IN THE NAME OF GOD

1. IN THE NAME OF GOD

2. SURGICAL TREATMENT OF RENAL CELL CARCINOMA MEHRDAD MOHAMMADI MD ENDOUROLOGY AND LAPARSCOPY UROLOGY DEPARTMENT, ISFAHAN UNIVERSITY OF MEDICAL SCIENCES BAHMAN 1390

3. surgery remains the mainstay for curative treatment of this disease

4. TREATMENT OF LOCALIZEDRENAL CELL CARCINOMA 1)Laparoscopic radical nephrectomy (LRN) 2)Open radical nephrectomy(ORN) 3)Laparoscopic partial nephrectomy (LPN) 4)Open partial nephrectomy (OPN) 5)Thermal ablation (TA) 6)Active surveillance (AS)

5. Case 1

6. Case 22

7. Case Case 2 scan

8. Case 3

9. Case 3

11. Case 4

12. Case 5

13. Case 5

14. Case 6

15. Partial Nephrectomy • bilateral RCC • RCC involving a solitary functioning kidney. unilateral renal agenesis, prior removal of the contralateral kidney, irreversible impairment of contralateral renal • RCC with benign renal threatening disease: renal artery stenosis , hydronephrosis, chronic pyelonephritis, ureteral reflux, calculus disease, or systemic diseases such as diabetes and nephrosclerosis

16. PN is now standard of care for the management of clinical T1 renal masses in the presence of a normal contralateral Kidney.

17. OUTCOME • Prior experience with “elective” PN for T1a RCC demonstrated local recurrence rates of 1% to 2%, and overall cancer-free survival well over 90%.

18. PN is replacing RN • Overall, about 20% of solid, enhancing, clinical T1 renal masses are benign, most often oncocytomas or atypical AMLs.

23. TUMOR SIZE • Frank and colleagues (2003b) have demonstrated a direct relationship between tumor size and the incidence of malignancy. • Tumor size has also correlated with biologic aggressiveness for clinical T1 renal masses, as reflected by high tumor grade, locally invasive phenotype, or adverse histologic subtype

25. predict tumor aggressiveness • clinical and radiographic factors: very limited accuracy. • Conventional renal mass biopsy: demonstrated reasonable accuracy

26. RADICAL NEPHRECTOMY • very large tumors (most clinical T2 tumors) • clinical T1 tumors that are not amenable to nephron-sparing approaches

27. RN has more recently fallen out of favor for small renal tumors due to concerns about CKD, and should only be performed when necessary .

28. Several studies illustrate the negative implications of CKD. • increased rates of cardiovascular events and death as the degree of CKD worsened .

29. The relative risks of cardiovascular events were: • eGFR OF 45 to 60: 1.4, • 30-45: 2.0, • 15-30 2.8, • < 15 3.4

31. BASIC PRINCIPLES OF RN • early ligation of the renal artery and vein, • removal of the kidney external to the Gerota fascia, • excision of the ipsilateral adrenal gland, • complete regional lymphadenectomy from the crus of the diaphragm to the aortic bifurcation

32. Performance of a perifascialnephrectomy is of undoubted importance.

33. IPSILATERAL ADRENALECTOMY 1) radiographic adrenal enlargement 2)malignant lesion extensively involves the kidney, 3))tumor is located in the upper portion of the kidney

34. LYMPHADENECTOMY First, RCC metastasizes through the bloodstream and the lymphatic system with equal frequency. the lymphatic drainage of the kidney is variable and even an extensive retroperitoneal dissection may not remove all possible sites of metastasis.

35. RECOMMENDATION • the renal hilar and immediately adjacent paracaval or para-aortic lymph nodes.

36. Laparoscopic RN • low- to moderate-volume • localized RCCs with no local invasion, • limited or no renal vein involvement, • manageable lymphadenopathy

37. Laparoscopic RN is associated with diminished postoperative discomfort and shortened recovery, and costs compare favorably with the open approach

38. cancer-specific survival after laparoscopic RN is comparable to that after open RN.

39. The current data suggest that elderly and morbidly obese patients, those with a history of previous abdominal surgery, and those with large tumor size may also be considered for laparoscopic renal surgery.

42. laparoscopic PN • shorter operative times • less blood loss, • longer warm ischemic times • higher risk of urologic complications

44. Because proteinuria is the initial manifestation of this phenomenon, a 24-hour urinary protein measurement should be obtained yearly in patients with a solitary remnant kidney to screen for hyperfiltration nephropathy

45. Thermal Ablative Therapies • renal cryosurgery and • radiofrequency ablation (RFA),

46. However, long-term efficacy is not as established as with surgical excision and preliminary data suggest that the local recurrence rates may be somewhat higher than that reported for traditional surgical approaches.

47. Another concern has been the lack of accurate histologic and pathologic staging associated with these modalities, because the treated lesion is left in situ

48. Ideal candidates for TA procedures • advanced age or significant comorbiditieswho prefer a proactive approach but are not optimal candidates for conventional surgery, • patients with local recurrence after previous nephron-sparing surgery, • patients with hereditary renal cancer who present with multifocal lesions for which multiple PNs might be cumbersome if not impossible

49. Finally, tumor size is also an important factor in patient selection because the current technology does not allow for reliable treatment of lesions larger than 4.0 cm in diameter.

50. Diagnosis of local recurrence after thermal ablative treatments can be challenging because evolving fibrosis within the tumor bed can be difficult to differentiate from residual cancer.