Who are Candidates for Laparoscopic or Open Radical Nephrectomy. Arieh Shalhav

Transcription

1 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

2 Who are Candidates for Laparoscopic or Open Radical Nephrectomy Patients who are not candidates for active surveillance Patients with a single kidney or egfr< 60 Patients who are not technically amenable for Nephron Sparing Surgery (Partial Nephrectomy)

3 997 patients older than age 75 diagnosed with renal masses 110 (11%) initially managed with active surveillance Median age 81 y Median tumor size 2.5 cm ( cm) 43% - stable disease 57% - radiographic growth Average growth rate = 0.26 cm /year Not a strong association between tumor size and growth rate REF : Abouasally et al, J Urol 2008

4 Median follow-up 24 months 4 of 110 patients off surveillance Cancer specific survival: 100% No patient developed metastases REF : Abouasally et al, J Urol 2008

5 Small Renal Masses Pathologic Characteristics Based on Tumor Size: Mayo Clinic (n=2,935) Likelihood of RCC strongly associated with tumor size Of tumors < 4 cm, 23% are benign Consider a biopsy! Ref: Frank et al, J Urol 2003

6 Ref: Thompson et al, J Urol 2009

7 Patient Counseling We offer Active Surveillance + - Bx to 1) Elderly and co morbid patients 2) Patients with Chronic renal failure 3) Patients with small renal masses

8 Partial vs. Radical Nephrectomy Radical Nephrectomy is a known risk factor for chronic kidney disease (CKD) 1 CKD associated with CV disease and premature death 2 Nonetheless, radical nephrectomy remains the most common surgical treatment for small renal tumors 3 This may be contributing to increasing mortality in patients with small renal tumors, despite downward stage migration 4 1. Huang WC, Lancet Oncol 7: 735, Hollenbeck BK et al, Urology 67:254, Go AS et al, NEJM 351:1296, Hollingsworth JM et al, JNCI 98:1331, 2006

9

10 Despite normal preoperative serum creatinine levels, 26% of patients with a solitary, small, renal cortical tumour (<4 cm) and two normally functioning kidneys have pre-existing chronic kidney disease Stage 3 (GFR <60 ml/min per 1 73 m 2 ) Surgery related to New onset of estimated GFR < 60; < 45

11

12 1,228 partial nephrectomies from 6 institutions Prior to surgery, 22% had Stage III CKD (GFR: l/min/1.73m 2 ) 29% of pts with preop Stage I, II CKD Stage III or higher CKD Predictors of new Stage III-V CKD: Age, female, tumor size, lower baseline GFR Reference: Clark M et al. J Urol, 2011.

13 Association of Renal Function With Death, Cardiovascular Events, and Hospitalization Reference: Go et al. NEJM, 2004.

14 J Urol 181:55-62, 2009 SEER-Medicare study ( ) Patients 66 yrs Renal tumors 4 cm N = 2,991 2,547 (81%) radical nephrectomy 556 (19%) partial nephrectomy Radical nephrectomy associated with: risk overall mortality (HR 1.38; p < 0.01) 1.4 times greater number of CV events after surgery (p < 0.05)

15 J Urol 179: , 2008 RR 2.16 p = N = 327 pts < 65 yrs pt1a renal tumors 187 PN; 140 RN 10 yr overall survival: 82% RN 93% PN

16 Overuse of Radical Nephrectomy Despite the above data up to 90% of patients with small renal masses undergo radical nephrectomy Technical challenges of LPN vs LRN may be contributing factor We should Partial whenever technically feasible! Especially with GFR< 60 But is partial nephrectomy necessarily better...?

17 541 patients with 5cm renal mass 268 to NSS, 273 to RN Both groups had limited LND T1-2, N0 Normal contralateral kidney

18 10 year overall survival 81.1% RN 75.7% NSS p = progressions, 4 deaths due to RCC for RN 12 progressions, 8 deaths due to RCC for NSS

19 Critique: Incidence of other chronic disease 12.7% NSS vs. 7.7% RN, p=0.055 Crossover: 14.6% in NSS underwent RN vs. 5.9% in RN underwent NSS, p=0.001

20 Open vs. Lap Radical Nephrectomy 61 patients undergoing LRN vs. 33 ORN LRN: Less blood loss (172 vs. 451ml), shorter hospital stay (3.4 vs. 5.2 days), less pain medication (28 vs. 78 mg), quicker return to normal activity (3.6 vs. 8.1 weeks) Same cancer control

21 631 patients LRN, 924 patients ORN from LRN: Longer OR time (219 vs. 182 min), less blood loss (327 vs. 388 ml), lower complication rate (9.8 vs. 15.5%) 5-yr Overall Survival: 93.5% vs. 89.8%, LRN vs. ORN 5-yr RFS: 94.0 vs. 92.8%, LRN vs. ORN No difference when adjusted for age, sex, T stage, tumor grade, BMI

22 23 pts underwent LRN for masses >7cm vs. 25 ORN LRN: Longer operative time (171 vs. 141 min) Less blood loss (227 vs. 536 ml) Shorter hospital stay (6 vs. 11 days) Less postoperative analgesic requirement (45 vs. 112 mg) Better QOL and pain scores to 6 months postop Quicker return to 100% normal health (75 vs. 183 days)?economic impact

23 Open vs. Lap Radical Nephrectomy LRN: Also had shorter incision length (7 vs. 21cm) Up to 50% of patients undergoing ORN have a permanent flank bulge 1 REF : 1 Chatterjee et al, Urol Oncol 2004

24 Technique Lap/ Robotic/ Open Robotic? Increased operative time and cost 1 Transperitoneal vs. Retroperitoneal Equivalent oncologic outcomes at median follow-up 30 months 2 Hand-assisted reported for tumors up to 14cm 3 Technique does not matter think about the patient Bottom line if experience and technical skill exists do minimally invasive. REF : 1 Hemal and Kumar, World J Urol 2009; 2 Ha et al, BJU 2010; 3 Malaeb et al, Urol Oncol 2005

25 The Future... Proceed with Caution Zero Ischemia Partial

26 Thank you. It s good to be in Sao Paolo. Chicago February 2011.

27 Radical Nephrectomy Radical nephrectomy = Gold standard for patients with renal tumors not amenable to partial nephrectomy Outline Who is a candidate for radical nephrectomy? Open vs. Lap Radical Nx: Oncologic efficacies Perioperative complications Laparoscopic approaches transperitoneal, retroperitoneal, robotic Is partial nephrectomy necessarily superior to radical nephrectomy?