Nefrectomía parcial vs enucleación tumoral

Palabras clave: cirugía conservadora de nefronas, nefrectomía parcial, enucleación simple

Resumen

Antecedentes y objetivo: La cirugía conservadora de nefronas se ha convertido en la técnica quirúrgica estándar para masas renales de pequeño tamaño, desbancando la tradicional nefrectomía radical. El objetivo del estudio es comparar nefrectomía parcial y enucleación tumoral en función de morbilidad y resultados oncológicos.

Material y métodos: Estudio de cohortes retrospectivo de pacientes sometidos a nefrectomía parcial o enucleación en el Hospital Clínico Universitario Lozano Blesa de Zaragoza, entre agosto de 2011 y octubre de 2019. Variables demográficas, clínicas, quirúrgicas y resultados oncológicos han sido analizadas.

Resultados: 48 pacientes fueron seguidos 36.1±28.0 meses. Los pacientes sometidos a enucleación tumoral, respecto al grupo de nefrectomía parcial presentaron valores inferiores de sangrado medio (117.7±95.1 ml y 221±293.1 ml, p=0.488), isquemia (46% y 95%, p<0.001), tiempo de isquemia medio (24.6±7.2 min y 25.1±10.4 min, p=0.844) y complicaciones (11.5% y un 22.7%, p=0.442) respectivamente. No se observó recidiva local.

Conclusiones: Ambos grupos son comparables en cuanto a estadio tumoral, presentando en el grupo de enucleación un menor sangrado, menor necesidad de clampaje vascular y un tiempo de isquemia similar al grupo de nefrectomía parcial. Ambas técnicas son seguras a nivel oncológico, con una baja tasa de márgenes afectos. Ambas técnicas presentan una baja morbilidad postoperatoria.

Citas

Wein AJ, M.D AWP, M.D LRK, Novick AC. Campbell-Walsh Urologia. 9th ed. Buenos Aires: Médica Panamericana; 2008. 1280 p.

Ljungberg B, Albiges L, Bensalah K, Bex A, Giles RH, Hora M, et al. EAU Guidelines on Renal Cell Carcinoma. European Association of Urology. 2019.

Escudier B, Kataja V. Renal cell carcinoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals of Oncology. 2010;21:v137–9. doi: 10.1093/annonc/mdq206

Petejova N, Martinek A. Renal cell carcinoma: Review of etiology, pathophysiology and risk factors. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2016;160(2):183–94. doi: 10.5507/bp.2015.050

Ward RD, Tanaka H, Campbell SC, Remer EM. 2017 AUA Renal Mass and Localized Renal Cancer Guidelines: Imaging Implications. RadioGraphics. 2018;38(7):2021–33. doi: 10.1148/rg.2018180127

Campbell MF, Walsh PC, Wein AJ, Kavoussi LR, Novick AC, Partin AW, et al. Campbell’s -Walsh Urologia / Campbell - Walsh Urologia. 9a ed. Vol. 2. Buenos Aires: Medica Panamericana; 2008. 4 p.

Sánchez-Coral M, Báez-Reyes J-R, García-Cano E, Quintero-León MÁ, Cárdenas-Rodríguez E, Priego-Niño A. Experience in nephron-sparing surgery in patients with small renal tumours. Cirugía y Cirujanos (English Edition). 2015;83(4):297–302. doi: 10.1016/j.circen.2015.09.011

Venkatramani V, Swain S, Satyanarayana R, Parekh DJ. Current Status of Nephron-Sparing Surgery (NSS) in the Management of Renal Tumours. Indian J Surg Oncol. 2017;8(2):150–5. doi: 10.1007/s13193-016-0587-0

Van Poppel H, Becker F, Cadeddu JA, Gill IS, Janetschek G, Jewett MAS, et al. Treatment of localised renal cell carcinoma. Eur Urol. 2011;60(4):662–72. doi: 10.1016/j.eururo.2011.06.040

Volpe A, Amparore D, Mottrie A. Treatment outcomes of partial nephrectomy for T1b tumours. Curr Opin Urol. 2013;23(5):403–10. doi: 10.1097/MOU.0b013e328363a5c0

Pahernik S, Roos F, Röhrig B, Wiesner C, Thüroff JW. Elective nephron sparing surgery for renal cell carcinoma larger than 4 cm. J Urol. 2008;179(1):71–4; discussion 74. doi: 10.1016/j.juro.2007.08.165

Van Poppel H. Efficacy and safety of nephron-sparing surgery. Int J Urol. 2010;17(4):314–26. doi: 10.1111/j.1442-2042.2010.02482.x

Hansen J, Sun M, Bianchi M, Rink M, Tian Z, Hanna N, et al. Assessment of cancer control outcomes in patients with high-risk renal cell carcinoma treated with partial nephrectomy. Urology. 2012;80(2):347–53. doi: 10.1016/j.urology.2012.04.043

Gill IS, Kavoussi LR, Lane BR, Blute ML, Babineau D, Colombo JR, et al. Comparison of 1,800 laparoscopic and open partial nephrectomies for single renal tumors. J Urol. 2007;178(1):41–6. doi: 10.1016/j.juro.2007.03.038

Lane BR, Campbell SC, Gill IS. 10-year oncologic outcomes after laparoscopic and open partial nephrectomy. J Urol. 2013;190(1):44–9. doi: 10.1016/j.juro.2012.12.102

Leslie S, Goh AC, Gill IS. Partial nephrectomy--contemporary indications, techniques and outcomes. Nat Rev Urol. 2013;10(5):275–83. doi: 10.1038/nrurol.2013.69

Ficarra V, Rossanese M, Gnech M, Novara G, Mottrie A. Outcomes and limitations of laparoscopic and robotic partial nephrectomy. Curr Opin Urol. 2014;24(5):441–7. doi: 10.1097/MOU.0000000000000095

Huang WC, Elkin EB, Levey AS, Jang TL, Russo P. Partial nephrectomy versus radical nephrectomy in patients with small renal tumors--is there a difference in mortality and cardiovascular outcomes? J Urol. 2009;181(1):55–61; discussion 61-62. doi: 10.1016/j.juro.2008.09.017

Novick AC. Renal hypothermia: in vivo and ex vivo. Urol Clin North Am. 1983;10(4):637–44.

Thompson RH, Leibovich BC, Lohse CM, Zincke H, Blute ML. Complications of contemporary open nephron sparing surgery: a single institution experience. J Urol. 2005;174(3):855–8. doi: 10.1097/01.ju.0000169453.29706.42

Becker F, Van Poppel H, Hakenberg OW, Stief C, Gill I, Guazzoni G, et al. Assessing the impact of ischaemia time during partial nephrectomy. Eur Urol. 2009;56(4):625–34. doi: 10.1016/j.eururo.2009.07.016

Liu W, Li Y, Chen M, Gu L, Tong S, Lei Y, et al. Off-clamp versus complete hilar control partial nephrectomy for renal cell carcinoma: a systematic review and meta-analysis. J Endourol. 2014;28(5):567–76. doi: 10.1089/end.2013.0562

Rais-Bahrami S, George AK, Herati AS, Srinivasan AK, Richstone L, Kavoussi LR. Off-clamp versus complete hilar control laparoscopic partial nephrectomy: comparison by clinical stage. BJU Int. 2012;109(9):1376–81. doi: 10.1111/j.1464-410X.2011.10592.x

Ebbing J, Menzel F, Frumento P, Miller K, Ralla B, Fuller TF, et al. Outcome of kidney function after ischaemic and zero-ischaemic laparoscopic and open nephron-sparing surgery for renal cell cancer. BMC Nephrol. 2019;20. doi: 10.1186/s12882-019-1215-3

Marszalek M, Carini M, Chlosta P, Jeschke K, Kirkali Z, Knüchel R, et al. Positive surgical margins after nephron-sparing surgery. Eur Urol. 2012;61(4):757–63. doi: 10.1016/j.eururo.2011.11.028

Sundaram V, Figenshau RS, Roytman TM, Kibel AS, Grubb RL, Bullock A, et al. Positive margin during partial nephrectomy: does cancer remain in the renal remnant? Urology. 2011;77(6):1400–3. doi: 10.1016/j.urology.2010.12.016

Smith ZL, Malkowicz SB. Tumor Enucleation for Renal Cell Carcinoma. J Kidney Cancer VHL. 2015;2(2):64–9. doi: 10.15586/jkcvhl.2015.27

Li W, Cheng Y, Cheng Y, Ren H, Han N. Clinical efficacy of radical nephrectomy versus nephron-sparing surgery on localized renal cell carcinoma. Eur J Med Res. 2014;19(1). doi: 10.1186/s40001-014-0058-4

Boulière F, Crepel M, Bigot P, Pignot G, Bessede T, de la Taille A, et al. [Nephron-sparing surgery is superior to radical nephrectomy in preserving renal function outcome in tumors larger than 4 cm]. Prog Urol. 2011;21(12):842–50. doi: 10.1016/j.purol.2011.05.005

Larcher A, Capitanio U, Terrone C, Volpe A, De Angelis P, Dehó F, et al. Elective Nephron Sparing Surgery Decreases Other Cause Mortality Relative to Radical Nephrectomy Only in Specific Subgroups of Patients with Renal Cell Carcinoma. J Urol. 2016;196 (4):1008–13.

Laguna MP. Re: Renal function after nephron-sparing surgery versus radical nephrectomy: results from EORTC randomized trial 30904. J Urol. 2014;192(2):369–70. doi: 10.1016/j.juro.2014.05.064

. Liek E, Elsebach K, Göbel H, Krah X, Krautschick-Wilkens AW, Schweiger J, et al. The Overall Survival Benefit for Patients with T1 Renal Cell Carcinoma after Nephron-Sparing Surgery Depends on Gender and Age. Urol Int. 2018;100(3):309–16.

Veys R, Abdollah F, Briganti A, Albersen M, Poppel HV, Joniau S. Oncological and functional efficacy of nephron-sparing surgery versus radical nephrectomy in renal cell carcinoma stages ≥cT1b: a single institution, matched analysis. Cent European J Urol. 2018;71(1):48–57. doi: 10.5173/ceju.2017.1611

Janssen MWW, Linxweiler J, Terwey S, Rugge S, Ohlmann C-H, Becker F, et al. Survival outcomes in patients with large (≥7cm) clear cell renal cell carcinomas treated with nephron-sparing surgery versus radical nephrectomy: Results of a multicenter cohort with long-term follow-up. PLoS One. 2018;13(5):e0196427. doi: 10.1371/journal.pone.0196427

Lowrance W, Yee D, Savage C, Cronin A, O’Brien M, Donat S, et al. Complications after radical and partial nephrectomy as a function of age. J Urol. 2010;183(5):1725–30. doi: 10.1016/j.juro.2009.12.101

Scosyrev E, Messing EM, Sylvester R, Van Poppel H. Exploratory Subgroup Analyses of Renal Function and Overall Survival in European Organization for Research and Treatment of Cancer randomized trial of Nephron-sparing Surgery Versus Radical Nephrectomy. Eur Urol Focus. 2017;3(6):599–605. doi: 10.1016/j.euf.2017.02.015

Patel HD, Pierorazio PM, Johnson MH, Sharma R, Iyoha E, Allaf ME, et al. Renal Functional Outcomes after Surgery, Ablation, and Active Surveillance of Localized Renal Tumors: A Systematic Review and Meta-Analysis. Clin J Am Soc Nephrol. 2017;12(7):1057–69. doi: 10.2215/CJN.11941116

García AG, León TG. Simple Enucleation for Renal Tumors: Indications, Techniques, and Results. Curr Urol Rep. 2016;17(1):7. doi: 10.1007/s11934-015-0560-4

Engel JD, Williams SB. Unclamped hand-assisted laparoscopic partial nephrectomy for predominantly endophytic renal tumors. Urol J. 2013;10(1):767–73.

Heemels WPMH, van de Wouw N. Stability and Stabilization of Networked Control Systems. In: Bemporad A, Heemels M, Johansson M, editors. Networked Control Systems. London: Springer; 2010. p. 203–53: https://doi.org/10.1007/978-0-85729-033-5_7

Longo N, Minervini A, Antonelli A, Bianchi G, Bocciardi AM, Cunico SC, et al. Simple enucleation versus standard partial nephrectomy for clinical T1 renal masses: perioperative outcomes based on a matched-pair comparison of 396 patients (RECORd project). Eur J Surg Oncol. 2014;40(6):762–8. doi: 10.1016/j.ejso.2014.01.007

Minervini A, Ficarra V, Rocco F, Antonelli A, Bertini R, Carmignani G, et al. Simple enucleation is equivalent to traditional partial nephrectomy for renal cell carcinoma: results of a nonrandomized, retrospective, comparative study. J Urol. 2011;185(5):1604–10. doi: 10.1016/j.juro.2010.12.048

Minervini A, Vittori G, Salvi M, Sebastianelli A, Tuccio A, Siena G, et al. Analysis of surgical complications of renal tumor enucleation with standardized instruments and external validation of PADUA classification. Ann Surg Oncol. 2012;20(5):1729–36. doi: 10.1245/s10434-012-2801-9

Ghandour RA, Danzig MR, McKiernan JM. Renal cell carcinoma: risks and benefits of nephron-sparing surgery for T1 tumors. Adv Chronic Kidney Dis. 2015;22(4):258–65. doi: 10.1053/j.ackd.2015.03.006

Rossi SH, Klatte T, Stewart GD. Quality of life outcomes in patients with localised renal cancer: a literature review. World J Urol. 2018;36(12):1961–72. doi: 10.1007/s00345-018-2415-3

Tomaszewski JJ, Smaldone MC, Uzzo RG, Kutikov A. Is radical nephrectomy a legitimate therapeutic option in patients with renal masses amenable to nephron-sparing surgery? BJU Int. 2015;115(3):357–63. doi: 10.1111/bju.12696

Xu C, Lin C, Xu Z, Feng S, Zheng Y. Tumor Enucleation vs. Partial Nephrectomy for T1 Renal Cell Carcinoma: A Systematic Review and Meta-Analysis. Front Oncol. 2019;9. doi: 10.3389/fonc.2019.00473

Rod X, Peyronnet B, Seisen T, Pradere B, Gomez FD, Verhoest G, et al. Impact of ischaemia time on renal function after partial nephrectomy: a systematic review. BJU Int. 2016;118(5):692–705. doi: 10.1111/bju.13580

Mir MC, Ercole C, Takagi T, Zhang Z, Velet L, Remer EM, et al. Decline in renal function after partial nephrectomy: etiology and prevention. J Urol. 2015;193(6):1889–98. doi: 10.1016/j.juro.2015.01.093

Nahar B, Bhat A, Parekh DJ. Does Every Minute of Renal Ischemia Still Count in 2019? Unlocking the Chains of a Flawed Thought Process over Five Decades. European urology focus. 2019;5(6):939–42. doi: 10.1016/j.euf.2019.03.019

Zhang L, Wu B, Zha Z, Zhao H, Yuan J, Jiang Y. Comparison of selective and main renal artery clamping in partial nephrectomy of renal cell cancer. Medicine (Baltimore). 2018;97(34). doi: 10.1097/MD.0000000000011856

Kwon EO, Carver BS, Snyder ME, Russo P. Impact of positive surgical margins in patients undergoing partial nephrectomy for renal cortical tumours. BJU Int. 2007;99 (2):286–289.

Wang L, Hughes I, Snarskis C, Alvarez H, Feng J, Gupta GN, et al. Tumor enucleation specimens of small renal tumors more frequently have a positive surgical margin than partial nephrectomy specimens, but this is not associated with local tumor recurrence. Virchows Arch. 2017;470(1):55–61. doi: 10.1007/s00428-016-2031-9

Minervini A, Campi R, Sessa F, Derweesh I, Kaouk JH, Mari A, et al. Positive surgical margins and local recurrence after simple enucleation and standard partial nephrectomy for malignant renal tumors: systematic review of the literature and meta-analysis of prevalence. Minerva Urol Nefrol. 2017;69(6):523–38. doi: 10.23736/S0393-2249.17.02864-8

Li G, Zhu D-S, Lang Z-Q, Wang A-X, Li Y-H, Zhang R-Y, et al. Classification of positive surgical margins and tumor recurrence after nephron-sparing surgery for small renal masses. Cancer Manag Res. 2018;10:6591–8. doi: 10.2147/CMAR.S181843

Dong W, Gupta GN, Blackwell RH, Wu J, Suk-Ouichai C, Shah A, et al. Functional Comparison of Renal Tumor Enucleation Versus Standard Partial Nephrectomy. Eur Urol Focus. 2017;3(4–5):437–43. doi: 10.1016/j.euf.2017.06.002

Publicado
2021-01-13
Sección
Artículos de revisión