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6th Macedonian Urological Symposium

6th Macedonian Urological Symposium. State of the art lecture Nephron sparing surgery Chr. Leiber, W.Schultze-Seemann, G. Dimitriadis Freiburg i. Br., Thessaloniki. 6th Macedonian Urological Symposium. State of the art - Nephron sparing surgery.

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6th Macedonian Urological Symposium

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  1. 6th Macedonian Urological Symposium State of the art lecture Nephron sparing surgery Chr. Leiber, W.Schultze-Seemann, G. Dimitriadis Freiburg i. Br., Thessaloniki

  2. 6th Macedonian Urological Symposium State of the art - Nephron sparing surgery History of renal surgery/nephron sparing surgery 1861 (Walcott) and 1867 (Spiegelberg) – parts of the kidney were removed mistakenly - both patients died 1869 first planned nephrectomy by Simon (for urinary fistula) - a kidney can be extirpated safely from a human being - a patient can survive with only one kidney 1870 partial nephrectomy by Simon for hydronephrosis 1884 Wells accidentally removed a third of a kidney (perirenal fibrolipoma) 1887 Czerny did the first partial resection for a tumor (angiosarcoma) 1950 – Vermooten – foundation of modern nephron sparing surgery „ there are certain instances, when, for the patients well being, it is unwise to do a nephrectomy, even in the presence of a malignant growth involving the kidney. The question is, whether such a procedure is ever justifiable when the opposite kidney is normal. I am inclined to think that in certain circumstances it may be“

  3. 6th Macedonian Urological Symposium State of the art - Nephron sparing surgery Standard indications for nephron sparing surgery fall into three categories Absolute anephric patient postop., need for dialysis Relative impaired renal function on the contralateral kidney, bilateral tumors, heriditary cancer Elective localized unilateral RCC and a normal contralateral kidney (size ? [<4cm], cortical, clearly localized)

  4. 6th Macedonian Urological Symposium State of the art - Nephron sparing surgery TNM-Classification of Renal Cell Carcinoma 1987 1997 2002 T 1 <2,5cm <7cm T1a <4cm T1b 4,1-7cm T2 >2,5cm >7cm >7cm T3a infiltration perirenal fat, adrenal gland T3b infiltration of renal vein, vena cava T3c infiltr. of thoracic v. cava T4 tumor outside gerota‘s fascia

  5. 6th Macedonian Urological Symposium State of the art - Nephron sparing surgery Reassessment of the 1997 TNM classification in pT1 (a/b) RCC Database of 1324 pts with RCC who had a RN between 1960 and 1991 Patients with stage I disease were stratified by size cut-offs ranging from 2,5-7cm in 5mm increments 5 year disease specific survival was estimated in each subgroup The most discriminating cut-off was identified 233 had TNM 1997 stage I disease tumor <5cm tumor >5cm p Cancer spec. surv. 94,6% 79,2% 0,003 Nonorgan confined dis. 16,2% 36,8% „patients with pT1 tumor >5cm had the same survival as patients with stage II disease. … the subclassification into T1a/b (AJCC 6.edition) may not be optimal“ Elmore,JM et al. Cancer 98,2329:2003

  6. 6th Macedonian Urological Symposium State of the art - Nephron sparing surgery Radical nephrectomy/ nephron sparing surgery 2746 patients – between 1970 and 2000 812 deaths from RCC 5year cancer specific survival rate based on the 2002 classification by the American Joint Committee on Cancer were pT1a 97% pT1b 87% pT2 71% pT3a 53% pT3b 44% pT3c 37% pT4 20% „excellent subclassification of pT1 tumors in pT1a and pT1b“ Blute,F. et al. J. Urol. 173,1889:2005

  7. 6th Macedonian Urological Symposium State of the art - Nephron sparing surgery Type of nephrectomy - Mayo Clinic 1970-79 1980-89 1990-99 2000-02 RN 650 946 1269 362 NSS 50 182 527 338 Percentage of NSS Mayo Clinic 7,1 16,1 29,3 48,3 USA 4 7 Freiburg 25 35

  8. 6th Macedonian Urological Symposium State of the art - Nephron sparing surgery Type of nephrectomy - U. S. A. 2003 Nationwide Inpatient sample + American Hospital Association Survey 4914 patients for RCC surgery open nephrectomy 3310 (67,4 %) open partial nephrectomy 784 (15,9 %) laparoscopic parital nephrectomy 820 (16,7%) Miller D. et al. Abstract 637 AUA 2007

  9. 6th Macedonian Urological Symposium State of the art - Nephron sparing surgery Nephron sparing surgery in tumors between 4 and 7cm 932 patients with pT1b tumors (RCC) between 1970 and 2000 NSS – 91 cases RN – 841 cases cancer spec. Surv(5y) 98% 86% (n.s. after adjusting for features associated with death – stage, grade, histol. tumor necrosis, histol. subtype) distant metast. free 94% 83% (n.s. after adjusting for features associated with death – stage, grade, histol. tumor necrosis, histol. subtype) local recurrence RR 0,32 „NSS results in excellent outcome in appropiately selected patients“ Leibovich,BC et al. J. Urol. 171,1066:2004

  10. 6th Macedonian Urological Symposium State of the art - Nephron sparing surgery Nephron sparing surgery – Freiburg 1990-3/2007 438 partial nephrectomies - 333 sporadic RCC Pathol. – pT1a - 87% - 66 heriditary cancer (VHL) pT1b - 10% - 39 benign tumors pT2 - 0,3% Median follow-up 69 months pT3a - 2% Mean age 61 years pT3b -0,7% Mean number of tumors 1,1 indicationelective 82% Mean tumor size 3,5cm imperat. 18% Cold ischaemia 84,6% Mean time of ischaemia 28 min (6-120 min.) Mean op. time 110 min. Mean blood loss 175ml

  11. 6th Macedonian Urological Symposium State of the art - Nephron sparing surgery Tumor enucleation in nephron-sparing surgery? 108 patients underwent NSS between 1989 and 2000 (enucleation) Mean follow-up – 88,3 months Mean tumor size 2,7 cm pT1a – 95%, pT1b – 4%, pT3a – 1% Cancer specific survival : 5 years – 99% 10 years – 97,8% Progression free survival : 5 years – 98,1% 10 years – 94,7% Local progression : 2pt (1,9%) – 1 alone, 1associated with distant metastases „enucleation is not associated with an increased risk of local recurrence compared with partial nephrectomy“ Lapini A. J.Urol.174,57:2005

  12. 6th Macedonian Urological Symposium State of the art - Nephron sparing surgery Nephron-sparing surgery - Can it be done laparoscopical? Comparison open (OPN) versus laparoscopic (LPN) partial nephrectomy Cleveland clinic + 2 other centers 1800 patients (1029 OPN, 771 LPN) Bias to open group (more patients symptomatically, reduced Karnofsky Index, more tumors > 4 cm and centrally located. LPN shorter OP-time, reduced blood loss, shorter hospital stay. Intraoperative complication rate comparable. But, LPN longer ischemia time, more postoperative complications, increased number of subsequent procedures. Gill I. et al. Abstract 495 AUA 2007

  13. 6th Macedonian Urological Symposium State of the art - Nephron sparing surgery Nephron-sparing surgery - Can it be done laparoscopical? 557 laparoscopic partial nephrectomy at Cleveland clinic but only 56 patients with follow-up > 60 months Mean tumor size 2,9 cm pT1a – 86%, pT1b – 14% Cancer specific survival : 5 years – 100% Overall survival : 5 years – 86% Local recurrence : 1 patient „At our center laparoscopic partial nephrectomy is an established alternative to open partial nephrectomy“ Lane R. + Gill I. Abstract 496 AUA 2007

  14. 6th Macedonian Urological Symposium State of the art - Nephron sparing surgery von Hippel-Lindau Disease

  15. 6th Macedonian Urological Symposium State of the art - Nephron sparing surgery • Nephron sparing surgery – Freiburg 1990-2007 heriditary tumors (VHL) • Evidence for heriditary cancer (VHL) • young patient (20-40 years) • concomittant cysts (cystcystadenoma carcinoma) • concomittant or known history of pheochromocytoma • bilateral tumors • pos. family history of RCC • ® indication for nephron sparing surgery without genetic proof

  16. 6th Macedonian Urological Symposium State of the art - Nephron sparing surgery von Hippel-Lindau Disease inherited, autosomal-dominant de novo mutations in 1-3% of the cases penetrance approx. 100% responsable are mutations of the vHL-gene tumor-suppressor-gene on the short arm of chromosome3 (3p25) cytoplasmatic proteine (213 amino acids, 28-30 kDa) expression in nearly every tissue the vHL gene is mutated as well in 80% of the sporadic RCC [Latif et al, "Identification of the vHL disease tumor suppressor gene", Science, 260, 1993]

  17. 6th Macedonian Urological Symposium State of the art - Nephron sparing surgery von Hippel-Lindau Disease 1. Hemangioblastoma of the CNS 60-80% 2. Cysts and Tumors of the Pancreas 60-80% 3. Hemangioblastoma of the Retina 50-60% 4. Renal Cysts and RCC 30-60% 5. Cystadenoma of the Epididymis 20-54% 6. Pheochromocytoma 11-24% 7. Tumors of the Saccus endolymphaticus 2-11% Maddock et al, "A genetic register for vHL disease", J Med Genet, 33, 1996 Maher et al, "Clinical features and natural history of vHL disease", Q J Med, 77, 1990 Richard et al, "Haemangioblastoma of the central nervous system in vHL disease. French VHL study group", J Intern Med, 243, 1998

  18. 6th Macedoian Urological Symposium State of the art - Nephron sparing surgery Nephron sparing surgery – Freiburg 1990-2007 66 heriditary cancer (VHL) Mean age 36 years Number of tumors removed 1-55 Mean number of tumors 10 Median number of tumors 7 ------------------------------------------------------------- postop. Bleeding 15% urinary leakage 3% op. revision 12% mean op. time 155 min. mean blood loss 320ml

  19. 6th Macedonian Urological Symposium State of the art - Nephron sparing surgery Freiburg technique of nephron sparing surgery • open retroperitoneal access • (cold) ischaemia by vessel loops

  20. 6th Macedonian Urological Symposium State of the art - Nephron sparing surgery Freiburg technique of nephron sparing surgery • resection of the peritumoral fat

  21. 6th Macedonian Urological Symposium State of the art - Nephron sparing surgery Freiburg technique of nephron sparing surgery • open retroperitoneal access • (cold) ischaemia by vessel loops and in situ hypothermia by ice

  22. 6th Macedonian Urological Symposium State of the art - Nephron sparing surgery Freiburg technique of nephron sparing surgery • partial resection in sporadic RCC, enucleation in heriditary cancer (all tumors and cysts) • no frozen sections • haemostasis of the bigger vessels by absorbable sutures, Argon-cauterization

  23. 6th Macedonian Urological Symposium State of the art - Nephron sparing surgery Freiburg technique of nephron sparing surgery • haemostasis of the bigger vessels by absorbable sutures, Argon-cauterization

  24. 6th Macedonian Urological Symposium State of the art - Nephron sparing surgery Freiburg technique of nephron sparing surgery • Haemostyptics (Tachosil®, Floseal® or Bioglue®)

  25. 6th Macedonian Urological Symposium State of the art - Nephron sparing surgery Freiburg technique of nephron sparing surgery • no adaptation of the parenchyma (decompression after tumor resection)

  26. 6th Macedonian Urological Symposium State of the art - Nephron sparing surgery Frozen section in nephron-sparing surgery? 172 patients underwent NSS between 1988 and 2003 Mean tumor size 3,56 cm Frozen section was routinely done during surgery Positive tumor margins in 2 cases – both central tumors Immediate nephrectomy was performed in both – no residual tumor Paraffin sections disclosed 4 more positive margins 1 nephrectomy for tumor recurrence after 9 months in 3 cases no recurrence (26, 59 and 120 months) „frozen section analysis during nephron sparing surgery has minimal clinical significance“ Duvdevani,M. J.Urol.173,385:2005

  27. 6th Macedonian Urological Symposium State of the art - Nephron sparing surgery Freiburg technique of nephron sparing surgery • In selected cases photodynamic diagnostic by aminolevulinic acid

  28. 6th Macedonian Urological Symposium State of the art - Nephron sparing surgery Nephron sparing surgery – Freiburg 1990-2007 – long term results 333 sporadic RCC cancer spec. Surv. (5yr) overall survival % % 3 years 100 94 5 years 97 89 10 years 97 84

  29. 6th Macedonian Urological Symposium State of the art - Nephron sparing surgery Nephron sparing surgery – Summary Nephron sparing surgery (NSS) and radical nephrectomy provide equally effective treatment for patients with a single, small, clearly localized T1 tumor Cancer free survival is much better in tumors smaller than 4cm (5cm?) compared to patients with greater tumors (cut-off) The results of NSS are less satisfactory in patients with greater than T1 tumors The morbidity of NSS is acceptable Renal function after NSS remains stable in >95% of the patients NSS is mandatory in all cases of heriditary RCC

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