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Thank you for the invitation

Thank you for the invitation. Karazan. 1st International Congress of Georgian Association Oncological Urology. Visitors to Leuven. Bzikadze 2011. Koba Kiknavelidze 2014. My last visit to Georgia. Tbilisi, October 2017. Partial Nephrectomy

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Thank you for the invitation

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  1. Thankyoufortheinvitation Karazan 1st International Congress of Georgian Association Oncological Urology

  2. Visitorsto Leuven Bzikadze 2011 Koba Kiknavelidze 2014

  3. My last visitto Georgia Tbilisi, October 2017

  4. Partial Nephrectomy Whenever possible ? Hein Van Poppel UZ Leuven, Belgium Adj. Secretary General EAU 12th National Congress of Urology, Kosovo, 27-5-2017 1st International Congress of Georgian Association Oncological Urology

  5. Partial Nephrectomy in Guidelines

  6. What would you do here? Healthy, 65 year old, golf playing, retired pharmacist Open / Lap. Radical Nx ? Open / Lap. Partial Nx ?

  7. PartialNx = Standard for T1 RCC T1a T1b The use of partial nephrectomy in European tertiary care centers… WHY? Zini L et al. Eur J Surg Oncol 2009

  8. Risk Factors for CKD Rationale of NSS

  9. eGFR< 60 eGFR< 45 Partial Nephrectomy avoids significant renal function loss

  10. CKD leads to Cardiac Disease

  11. Cardiac Specific Survival Eur.Urol. 2010

  12. Simple Partial Nephrectomy Small tumor Clamping AV Wedgeresection Hemostasis Renorrhaphy Unclampwhendone Short, safe, easy

  13. How to preserve renal function? • Avoidkidneyfunctionlossby the resectionitself - Do not do a radicalif a partial is safe - Ifyou do a partial ° Do notremovetoomuchhealthyparenchyma = concept of “enucleation / enucleoresection” ° Avoidintra-operativeischemia

  14. Pure Enucleation Circumcise in healthyparenchyma Get to pseudocapsule Enucleate No bloodloss, easy quick and safe

  15. Enucleation is oncologically safe enucleation standard NSS PFS 982 standard NSS vs. 537 simple enucleation (Local Recurrence was similar) Non-randomized, retrospective, comparative study by SATURN Project-LUNA Foundation Minervini et al. J Urol 2011; 185: 1604 - 1610

  16. Larger tumor AV clamping Circumcise Pseudocapsule No margin Complete resection Reconstruction and renorrhaphy without earlyunclamping

  17. How to preserve renal function? • Avoidkidneyfunctionlossby the resectionitself - Do not do a radicalif a partial is safe - Ifyou do a partial ° Do notremovetoomuchhealthyparenchyma = concept of “enucleation / enucleoresection” ° Avoidintra-operativeischemia

  18. Warm Ischemia Time = risk of developing ESRD

  19. Resection of T1b tumor Prepare and twist the kidney AV Clamp Enucleation Marginal complete resection Few nephrons sacrificed Short WIT < 25-30 minutes

  20. Partial Nephrectomy in Guidelines

  21. Central tumor Ultrasound planning AV clamping Sacrificewedge of overlyingparenchyma Enucleatesharply PCS evt. DJ (?) Close renal sinus Close defect, no sponges …

  22. Yes, we can…

  23. Why the hell are we doing thisin otherwise healthy patients with a normal contralateral kidney ? Because the Guidelines tell us to do so, and …we like it !

  24. Brit. J. Urol., 1991, 67: 129-133

  25. Intergroup Study 30904 A Prospective Randomized Phase III Study Comparing Radical Surgery to Kidney Sparing Surgery in Solitary T1 T2 Renal Cell Carcinoma H. Van Poppel (Study Coordinator), L. DaPozzo, W. Albrecht, V. Matveev, A. Bono A. Borkowski, J.M. Maréchal, L. Klotz, E. Skinner, T. Keane, L. De Prijck, S. Marréaud, S. Collette, R. Sylvester Tumors up to 5cm in diameter To show equivalence!!

  26. Overall Survival Renal Cell Carcinoma 100 Radical 90 80 Partial 70 60 % 50 40 30 20 10 H.Van Poppel et al., Eur. Urol. 2011 0 (years) 0 2 4 6 8 10 12 14 16 18 O N 45 232 224 204 182 130 81 44 17 2 Radical 60 227 217 201 173 121 78 38 12 1 Conservative

  27. Meta-analysis of PN vs. RN N = 36 studies, > 40,000 patients analyzed All but one retrospective, almost all subject to selection bias Advantages of PNx based on pooled estimates: - 61% risk reduction for severe CKD p<0.0001 - 19% risk reduction all cause mortality p<0.0001 Kim S.,Thompson RH. et al, J.Urol 2012

  28. Metanalysis Cochrane, Medline, Embase, Scopus, Web of science All cause mortality Cancer specific mortality PN confers a survival benefit and a lower risk of CKD “Low quality of the existing evidence” Kim S.,Thompson RH. et al, J.Urol 2012

  29. Re-analysis EORTC GU 30904 E.Scosyrev, Van Poppel et al. et al.,Eur. Urol., 2013

  30. Re-analysis EORTC GU 30904 This happens in real life in “healthy” RCC patients E.Scosyrev, Van Poppel et al. et al.,Eur. Urol., 2013

  31. Re-analysis EORTC GU 30904 • The beneficial effect of NSS on eGFR did not result in improved survival over a median FU of 9,3 y for all cause mortality • Moderate renal dysfunction arising from surgery may not have the same negative implications for overall health as when arising from medical causes as diabetes or hypertension E.Scosyrev, Van Poppel et al. et al.,Eur. Urol., 2013

  32. Urologic Dogma • PNx is always better than RNx, because it avoids CKD and thus leads to better overall survival • Ischemia is the most important factor affecting renal function after PNx, and must be avoided at all cost Steven C. Campbell

  33. CV events and RN or NSS CVe= onset of coronary artery disease, cardiomyopathy, hypertension, heart failure, dysrhythm... - Multi-institutional 1987-2013 - 1331 T1a-b renal mass - Normal initial renal function ! Capitanio et al. Eur Urol 2015

  34. Another Metanalysis PNx vs RNx Pubmed, Cochranelibrary and Embase • 26 studies werepooledfor new-onset CKD - 6 werepooledfor cardio-vascularoutcomes • PNx gave a 73% risk reduction of new-onset CKD comparedwithRNx • PNxdidnotreducethe risk of cardiovascularoutcomes Wang Z. et al., Urologic Oncology 2016

  35. Who really benefits from NSS? !!! 1306 Pts CKD I >90 eGFR II 60-89 III 30-59 Probability of developing significant renal function impairment 1306 pts 364 pts 680 pts 188 pts S.L.Woldu et al., Urology 84: 860-68, 2014

  36. Who really benefits from NSS? • 1783 Ptsfrom 5 Italianinstitutes • No CKD, T1 renalmass NSS or Rad. Nx • OtherCauseMortality (OCM) was equal in the overall population • CharlsonComorbidity Index (CCI) increase = increased OCM afterRNx • Patientsthat are ill, with relevant comorbidities, benefit most from NSS A. Larcher et al., J. Urol. 196: 1008-13, 2016

  37. Conclusion NSS for RCC in otherwise healthy patients • We should not resect kidneys if it is safe to do otherwise. • SRM’s will often be amenable for an oncologically and technically safe NSS. • Larger and more complex RCC’s can be subjected to elective NSS • But this is allowed only if oncologically and technically safe If not, Radical Nephrectomy will only rarely induce CKD and impact on overall survival

  38. Conclusion NSS for RCC • A patientwith a T1 renal tumor who is elderly, • has CCI>2, uncontrolledhypertension, diabetes, • preoperative stage 3 or greater CKD, and/or proteinuria • shouldbeoffered NSS.

  39. What would you do here? Healthy, 65 year old, golf playing, retired pharmacist

  40. What would you do here? 65 year old retired pharmacist, CKD II, CVD, AHT and Diabetes

  41. Yes, we can… …If we have to!!

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