Preservation of Renal Function Following Partial or Radical Nephrectomy Using 24-Hour Creatinine Clearance
|
|
- Christopher Carter
- 5 years ago
- Views:
Transcription
1 european urology 54 (2008) available at journal homepage: Kidney Cancer Preservation of Renal Function Following Partial or Radical Nephrectomy Using 24-Hour Creatinine Clearance Aaron T.D. Clark a, Rodney H. Breau a, Chris Morash a, Dean Fergusson b, Steve Doucette b, Ilias Cagiannos a, * a Division of Urology, Department of Surgery, University of Ottawa, Ontario, Canada b Ottawa Health Research Institute, University of Ottawa, Ontario, Canada Article info Article history: Accepted March 16, 2008 Published online ahead of print on March 27, 2008 Keywords: Creatinine Creatinine clearance Partial nephrectomy Nephrectomy Nephron sparing Renal function Renal function tests Abstract Objective: To compare the effect on renal function of partial and radical nephrectomy using creatinine clearance measurements from 24-hr urine collection. Methods: All patients with a solid enhancing renal mass suspicious for renal cell carcinoma, a normal contralateral kidney, and not dialysis dependent were enrolled in this prospective cohort study. Patients were treated with partial or radical nephrectomy by one urologist. Creatinine clearance (CrCl) measurements were prospectively obtained by 24-hr urine collection preoperatively, and at 3, 6, and 12 mo postoperatively. Mean change in creatinine clearance from baseline was compared at 3, 6, and 12 mo. Serum creatinine and Cockcroft-Gault calculations were also performed for comparison. Mixed model analysis incorporating patient and tumor characteristics and the procedure type was performed in SAS Version 9.1. Results: Sixty-three consecutive patients were enrolled in this study. The partial nephrectomy (n = 26) and radical nephrectomy (n = 37) groups were similar with respect to age, sex, presence of hypertension, vascular disease, diabetes mellitus, and angiotensin converting enzyme inhibitor or receptor blocker use. The postoperative change in creatinine clearance was significantly less ( p-value < ) in the partial nephrectomy group ( 0.09 ml/s, 6.1%) compared to the radical nephrectomy group ( 0.56 ml/s, 31.6%). Linear regression analysis showed intervention type (partial vs. radical nephrectomy) was the most significant predictor of change in creatinine clearance ( p-value < ). Conclusions: There is significantly less deterioration in the overall renal function of patients who are treated with partial nephrectomy compared to radical nephrectomy. This highlights the importance of performing nephron-sparing surgery on appropriate patients. # 2008 European Association of Urology. Published by Elsevier B.V. All rights reserved. Abbreviations: CrCl, Creatinine Clearance; egfr, estimated Glomerular Filtration Rate; Cr, Serum Creatinine; NSS, Nephron Sparing Surgery; PN, Partial Nephrectomy; RN, Radical Nephrectomy; NSAID, Non-Steroidal Anti-Inflammatory Drugs; ACEI, Angiotensin Converting Enzyme Inhibitor; ARB, Angiotensin Receptor Blocker; CT, Computed Tomography; GFR, Glomerular Filtration Rate. * Corresponding author. Division of Urology, Department of Surgery, The Ottawa Hospital Civic Campus, B3 Urology, 1053 Carling Avenue, Ottawa, Ontario K1Y 4E9, Canada. Tel ; Fax: address: icagiannos@ottawahospital.on.ca (I. Cagiannos) /$ see back matter # 2008 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi: /j.eururo
2 144 european urology 54 (2008) Introduction Surgical extirpation with radical or partial nephrectomy remains the preferred management for solid or complex cystic renal masses. In appropriate patients, it has been found that oncologic outcome is equivalent between radical and partial nephrectomy, and the incidence of adverse surgical events is similar [1 4]. As favorable outcome and safety data mature, urologists have become more aggressive in sparing kidneys which contain large tumors in patients who have a normal contralateral kidney. Furthermore, ubiquitous use of, and improvement in, abdominal imaging modalities such as computed tomography has resulted in an increase in the detection of incidental small renal masses that now account for 60% 70% of all diagnosed renal masses [5]. These small renal masses are thought to be ideal candidates for nephron-sparing surgery. However, recent population-based studies have revealed, somewhat surprisingly, that radical nephrectomies were being performed on the great majority of patients (92% to 96%), and up to 80% of those tumors that may be amenable to partial nephrectomy [6 8]. These findings are concerning, as several studies have shown that patients who undergo partial nephrectomy have better renal function and are less likely to require renal replacement therapy [9 12]. These studies evaluated renal function using serum creatinine or calculated glomerular filtration rates (GFR), which have been shown to underestimate true kidney function and are less accurate when compared to measured creatinine clearance by 24-hr urine collection [13,14]. In this study, we compare renal function in patients who have undergone a partial or radical nephrectomy using 24-hr urine creatinine clearance, considered a superior measure for renal function estimation over the use of serum creatinine alone or GFR estimate equations. 2. Methods Between November 2003 and November 2006, 81 consecutive patients with solid enhancing renal masses suspicious for renal cell carcinoma (RCC) were treated by a single urologic oncologist at our institution. Patients presenting with a solitary renal mass and a normal contralateral kidney were enrolled in a prospective internal review board (IRB) approved study. Patients were excluded if they had a solitary kidney, bilateral renal tumors, were on dialysis preoperatively, or had a diagnosis of renal artery stenosis. Other exclusion criteria were noncompliance with 24-hr urine collection or follow-up, postoperative NSAID use for greater than 1 wk, postoperative use of gentamicin, intravenous contrast within the first 3 mo, or postoperative shock. Treatment with radical (RN) or partial nephrectomy (PN) was selected at the discretion of the treating surgeon. Laparoscopic or open radical nephrectomy was deemed necessary or preferred in patients with large or extensive tumors and in those with suspected lymph node involvement. Patients with tumors less than 4 cm and those with impaired renal function were predominantly treated with open partial nephrectomy. Partial nephrectomy was performed using an open retroperitoneal approach. Cold ischemia was employed in all partial nephrectomy cases by clamping the renal vessels and packing the kidney with ice for 10 min prior to tumor excision. Radical nephrectomy was performed by either an open retroperitoneal approach or laparoscopic transperitoneal approach. Patients baseline demographic information was collected, including age; sex; presence of hypertension, vascular disease, and diabetes; use of angiotensin converting enzyme inhibitors (ACEI) or receptor blockers (ARB); and tumor size, histology, and stage. Renal function evaluations were performed preoperatively and at 3, 6, and 12 mo postoperatively. Creatinine clearance (CrCl) measurements were obtained in all patients who met the inclusion criteria by 24-hr urine collection (CrCl = (24-hr urine creatinine 24-hr urine volume)/(serum creatinine s/day)). Routine blood work, including serum creatinine (Cr), was also collected at the same intervals for comparison. Cockcroft-Gault calculations of estimated glomerular filtration rate (egfr) were also performed. The mean change in 24-hr urine CrCl and egfr was calculated for each procedure type and compared using a standard t-test. Linear regression multivariate analysis using average postoperative CrCl as the dependent variable and incorporating the recorded patient and tumor characteristics as well as procedure type was performed in SAS Version 9.1 (SAS Institute Inc., Cary, NC) to show the effect of individual risk factors on renal function. To account for correlation in responses within each patient, the spatial power covariance structure in SAS proc mixed was used. 3. Results Of the 81 patients who underwent a radical or partial nephrectomy during the study period (Fig. 1), 18 patients were excluded. Eight patients in the RN group and 10 patients in the PN group were excluded. Sixty-three consecutive patients who had two kidneys, had unilateral tumor involvement, and were not dialysis dependent had preoperative CrCl measured by 24-hr urine collection available for analysis. Of 26 patients in the PN group, 24 patients had 3-mo follow-up, 19 had 6-mo follow-up, and 21 had 12-mo follow-up. Of 37 patients in the RN group, 35 patients had 3-mo follow-up, 29 had 6-mo follow-up, and 33 had 12-mo follow-up. Preoperative risk factors were similar between the two groups (Table 1); however, the PN group had worse preoperative creatinine clearance measured
3 european urology 54 (2008) Fig. 1 Selection of patients during the study. Table 1 Demographics and distribution of preoperative risk factors for renal insufficiency Radical nephrectomy Partial nephrectomy p-value No. pts Baseline CrCl ml/s ml/s 0.06 Baseline serum Cr mmol/l mmol/l 0.11 Age (mean) Male sex 21 (56.8%) 21 (80.8%) 0.05 Hypertension 23 (62.2%) 16 (61.5%) 0.96 Vascular disease 11 (29.7%) 10 (38.5%) 0.47 Diabetes 5 (13.5%) 2 (7.8%) 0.47 ACEI/ARB use 12 (32.4%) 9 (34.6%) 0.87 Tumor size (mean) cm cm < by 24-hr urine (1.48 ml/min. vs ml/min, p-value = 0.06) and higher preoperative serum Cr (109 mmol/l vs. 90 mmol/l, p-value = 0.11). Tumor size was smaller in patients undergoing PN as compared to RN (2.7 cm vs 5.2 cm, p-value < ). The mean decrease in measured CrCl was 0.09 ml/s ( 6.1%) in the PN group and 0.56 ml/ min ( 31.6%) in the RN group ( p-value < ) (Table 2). Mean decrease in egfr was 0.05 ml/s ( 5.3%) in the PN group and 0.21 ml/s ( 21.2%) in the RN group ( p-value = ) (Table 3). The change in CrCl at 3-, 6-, and 12-mo follow-up periods is shown in Fig. 2. One patient in the RN group and no patients in the PN group went on permanent dialysis. The linear regression analysis using average postoperative CrCl as the dependent variable and controlling for tumor size, patient age, sex, comorbidity, angiotensin active medication, baseline measured CrCl, and procedure type showed that Table 2 Preoperative CrCl, average of postoperative CrCl, and change (D) in CrCl Preop CrCl (ml/s) Postop CrCl (ml/s) D CrCl 95% CI PN (6.1%) RN (31.6%) p-value (D CrCl) <
4 146 european urology 54 (2008) Table 3 Preoperative egfr, average of postoperative egfr, and change (D) in egfr Preop egfr (ml/s) Postop egfr (ml/s) D egfr 95% CI PN (5.3%) RN (21.2%) p-value (D CrCl) Fig. 2 Change in creatinine clearance over 12 mo of followup after a partial or radical nephrectomy. Table 4 Results of the regression analysis of factors affecting kidney function Variable Model coefficient p-value Baseline creatinine clearance 0.69 < Partial procedure 0.39 < Hypertension Vascular disease ACEI/ARB Diabetes Tumor size Age only type of procedure (PN vs RN), age, and preoperative CrCl were predictive of postoperative change in kidney function measured by 24-hr urine creatinine clearance ( p-value < ) (Table 4). 4. Discussion Radical nephrectomy has been the standard of care for the management of solid or complex cystic masses for many years [15]. It has been traditional thinking among urologists that removal of the entire kidney provides excellent cancer control without compromise of overall renal function. This rationale stems from transplant literature where renal donors have not been found to have a higher long-term risk of renal insufficiency or dialysis compared to agematched controls [16 21]. For this reason, partial nephrectomy was originally reserved for patients with compromised renal function and for those with a solitary kidney or bilateral tumors. As indications and experience with partial nephrectomy have expanded, more recent studies have suggested that there is a significant decline in renal function after radical nephrectomy as compared to partial nephrectomy [9 12]. In the present study, we have shown radical nephrectomy results in a 31.6% reduction in overall renal function, as measured by 24-hr urine CrCl, compared to only a 6.1% reduction with partial nephrectomy ( p-value < ). Patients undergoing RN therefore had a 25.5% greater decline in their renal function compared to those having PN. This is the first study to use 24-hr urine CrCl measurements and, therefore, provides the most compelling evidence to date of the superiority of partial nephrectomy regarding renal function preservation. The changes in renal function as a result of PN and RN were seen at the 3-, 6-, and 12-mo follow-up assessments and were consistent throughout (Fig. 2). The immediate and then persistent change in CrCl measurement suggests that the choice of operation will have long-term impact on renal function. Indeed, in our multivariate analysis controlling for preoperative factors that may impact renal function, the operation performed, RN or PN, strongly predicted postoperative change, with patients undergoing PN having significantly less deterioration in their renal function. Over the past 10 yr, nephron-sparing surgery has become the standard of care for patients with tumors 4 cm as studies have demonstrated equivalent cancer control compared to radical nephrectomy [1 4,22]. The boundary for NSS surgery is constantly being challenged, with recent evidence suggesting that expanding the indications to tumors up to 7 cm in appropriately selected patients is safe and efficacious [23 26]. Recent advances in technology, patient demands, and widespread acceptance of laparoscopic techniques have, however, produced a resurgence in radical nephrectomy for small, solitary tumors. A recent paper revealed that 58% of patients with tumors < 2 cm and 80% of patients with tumors 2 4 cm were managed with radical nephrectomy in the United States in 2001 [6]. The Nationwide Inpatient Sample also showed that only 7.5% of all kidney cancer was surgically managed
5 european urology 54 (2008) with partial nephrectomy [7]. This trend also applied to England, where only 4% of kidney cancer surgeries were partial nephrectomies in 2002 [8]. The authors of that study concluded that partial nephrectomy is underutilized in the ideal candidates for nephron-sparing surgery and suggested this is due to urologists unfamiliarity with this procedure. Furthermore, due to emphasis on outcomes such as reduced hospital stay, reduced analgesic usage, and earlier return to work, some are concerned that patients are preferentially being offered laparoscopic nephrectomy when an open partial nephrectomy may provide the best outcome [27]. Overemphasis on the short-term benefits of laparoscopy may drive surgeons unable to perform the more technically advanced procedure of laparoscopic partial nephrectomy away from nephronsparing surgery altogether. In other cases in which attempted laparoscopic partial nephrectomies are abandoned for technical reasons, surgeons are preferentially performing laparoscopic total nephrectomies instead of converting to an open partial nephrectomy. Our study indicates that the underutilization of PN comes with significant renal function consequences. Previous studies have also suggested that there is a significant decline in renal function after radical nephrectomy as compared to partial nephrectomy. Matin et al compared the outcomes of open partial nephrectomy and laparoscopic radical nephrectomy for patients with tumors less than 4 cm [1]. This group found that there was a 25% (0.97 to 1.38 mg/dl) increase in mean serum creatinine from preop to postop in the laparoscopic radical nephrectomy group as compared to 0% (0.91 to 0.96 mg/dl) in the open partial nephrectomy group ( p < 0.001). McKiernan et al found an increase in mean serum creatinine from 1.0 mg/dl to 1.5 mg/ dl for the RN group compared to 0.98 to 1.0 mg/dl for the partial nephrectomy group ( p-value < 0.001) [2]. Lau et al retrospectively compared the two procedures and found a lower 10-yr cumulative incidence of chronic renal insufficiency, as defined by a serum creatinine level greater than 2 mg/dl, in patients who underwent partial nephrectomy compared to radical nephrectomy (11.6% vs 22.4%, RR = 3.7, p = 0.01) [3]. A recent paper by Huang et al estimated glomerular filtration rate (GFR) from serum creatinine using the abbreviated Modification in Diet and Renal Disease (MDRD) study equation; they found that patients undergoing a radical nephrectomy were at significant risk (65% 3-yr probability) compared to partial nephrectomy (20% 3-yr probability) for the development of chronic kidney disease, defined as GFR less than 60 ml/min per 1.73 m 2 and less than 45 ml/min per 1.73 m 2 [12]. All of these studies evaluated renal function using serum creatinine or calculated glomerular filtration rates. Serum creatinine or calculations using only serum Cr are inaccurate in patients with mild renal insufficiency, in patients who are older, and in patients who are not in a steady state of creatinine production and distribution [28]. GFR estimate equations, including the MDRD and Cockcroft-Gault equations, were designed using populations with chronic kidney disease and are therefore less accurate in populations with mild renal insufficiency or normal renal function [28]. All of these variables are represented in this patient population. For this reason, in our study, we used creatinine clearance based on direct measurement of 24-hr urine collection. Although still a surrogate marker of GFR, this is considered a far more accurate estimation [12,13]. A recent paper looking at different calculations to estimate GFR in patients with advanced bladder cancer concluded that these calculations underestimate GFR when compared to CrCl measurements by 24-hr urine [13]. In our analysis, the percentage decline in postoperative renal function comparing RN to PN was, 21.2% vs 5.3% for the Cockroft-Gault equation and 31.6% vs 6.1% with 24-hr urine CrCl measurements. This highlights that egfr based on serum Cr underestimates the true impact of radical nephrectomy on postoperative renal function. Using the more accurate measure of 24-hr urine CrCl shows the true detriment that loss of an entire kidney causes. Conversely, partial nephrectomy is excellent at preserving renal function. There was only a minimal 6.1% decline in CrCl, which, although statistically significant, may not be clinically relevant. Only one of the patients in our study met criteria for renal failure and went onto dialysis over the 12-mo follow-up. However, the changes in kidney function estimated by 24-hr urine creatinine clearance seen in our patient population puts them at an increased risk of developing chronic renal failure with longer-term follow-up. Patients with chronic renal failure have reduced quality of life and are at increased risk of comorbid events such as hypertension, anemia, malnutrition, neuropathy, cardiovascular disease, and mortality [29,30]. This study has several limitations. We designed this study to prospectively collect data on all patients surgically treated for a renal mass for 3 yr total as opposed to performing power calculations for sample size. This could be viewed as a limitation with our sample size; however, the 95% confidence interval calculations for change in CrCl
6 148 european urology 54 (2008) are significantly different for the PN and RN groups, therefore limiting the possibility of a Type II error (Table 2). Additionally, this study represents a single-surgeon experience performed in a nonrandomized fashion. We should also point out that creatinine clearance measured by 24-hr urine collection can have inherent difficulties with respect to patient compliance when applied to the general population outside the study setting. The results of a 24-hr urine collection must be interpreted with caution if applied outside the study setting because of errors in collection of timed urine. Despite these limitations, we feel the results of this study contribute to our knowledge of the natural history of renal function following surgical management for renal cell carcinoma. This data set is the first to our knowledge to use CrCl measured by 24-hr urine collection and provides compelling evidence for the benefits of PN. 5. Conclusion Partial nephrectomy has minimal impact on postoperative renal function measured by 24-hr urine CrCl, whereas radical nephrectomy is associated with significantly greater renal function decline. Our study highlights the importance of using more accurate measurements of renal function in assessing the true impact on renal function in patients undergoing surgical management of kidney cancer. Partial nephrectomy is currently an underutilized procedure, and our data highlight the importance of performing nephron-sparing surgery in all eligible patients. Author contributions: Ilias Cagiannos had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Clark, Cagiannos, Morash Acquisition of data: Clark, Breau Analysis and interpretation of data: Clark, Cagiannos, Breau, Fergusson, Doucette Drafting of the manuscript: Clark, Cagiannos, Breau Critical revision of the manuscript for important intellectual content: Cagiannos, Morash, Fergusson Statistical analysis: Doucette, Fergusson, Clark Obtaining funding: none Administrative, technical, or material support: none Supervision: Cagiannos, Morash Other (specify): none Financial disclosures: I certify that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript (eg, employment/ affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: none Funding/Support and role of the sponsor: none References [1] Belledegrun A, Tsui KH, dekernion JB, Smith RB. Efficacy of nephron-sparing surgery for renal cell carcinoma: analysis based on the new 1997 tumor-node-metastasis staging system. J Clin Oncol 1999;17: [2] Lerner SE, Hawkins CA, Blute ML, et al. Disease outcome in patients with low stage renal cell carcinoma treated with nephron sparing or radical surgery. J Urol 1996;155: [3] Hafez KS, Fergany AF, Novick AC. Nephron sparing surgery for localized renal cell carcinoma: impact of tumor size on patient survival, tumor recurrence and TNM staging. J Urol 1999;162: [4] Herr H. Partial nephrectomy for unilateral renal carcinoma and a normal contralateral kidney: 10 year followup. J Urol 1999;161:33 4. [5] Russo P. Renal cell carcinoma: presentation, staging, and surgical treatment. Semin Oncol 2000;27: [6] Hollenbeck BK, Taub DA, Miller DC, et al. National utilization trends of partial nephrectomy for renal cell carcinoma: a case of underutilization. Urol 2006;67: [7] Miller DC, Hollingsworth JM, Hafez KS, et al. Partial nephrectomy for small renal masses: an emerging quality of care concern? J Urol 2006;175: [8] Nuttall M, Cathcart P, van der Meulen J, et al. A description of radical nephrectomy practice and outcomes in England: BJU Int 2005;96: [9] Matin SF, Gill IS, Worley S, Novick AC. Outcome of laparoscopic radical and open partial nephrectomy for the sporadic 4 cm or less renal tumor with a normal contralateral kidney. J Urol 2002;168: [10] McKiernan J, Simmons R, Katz J, Russo P. Natural history of chronic renal insufficiency after partial and radical nephrectomy. Urology 2002;59: [11] Lau WK, Blute ML, Weaver AL, Zincke H. Matched comparison of radical nephrectomy vs nephron-sparing surgery in patients with unilateral renal cell carcinoma and a normal contralateral kidney. Mayo Clin Proc 2000;75: [12] Huang WC, Levey AS, Serio AM, et al. Chronic kidney disease after nephrectomy in patients with renal cortical tumors: a retrospective cohort study. Lancet Oncol 2006;7: [13] Raj GV, Iasonos A, Herr H, Donat SM. Formulas calculating creatinine clearance are inadequate for determining eligibility for cisplatin based chemotherapy in bladder cancer. J Clin Oncol 2006;24: [14] Toussaint ND, Agar JWM, D Intini V. Calculating glomerular filtration rate in a young man with a large muscle mass. Med J Aust 2006;4:221 2.
7 european urology 54 (2008) [15] Robson CJ, Churchill BM, Anderson W. The results of radical nephrectomy for renal cell carcinoma. J Urol 1969;101: [16] Talseth T, Fauchald P, Skrede S, et al. Long-term blood pressure and renal function in kidney donors. Kidney Int 1986;29: [17] Vincenti F, Amend WJC, Kaysen G, et al. Long-term renal function in kidney donors. Transplantation 1983;36: [18] Williams SL, Oler J, Jorkansky DK, et al. Long-term renal function in kidney donors: a comparison of donors and their siblings. Ann Intern Med 1986;105:1 8. [19] Najarian JS, Chavers BM, McHugh LE, et al. 20 years and more follow-up of living related kidney donors. Lancet 1992;340: [20] Miller IJ, Suthanthiran M, Riggio RR, et al. Impact of renal donation: long-term clinical and biochemical follow-up of living related donors in a single center. Am J Med 1985;79: [21] Fehrman-Ekholm I, Norden G, Lennerling A, et al. Incidence of end-stage renal disease among live kidney donors. Transplantation 2006;82: [22] Ljungberg B, Hanbury DC, Kuczyk MA, et al. Renal cell carcinoma guideline. Eur Urol 2007;51: [23] Becker F, Siemer S, Hack M, et al. Excellent long-term cancer control with elective nephron-sparing surgery for selected renal cell carcinomas measuring more than 4 cm. Eur Urol 2006;49: [24] Leibovich BC, Blute ML, Cheville JC, et al. Nephron sparing surgery for appropriately selected renal cell carcinoma between 4 and 7 cm results in outcome similar to radical nephrectomy. J Urol 2004;171: [25] Patard JJ, Shvarts O, Lam JS, et al. Safety and efficacy of partial nephrectomy for all T1 tumors based on an international multicenter experience. J Urol 2004;171: [26] Russo P, Goetzl M, Simmons R, et al. Partial nephrectomy: the rationale for expanding the indications. Ann Surg Oncol 2002;9: [27] Kirkali Z. The motion: open partial nephrectomy is the standard of care for small respectable solid renal masses. Eur Urol 2007;51: [28] Stevens LA, Coresh J, Greene T, Levey AS. Assessing kidney function measured and estimated glomerular filtration rate. N Engl J Med 2006;354: [29] Levey AS, Coresh J, Balk E, et al. National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Ann Intern Med 2003;139: [30] Go A, Chertow G, Fan D, et al. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med 2004;351: Editorial Comment on: Preservation of Renal Function Following Partial or Radical Nephrectomy Using 24-Hour Creatinine Clearance Paul Russo Cornell Weill Medical College, Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, New York, USA russop@mskcc.org The authors evaluated 63 consecutive patients with renal tumors, 37 of whom underwent a radical nephrectomy (mean tumor size 5.2 cm) and 26 of whom underwent a partial nephrectomy (mean tumor size 2.7 cm). Patients were otherwise similar relative to age, sex, and presence of medical comorbidities [1]. A 24-h creatinine clearance (CrCl) was obtained preoperatively and at 3, 6, and 12 mo postoperatively. Radical nephrectomy was associated with a significantly greater decline in CrCl versus partial nephrectomy (31.6% vs 6.1%). A similar result was obtained when glomerular filtration rate was estimated (egfr) using the Cockcroft Gault equation (21.2% vs 5.3%). Although the impact on baseline renal function of larger renal tumors ultimately treated by radical nephrectomy is not known, particularly those that are endophytic and clearly replace normal kidney, and setting aside differences in accuracy between CrCl and egfr and patient compliance issues with 24-h urinary collections, the results obtained in this study confirm the deleterious impact on kidney function of radical nephrectomy previously reported. It is now abundantly clear that for small renal tumors (< 7 cm), oncologic control is equivalent whether radical or partial nephrectomy is performed [2,3]. In addition, approximately 20% of patients will have a benign tumor (including oncocytoma, lipid poor angiomyolipoma), and an additional 25% will have an indolent tumor (papillary or chromophobe carcinoma) with limited metastatic potential [4,5]. Iatrogenic creation or worsening of preexisting chronic kidney disease is now a serious concern following radical nephrectomy, and evidence is emerging that overall survival (not cancer-specific survival) is worse for radical nephrectomy patients when compared to a similar cohort of patients treated with partial nephrectomy [6]. In western societies where medical comorbidities related to obesity, diabetes, hypertension, and cardiovascular disease are on the rise, chronic kidney disease is considered an independent risk factor for hospitalization, cardiovascular events, and death [7]. In a recent study from our center, 26%
8 150 european urology 54 (2008) of patients with small renal tumors (< 4 cm), a serum creatinine within normal limits, and a normal-appearing contra lateral kidney had a preoperative egfr of less than 60 ml/min/1.73 m 2, consistent with stage 3 chronic kidney disease [8]. The casual radical nephrectomy for these small renal tumors, whether done by open or minimally invasive techniques, serves only to overtreat the renal tumor and create or worsen preexisting chronic kidney disease. Although radical nephrectomy is still required for massive renal tumors that are locally advanced with or without regional adenopathy, that involve the renal vein and vena cava, or as part of a cytoreductive strategy prior to systemic treatment, it should be discouraged for patients with small renal tumors amenable to partial nephrectomy. Urologists must now carefully consider chronic kidney disease and its serious consequences as they consult with patients and plan operations, particularly for T1 tumors. An easyto-do preoperative determination of egfr using web-based formulas (ie, MDRD_GFR.cgi) may change surgical plans toward partial nephrectomy or careful observation in elderly patients with significant comorbidities. References [1] Clark ATD, Breau RH, Morash C, et al. Preservation of renal function following partial or radical nephrectomy using 24-hour creatinine clearance. Eur Urol 2008;54: [2] Lee CT, Katz J, Shi WW, Thaler HT, Reuter VE, Russo P. Surgical management of renal tumors of 4 cm or less in a contemporary cohort. J Urol 2000;163: [3] Dash A, Vickers AJ, Schachter LR, et al. Comparison of outcomes in elective partial vs. radical nephrectomy for clear cell renal cell carcinoma of 4 7 cm. BJU International 2006;97: [4] McKiernan JM, Yossepowitch O, Kattan M, Simmons R, Motzer RJ, Reuter VE, et al. Partial nephrectomy for renal cortical tumors: pathological findings and impact on outcome. Urology 2002;60: [5] Snyder ME, Bach A, Kattan MW, Raj GV, Reuter VE, Russo P. Incidence of benign lesions for clinically localized renal masses < 7 cm in radiological diameter: influence of gender. J Urol 2006;176: [6] Thompson HR, Boorjian SA, Lohse CM, et al. Radical nephrectomy for pt1a renal masses may be associated with decreased overall survival compared to partial nephrectomy. J Urol 2008;179: [7] Go AS, Chertow GM, Fan D, McCulloch CE, et al. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Eng J Med 2004;351: [8] Huang WC, Levey AS, Serio AM, et al. Chronic kidney disease after nephrectomy in patients with renal cortical tumors: a retrospective cohort study. Lancet Oncology 2006;7: DOI: /j.eururo DOI of original article: /j.eururo Editorial Comment on: Preservation of Renal Function Following Partial or Radical Nephrectomy Using 24-Hour Creatinine Clearance Francesco Porpiglia University of Turin, Department of Clinical and Biological Sciences, San Luigi Hospital Orbassano (Turin), Italy porpiglia@libero.it In the past 10 years, partial nephrectomy (PN) has become the standard of care for patients with tumour 4 cm. It has been widely demonstrated that oncological control after PN is equivalent to that following radical nephrectomy (RN) and that renal function preserved for quality of life is better after nephron-sparing surgery [1 3]. Renal function after RN decreases significantly over time related to the development of a focal glomeruloscerosis because of hyperfiltration by the remaining nephrons. The severity of the glomerulosclerosis correlates with the number of removed nephrons. To prevent or avoid hyperfiltration when treating a small renal mass, it is essential to preserve the highest number of nephrons. This goal can be achieved by performing PN in eligible patients and by resecting few millimetres of healthy parenchyma during PN. The assessment of renal function should be estimated with the glomerular filtration rate (GFR). The best methods for estimating GFR are the plasmatic clearance of inuline and the 51Crethylenediaminetetraacetic acid (EDTA) scientigraphy [4]. Urinary creatinine clearance or GFR estimate equations (Cockcroft-Gauldt) can be considered as surrogates. Clark et al s well-designed, prospective study [5] compares the GFR obtained with the two abovementioned surrogates to assess renal function after PN and RN. The authors demonstrate in a
9 european urology 54 (2008) small series that patients undergoing RN had a 25.5% greater decline in their renal function compared to those who underwent PN. They state that the best method for evaluating global renal function is the 24-h creatinine clearance. These authors should be congratulated, first, for using a scientific method to evaluate overall renal function that can be considered in the design of other urological trials and, second, especially for stressing the functional benefits of an underutilized procedure such as PN. References [1] Ljungberg B, Hanbury DC, Kuczyk MA, et al. Renal cell carcinoma guideline. Eur Urol 2007;51: [2] Lesage K, Joniau S, Fransis K, Van Poppel H. Comparison between open partial and radical nephrectomy for renal tumours: perioperative outcome and health-related quality of life. Eur Urol 2007;51: [3] Becker F, Siemer S, Humke U, Hack M, Ziegler M, Stöckle M. Elective nephron-sparing surgery should become standard treatment for small unilateral renal cell carcinoma: long-term survival data of 216 patients. Eur Urol 2006;49: [4] Porpiglia F, Renard J, Billia M, et al. Is renal warm ischemia over 30 minutes during laparoscopic partial nephrectomy possible? One-year results of a prospective study. Eur Urol 2007;52: [5] Clark ATD, Breau RH, Morash C, Fergusson D, Doucette S, Cagiannos I. Preservation of renal function following partial or radical nephrectomy using 24-hours creatinine clearance. Eur Urol 2008;54: DOI: /j.eururo DOI of original article: /j.eururo Editorial Comment on: Preservation of Renal Function Following Partial or Radical Nephrectomy Using 24-Hour Creatinine Clearance Ziya Kirkali Dokuz Eylul University School of Medicine, Department of Urology, Izmir, Turkey ziya.kirkali@gmail.com Chronic kidney disease (CKD) is an important health problem for the community. Not only do patients with renal insufficiency require renal replacement therapy, which adds a major burden to healthcare costs. Patients with various stages of CKD also have reduced quality of life and are more prone to develop cardiovascular disease and hypertension. They have increased hospitalization and mortality [1]. Contrary to our beliefs that renal insufficiency rates in patients with congenital unilateral renal agenesis, renal transplant donors, and those undergoing nephrectomy for benign disease do not differ from renal insufficiency rates in the general population, there is increasing evidence that radical nephrectomy for renal cell carcinoma (RCC) causes significantly more risk of deteriorated renal function [2]. Despite its small sample size and some minor drawbacks, the study by Clark et al [3] is important and shows us that it is time to change our paradigm and attitude. These authors have prospectively assessed preoperative and postoperative renal function by 24-hr creatinine clearance in all new patients coming to their institution with suspected RCC and a normal contralateral kidney. They found that the postoperative renal function decline is significantly higher in those undergoing radical nephrectomy compared with partial nephrectomy. This decline was persistent throughout 12 mo. The most important aspect of this study is that the authors have used 24-h creatinine clearance for the first time in this setting. While serum creatinine levels, measurement of glomerular filtration rate (GFR) by Cockroft-Gault formula, or the Modification of Diet in Renal Disease study (MDRD) equation are reasonable estimations of renal function, they may not be as accurate as the 24- h creatinine clearance in those populations with normal or minimal loss of renal function. Although we have no level 1 evidence that partial nephrectomy is oncologically equal or superior to radical nephrectomy for RCC, it has been the standard practice based on accumulated data that show equal if not better survival rates. As stated in the paper, partial nephrectomy and other nephronsparing approaches are underutilized in different parts of the world. It is not uncommon even today to see that a patient with a T1 renal mass is treated by laparosocopic radical nephrectomy. The time has come to change our paradigm and consider nephron-sparing surgery for RCC whenever feasible and possible. We must train our colleagues on the proper management of patients
10 152 european urology 54 (2008) with small renal masses. It is also our endeavor to teach our colleagues the techniques of partial nephrectomy and reduce the complications with an attempt to preserve renal function as much as possible while obtaining the best oncologic outcome. [2] Lucas SM, Stern JM, Adibi M, Zeltser IS, Cadeddu JA, Raj GV. Renal function outcomes in patients treated for renal masses smaller than 4 cm by ablative and extirpative techniques. J Urol 2008;179: [3] Clark ATD, Breau RH, Morash C, Fergusson D, Doucette S, Cagiannos I. Preservation of renal function following partial or radical nephrectomy using 24-hour creatinine clearance. Eur Urol 2008;54: References [1] Go A, Chertow G, Fan D, et al. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med 2004;351: DOI: /j.eururo DOI of original article: /j.eururo
Comparison of Partial and Radical Nephrectomy for pt1b Renal Cell Carcinoma
www.kjurology.org DOI:10.4111/kju.2010.51.9.596 Urological Oncology Comparison of Partial and Radical Nephrectomy for pt1b Renal Cell Carcinoma Jong Min Kim, Phil Hyun Song, Hyun Tae Kim, Tong Choon Park
More informationRapid communication chronic renal insufficiency after laparoscopic partial nephrectomy and radical nephrectomy for pathologic T1a lesions
Washington University School of Medicine Digital Commons@Becker Open Access Publications 2008 Rapid communication chronic renal insufficiency after laparoscopic partial nephrectomy and radical nephrectomy
More informationWho are Candidates for Laparoscopic or Open Radical Nephrectomy. Arieh Shalhav
Who are Candidates for Laparoscopic or Open Radical Nephrectomy Arieh Shalhav Fritz Duda Chair of Urologic Surgery Professor of Surgery and the Comprehensive Cancer Research Center Who are Candidates for
More informationOverall Survival and Development of Stage IV Chronic Kidney Disease in Patients Undergoing Partial and Radical Nephrectomy for Benign Renal Tumors
EUROPEAN UROLOGY 64 (2013) 600 606 available at www.sciencedirect.com journal homepage: www.europeanurology.com Platinum Priority Kidney Cancer Editorial by Alexander Kutikov, Marc C. Smaldone and Robert
More informationPartial Nephrectomy Is Associated with Improved Overall Survival Compared to Radical Nephrectomy in Patients with Unanticipated Benign Renal Tumours
EUROPEAN UROLOGY 58 (2010) 293 298 available at www.sciencedirect.com journal homepage: www.europeanurology.com Kidney Cancer Partial Nephrectomy Is Associated with Improved Overall Survival Compared to
More informationComparison of Glomerular Filtration Rate (GFR) (RCC)
Merit Research Journal of Medicine and Medical Sciences (ISSN: 2354-323X) Vol. 3(10) pp. 467-471, October, 2015 Available online http://www.meritresearchjournals.org/mms/index.htm Copyright 2015 Merit
More informationComparison of Long-Term Results After Nephron-Sparing Surgery and Radical Nephrectomy in Treating 4- to 7-cm Renal Cell Carcinoma
:3-8 3 Comparison of Long-Term Results After Nephron-Sparing Surgery and Radical Nephrectomy in Treating 4- to 7-cm Renal Cell Carcinoma Daimantas Milonas, Giedrius Skulčius, Ruslanas Baltrimavičius, Stasys
More informationNephron-Sparing Surgery versus Radical Nephrectomy in the Treatment of Intracapsular Renal Cell Carcinoma up to 7 cm
european urology 53 (2008) 803 809 available at www.sciencedirect.com journal homepage: www.europeanurology.com Kidney Cancer Nephron-Sparing Surgery versus Radical Nephrectomy in the Treatment of Intracapsular
More informationCanadian Guidelines for Management of the Small Renal Mass (SRM)
Canadian Guidelines for Management of the Small Renal Mass (SRM) Michael A.S. Jewett*, Ricardo Rendon, Louis Lacombe, Pierre I. Karakiewicz, Simon Tanguay, Wes Kassouf, Mike Leveridge, Ilias Cagiannos,
More informationIndications For Partial
Indications For Partial Nephrectomy Christopher G. Wood, M. D., FACS Professor and Deputy Chairman Douglas E. Johnson, M. D. Endowed Professorship in Urology Department of Urology The University of Texas
More informationSt. Dominic s Annual Cancer Report Outcomes
St. Dominic s 2017 Annual Cancer Report Outcomes Cancer Program Practice Profile Reports (CP3R) St. Dominic s Cancer Committee monitors and ensures that patients treated at St. Dominic Hospital receive
More informationVincenzo Ficarra 1,2,3. Associate Editor BJU International
Partial Nephrectomy for RCC Vincenzo Ficarra 1,2,3 1 Director Department of Urology University of Udine, Italy 2 Associate Editor BJU International 3 Scientific Director OLV Robotic Surgery Institute,
More informationResearch Article Practice Trends in the Surgical Management of Renal Tumors in an Academic Medical Center in the Past Decade
ISRN Endoscopy Volume 2013, Article ID 945853, 5 pages http://dx.doi.org/10.5402/2013/945853 Research Article Practice Trends in the Surgical Management of Renal Tumors in an Academic Medical Center in
More informationEUROPEAN UROLOGY 61 (2012)
EUROPEAN UROLOGY 61 (2012) 1156 1161 available at www.sciencedirect.com journal homepage: www.europeanurology.com Platinum Priority Kidney Cancer Editorial by Alvin C. Goh and Inderbir S. Gill on pp. 1162
More informationKey Words: kidney; carcinoma, renal cell; renal insufficiency; nephrectomy; mortality
Comparative Effectiveness for Survival and Renal Function of Partial and Radical Nephrectomy for Localized Renal Tumors: A Systematic Review and Meta-Analysis Simon P. Kim, R. Houston Thompson, Stephen
More informationSmall Renal Mass Guidelines. Clif Vestal, MD USMD Arlington, Texas
Small Renal Mass Guidelines Clif Vestal, MD USMD Arlington, Texas Evaluation/Diagnosis 1. Obtain high quality, multiphase, cross-sectional abdominal imaging to optimally characterize/stage the renal mass.
More informationPartial Nephrectomy Techniques for Renal Preservation: Historical and Modern Approaches
Partial Nephrectomy Techniques for Renal Preservation: Historical and Modern Approaches Cary N Robertson MD FACS Associate Professor Division of Urology Associate Director Urologic Oncology Duke Cancer
More informationThe Role of Multitargeted Therapies in the Adjuvant Setting in Renal Cell Carcinoma
european urology supplements 7 (2008) 63 70 available at www.sciencedirect.com journal homepage: www.europeanurology.com The Role of Multitargeted Therapies in the Adjuvant Setting in Renal Cell Carcinoma
More informationComparison of radiographic and pathologic sizes of renal tumors
ORIGINAL Article Vol. 39 (2): 189-194, March - April, 2013 doi: 10.1590/S1677-5538.IBJU.2013.02.06 Comparison of radiographic and pathologic sizes of renal tumors Wei Chen, Linhui Wang, Qing Yang, Bing
More informationRAPN. in T1b Renal Masses? A. Mottrie. G. Denaeyer, P. Schatteman, G. Novara
RAPN in T1b Renal Masses? A. Mottrie G. Denaeyer, P. Schatteman, G. Novara Department of Urology O.L.V. Clinic Aalst OLV Vattikuti Robotic Surgery Institute Aalst Belgium Guidelines on Renal Cell Carcinoma
More informationOptimal Treatment of ct1b Renal Mass in Patient with Normal GFR: a Role for Radical Nephrectomy?
Optimal Treatment of ct1b Renal Mass in Patient with Normal GFR: a Role for Radical Nephrectomy? Steven C. Campbell, MD, PhD Program Director, Vice Chairman Department of Urology Center for Urologic Oncology
More informationEffects of Partial Nephrectomy on Postoperative Blood Pressure
www.kjurology.org http://dx.doi.org/10.4111/kju.2012.53.3.154 Urological Oncology Effects of Partial Nephrectomy on Postoperative Blood Pressure Nathan Lawrentschuk, Greg Trottier 1, Karli Mayo 2, Ricardo
More informationOUTCOME OF STAGE T1 RENAL CELL CARCINOMA TREATED WITH PARTIAL NEPHRECTOMY: INITIAL EXPERIENCES FROM A TEACHING HOSPITAL IN BANGLADESH
Public Health of Indonesia Morshed, M. S., et al. Public Health of Indonesia. 2018 September;4(3):91-99 http://stikbar.org/ycabpublisher/index.php/phi/index Original Research ISSN: 2477-1570 OUTCOME OF
More informationEUROPEAN UROLOGY 60 (2011)
EUROPEAN UROLOGY 60 (2011) 458 464 available at www.sciencedirect.com journal homepage: www.europeanurology.com Platinum Priorty Kidney Cancer Editorial by Christian G. Stief on pp. 465 466 of this issue
More informationAUA Guidelines Renal Mass and Localized Kidney Cancer
AUA Guidelines Renal Mass and Localized Kidney Cancer Steven C. Campbell, MD, PhD Chair AUA Guidelines Panel Professor Surgery, Vice Chair, Program Director Department of Urology Glickman Urological and
More informationOncourology COMPLICATIONS OF PARTIAL NEPHRECTOMY AT OPERATIVE TREATMENT OF RENAL CELL CARCINOMA
1 Oncourology COMPLICATIONS OF PARTIAL NEPHRECTOMY AT OPERATIVE TREATMENT OF RENAL CELL CARCINOMA Address: Eduard Oleksandrovych Stakhovsky, 03022, Kyiv, Lomonosova Str., 33/43, National Cancer Institute
More informationPartial versus radical nephrectomy for pt1a renal cancer in Serbia
JBUON 2016; 21(6): 1449-1453 ISSN: 1107-0625, online ISSN: 2241-6293 www.jbuon.com E-mail: editorial_office@jbuon.com ORIGINAL ARTICLE Partial versus radical nephrectomy for pt1a renal cancer in Serbia
More informationELECTIVE PARTIAL NEPHRECTOMY FOR T1B RCC. Vitaly Margulis MD. Associate Professor of Urology
ELECTIVE PARTIAL NEPHRECTOMY FOR T1B RCC Vitaly Margulis MD Associate Professor of Urology NEPHRON SPARING SURGERY WHY? MAXIMIZING NEPHRON MASS SAVES LIVES ELECTIVE PARTIAL NEPHRECTOMY IF: TECHNICALLY
More informationCan we predict which patients will evolve to chronic kidney disease after nephrectomy for cortical renal tumors?
ORIGINAL Article Vol. 38 (5): 637-644, September - October, 2012 Can we predict which patients will evolve to chronic kidney disease after nephrectomy for cortical renal tumors? Fabio Cesar Miranda Torricelli,
More informationPercutaneous Renal Cryoablation After Partial Nephrectomy: Technical Feasibility, Complications and Outcomes
Percutaneous Renal Cryoablation After Partial Nephrectomy: Technical Feasibility, Complications and Outcomes Ryan M. Hegg, Grant D. Schmit,* Stephen A. Boorjian, Robert J. McDonald, A. Nicholas Kurup,
More informationWhat is the role of partial nephrectomy in the context of active surveillance and renal ablation?
What is the role of partial nephrectomy in the context of active surveillance and renal ablation? Dogu Teber Department of Urology University Hospital Heidelberg Coming from Heidelberg obligates to speak
More informationRenal Tumor Contact Surface Area: A Novel Parameter for Predicting Complexity and Outcomes of Partial Nephrectomy
EUROPEAN UROLOGY 66 (2014) 884 893 available at www.sciencedirect.com journal homepage: www.europeanurology.com Platinum Priority Kidney Cancer Editorial by Homayoun Zargar, Riccardo Autorino, Oktay Akca
More informationChallenges in RCC surgery. Treatment Goals. Surgical challenges. Management options in VHL associated RCCs
Management options in VHL associated RCCs Challenges in RCC surgery JJ PATARD, MD, PhD Paris XI University Observation, Radical nephrectomy, Renal parenchymal sparing surgery, Open, laparoscopic, robotic
More informationRenal Function Adaptation up to the Fifth Decade After Treatment of Children With Unilateral Renal Tumor: A Cross-Sectional and Longitudinal Study
Pediatr Blood Cancer 2013;60:1534 1538 Renal Function Adaptation up to the Fifth Decade After Treatment of Children With Unilateral Renal Tumor: A Cross-Sectional and Longitudinal Study Denis A. Cozzi,
More informationUniversità di Roma La Sapienza
Università di Roma La Sapienza U.O.C. Chirurgia Pediatrica - Policlinico Umberto I Direttore: Prof Francesco Cozzi Chirurgia nephron-sparing per tumori renali primitivi in età pediatrica. Prof. Denis A.
More informationTumor necrosis is a strong predictor for recurrence in patients with pathological T1a renal cell carcinoma
ONCOLOGY LETTERS 9: 125-130, 2015 Tumor necrosis is a strong predictor for recurrence in patients with pathological T1a renal cell carcinoma KEIICHI ITO 1, KENJI SEGUCHI 1, HIDEYUKI SHIMAZAKI 2, EIJI TAKAHASHI
More informationRenal Mass Biopsy: Needed Now More than Ever
Renal Mass Biopsy: Needed Now More than Ever Stuart G. Silverman, MD, FACR Professor of Radiology Harvard Medical School Director, Abdominal Imaging and Intervention Brigham and Women s Hospital Boston,
More informationPatient Selection for Surgery in RCC with Thrombus. E. Jason Abel, M.D.
Patient Selection for Surgery in RCC with Thrombus E. Jason Abel, M.D. RCC with venous invasion Venous invasion occurs in ~10% of RCC Surgery more complex Increased risk for morbidity Thrombus may be confined
More informationIs There a Need to Further Subclassify pt2 Renal Cell Cancers as Implemented by the Revised 7th TNM Version?
EUROPEAN UROLOGY 59 (2011) 258 263 available at www.sciencedirect.com journal homepage: www.europeanurology.com Kidney Cancer Is There a Need to Further Subclassify pt2 Renal Cell Cancers as Implemented
More informationPrognostic factors in localized renal cell cancer
Original Article PROGNOSTIC FACTORS IN LOCALIZED RENAL CELL CANCER KNIGHT and STADLER Prognostic factors in localized renal cell cancer David A. Knight and Walter M. Stadler Section of Hematology/Oncology,
More informationLaparoscopic Partial Nephrectomy versus Laparoscopic Cryoablation for Multiple Ipsilateral Renal Tumors
european urology 53 (2008) 1210 1218 available at www.sciencedirect.com journal homepage: www.europeanurology.com Kidney Cancer Laparoscopic Partial Nephrectomy versus Laparoscopic Cryoablation for Multiple
More informationSurgery of Renal Cell Carcinoma Axel Bex, MD, PhD The Netherlands Cancer Institute
Surgery of Renal Cell Carcinoma Axel Bex, MD, PhD The Netherlands Cancer Institute 23 March 2012, Sao Paulo, Brazil Surgery of RCC Locally confined (small) renal tumours Locally advanced disease Metastatic
More informationEVALUATION OF THE OUTCOME OF THE MANAGEMENT OF PATIENTS WITH RENAL CELL CARCINOMA
International Invention Journal of Medicine and Medical Sciences (ISSN: 2408-7246) Vol. (9) pp. 99-204, November, 206 Available online http://internationalinventjournals.org/journals/iijmms Copyright 206
More informationAcknowledgements. National Kidney Foundation of Connecticut Mark Perazella. Co-PI Slowing the progression of chronic kidney disease to ESRD
A Practical Approach to Chronic Kidney Disease Management for the Primary Care Practioner: A web-site sponsored by the National Kidney Foundation of Connecticut Robert Reilly, M.D. Acknowledgements National
More informationGUIDELINES ON RENAL CELL CARCINOMA
GUIDELINES ON RENAL CELL CARCINOMA B. Ljungberg (chairman), D.C. Hanbury, M.A. Kuczyk, A.S. Merseburger, P.F.A. Mulders, J-J. Patard, I.C. Sinescu Introduction This EAU guideline was prepared to help urologists
More informationPredictive Preoperative Factors for Renal Insufficiency in Patients Followed for More Than 5 Years After Radical Nephrectomy
www.kjurology.org http://dx.doi.org/10.4111/kju.2013.54.5.303 Urological Oncology Predictive Preoperative Factors for Renal Insufficiency in Patients Followed for More Than 5 Years After Radical Nephrectomy
More informationRole of computed tomography-calculated intraparenchymal tumor volume in assessment of patients undergoing partial nephrectomy
International Journal of Urology (2018) 25, 436--441 doi: 10.1111/iju.13531 Original Article: Clinical Investigation Role of computed tomography-calculated intraparenchymal tumor volume in assessment of
More informationChronic kidney disease (CKD) has received
Participant Follow-up in the Kidney Early Evaluation Program (KEEP) After Initial Detection Allan J. Collins, MD, FACP, 1,2 Suying Li, PhD, 1 Shu-Cheng Chen, MS, 1 and Joseph A. Vassalotti, MD 3,4 Background:
More informationLymph Node Positive Bladder Cancer Treated With Radical Cystectomy and Lymphadenectomy: Effect of the Level of Node Positivity
EUROPEAN UROLOGY 61 (2012) 1025 1030 available at www.sciencedirect.com journal homepage: www.europeanurology.com Bladder Cancer Lymph Node Positive Bladder Cancer Treated With Radical Cystectomy and Lymphadenectomy:
More informationBilateral Renal Angiomyolipomas with Invasion of the Renal Vein: A Case Report
Case Study TheScientificWorldJOURNAL (2008) 8, 145 148 TSW Urology ISSN 1537-744X; DOI 10.1100/tsw.2008.29 Bilateral Renal Angiomyolipomas with Invasion of the Renal Vein: A Case Report C. Blick, N. Ravindranath,
More informationSAMPLING OF POST NEPHRECTOMY CANCER CARE (5)
SAMPLING OF POST NEPHRECTOMY CANCER CARE (5) Universally recognized post-nephrectomy cancer treatment. Sampling: National Comprehensive Cancer Network (NCCN) NCCN Clinical Practice Guidelines in Oncology
More informationAdverse Renal Outcomes in Subjects Undergoing Nephrectomy for Renal Tumors: A Population-Based Analysis
EUROPEAN UROLOGY 59 (2011) 333 339 available at www.sciencedirect.com journal homepage: www.europeanurology.com Platinum Priority Kidney Cancer Editorial by Paul Russo on pp. 340 341 of this issue Adverse
More informationRENAL CANCER GUIDELINES
Greater Manchester and Cheshire Cancer Network RENAL CANCER GUIDELINES Agreed by Urology CSG: July 2010 Review Date: July 2012 Renal Cancer Guidelines 1. Introduction 1.1 Kidney cancer accounts for 3%
More informationSurgical strategy of bilateral synchronous sporadic renal cell carcinoma experience of a Chinese university hospital
Hu et al. World Journal of Surgical Oncology (2017) 15:53 DOI 10.1186/s12957-016-1071-6 RESEARCH Surgical strategy of bilateral synchronous sporadic renal cell carcinoma experience of a Chinese university
More informationRoutine Drain Placement After Partial Nephrectomy is Not Always Necessary
Routine Drain Placement After Partial Nephrectomy is t Always Necessary Guilherme Godoy,* Darren J. Katz,* Ari Adamy, Joseph E. Jamal, Melanie Bernstein and Paul Russo From the Urology Service, Department
More informationLaparoscopic Surgery. The Da Vinci Robot. Limits of Laparoscopy. What Robotics Offers. Robotic Urologic Surgery: A New Era in Patient Care
Laparoscopic Surgery Robotic Urologic Surgery: A New Era in Patient Care Laparoscopic technique was introduced in urologic surgery in the 1990s Benefits: Improved recovery time, decreased morbidity Matthew
More informationQUICK REFERENCE FOR HEALTHCARE PROVIDERS
KEY MESSAGES 1 SCREENING CRITERIA Screen: Patients with DM and/or hypertension at least yearly. Consider screening patients with: Age >65 years old Family history of stage 5 CKD or hereditary kidney disease
More informationSung Han Kim, Jae Young Joung, Ho Kyung Seo, Kang Hyun Lee, and Jinsoo Chung
BioMed Research International Volume 2016, Article ID 5398381, 8 pages http://dx.doi.org/10.1155/2016/5398381 Research Article Baseline Chronic Kidney Disease and Ischemic Method of Partial Nephrectomy
More informationTreatment of Patients With Small Renal Masses: A Survey of the American Urological Association
Treatment of Patients With Small Renal Masses: A Survey of the American Urological Association Rodney H. Breau,*, Paul L. Crispen,* Sarah M. Jenkins, Michael L. Blute and Bradley C. Leibovich From the
More informationEvaluation of the Cockroft Gault, Jelliffe and Wright formulae in estimating renal function in elderly cancer patients
Original article Annals of Oncology 15: 291 295, 2004 DOI: 10.1093/annonc/mdh079 Evaluation of the Cockroft Gault, Jelliffe and Wright formulae in estimating renal function in elderly cancer patients G.
More informationGuidelines for the Management of Renal Cancer West Midlands Expert Advisory Group for Urological Cancer
Guidelines for the Management of Renal Cancer West Midlands Expert Advisory Group for Urological Cancer West Midlands Clinical Networks and Clinical Senate Coversheet for Network Expert Advisory Group
More informationSebastião Rodrigues Ferreira-Filho, Camila Caetano Cardoso, Luiz Augusto Vieira de Castro, Ricardo Mendes Oliveira, and Renata Rodrigues Sá
SAGE-Hindawi Access to Research International Nephrology Volume 211, Article ID 626178, 4 pages doi:1.461/211/626178 Research Article Comparison of Measured Creatinine Clearance and Clearances Estimated
More informationRisk of Chronic Kidney Disease After Nephrectomy for Renal Cell Carcinoma
www.kjurology.org http://dx.doi.org/10.4111/kju.2014.55.10.636 Review Article http://crossmark.crossref.org/dialog/?doi=10.4111/kju.2014.55.10.636&domain=pdf&date_stamp=2014-10-16 Risk of Chronic Kidney
More informationPrediction of complications after partial nephrectomy by RENAL nephrometry score
UROLOGY Ann R Coll Surg Engl 04; 96: 475 479 doi 0.308/00358844X3946849035 Prediction of complications after partial nephrectomy by RENAL nephrometry score UD Reddy, R Pillai, RA Parker, J Weston, NA Burgess,
More informationSurgical Management of Renal Cancer. David Nicol Consultant Urologist
Surgical Management of Renal Cancer David Nicol Consultant Urologist Roles of Surgery 1. Curative intervention localised disease 2. Symptomatic control advanced disease 3. Augmentation of efficacy of systemic
More informationRadical Cystectomy Often Too Late? Yes, But...
european urology 50 (2006) 1129 1138 available at www.sciencedirect.com journal homepage: www.europeanurology.com Editorial 50th Anniversary Radical Cystectomy Often Too Late? Yes, But... Urs E. Studer
More informationGuidelines on Renal Cell
Guidelines on Renal Cell Carcinoma (Text update March 2009) B. Ljungberg (Chairman), D.C. Hanbury, M.A. Kuczyk, A.S. Merseburger, P.F.A. Mulders, J-J. Patard, I.C. Sinescu Introduction Renal cell carcinoma
More informationLong-term Survival in Patients Undergoing Radical Nephrectomy and Inferior Vena Cava Thrombectomy: Single-Center Experience
EUROPEAN UROLOGY 57 (2010) 667 672 available at www.sciencedirect.com journal homepage: www.europeanurology.com Kidney Cancer Long-term Survival in Patients Undergoing Radical Nephrectomy and Inferior
More informationProspective multi-center study of oncologic outcomes of robot-assisted partial nephrectomy for pt1 renal cell carcinoma
Washington University School of Medicine Digital Commons@Becker Open Access Publications 2012 Prospective multi-center study of oncologic outcomes of robot-assisted partial nephrectomy for pt1 renal cell
More informationInternational Journal of Scientific & Engineering Research, Volume 6, Issue 2, February ISSN
International Journal of Scientific & Engineering Research, Volume 6, Issue 2, February-2015 1541 OPEN NEPHRECTOMY: A SEVEN- YEAR EXPERIENCE IN UNIVERSITY OF MAIDUGURI TEACHING HOSPITAL NORTH EASTERN NIGERIA
More informationAssociation between R.E.N.A.L. nephrometry score and perioperative outcomes following open partial nephrectomy under cold ischemia
original research Association between R.E.N.A.L. nephrometry score and perioperative outcomes following open partial nephrectomy under cold ischemia Dong Soo Park, MD; * Jin Ho Hwang, MD; * Moon Hyung
More informationS.C.D.U. Urologia Dir.: prof. Francesco Porpiglia
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 Chirurgia:
More informationeuropean urology 52 (2007)
european urology 52 (2007) 785 790 available at www.sciencedirect.com journal homepage: www.europeanurology.com Kidney Cancer Functional Significance of Using Tissue Adhesive Substance in Nephron-Sparing
More informationReflections on the current knowledge of epidemiology, treatment and prognosis for renal cell carcinoma Hew, M.N.
UvA-DARE (Digital Academic Repository) Reflections on the current knowledge of epidemiology, treatment and prognosis for renal cell carcinoma Hew, M.N. Link to publication Citation for published version
More informationPrecise Segmental Renal Artery Clamping Under the Guidance of Dual-source Computed Tomography Angiography During Laparoscopic Partial Nephrectomy
EUROPEAN UROLOGY 62 (2012) 1001 1008 available at www.sciencedirect.com journal homepage: www.europeanurology.com Platinum Priority Kidney Cancer Editorial by Inderbir S. Gill on pp. 1009 1010 of this
More informationIs the new Mayo Clinic Quadratic (MCQ) equation useful for the estimation of glomerular filtration rate in type 2 diabetic patients?
Diabetes Care Publish Ahead of Print, published online October 3, 2008 The MCQ equation in DM2 patients Is the new Mayo Clinic Quadratic (MCQ) equation useful for the estimation of glomerular filtration
More informationFlorida Cancer Specialist & Research Institute, Sebastian and Vero Beach, Fl, USA 3
Evaluation of Perioperative Outcomes and Renal Function after Robotic Assisted Laparoscopic Partial Nephrectomy Off/On Clamp: Comparison of ct1a versus ct1b Renal Masses Hugo H Davila 1-4*, Raul E Storey
More informationPresentation of Cases /Audience Voting/Panel/Discussion
Presentation of Cases /Audience Voting/Panel/Discussion JJ Patard Tim O Brien Ninth European International Kidney Cancer Symposium Dublin 25-26 April 2014 Clinical case 1 63 years old women Medical past
More informationElevation of Serum Creatinine: When to Screen, When to Refer. Bruce F. Culleton, MD, FRCPC; and Jolanta Karpinski, MD, FRCPC
Elevation of Serum Creatinine: When to Screen, When to Refer Bruce F. Culleton, MD, FRCPC; and Jolanta Karpinski, MD, FRCPC Presented at the University of Calgary s CME and Professional Development 2006-2007
More informationDebate: Lymphadenectomy is Important in mrcc, CON P. Mulder, M.D., Ph.D. JJ. Patard, MD, Ph.D.
Debate: Lymphadenectomy is Important in mrcc, CON P. Mulder, M.D., Ph.D. JJ. Patard, MD, Ph.D.. Eighth European International Kidney Cancer Symposium Budapest 03-04 May 2013 The role of LND In organ confined
More informationThe association between renal tumour scoring system components and complications of partial nephrectomy
Original research The association between renal tumour scoring system components and complications of partial nephrectomy Darren Desantis, MD, FRCSC;* Luke T. Lavallée, MD, FRCSC; * Kelsey Witiuk, PhD;
More informationIdentifying unrecognized collecting system entry and the integrity of repair during open partial nephrectomy: comparison of two techniques
ORIGINAL ARTICLE Vol. 40 (5): 637-643, September - October, 2014 doi: 10.1590/S1677-5538.IBJU.2014.05.08 Identifying unrecognized collecting system entry and the integrity of repair during open partial
More informationMODERN SYSTEM OF EVALUATION OF KIDNEY TUMOR (REVIEW)
MODERN SYSTEM OF EVALUATION OF KIDNEY TUMOR (REVIEW) E.A.Stakhovsky, I.V.Vitruk, O.A.Voilenko, O.Е.Stakhovskyi, P.S. Vukalovich, V.A.Kotov, O.M.Gavrylyuk National Canсer Institute, Kyiv, Ukraine Summary.
More informationIntroduction. Original Article: Clinical Investigation
International Journal of Urology (2019) 26, 120--125 doi: 10.1111/iju.13819 Original Article: Clinical Investigation Hypertension and diabetes mellitus are not associated with worse renal functional outcome
More informationDirectness Consistency Precision Reporting Bias
responsible for the accuracy and presentation of the material. Supplemental Table. Strength of evidence for primary. Key Outcomes* Studies (N) Study limitations Directness Consistency Precision Reporting
More informationLymphadenectomy in RCC: Yes, No, Clinical Trial?
Lymphadenectomy in RCC: Yes, No, Clinical Trial? Viraj Master MD PhD FACS Professor Associate Chair for Clinical Affairs and Quality Director of Clinical Research Unit Department of Urology Emory University
More informationClinical Symptoms Predict Poor Overall Survival in Chronic-dialysis Patients with Renal Cell Carcinoma Associated with End-stage Renal Disease
Jpn J Clin Oncol 2014;44(11)1096 1100 doi:10.1093/jjco/hyu117 Advance Access Publication 19 August 2014 Clinical Symptoms Predict Poor Overall Survival in Chronic-dialysis Patients with Renal Cell Carcinoma
More informationPatient Selection for Ablative Therapies. Adrian D Joyce Leeds UK
Patient Selection for Ablative Adrian D Joyce Leeds UK Therapy Renal Cell Ca USA: 30,000 new cases annually >12,000 deaths RCC accounts for 3% of all adult malignancy 40% of patients will die from their
More informationSalvage surgery after energy ablation for renal masses
Salvage surgery after energy ablation for renal masses Jose A. Karam, Christopher G. Wood, Zachary R. Compton, Priya Rao*, Raghunandan Vikram, Kamran Ahrar and Surena F. Matin Departments of Urology, *Pathology,
More informationSurgical Management of Metastatic and Locally Recurrent Kidney Cancer: Does it Make Sense?
Surgical Management of Metastatic and Locally Recurrent Kidney Cancer: Does it Make Sense? Philippe E. Spiess, MD, FACS Associate Member Department of GU Oncology Department of Tumor Biology Moffitt Cancer
More informationBJUI. Active surveillance of small renal masses offers short-term oncological efficacy equivalent to radical and partial nephrectomy
BJUI Active surveillance of small renal masses offers short-term oncological efficacy equivalent to radical and partial nephrectomy Nilay Patel, David Cranston, M. Zeeshan Akhtar, Caroline George, Andrew
More informationPROGNOSTIC FACTORS FOR SURVIVAL IN PATIENTS WITH METASTATIC RENAL CELL CARCINOMA TREATED WITH CHEMOTHERAPY
Journal of IMAB ISSN: 1312-773X http://www.journal-imab-bg.org http://dx.doi.org/10.5272/jimab.2016221.1045 Journal of IMAB - Annual Proceeding (Scientific Papers) 2016, vol. 22, issue 1 PROGNOSTIC FACTORS
More informationRenal functional outcomes after surgery for renal cortical tumors
Journal of Kidney Cancer and VHL 2015; 2(2):45-54 DOI: http://dx.doi.org/10.15586/jkcvhl.2015.26 Review Article Renal functional outcomes after surgery for renal cortical tumors Danny Lascano, Julia B.
More informationThe Diabetes Kidney Disease Connection Missouri Foundation for Health February 26, 2009
The Diabetes Kidney Disease Connection Missouri Foundation for Health February 26, 2009 Teresa Northcutt, RN BSN Primaris Program Manager, Prevention - CKD MO-09-01-CKD This material was prepared by Primaris,
More informationUro-Assiut 2015 Robotic Nephron Sparing Surgery
Uro-Assiut 2015 Robotic Nephron Sparing Surgery Khaled Fareed, MD, MBA Center for Advanced Laparoscopy, Robotics & Minimally Invasive Surgery Glickman Urological & Kidney Institute Associate Professor,
More informationLaparoscopic Partial Nephrectomy for Renal Tumours: Early Experience in Singapore General Hospital
576 Original Article Laparoscopic Partial Nephrectomy for Renal Tumours: Early Experience in Singapore General Hospital Nor Azhari Bin Mohd Zam, 1 MBBS, MRCS, MMed, Yeh Hong Tan, 1 FRCS, MMed, FAMS, Paul
More informationCanadian Urological Association guidelines for followup of patients after treatment of nonmetastatic
Canadian Urological Association guidelines for followup of patients after treatment of nonmetastatic renal cell carcinoma Wassim Kassouf, Leonardo L. Monteiro, Darrel E. Drachenberg, Adrian S. Fairey,
More informationWHAT IS THE ROLE OF ACTIVE SURVEILLANCE
WHAT IS THE ROLE OF ACTIVE SURVEILLANCE IN THE CONTEXT OF RENAL ABLATION AND PARTIAL NEPHRECTOMY? Alessandro Volpe University of Eastern Piedmont Novara, Italy RCC INCIDENCE SEER DATABASE (1975-2006) RCC
More informationSolitary Contralateral Adrenal Metastases after Nephrectomy for Renal Cell Carcinoma
Original Report ISSN 1537-744X; DOI 10.1100/tsw.2004.39 Solitary Contralateral Adrenal after Nephrectomy for Renal Cell Carcinoma Nikolaos Antoniou, M.D. and Demetrios Karanastasis, M.D. General Hospital
More informationSpecial Challenges and Co-Morbidities
Special Challenges and Co-Morbidities Renal Disease/ Hypertension/ Diabetes in African-Americans M. Keith Rawlings, MD Medical Director Peabody Health Center AIDS Arms, Inc Dallas, TX Chair, Internal Medicine
More information