Partial nephrectomy vs tumor enucleation
DOI:
https://doi.org/10.48193/revistamexicanadeurologa.v80i6.709Keywords:
Nephron-sparing surgery, Partial nephrectomy, Simple enucleationAbstract
Background and aims: Nephron-sparing surgery has become the standard surgical technique for small renal masses, taking the place of traditional radical nephrectomy. The aim of the present study was to compare partial nephrectomy and tumor enucleation, with respect to morbidity and oncologic results.
Materials and methods: A retrospective cohort study was conducted on patients that underwent partial nephrectomy or enucleation at the Hospital Clínico Universitario Lozano Blesa de Zaragoza, between August 2011 and October 2019. Demographics, clinical and surgical characteristics, and oncologic results were the variables analyzed.
Results: Forty-eight patients were followed for 36,1±28,0 months. Compared with the partial nephrectomy group, the patients that underwent tumor enucleation presented with lower values of mean blood loss (117,7±95.1 ml and 221±293.1 ml, p=0,488), ischemia (46% and 95%, p<0,001), mean ischemia time (24,6±7,2 min and 25,1±10,4 min, p=0,844), and complications (11,5% and 22,7%, p=0,442), respectively. No local recurrence was observed.
Conclusions: Both groups were comparable in relation to tumor stage. The enucleation group presented with less blood loss, less need for vascular clamping, and similar ischemia time, compared with the partial nephrectomy group. Both techniques were oncologically safe, with a low rate of compromised surgical margins. Postoperative morbidity with the two techniques was low.
References
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
