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, Aalst, Belgium
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, Aalst, Belgium
Partial Nephrectomy 1. Polar Nephrectomy 2. Wedge resection 3. Enucleoresection 4. Pure enucleation
The first postulate The are certain instances, when, it is unwise to do a nephrectomy It may also occur when the total renal function is such that nephrectomy for carcinoma would result in fatal uremia. The question is, whether such a procedure is ever justificable when the opposite kidney is normal. I am inclined to think that in certain circumstances it may be. Vermooten V. J Urol 1950; 64: 200-08
Potential indications for PN Imperative indications: RCC in solitary kidney, RCC in one kidney with inadequate contralateral renal function; bilateral synchronous RCC; Von Hippel-Lindau. Relative indications: conditions which could potentially impair renal function (e.g., stones, hypertension, diabetes, pyelonefritis) Elective indication: tumor 4cm, peripheral, normal contralateral kidney.
The aims of elective PN Complete removal of the tumor preserving the largest possible part of healthy renal parenchyma Renal function preservation (Chronic kidney disease prevention) (?) Overall survival improvement Oncological equivalence to Radical Nephrectomy Peri-operative morbidity equivalence to Radical Nephrectomy
Guidelines on Kidney Cancer Clinical NCCN, 2014 EAU, 2014 stage T1a PN preferred Open PN is recommended standard ( 4 cm) RN if PN not technically feasible, or central location Laparoscopic p PN optional in experienced centers Ablative technique for non-surgical candidate RN reasonable in selected cases T1b (4-7 cm) RN Whenever technically PN (whenever feasible, NSS is the standard technically ca feasible) e) procedure e for solitary tumours
2 1 3 1 2 1 2 2 1 1 Polar location Exophytic rate Rim location 2 1 2 2 2 1 1 3 Renal sinus involvement UCS involvement Tumour size
Surgeon experience Group 1, private practice, Surgeon age > 50 years, low PN case volume; Group 2, community base hospital practice, surgeon age 41 50 years, and moderate PN case volume; Group 3, academic practice setting, surgeon age 40 years, and high PN case volume. Wheight CJ et al BJU Inter 2013: 111: 731-738
PN: Main surgical approaches Open Laparoscopic Robot-assisted LESS/NOTES
PN: Main surgical steps Isolation of renal hilus Mobilisation of the kidney Clamping of renal artery (and vein) Tumour excision Renorrhaphy
Open PN: isolation of renal hilus
Open PN: tumor(s) isolation
Open PN: tumor(s) demarcation
Open PN: tumor(s) demarcation
Open PN: table check
Parenchymal ischemia Without ischemia (parenchymal compression around the tumour) Warm ischemia (clamping the renal peduncle) Could ischemia (20-25 C) - ice sluch around the kidney - transarterial cooling by perfusion of Ringer's solution (5-10 C)
Partial Nephrectomy: warm ischemia versus no ischemia 458 PN for a renal mass in solitary kidney Thompson RH. et al Eur Urol 2010; 58: 331-336
Every minute counts when the renal hilum is clamped during partial nephrectomy Thompson RH et al Eur Urol 2010; 58: 340-345
Open PN: tumor(s) excission
Open PN: tumor(s) excission
Open PN: minimal partial nephrectomy
Open PN: minimal partial nephrectomy
Open PN: clampless or clamping
Open PN: renorrhaphy
Open PN: renorrhaphy
Case #1 VF, male 60 years old LUTS due to BPE (September 2014): incidental detection during ultrasound examination for LUTS/BPE TC scan: Renal mass 4 x 3 cm, upper pole left kidney (ct1a N0 M0); normal controlateral t l kidney
Case #1 PADUA score: 12
Case #1 PADUA score: 12
Case #1 PADUA score: 12
Case #1
Case #1 WIT: 19 min EBL: 500 ml Tumor size: 4 cm (pt1a R-) - Oncocytoma Postop Creat: 1.3 mg/dl
Case #2 BD, male 58 years old Hypertension; diabetes; LUTS Serum creatinine: 0.91 mg/dl (October 2014): Left flank pain TC scan: Renal mass 5 x 5 cm hilar location in left TC scan: Renal mass 5 x 5 cm, hilar location in left kidney (ct1b N0 M0); normal controlateral kidney
Case #2 PADUA score: 12
Case #2
Case #2 WIT: 13 min; EBL: 300 ml Tumor size: 5 cm (pt1b R-) - Clear cell RCC; Grade 3; necrosis absent
Case #3 TL, male 75 years old Hypertension; diabetes; light chronic renal failure (Creatinine clearance: 49 ml/min) (October 2014): incidental detection during ultrasound examination for unrelated complaints TC scan: Renal mass 5 x 5 x 7 5 cm lower pole of TC scan: Renal mass 5 x 5 x 7.5 cm, lower pole of left kidney (ct2 N0 M0); normal controlateral kidney
Case #3 PADUA score: 12
Case #3 WIT: 17 min EBL: 600 ml Tumor size: 7 cm (pt3a R-) - Clear Cell RCC - Grading 1 Fuhrman - necrosis present Postop Creat: 14 1.4 mg/dl
Case #4 PS, female 77 years old Hypertension; Serum Creatinine: i 0.84 (October 2013): incidental detection during ultrasound examination for unrelated complaints TC scan: Renal mass 2.6 cm, hilar location in right kidney (ct1a N0 M0) suspicious for oncocytoma; normal controlateral kidney
Case #4 PADUA score: 12
Case #4
Case #4
Case #4
Case #4 WIT: 9 min EBL: 200 ml Tumor size: 3 cm (pt1a R-) - Oncocytoma Postop Creat: 0.9 mg/dl
Case #5 RM, male 72 years old In 1974 Left Simple Nephrectomy (TBC) (January 2014) hematuria Creatininemia: 1.58 mg/dl No co-morbidities
Case #5 Abdominal CT scan: Renal mass 7 x 7.5 cm, upper pole of right kidney (ct2 N0 M0)
Case #5 PADUA score: 12 Creatininemia (post-tc): 6.23 mg/dl Preop Creatininemia: 25 2.5 mg/dl
Case #5 WIT: 14 min EBL: 500 ml Tumor size: 8 cm (pt2a R-) - Clear Cea Cell RCC - Grading 2 Fuhrman - necrosis absent Postop dyalisis (2 mo) 6 mo: Creat 1.8
Case #6 SE, 63 years old, male At Arterial lhypertension, chronic renal lfailure (creatinine i 2 mg/dl) (January 2015): incidental detection of two masses of the left kidney at ultrasound performed for surveillance of chronic renal failure TC scan: two renal masses of the left kidney, one of 4 x 5 cm, lower pole, anterior face and one of 6.5 x 4.7 cm, upper pole, posterior face; small contralateral kidney
Case #6 * * Lesion #1: PADUA score 11
Case #6 * * Lesion #2: PADUA score 12
Case #6 WIT: 25 min EBL: 400 ml Pathological examination: in progress Postop Creat: 2.63 mg/dl One week postoperative One week postoperative creatinine: 2.10 mg/dl
Case #7 RA, 42-year-old male HCV+, alcoholism (December 2014): incidental detection of left kidney mass at ultrasound performed for elevated liver function tests TC scan: 4 x 3.4 cm solid hilar mass (?) of the left kidney, entirely endophytic between the sinus lines, in contact with renal vessels
Case #7 PADUA score: 12
Case #7
Case #7 WIT: 22 min EBL: 400 ml Tumor size: 4.5x3.5 cm, clear cell RCC, Grade II (pt1b Nx, R-) Postop Creat: 1.50 mg/dl