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PubMed2000

The safety and efficacy of laparoscopic live donor nephrectomy: a systematic review.

BACKGROUND: The aim of this systematic review was to compare the safety and efficacy of laparoscopic live donor nephrectomy with the "gold" standard of open live donor nephrectomy. METHODS SEARCH STRATEGY: Three search strategies were devised to enable literature retrieval from the Medline, Current Contents, Embase, and Cochrane Library databases up until, and including, February 2000. STUDY SELECTION: Inclusion of a report was determined on the basis of a predetermined protocol, independent assessment by two reviewers, and a final consensus decision. English language reports were selected and acceptable study designs included randomized-controlled trials, controlled clinical trials, case series, or case reports. Each report was required to provide information on at least one of several safety and efficacy outcomes as detailed in the protocol. DATA COLLECTION AND ANALYSIS: Twenty-five reports met the inclusion criteria. They were tabulated and critically appraised in terms of the methodology and design, sample size, outcomes, and the possible influence of bias, confounding, and chance. RESULTS: High level evidence comparing the safety and efficacy of laparoscopic live donor nephrectomy with open donor nephrectomy was not available at the time of this review. Limited low level evidence suggested that the laparoscopic approach might be advantageous regarding the donor's hospital stay, convalescence, pain, and resumption of employment. CONCLUSIONS: The ASERNIP-S Review Group concluded that the evidence-base for laparoscopic live donor nephrectomy was inadequate to make a safety and efficacy recommendation. Clinical and research recommendations were developed regarding the introduction and current practice of this procedure in Australia.

Australia↗

PubMed2002

Early experience with robotically assisted laparoscopic donor nephrectomy.

The da Vinci robotic system became available at our institution in late August 2000. We decided to use this system to perform robotically assisted laparoscopic donor nephrectomies. A prospective study was conducted of 10 consecutive patients who underwent robotically assisted laparoscopic donor nephrectomy between January and May 2001. The mean operative time was 166 minutes. The mean hospital stay was 1.8 days. The need for parenteral pain medication was limited to the first postoperative day. All kidneys were transplanted successfully; no rejections occurred. This early experience suggests that the results of robotically assisted laparoscopic donor nephrectomy are similar to those of laparoscopic donor nephrectomy. We believe that robotic surgery, which enables regaining of the hand-eye coordination and three-dimensional view lost in laparoscopic surgery, allows us to perform the donor nephrectomy with greater precision, confidence, and comfort.

Adult↗

PubMed2003

Expanded experience with laparoscopic nephrectomy and autotransplantation for severe ureteral injury.

PURPOSE: Complex injuries of the upper ureter with significant loss of length are difficult to manage. Traditional options include nephrectomy, bowel interposition and autotransplantation. The advent of laparoscopic donor nephrectomy has created a new option when preservation of functioning renal parenchyma is desirable. We update our experience with severe iatrogenic ureteral injuries requiring laparoscopic nephrectomy and autotransplantation. MATERIALS AND METHODS: Seven patients with severe ureteral injuries were referred for definitive management. In all cases preoperative evaluation demonstrated comparable split renal function and anatomy not amenable to routine reconstruction. Transperitoneal laparoscopic nephrectomy and autotransplantation to the ipsilateral pelvis were attempted. RESULTS: Of the patients 5 had a history of nephrolithiasis with intervention resulting in the ureteral injury and 5 underwent prior endoscopic or open management of the defects. All cases were associated with dense perinephric and perihilar fibrosis. Operative and warm ischemic times averaged 508 and 5 minutes, respectively. After ex vivo graft preparation, ureteral and vessel length and quality were adequate for transplantation in 6 cases. In the other patient the renal pelvis was not amenable for reconstruction. Urinary drainage consisted of ureteroneocystostomy in 2 cases and ipsilateral ureteroureterostomy in 4. There were no intraoperative complications and all grafts functioned immediately. Hospitalization averaged 6.4 days. At a mean followup of 17 months imaging studies demonstrated functioning renal autographs with a mean decrease in serum creatinine of 5%. CONCLUSIONS: Laparoscopic nephrectomy in conjunction with autotransplantation is a viable option for severe proximal ureteral loss. Acceptable perioperative morbidity and excellent graft function were obtained in all cases when the kidney was transplanted. Close cooperation with a transplant team is crucial to coordinate graft harvest, ensure appropriate organ preparation and select the optimal urinary anastomosis.

Adult↗

PubMed2004

Emerging nephron sparing treatments for kidney tumors: a continuum of modalities from energy ablation to laparoscopic partial nephrectomy.

PURPOSE: The current global medical trend toward minimally invasive treatment for various tumors has generated special interest in several minimally invasive options in the management of kidney tumors. We discuss the role of nephron sparing surgery by less invasive options than the time-honored partial nephrectomy, and the current multitude of energy based tumor ablative methods. MATERIALS AND METHODS: We searched the English literature following the introduction of nephron sparing surgery, with special attention to various emerging minimally invasive surgical and ablative alternatives. RESULTS: Laparoscopic partial nephrectomy can be performed safely following the surgical oncology principles established by open partial nephrectomy. Initial results from the various energy based modalities, most notably cryoablation, indicate that high local control rates can be achieved. However, caution is advised since viable tissue has been observed after minimally invasive ablative therapies. Available data, while promising, are still lacking for long-term followup. CONCLUSIONS: Compared to open partial nephrectomy the laparoscopic approach offers similar cancer-free survival rates. However, the procedure requires highly skilled surgeons. Of the energy based ablative treatments cryoablation followed by radio frequency ablation offers the most meaningful results, with promising local control rates indicated in some series. These methods can be performed less invasively than partial nephrectomy and require less surgical expertise. We anticipate that these modalities will be formalized into urological practice and serve as a single continuum of care, customized according to disease and surgical expertise.

Cryosurgery↗

PubMed2004

Clinical skills acquisition for hand-assisted laparoscopic donor nephrectomy.

PURPOSE: The learning curve associated with laparoscopic surgery may be associated with higher patient risk, and in the setting of kidney donation such risk may be unacceptable. We characterize the learning curve for hand-assisted laparoscopic donor nephrectomy in the context of a urology training program, and establish a case volume threshold after which improvements in laparoscopic skill can be demonstrated. MATERIALS AND METHODS: The study included 245 consecutive laparoscopic cases, including 111 donor nephrectomies, performed in 2 (1/2) years to characterize various measures of experience. Documentation of resident involvement in each case was made by a single surgeon and collected prospectively. Outcomes assessed included operative time, blood loss and intraoperative complications. RESULTS: Of the 111 hand-assisted donor nephrectomies the resident was surgeon in 47%. Operative time proved a reliable and sensitive measure of surgeon experience. Increasing laparoscopic experience, as measured by several parameters, was associated with decreasing operative time (each p <0.02). Measurable improvements in laparoscopic skill were realized after participating in 13 (p = 0.007) or serving as surgeon in as few as 6 (p = 0.02) hand-assisted donor nephrectomies. Conversion (2%) and intraoperative complication rates (3%) were low. CONCLUSIONS: Skills for hand-assisted laparoscopic donor nephrectomy can be safely taught in the context of a urology training program independent of resident training level. We documented measurable improvements in laparoscopic skill as gauged by operative time. Our findings provide a basis by which expectations can be set for laparoscopic skill acquisition in the context of a residency program and for the laparoscopically naïve surgeon.

Clinical Competence↗

PubMed2004

Laparoscopic partial nephrectomy in cold ischemia: renal artery perfusion.

PURPOSE: Laparoscopic partial nephrectomy represents a feasible option for patients with small renal masses. We describe our initial experience with laparoscopic partial nephrectomy in cold ischemia achieved by renal artery perfusion. MATERIALS AND METHODS: From November 2001 to March 2003 laparoscopic partial nephrectomy in cold ischemia was performed in 15 patients with renal cell carcinoma. Cold ischemia was achieved by continuous perfusion of Ringers lactate at 4C through the renal artery, which was clamped. Tumor excision was performed in a bloodless field with biopsy taken from the tumor bed. The collecting system was repaired if needed. Renal reconstruction was performed by suturing over hemostatic bolsters. RESULTS: All procedures were successfully completed laparoscopically by our new technique. Mean operative time was 185 minutes (range 135 to 220). Mean ischemia time was 40 minutes (range 27 to 101). Estimated mean intraoperative blood loss was 160 ml (range 30 to 650). Entry to the collecting system in 6 patients was repaired intraoperatively. Additional vascular repair was done in 2 patients. There were no significant postoperative complications. Postoperative followup in 8 patients showed that the renal parenchyma was not damaged by the ischemic period. CONCLUSIONS: Our initial experience of incorporating cold ischemia via arterial perfusion into laparoscopic partial nephrectomy shows the feasibility and safety of the technique. We believe that this approach has the potential to make laparoscopic partial nephrectomy for renal cell carcinoma safe and reliable.

Adult↗

PubMed2004

Ketorolac: safe and effective analgesia for the management of renal cortical tumors with partial nephrectomy.

PURPOSE: Ketorolac has demonstrated advantages as a supplement to opioid based analgesia in several surgical settings, including donor nephrectomy. To our knowledge there has been no published data to date on the use of ketorolac in patients undergoing partial nephrectomy. We compared analgesia with ketorolac and opioids to analgesia with opioids alone with regard to pain control, postoperative recovery and effects on renal function in patients with renal cortical tumors surgically managed by partial nephrectomy. MATERIALS AND METHODS: Records for 154 patients treated with partial nephrectomy for renal cortical tumors were retrospectively analyzed. Clinicopathological variables examined were age, gender, medication use, comorbidity profile, operation side, estimated blood loss, hospital stay, operative duration, American Society of Anesthesiologists class, histopathology results, perioperative transfusion status, ischemia type (warm vs cold vs none), duration of renal artery cross clamping, tumor size and intraparenchymal location, pathological stage and perioperative complications. Postoperative duration to the initiation of solid diet, discontinuation of patient controlled analgesia and overall pain control were assessed. Serum creatinine was measured during the preoperative period, and at 1, 3 or greater and 30 or greater days postoperatively. RESULTS: Patients who received ketorolac demonstrated superior postoperative recovery with an earlier return to solid diet and earlier discontinuation of patient controlled analgesia. Treatment groups were similar with respect to changes in serum creatinine, blood loss, transfusion rates and complication rates. Ketorolac was not associated with an increased risk of acute renal failure. CONCLUSIONS: Ketorolac is a safe and effective supplement to opioid based analgesia for pain control after partial nephrectomy.

Adult↗

PubMed2004

Cytoreductive nephrectomy in patients with metastatic renal cancer: a combined analysis.

PURPOSE: Metastatic renal cancer is associated with a poor prognosis. Recent advances in immunotherapy for this problem have rekindled interest in cytoreductive nephrectomy. We report a combined analysis of 2 prospective randomized trials that used an identical study protocol. MATERIALS AND METHODS: A total of 331 patients were randomized to 2 identical protocols comparing cytoreductive nephrectomy plus interferon alpha-2b vs interferon alpha-2b alone in patients with metastatic renal cancer, in whom the primary tumor was present and believed to be resectable. The primary end point for each trial was overall survival with a secondary end point of the response rate. Patients were stratified at pre-randomization by performance status (0 or 1), site of metastases (lung only vs other) and disease measurability. All results were analyzed by intent to treat criteria. Assuming a median survival of 1 year for interferon only, the Southwest Oncology Group trial was designed to detect a 50% improvement in median survival duration and a 15% improvement in response rate with a power of 0.85. The European Organization for the Research and Treatment of Cancer accrued an additional 80 patients in that study. RESULTS: The combined analysis of these 2 trials yielded a median survival of 13.6 months for nephrectomy plus interferon vs 7.8 months for interferon alone. This difference represents a 31% decrease in the risk of death (p = 0.002). There was no evidence of a difference in the size of the treatment effect according to pre-randomization stratification factors. CONCLUSIONS: Cytoreductive nephrectomy appears to improve significantly overall survival in patients with metastatic renal cancer treated with interferon immunotherapy independent of patient performance status, the site of metastases and the presence of measurable disease. Although it is highly statistically significant, the overall survival advantage is only 5.8 months for the entire group. These data emphasize the need to determine if this survival advantage can be further improved using more aggressive immunotherapy or other novel agents in the setting of cytoreductive nephrectomy.

Adult↗

PubMed2004

Technique, indications and outcomes of pure laparoscopic right donor nephrectomy.

PURPOSE: Laparoscopic nephrectomy for living renal transplantation has emerged as the gold standard. Nevertheless, experience with this technique for procuring right kidneys is limited. We report our single institution results of pure laparoscopic right donor nephrectomy. MATERIALS AND METHODS: Laparoscopic donor nephrectomy was initiated at the our institution in November 1999. Patient selection was initially limited to the left kidney but right surgery was started 2 years later after 97 operations had been performed. We prospectively acquired data on the donor and recipient, and specifically analyzed outcomes of the right kidneys. RESULTS: In a 40-month period 300 laparoscopic donor operations were performed. Overall 44 procedures (15%) were on the right side with the fraction greater (22%) after removing exclusion of the right kidney from laparoscopic selection criteria. In this cohort mean operative time was 170 minutes, significantly less than the 190 minutes for 50 contemporaneous left kidneys (p = 0.001). No case of right donor nephrectomy required open conversion and vessels were of adequate length. Donor and recipient complications were similar in the 2 groups without technical graft loss in the entire series. CONCLUSIONS: Our method of laparoscopic right donor nephrectomy yields excellent graft quality with adequate vascular length and without the need for elaborate modifications or hand assistance. Moreover, the right operation is technically easier and it achieved comparable donor morbidity and recipient renal function. With sufficient experience the right kidney should be procured laparoscopically when indicated.

Adolescent↗

PubMed2004

Guidelines for the surveillance of localized renal cell carcinoma based on the patterns of relapse after nephrectomy.

PURPOSE: We characterized relapse patterns in patients with sporadic renal cell carcinoma (RCC) following radical and partial nephrectomy, and developed surveillance guidelines. MATERIALS AND METHODS: Between 1989 and 2000, 495 patients underwent nephrectomy for RCC at 1 of 5 Canadian referral centers. Median followup was 42 months. RESULTS: The rate of relapse, time to relapse and site of relapse were associated with pathological stage. Five-year progression-free probability was 93% for pT1, 81% for pT2, 67% for pT3A and 57% for pT3B (p <0.001). Compared to patients with pT1-2 those with pT3A-B lesions had earlier relapse after nephrectomy (median 12 vs 26 months, p = 0.001) and were at higher risk for relapse at abdominal sites (14% vs 1.8%, p < 0.001). Abdominal relapse was detected in the absence of symptoms, abnormal biochemical profile or thoracic metastases detectable by chest x-ray in 7 patients (1.4%) overall, including 3 (0.9%) with pT1, 3 (4%) with pT3A and 1 (3%) with pT3B. CONCLUSIONS: The risk and the pattern of relapse of RCC after nephrectomy are associated with pathological stage. For the surveillance of recurrent disease after nephrectomy we recommend annual clinical assessment and chest x-ray in pT1-2 cases. Patients with pT3A-B should be followed every 6 months for the first 3 years with clinical assessment and chest x-ray, and annual followup thereafter. The higher risk of abdominal relapse in patients with pT3A-B indicates that they should receive surveillance abdominal imaging. We recommend abdominal computerized tomography 6, 12, 24 and 36 months postoperatively.

Adult↗

PubMed2004

Differences in complications and outcomes for obese patients undergoing laparoscopic radical, partial or simple nephrectomy.

PURPOSE: Obesity has increased dramatically in American society during the last 2 decades. While the laparoscopic approach is common for patients requiring radical and partial nephrectomy, it is unclear if this procedure leads to worse outcomes and complications in obese patients. We determined if obese patients undergoing laparoscopic radical (RN), partial (PN) and simple (SN) nephrectomy are at risk for worse surgical outcomes or increased complications. MATERIALS AND METHODS: We retrospectively identified patients treated with nontransplant transperitoneal laparoscopic nephrectomies from 1998 to 2003. Patients with missing body mass index (BMI), operative, postoperative or pathological information were excluded from study. Obese patients (BMI 30 or greater) were compared to nonobese patients (BMI less than 30). RESULTS: A total of 189 patients undergoing 117 RN, 44 PN and 30 SNs met study criteria, and 29.0% of patients were obese. Overall obese patients had longer operative times (280 versus 241 minutes, p = 0.003), greater estimated surgical blood loss (230 versus 109 ml, p = 0.0001) and higher transfusion rates (6.8% versus 0.8%, p = 0.032) than nonobese patients. In subgroup analyses obese patients receiving RN and PN had longer operative times and increased blood loss. Obese and nonobese patients have similar open conversion rates, analgesic requirements, hospital stay, time to oral intake, and major and minor complication rates regardless of nephrectomy type. CONCLUSIONS: Laparoscopic nephrectomy is associated with slightly greater operative time, estimated blood loss and transfusion rates in obese patients. Laparoscopic RN, PN and SN are safe and well tolerated in obese patients. Obesity is not a contraindication to laparoscopic renal surgery.

Female↗

PubMed2005

A history of partial nephrectomy for renal tumors.

PURPOSE: This article records the history of nephron sparing surgery for renal tumors. MATERIALS AND METHODS: Multiple biomedical databases were queried. Original sources were reviewed to document the history of partial nephrectomy. RESULTS: For more than a century partial nephrectomy evolved as treatment for renal tumors, first by accident, then rejected as a planned procedure in favor of radical nephrectomy, later in mandatory cases of solitary kidney, poor renal function or bilateral renal tumors and then to an accepted elective procedure in cases with a healthy opposite kidney. Partial nephrectomy became widely accepted only recently for many renal tumors due to parallel advances in tumor biology, radiological imaging and surgical technology. CONCLUSIONS: The history of partial nephrectomy is a timely story setting important precedents for understanding current and future strategies to treat changing patterns of renal neoplasms.

History, 19th Century↗

PubMed2005

Associations with contralateral recurrence following nephrectomy for renal cell carcinoma using a cohort of 2,352 patients.

PURPOSE: We determined the incidence of and factors associated with the development of renal cell carcinoma (RCC) in the contralateral kidney after nephrectomy for localized RCC. MATERIALS AND METHODS: Between 1970 and 2000, 2,352 patients with sporadic, localized unilateral RCC and a normal contralateral kidney underwent nephrectomy for RCC. Cancer specific survival rates were estimated using the Kaplan-Meier method. Univariate Cox proportional hazards models were used to determine associations with outcome. RESULTS: Of the 2,352 patients studied 28 (1.2%) had RCC in the contralateral kidney, including 20 with clear cell and 8 with papillary RCC. Mean time from primary surgery to contralateral recurrence was 5.2 years (median 4.8, range 0 to 18) for clear cell RCC compared with 5.6 years (median 1.3, range 0 to 21) for papillary cell RCC. Positive surgical margins (risk ratio 14.23, p = 0.010) and multifocality (risk ratio 5.74, p = 0.019) were significantly associated with contralateral recurrence following nephrectomy for clear cell RCC, while nuclear grade (risk ratio for grades 3/4 vs 1/2, 4.78, p = 0.040) was significantly associated with contralateral recurrence following nephrectomy for papillary RCC. In patients with clear cell RCC estimated cancer specific survival rates 1, 3, and 5 years following contralateral recurrence were 93.8%, 80.2% and 72.9%, respectively. CONCLUSIONS: In patients with localized RCC and a normal contralateral kidney who underwent nephrectomy for RCC positive surgical margins and multifocality were significant predictors of contralateral recurrence for clear cell RCC, while nuclear grade was a significant predictor of contralateral recurrence for papillary RCC.

Adult↗

PubMed2005

Effect of warmed, humidified insufflation gas and anti-inflammatory agents on cytokine response to laparoscopic nephrectomy: porcine model.

PURPOSE: We evaluated the effects of warmed, humidified CO2 and anti-inflammatory agents on the local and systemic cytokine response after laparoscopic nephrectomy. MATERIALS AND METHODS: A total of 15 pigs were randomized to undergo standard laparoscopic nephrectomy, laparoscopic nephrectomy with warmed, humidified CO2 gas or laparoscopic nephrectomy with perioperative administration of intravenous dexamethasone and oral rofecoxib. At baseline, and 1, 4, 24 and 48 hours after surgery duplicate blood and peritoneal samples were drawn to analyze cortisol, glucose, tumor necrosis factor-alpha (TNF-alpha), interleukin (IL)-1beta and IL-6 via a microassay technique. Body temperature was determined at operation, intraoperatively and 1 hour postoperatively. Surgical parameters, including operative time, gas volume used and blood loss, were recorded. RESULTS: Pigs in the warmed, humidified CO2 and anti-inflammatory arms maintained higher intraoperative and postoperative core body temperatures than controls. Warmed, humidified CO2 did not affect peritoneal or systemic cytokine levels. Peak peritoneal TNF-alpha levels in the anti-inflammatory group were significantly higher than in controls at 4 hours. Considerably higher serum TNF-alpha levels in the anti-inflammatory group were observed at 48 hours. Peritoneal IL-1beta and IL-6 levels in the anti-inflammatory group remained similar to those in controls, while serum levels were noticeably lower. There was no observable difference in serum cortisol or the glucose response to laparoscopic nephrectomy among the groups. CONCLUSIONS: While preserving core body temperature, humidified, warmed CO2 did not affect local or systemic trends of pro-inflammatory mediators. The administration of perioperative anti-inflammatory agents produced conflicting local and systemic cytokine response of uncertain clinical significance.

Animals↗

PubMed2005

Long-term survival analysis after laparoscopic radical nephrectomy.

PURPOSE: This report assesses the long-term oncological efficacy of laparoscopic radical nephrectomy compared with open radical nephrectomy in patients with clinically localized renal cell carcinoma. MATERIALS AND METHODS: We analyzed the data from 121 patients who underwent radical nephrectomy between 1991 and 1999 for clinical tumor stage T1/2 N0M0. The medical records of all patients were retrospectively reviewed with emphasis on tumor recurrence and survival. Statistical comparison was performed using Kaplan-Meier analysis. RESULTS: The median followup was 73 months for the laparoscopic group and 80 months for the open group. Of the 67 patients who underwent laparoscopic surgery, 53 survived without any recurrence of disease, 2 are currently alive with metastasis, 2 died of metastatic disease in months 12 and 17, and 10 patients died without any disease recurrence. Laparoscopic port site metastasis did not develop in any patients. Of the 54 who underwent open surgery, 34 survived without any recurrence of disease, 1 currently has metastasis, 6 died of metastasis within 17 to 74 months, and 13 died without any disease recurrence. A comparison of the 5 and 10-year disease-free survival rates of the laparoscopic and open groups revealed no significant differences. In addition, the 5 and 10-year cancer specific and actuarial survival rates were not significantly different. CONCLUSIONS: Based on long-term followup, our evaluation confirmed for clinical tumor stage T1/2 N0M0 that laparoscopic radical nephrectomy is oncologically equivalent to open radical nephrectomy.

Carcinoma, Renal Cell↗

PubMed2004

Advances in laparoscopic partial nephrectomy.

PURPOSE OF REVIEW: The advantages of the laparoscopic approach in the management of kidney tumors are unequivocal and the role of laparoscopy in nephron-sparing surgery is evolving. In a selected group of patients with small exophytic renal tumors laparoscopic partial nephrectomy became an alternative to open partial nephrectomy. However, the application of laparoscopic partial nephrectomy to larger, centrally located tumors or tumors in unfavorable sites is limited by the difficulty of achieving adequate, prompt collecting system closure and hemostasis with a limited warm ischemia time. The most recent developments in laparoscopic partial nephrectomy are the subject of this review. RECENT FINDINGS: A number of sealant products have been used as an adjunct or principal hemostatic agent in the animal model. Their application in the clinical setting remains limited to small parenchymal bleeding; larger vessels and pelvicaliceal openings are better managed by vascular clamping and intracorporeal suturing. Vascular clamping confers warm ischemia, and attempts at renal hypothermia included cold kidney irrigation through either a ureteral stent or a renal artery cannulation, and the application of ice slush for parenchymal surface cooling. SUMMARY: Laparoscopic partial nephrectomy is technically demanding; efforts directed towards facilitating hemostasis, improving renal cooling or shortening the warm ischemia time will expand its indications further.

Humans↗

PubMed2005

Laparoscopic radical nephrectomy for renal cell carcinoma: the standard of care already?

PURPOSE OF REVIEW: Laparoscopic radical nephrectomy has been developed and applied for patients with renal cell carcinoma since 1992. The number of patients undergoing laparoscopic radical nephrectomy has increased explosively worldwide in recent years, and laparoscopy is now extended to patients with advanced disease. It is very important to clarify the present status of laparoscopic radical nephrectomy among the treatment modalities for patients with renal cell carcinoma. RECENT FINDINGS: Laparoscopic radical nephrectomy has a minimally invasive nature as well as comparable long-term cancer control in patients with pT1-3a renal cell carcinoma to open surgery. It is technically applicable for N1-2 disease and T3b disease if the tumor thrombus is within the renal vein. Also, it is feasible as a cytoreductive surgery for patients with M1 disease. SUMMARY: Laparoscopic radical nephrectomy is a standard treatment modality for T1-3a renal cell carcinoma patients. It is also available for treating patients with N1-2 disease, and for patients with M1 disease as a cytoreductive surgery.

Carcinoma, Renal Cell↗

PubMed2006

Evaluation of the nonneoplastic pathology in tumor nephrectomy specimens: predicting the risk of progressive renal failure.

Pathologic changes in nonneoplastic renal parenchyma of nephrectomy specimens for renal tumors and the significance of these changes with regard to the outcome of contralateral kidney function have not been studied previously. We examined the nonneoplastic renal parenchymal changes in 110 consecutive tumor nephrectomy specimens, and we correlated our findings with patients' clinical information. The material was examined for the presence of any glomerular, tubulointerstitial, or vascular pathology. In our analysis, only about 10% of cases had unremarkable renal parenchyma and vasculature. A further 28% of cases had unremarkable parenchyma, but some degree of vascular sclerosis was noted. The remaining cases (>60%) had evident pathologic abnormalities, most commonly related to vascular disease or diabetes mellitus. Regardless of the type of renal cancer they have, the majority of our cases can be placed in one of three principal groups: 1) unremarkable kidney parenchyma, with or without vascular sclerosis (38%); 2) parenchymal scarring and marked vascular changes, including cases of atheroembolic disease, and chronic thrombotic microangiopathy (28%); and 3) changes related to diabetes mellitus, such as glomerular hypertrophy, mesangial expansion, and diffuse glomerulosclerosis (24%). Follow-up data on serum creatinine 6 months postoperatively were available in a third of our patients. Patients with severe histopathologic findings (parenchymal scarring with >20% global glomerulosclerosis and advanced diffuse diabetic glomerulosclerosis) showed a significant change in serum creatinine from the preoperative period to 6 months after radical nephrectomy (P=0.001), indicative of progressive worsening of renal function; this change is significantly greater than that seen in patients with unremarkable renal parenchyma (P=0.01). We conclude that adequate examination of nonneoplastic renal parenchyma is an important tool in recognizing patients at risk for progressive renal disease after nephrectomy and could be an essential step in providing early preventive and treatment measures and better medical care of patients undergoing nephrectomy for neoplastic processes.

Adult↗