Transcript Folie 1

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
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“
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)
6th Macedonian Urological Symposium
State of the art - Nephron sparing surgery
TNM-Classification of Renal Cell Carcinoma
T1
T1a
T1b
T2
T3a
T3b
T3c
T4
1987
1997
<2,5cm
<7cm
2002
<4cm
4,1-7cm
>7cm
>2,5cm
>7cm
infiltration perirenal fat, adrenal gland
infiltration of renal vein, vena cava
infiltr. of thoracic v. cava
tumor outside gerota‘s fascia
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
Cancer spec. surv.
94,6%
79,2%
Nonorgan confined dis.
16,2%
36,8%
p
0,003
„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
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
6th Macedonian Urological Symposium
State of the art - Nephron sparing surgery
Type of nephrectomy - Mayo Clinic
RN
1970-79
1980-89
1990-99
650
946
1269
362
50
182
527
338
7,1
16,1
29,3
48,3
4
7
25
35
NSS
2000-02
Percentage of NSS
Mayo Clinic
USA
Freiburg
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
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
cancer spec. Surv(5y)
98%
RN – 841 cases
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
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
Mean tumor size 3,5cm
Cold ischaemia 84,6%
Mean time of ischaemia 28 min (6-120 min.)
Mean op. time 110 min.
Mean blood loss 175ml
indication elective 82%
imperat. 18%
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
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
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
6th Macedonian Urological Symposium
State of the art - Nephron sparing surgery
von Hippel-Lindau Disease
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
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]
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
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
urinary leakage
15%
3%
op. revision
12%
mean op. time
155 min.
mean blood loss
320ml
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
6th Macedonian Urological Symposium
State of the art - Nephron sparing surgery
Freiburg technique of nephron sparing surgery
-
resection of the peritumoral fat
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
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
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
6th Macedonian Urological Symposium
State of the art - Nephron sparing surgery
Freiburg technique of nephron sparing surgery
Haemostyptics (Tachosil®, Floseal® or Bioglue®)
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)
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
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
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
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