S.C.D.U. Urologia Dir.: prof. Francesco Porpiglia

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1 UNIVERSITA degli STUDI di TORINO Facolta di Medicina e Chirurgia, Polo San Luigi Dipartimento di Oncologia S.C.D.U. Urologia Dir.: prof. Francesco Porpiglia A.O.U. San Luigi Gonzaga Orbassano

2 Chirurgia: Come quando e perchè Pro e Contro dott. C. Fiori conflitto di interesse: nessuno

3 MAIN MENU Active surveillance (AS) Partial versus Radical Nephrectomy (PN vs RN) Laparoscopic versus open approach (Lap vs open) Lymphnode dissection () rectomy (neph)

4 Lapvs Open AS: Rational and Pro Mean growth/y 0.28 cm Avoid surgery! (and related risks) Reduce the risk of CKD Reduce the potentially risk of cardiovascular mortality Volpe et al, 2004 Chawlaet al, 2006 EAU guidelines, 2013

5 AS: Cons Overall data: 18/880 (2%) of patients progressed to mts Pooled data 9/230 (3.9%) of patients progressed to mts NSM is associated with % worse survival relative to nephrectomy Zini et al, 2009

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9 RN>PN: +4.9%, + 3.1% Mortality risk 5 and 10 y

10 1068 patients treated with PN vs 1068 patients treated with RN (stage: pt1a) OCM RN>PN OCM 2y 5% vs 6.9% OCM 5y 16% vs 18.1%

11 Results of the studies about overall mortality should be handled with care! Based on retrospective SEER database Results are valid for >66 yrs old patients (Sun) 10yrs survival in the only prospective RCT = opposite results (EORTC, ongoing) Recent analysis of pool of donors ( ) failed to show worse survival or CKD when compared to general population Different population! (USA vs Europe, Italian study ongoing)

12 Results of the studies about overall mortality should be handled with care! Risk of reoperation is twice for PN Risk of complications is >20% for PN

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14 T stage 1-2 Surv 5y LRN 87% OPN 88% LRN = HA LRN = LESS RN = robotic RN (poor data!)

15 T stage 1-2 Blood Transfusion Analgesic LOS req. Op Times

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17 : Rational and Pro It was basic part of radical nephrectomy as described by Robson in the 60s It represents the most accurate and reliable staging procedure for the detection of lymph node invasion (LNI) [Patients with LNI have 7.8 fold greater chance of dying form their disease than those without LNI] May improve survival following surgery May improve response to systemic therapy Blute et al 2004 Godoy et al 2008

18 : Cons and doubts It is a technical demanding, time consuming procedure (especially during laparoscopic interventions) Morbibity (bleeding, lymphocele, chylous ascites) To date no studies have demonstrated which candidates should undergo No template has been defined In low stage / low risk patients LNI is low ( %) thus seems to be an overtreatment Its therapeutic role remains unclear Many urologists have abandoned at the time of nephrectomy Blute et al 2004

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20 Possible survival benefits?

21 Bloom et al 2005

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23 Adrenalectomy: Rational and Pro It was basic part of radical nephrectomy as described by Robson in the 60s May improve survival following surgery by reducing the risk of RCC recurrence Robson et al 1969 Cons and doubts Recent data (lap, PN) have challenged this approach Stage migration! Operative risks, times Risk of adrenal insufficiency Bekema et al 2013

24 179 pts undergone: Nephrectomy + Adr (n=91) Nephrectomy (n=88) Adrenal invasion 4.4% High accuracy of imaging No correlation between tumour location and size N+ or M+ Local disease

25 48/2065 patients undergone PN + Adr 6 RCC involvement/mts Metachronous adr mts during follow up (5.5y) 15 cases (0.7%)

26 Data of 956 pts (30 adr), 19 Institutions

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29 TAKE HOME MESSAGEs AS: small lesions in patients unfit to surgery or in the elderly PN: do it whenever feasible (caveats: complications and status of the patients) Lap nephrectomy is the goal (T1 and 2 stage), Lap PN in tertiary Centres and adrenalectomy: can be omitted when imaging is negative