoscopic partial nephrectomy itself

Patients and Methods: 81 patients with t1 oder t2 re- nal cell carcinoma (RCC) were included in this prospective single-center study. all patients were oper- ated in a single institution either by open radical nephrectomy (oRn) or nephron sparing surgery (nss). Patients and doctors were evaluated using a written questionnaire with a follow-up of 12 months. follow-up intervals, follow-up modalities (e. g. imaging modalities, laboratory controls of blood and urine) and the call on psycho-oncological support were evaluated. Results: the majority of patients (72%) were followed up by their urologists. follow-up examinations includ- ed abdominal ultrasound, urine and blood diagnostics, conventional chest x-rays, computed tomography (Ct) of abdomen, chest or head or abdominal Magnetic Resonance Imaging (MRI). there were no significant differences between patients operated by oRn or nss. In total, 12.5% of patients were asking for psy- cho-oncological support.

Retrospective multi-institutional studies showed a trend towards a benefit of survival in patients submitted to PN when comparing to RN, although a recent prospective study brings conflicting evidence around this subject. In the only randomized trial of RN versus nephron-sparing surgery (NSS), it was concluded that NSS substantially reduced the incidence of at least moderate renal dysfunction (eGFR < 60), while the incidence of advanced kidney disease (eGFR < 30) and kidney falilure (eGFR < 15) was relatively similar in the two treatment arms. They further add that the beneficial impact of NSS on eGFR did not result in improved survival over a period of 9,3 years of follow-up. 12-14