SURGERY
(CLICK HERE FOR SURGICAL NOTES ie. intraoperative stuff)
NEPHRECTOMY EFFECT ON KIDNEY FUNCTION
Balancing the loss of nephrons with cancer control can determine overall survival benefit. 1 in 10 who undergo radical nephrectomy (RN) will develop stage IV or worse CKD and 1 in 20 partial nephrectomy patients. (15) A study of 2445 patients found elevated CRP prior to nephrectomy (PN or RN) to have 2x increase risk of GFR <30. (19) See CKD/HD for more information about the value of nephrons.
PARTIAL NEPHRECTOMY -A Retrospective review of 2,256 patients showed positive margins found in 16% of recurrence group vs. 3% of control group. The median detection time was 23 months (range 2 to 107). Male gender was associated with recurrence. (12) Partial nephrectomy rates of recurrence have been 1.4% in T1 (8), 3.4% for cT1a, 6.4% for cT1b (9) in studies previously. An interesting meta-analysis evaluated off clamp and on clamp and showed the pooled odds ratios for acute renal failure and postoperative progress to chronic kidney disease (stage≥3) in the off-PN group were found to be 0.25 (p = 0.003) and 0.73 (p = 0.34), respectively, compared with the on-PN group.(14) A study in 2019 found no benefit from icing kidney during partial nephrectomy. (18) A 2019 study of 1893 partial nephrectomy patients found 20% patients experienced AKI after surgery and these patients were more likely to not recover 90% of their GFR, this study was a nice look into the long term renal effects of partial nephrectomy. (20)
RADICAL NEPHRECTOMY
One study showed local recurrence rates after radical nephrectomy was 1.8% with css 28% at 5 year but improved with surgical resection of recurrence. (5) Other studies have found 1.8% (6) and 2.9% (7) after radical nephrectomy. At median f/u of 13.9yrs, 4.3% recurred at median of 9.3 years and 11.8% developed metastases at a median of 9.6 years after surgery. The estimated recurrence-free survival rate at 10 and 15 years was 97.3% and 95.2% for renal recurrence, and 93.1% and 85.9% for distant metastases, respectively. (13)
CYTOREDUCTIVE NEPHRECTOMY
See renal metastasis.
LYMPHADENECTOMY - Recommended only in presence of clinically suspicious nodes (1,2)
LOCAL RECURRENCE - One study showed local recurrence rates after radical nephrectomy was 1.8% with css 28% at 5 year but improved with surgical resection of recurrence. (5) Other studies have found 1.8% (6) and 2.9% (7) after radical nephrectomy. Partial nephrectomy rates of recurrence have been 1.4% in T1 (8), 3.4% for cT1a, 6.4% for cT1b (9) in studies previously. A Retrospective review of 2,256 patients showed positive margins found in 16% of recurrence group vs. 3% of control group. The median detection time was 23 months (range 2 to 107). Male gender was associated with recurrence. (12)
PSEUDOCAPSULE
A study of 1,307 patients, 1,244 (95.2%) presented with a pseudocapsule, including 350 (28.1%), 643 (51.7%) and 251 (20.2%) with a grade 0, 1 and 2 pseudocapsule invasion extent, respectively. Kaplan-Meier curves revealed great losses in overall and progression-free survival for an increased extent of invasion and pseudocapsule absence. On multivariate analyses we identified significant overall and progression-free survival harms for grade 2 pseudocapsules (HR 2.12 and 2.66, each p <0.0001) and lack of a pseudocapsule (HR 1.95, p = 0.0248 and HR 2.54, p = 0.0007, respectively) compared to grade 0 pseudocapsules. A change in statistical risk from grade 1 to 0 was only detected for progression-free survival. The prognostic value of pseudocapsule status was shown by a higher HR on multivariable analyses in individuals with localized renal cell carcinoma. The authors state their findings suggest that pseudocapsule status has good prognostic implications in renal cell carcinoma and lack of a pseudocapsule certainly had a remarkably adverse impact on the patient outcome. Accessibility in use and cost makes pseudocapsule status a potential cost-effective parameter in clinical practice. (10)
SMALL RENAL MASSES
Older age may be linked to higher cancer specific mortality among patients treated surgically for small renal tumors research indicates. (11) Cryoablation for T1b tumors was found to have 2.5x CSM compared to PN in a large retrospective study from SEER database. (16)
MANNITOL
CYST RUPTURE
Intraoperative cyst rupture during cancer operations of cystic renal masses showed no increased risk of negative outcomes in a small study. (17)
NEPHRECTOMY EFFECT ON KIDNEY FUNCTION
Balancing the loss of nephrons with cancer control can determine overall survival benefit. 1 in 10 who undergo radical nephrectomy (RN) will develop stage IV or worse CKD and 1 in 20 partial nephrectomy patients. (15) A study of 2445 patients found elevated CRP prior to nephrectomy (PN or RN) to have 2x increase risk of GFR <30. (19) See CKD/HD for more information about the value of nephrons.
PARTIAL NEPHRECTOMY -A Retrospective review of 2,256 patients showed positive margins found in 16% of recurrence group vs. 3% of control group. The median detection time was 23 months (range 2 to 107). Male gender was associated with recurrence. (12) Partial nephrectomy rates of recurrence have been 1.4% in T1 (8), 3.4% for cT1a, 6.4% for cT1b (9) in studies previously. An interesting meta-analysis evaluated off clamp and on clamp and showed the pooled odds ratios for acute renal failure and postoperative progress to chronic kidney disease (stage≥3) in the off-PN group were found to be 0.25 (p = 0.003) and 0.73 (p = 0.34), respectively, compared with the on-PN group.(14) A study in 2019 found no benefit from icing kidney during partial nephrectomy. (18) A 2019 study of 1893 partial nephrectomy patients found 20% patients experienced AKI after surgery and these patients were more likely to not recover 90% of their GFR, this study was a nice look into the long term renal effects of partial nephrectomy. (20)
RADICAL NEPHRECTOMY
One study showed local recurrence rates after radical nephrectomy was 1.8% with css 28% at 5 year but improved with surgical resection of recurrence. (5) Other studies have found 1.8% (6) and 2.9% (7) after radical nephrectomy. At median f/u of 13.9yrs, 4.3% recurred at median of 9.3 years and 11.8% developed metastases at a median of 9.6 years after surgery. The estimated recurrence-free survival rate at 10 and 15 years was 97.3% and 95.2% for renal recurrence, and 93.1% and 85.9% for distant metastases, respectively. (13)
CYTOREDUCTIVE NEPHRECTOMY
See renal metastasis.
LYMPHADENECTOMY - Recommended only in presence of clinically suspicious nodes (1,2)
- 701 Patients from the ASSURE trial underwent lympadenectomy. No OS benefit observed (HR 1.14, 95% 0.93-1.39, p=0.20) (3)
- EORTC 30881 (4)
- no survival benefit for clinically negative nodes
- however, 77% of patients were low grade with 4% LN involvement
- this population likely doesn't represent those who would likely benefit
LOCAL RECURRENCE - One study showed local recurrence rates after radical nephrectomy was 1.8% with css 28% at 5 year but improved with surgical resection of recurrence. (5) Other studies have found 1.8% (6) and 2.9% (7) after radical nephrectomy. Partial nephrectomy rates of recurrence have been 1.4% in T1 (8), 3.4% for cT1a, 6.4% for cT1b (9) in studies previously. A Retrospective review of 2,256 patients showed positive margins found in 16% of recurrence group vs. 3% of control group. The median detection time was 23 months (range 2 to 107). Male gender was associated with recurrence. (12)
PSEUDOCAPSULE
A study of 1,307 patients, 1,244 (95.2%) presented with a pseudocapsule, including 350 (28.1%), 643 (51.7%) and 251 (20.2%) with a grade 0, 1 and 2 pseudocapsule invasion extent, respectively. Kaplan-Meier curves revealed great losses in overall and progression-free survival for an increased extent of invasion and pseudocapsule absence. On multivariate analyses we identified significant overall and progression-free survival harms for grade 2 pseudocapsules (HR 2.12 and 2.66, each p <0.0001) and lack of a pseudocapsule (HR 1.95, p = 0.0248 and HR 2.54, p = 0.0007, respectively) compared to grade 0 pseudocapsules. A change in statistical risk from grade 1 to 0 was only detected for progression-free survival. The prognostic value of pseudocapsule status was shown by a higher HR on multivariable analyses in individuals with localized renal cell carcinoma. The authors state their findings suggest that pseudocapsule status has good prognostic implications in renal cell carcinoma and lack of a pseudocapsule certainly had a remarkably adverse impact on the patient outcome. Accessibility in use and cost makes pseudocapsule status a potential cost-effective parameter in clinical practice. (10)
SMALL RENAL MASSES
Older age may be linked to higher cancer specific mortality among patients treated surgically for small renal tumors research indicates. (11) Cryoablation for T1b tumors was found to have 2.5x CSM compared to PN in a large retrospective study from SEER database. (16)
MANNITOL
CYST RUPTURE
Intraoperative cyst rupture during cancer operations of cystic renal masses showed no increased risk of negative outcomes in a small study. (17)
- Motzer, Robert J., et al. "Kidney cancer, version 3.2015." Journal of the National Comprehensive Cancer Network 13.2 (2015): 151-159.
- Ljungberg, Borje, et al. "EAU guidelines on renal cell carcinoma: 2014 update." European urology 67.5 (2015): 913-924.
- Ristau, Benjamin T., et al. "Retroperitoneal lymphadenectomy for high risk, nonmetastatic renal cell carcinoma: an analysis of the ASSURE (ECOG-ACRIN 2805) adjuvant trial." The Journal of urology 199.1 (2018): 53-59.
- Blom, Jan HM, et al. "Radical nephrectomy with and without lymph-node dissection: final results of European Organization for Research and Treatment of Cancer (EORTC) randomized phase 3 trial 30881." European urology 55.1 (2009): 28-34.
- Itano, Nancy B., et al. "Outcome of isolated renal cell carcinoma fossa recurrence after nephrectomy." The Journal of urology164.2 (2000): 322-325.
- Thomas, Arun Z., et al. "Surgical management of local retroperitoneal recurrence of renal cell carcinoma after radical nephrectomy." The Journal of urology 194.2 (2015): 316-322.
- Margulis, Vitaly, et al. "Predictors of oncological outcome after resection of locally recurrent renal cell carcinoma." The Journal of urology 181.5 (2009): 2044-2051.
- Kreshover, Jessica E., Lee Richstone, and Louis R. Kavoussi. "Renal cell recurrence for T1 tumors after laparoscopic partial nephrectomy." Journal of endourology 27.12 (2013): 1468-1470.
- Thompson, R. Houston, et al. "Comparison of partial nephrectomy and percutaneous ablation for cT1 renal masses." European urology 67.2 (2015): 252-259.
- Xi, Wei, et al. "Evaluation of Tumor Pseudocapsule Status and Its Prognostic Significance in Renal Cell Carcinoma." The Journal of urology (2017).
- Bandini, Marco, et al. "The effect of age on cancer specific mortality in patients with small renal masses: A population-based analysis." Canadian Urological Association Journal12.7 (2018).
- Wood, Erika L., et al. "Local tumor bed recurrence following partial nephrectomy in patients with small renal masses." The Journal of urology 199.2 (2018): 393-400.
- Kim, Simon P., et al. "Outcomes and clinicopathologic variables associated with late recurrence after nephrectomy for localized renal cell carcinoma." Urology 78.5 (2011): 1101-1106.
- Deng, Wen, et al. "Off-clamp partial nephrectomy has a positive impact on short-and long-term renal function: a systematic review and meta-analysis." BMC nephrology 19.1 (2018): 188.
- Leppert, John T., et al. "Incident CKD after radical or partial nephrectomy." J Am Soc Nephrol 29.1 (2018): 207-216.
- Pecoraro, Angela, et al. "In Non-Metastatic pT1b Kidney Cancer Patients Cryoablation Predisposes to Higher Cancer Specific Mortality Relative to Partial Nephrectomy." The Journal of Urology (2019): 10-1097.
- Pradere, Benjamin, et al. “Intraoperative Cyst Rupture during Partial Nephrectomy for Cystic Renal Masses—Does It Increase the Risk of Recurrence?” The Journal of Urology, vol. 200, no. 6, 2018, pp. 1200–1206.
- Breau, Rodney, et al. "LBA-15 RENAL HYPOTHERMIA DURING PARTIAL NEPHRECTOMY: A RANDOMIZED CONTROLLED TRIAL." The Journal of Urology 201.Supplement 4 (2019): e998-e999.
- Cotta B, Saito K, Meagher M, et al. Elevated C-reactive protein is independently associated with progressive renal functional decline after surgery for renal cell carcinoma: Results of an international cohort study. Presented at the 2019 American Urological Association annual meeting held May-3-6 in Chicago. Abstract MP31-16.
- Bravi, Carlo Andrea, et al. "Impact of acute kidney injury and its duration on long-term renal function after partial nephrectomy." European urology 76.3 (2019): 398-403.