2

URGENT HYPER SELECTIVE SEGMENTAL RENAL ARTERY EMBOLIZATION AS A THERAPEUTIC OPTION FOR RENAL HAEMORRHAGE

Pappas P.¹, Papadoukakis S.², Leonardou P.¹, Stravodimos K.², Tzortzis G.¹, Giannopoulos A.²

¹Laikon Hopsital, Department of Radiology, Athens, Greece, ²Medical School, University of Athens, 1st Department of Urology, Athens, Greece

INTRODUCTION & OBJECTIVES: Renal haemorrhage is a life-threatening situation, occurring mostly after renal biopsy, spontaneous rupture of renal angiomyolipomas and other tumours. Renal biopsy is a well-known and widely used method to access diagnostically problems in renal pathology after renal transplantation. Nevertheless, it is associated with a number of complications. The overall complication rate of a renal biopsy has been reported to range between 2.1 to 10.8 %. Most urologists have to treat hemodynamically unstable patients, due to massive renal haemorrhage. We report our experience in dealing with renal haemorrhage.

MATERIAL & METHODS: Between July 1997 and May 2002, seventeen patients presented with severe renal haemorrhage. Thirteen of them had undergone renal biopsy, for diagnostic purposes, after functional deterioration of the fenal graft and four of them had bleeding tumours. All patients presented with gross haematuria, and all of our patients required transfusion of at least one blood unit prior to the embolization. Radiologic evaluation revealed renal and perirenal haematomas, peritoneal blood accumulation, pseudo aneurysms and arteriovenous fistulas. Embolization was performed under local anaesthesia in all our patients. Embolization with gel foam particles was the preferred technique.

RESULTS: All patients who underwent embolization had an excellent angiographic result and there was also a significant improvement of their clinical course. There was no further fall of their haematocrit and the blood pressure ceased to decrease as well. The rest of the renal parenchyma remained well perfused and showed no radiological signs of significant damage. Even though a certain part of renal parenchyma is not functional, the creatinine value of those patients was either stabilized, or improved, but never deteriorated.

CONCLUSIONS: Haemorrhage is one of the most life threatening complications of renal biopsies and of renal tumours. The treatment of those complications is conservative at first, because 70% of the fistulas are reported to heal spontaneously, and most of the renal haematomas tamponade themselves and are absorbed later. However, immediate measures have to be taken, once the patient becomes hemodynamically unstable and the life is threatened. Super selective renal embolization has proven to be a very attractive

35

LONG-TERM RESULTS ≥ 5 YEARS AFTER OPEN PYELOPLASTY OR ANTEGRADE ENDOPYELOTOMY FOR URETEROPELVIC JUNCTION OBSTRUCTION

Dobry E., Usai P., Studer U.E., Danuser H.

University Hospital of Bern, Department of Urology, Bern, Switzerland

INTRODUCTION & OBJECTIVES: Little is known about long-term follow-up of corrected UPJ-obstruction. It is also not clear how long and how often patients have to be controlled by regular follow-ups. Therefore, we analysed the rate and time of treatment failures and searched for criteria for how to follow patients.

MATERIAL & METHODS: Ureteropelvic junction obstruction was treated by open pyeloplasty (Anderson-Hynes technique) in 98 cases from 1980-1991 and by antegrade endopyelotomy in 193 cases from 1991-2003. Thirty-nine of 98 patients after open pyeloplasty (median follow-up 139 months (63-251)) and 110 of 193 patients after antegrade endopyelotomy (median follow-up 87 months (60-152)) had a follow-up of more than 5 years. At regular controls 6 and 24 months postoperatively they were assessed clinically, by an excretory urogram (IVU) and/or diuretic renography and clinically and by ultrasound every 2-3 years thereafter.

RESULTS: After open pyeloplasty 2 of the 39 patients with a follow-up of more than five years failed initially but none failed in the long-term follow-up, resulting in a longterm success rate of 95%. After antegrade endopyelotomy 30 of the 110 patients failed. Eighteen of the 30 failures occurred within the first 6 postoperative months, 6/30 failures between 6 and 24 months postoperatively and 6/30 failures more than 2 years postoperatively resulting in a long-term success rate of 73%. None of the late failures had signs of obstruction in the diuretic renal scan or the IVU at the 6 month control.

CONCLUSIONS: Open pyeloplasty is an invasive but very successful procedure with a low failure rate. Long-term success rate of the less invasive antegrade endopyelotomy is 20% less than after open pyeloplasty. Forty percent of the failures occur later than 6 months postoperatively. Therefore regular controls are recommended for at least 5 years.

36

HOW SHOULD WE CORRECT URETEROPELVIC JUNCTION REOBSTRUCTION AFTER FAILED ENDOPYELOTOMY. RESULTS OF SECONDARY PROCEDURES

Danuser H., Dobry E., Burkhard F.C., Hochreiter W., Studer U.E.

University Hospital of Bern, Department of Urology, Bern, Switzerland

INTRODUCTION & OBJECTIVES: Antegrade endopyelotomy has a success rate of 80%, but there are no guidelines for the treatment of failures. Therefore we analyzed the secondary procedures of our endopyelotomy failures.

MATERIAL & METHODS: Forty-two of 195 patients treated with antegrade endopyelotomy for ureteropelvic junction obstruction (UPJO) failed. Except for one patient with an asymptomatic, afunctional kidney, all others (41/42) had further treatment for UPJO: One patient was treated with a permanent double-J-stent. Eighteen patients had minimally invasive retreatment: Laparoscopic nephropexy for a hypermobile kidney (1), retrograde balloon dilatation with additional prolonged stenting (7), retrograde Acucise® endopyelotomy (4), second antegrade endopyelotomy (2) and retrograde laserendopyelotomy (5). Seventeen patients had an open pyeloplasty and 5 had a nephrectomy because of poor kidney function. Therefore 36 of 41 patients had a treatment demanding regular follow-up.

RESULTS: Thirty-one of the 36 patients had a successful secondary procedure and 5 failed a second time. Two of these 5 patients failed after retrograde balloon dilatation and were retreated by open pyeloplasty in one patient and an unsuccessful laser endopyelotomy in another, who later underwent open pyeloplasty. Another 2 of these 5 patients failed again after retrograde laser endopyelotomy. One of them had an open pyeloplasty, the other should have a laparoscopic nephropexy because of a hypermobile kidney. The last of these 5 patients failed after open pyeloplasty and developed a stoneinduced pyonephrosis in a poorly functioning kidney. He had a nephrectomy.

CONCLUSIONS: Open pyeloplasty remains the procedure with the highest success rate (94%) after failed endopyelotomy, and although the most invasive procedure should be recommended first. Minimally invasive procedures such as retrograde balloon dilatation, antegrade endopyelotomies and retrograde Acucise®- or Laser-endopyelotomies have a risk of failure of 22% and does not preclude open pyeloplasty. The hypermobile kidney, a rare disease especially in long, slim ladies, can imitate UPJ-obstruction and should be recognized as an important differential diagnosis.

281

SAFETY AND EFFICACY OF PARTIAL NEPHRECTOMY FOR ALL T1 TUMOURS BASED ON AN INTERNATIONAL MULTICENTRE EXPERIENCE

Patard J.J.¹, Shvarts O.², Pantuck A.², Kim H.², Ficarra V.³, Cindolo L.⁴, Han K.², De la Taille A.⁵, Tostain J.⁶, Artibani W.³, Abbou C.C.⁵, Lobel B.⁷, Guillé F.⁷, Chopin D.⁵, Figlin R.², Mulders P.⁸, Belldegrun A.²

¹CHU Pontchaillou, Department of Urology, Rennes, France, ²UCLA, Department of Urology, Los Angeles, United States, ³Verona University Hospital, Department of Urology, Verona, Italy, ⁴Naples University Hospital, Department of Urology, Naples, Italy, ⁵CHU Henri Mondor, Department of Urology, Creteil, France, ⁶CHU Saint Etienne, Department of Urology, Saint Etienne, France, ⁷CHU Rennes, Department of Urology, Rennes, France, ⁸Nijmegen University, Department of Urology, Nijmegen, The Netherlands

INTRODUCTION & OBJECTIVES: To compare cancer specific survival of patients undergoing partial and radical nephrectomies for T1N0M0 renal tumours according to tumour size in a large multicentre series.

MATERIAL & METHODS: A retrospective analysis of patients undergoing either partial or radical nephrectomy for T1N0M0 renal tutors from 7 international academic centres was performed. The following data was obtained for each patient: TNM stage (determined according to the 2002 TNM criteria), tumour size, type of surgery (partial vs. radical nephrectomy) and cancer specific survival. Recurrence events were recorded when available.

RESULTS: 1454 patients with T1N0M0 renal tumours were included in this study. Partial and radical nephrectomies were performed in 379 (26.1%) and 1075 (73.9%) cases, respectively. Mean follow up was 62.5 months. In 544 patients whose data on recurrence was available, neither local nor distant recurrences rates significantly differed between the partial and total nephrectomy groups for T1a and T1b tumours (p: 0.6 and 0.5 respectively). For patients with T1a tumours, 2.2 and 2.6% died from cancer in the nephron sparing surgery and radical nephrectomy groups, respectively (p: 0.8). For patients with T1b tumours, 6.2% died from cancer when a partial nephrectomy was performed compared to 9% when a radical nephrectomy was carried out (p: 0.6).

CONCLUSIONS: Although retrospective, this large multicentre study suggests that it is safe to expand the indications of partial nephrectomy to include patients with T1N0M0 tumours up to 7 cm in size. However careful patients’ selection remains necessary.

282

IMPACT OF RESECTION MARGIN WIDTH AFTER NEPHRON-SPARING SURGERY FOR RENAL CELL CANCER

Berdjis N., Novotny V., Oehlschläger S., Hakenberg O., Manseck A., Wirth M.

Technical University Dresden, Department of Urology, Dresden, Germany

INTRODUCTION & OBJECTIVES: It is widely accepted that tumour excision with a surrounding margin of normal parenchyma is the safest approach to ensure complete removal of malignancy after nephron-sparing surgery. However, the necessary amount of healthy parenchyma surrounding the tumour that should be removed is a controversial issue.

MATERIAL & METHODS: The records of 121 patients who underwent nephronsparing surgery for non metastatic renal cell carcinoma including 85 elective and 36 imperative indications were retrospectively reviewed. Intraoperative frozen sections were routinely performed and revealed negative margins in all patients. All patients were followed for a minimum of 12 months. Tumour size and the shortest distance of normal parenchyma around the tumour were assessed.

RESULTS: After a mean postoperative follow-up of 49,3 months (range 12 to 113 months) 6 patients suffered disease progression (3 with local recurrence, 2 of whom also had distant metastases, pure local recurrence in one case and pure metastatic disease in 3). Mean size of the negative margins was 0.56 cm (range 0.1 to 2.3 cm). The width of the resection margin did not correlate with disease progression, while tumour size was a strong predictor of progression (p=0.01). The mean tumour size was 5.1 cm in patients with progression and 3.1 cm in patients who remained tumour-free.

CONCLUSIONS: Our data suggest that the width of the resection margin does not influence the risk of tumour recurrence.

289

LONG-TIME SURVIVAL (>4 YRS) IN NON RESECTABLE PULMONARY METASTATIC RENAL CELL CARCINOMA AND AEROSOL INTERLEUKIN-2 THERAPY

Heinzer H., Huland E., Huland H.

University Hospital Hamburg, Department of Urology, Hamburg, Germany

INTRODUCTION & OBJECTIVES: Patients with exclusive lung metastases of renal cell carcinoma (mRCC) and curative complete surgical resection have a median survival of 43 months. If resection however is incomplete no patient survived longer than 29 months (Piltz, Ann Thorac Surg 2002). We report long-time survival (> 4 years) of patients with non-resectable lung metastases receiving immunotherapy using aerosol interleukin-2.

MATERIAL & METHODS: Between 1989 and 1999 a total number of 199 pts. were treated by inhaled IL-2. Treatment mainly consisted of high-dose aerosol IL-2 (90% of total IL-2 dose), systemic IL-2 (10% of total IL-2 dose) or interferon-a (15 Mio IU weekly). Toxicity was mild to moderate with low incidence of WHO grade 3 toxicity (24%), mainly cough. Comedication was not required except for cough.

RESULTS: 35 pts. (18%) survived > 4 years, 19 pts. still alive in 2003. The median survival of these pts. is 73.1 months after start of treatment. Characteristics of these longtime survivors are performance status ECOG 1 in 89% and 0 in 5%. 100% of the pts. had nephrectomy prior therapy. 40% had a time interval less than 1 year between first diagnosis of RCC and treatment start and weight loss was noticed in 17%. 89% of the pts. responded to therapy by remission (CR 8%, PR 8%) or long-time stabilization (72%) with a median response duration of 16.1 (3.2 – 82.8) months. Of these long-time survivors 2 patients are still in complete remission.

CONCLUSIONS: Inhaled IL-2 causes long-time survival > 4 years in 18% of consecutive pts. This is well in the range of patients receiving high dose systemic therapy as published recently (Yang et al., JCO, 2003), a treatment with significant higher toxicity and risk, which requires stringent patient selection. The low toxicity of aerosol IL-2 may contribute to this favourable outcome because it permits long-time therapy resulting in long-time control of lung metastases.

372

PROGNOSTIC VALUE OF LYMPHOVASCULAR INVASION IN TRANSITIONAL CELL CARCINOMA OF THE UPPER URINARY TRACT

Park S., Song C., Kim J.B., Hong B., Kim C.S., Ahn H.

Asan Medical Centre, Department of Urology, Seoul, Korea, South

INTRODUCTION & OBJECTIVES: Lymphovascular invasion (LVI) is related to tumour grade and pathological stage of transitional cell carcinoma (TCC) of the upper urinary tract. This study was conducted to elucidate the prognostic significance of LVI in patients with upper tract TCC.

MATERIAL & METHODS: Of 86 patients with upper tract TCC who underwent nephroureterectomy with bladder cuff (95%) or parenchymal-sparing surgery (5%) from 1991 to 2002, 73 were available for pathologic review of LVI. Of 10 patients with positive lymph node, 8 had LVI. The influence of multiple prognostic factors - such as including age, gender, tumour stage, grade, tumour location, and LVI - on 5-year diseasespecific and recurrence (local recurrence or distant metastasis)-free survival rates were analyzed by univariate and multivariate analysis. Five-year disease-specific and recurrence-free survival curves were generated by the existence of LVI in patients without involvement of lymph node.

RESULTS: Overall 5-year disease-specific and recurrence-free survival rates were 88% and 75% (n=73). In the univariate analysis, stage, grade, tumour location, and LVI were significant on both survival rates. In multivariate analysis, tumour location and LVI were the only significant predictors for recurrence-free survival (p=0.009, p=0.016, respectively) while neither were significant for disease-specific survival. In patients without involvement of lymph node or T4 (Ta-3N0M0, n=62), 5-year disease-specific and recurrence-free survival rates were 98% and 94% in the absence of LVI, 70% and 60% in the existence of LVI, respectively (p=0.0005, 0.0007, respectively). In the meantime, 5-year disease-specific and recurrence-free survival rates were 67% and 20% in patients (n=10) with involvement of lymph node.

CONCLUSIONS: LVI, in addition to tumour location, is an independent prognostic factor for recurrence-free survival in transitional cell carcinoma of the upper urinary tract. Because LVI is strongly associated with poorer prognosis as involvement of lymph node, systemic adjuvant therapy should be considered in the existence of LVI even if lymph node was not involved.

505

LONG TERM OUTCOME OF LAPAROSCOPIC RADICAL NEPHRECTOMY FOR RENAL CELL CANCER

Peschel R.¹, Neururer R.¹, Bartsch G.¹, Zussner F.², Jeschke K.²

¹University Hospital Innsbruck, Department of Urology, Innsbruck, Austria, ²Hospital Klagenfurt, Department of Urology, Klagenfurt, Austria

INTRODUCTION & OBJECTIVES: Laparoscopic radical nephrectomy has become a standard treatment for RCC. We retrospectively reviewed the medical records of 425 patients to evaluate the oncologic efficacy of this method.

MATERIAL & METHODS: Between April 1994 and September 2003 425 patients with clinically stage T1 RCC were treated by laparoscopic radical nephrectomy. The kidney was dissected en bloc and the adrenal gland was spared in the case of a lower pole tumour. The specimen was delivered by a muscle splitting incision until March 2003. Since then specimen delivery was performed either by morcellation or in toto.

RESULTS: Tumour size ranged from 2 – 12 cm (mean 5.23), OR time from 57 – 230 min (mean 127). 3 conversions to open surgery were necessary. From the 425 T1 Tumours 316 were pathologic T1, 16 pT2, 70 pT3, 23 were no renal cancer but 6 oncocytomas, 5 TCC, 1 Bellini collecting duct carcinoma, 1 angiosarcoma, 2 metastases, 5 angiomyolipomas, 1 renal abscess, 2 cystic nephromas). Follow up ranges from 1 –112 months (mean 38). No local recurrence and no port site metastasis occurred. The disease free rate for pT1 tumours was 98% after three years and 97% after 5 years.

CONCLUSIONS: Laparoscopic radical nephrectomy for renal cell cancer is less invasive than open surgery and the oncologic outcome is similar to those reported in the literature for open surgery.

507

PAPILLARY RENAL CELL CARCINOMA: CLINICAL AND PATHOLOGICAL CHARACTERISTICS AND PROGNOSTIC FACTORS

Novara G.¹, Ficarra V.¹, Martignoni G.², Zecchini Antoniolli S.¹, Dalpiaz O.¹, Artibani W.¹

¹University of Verona, Department of Urology, Verona, Italy, ²University of Verona, Department of Pathology, Verona, Italy

INTRODUCTION & OBJECTIVES: To assess the clinical and pathological characteristics and to identify independent predictive variables in papillary renal cell carcinoma (RCC).

MATERIAL & METHODS: We reviewed the clinical records of 86 patients who had undergone surgical treatment for papillary RCC from 1980 to 2000. In every patient we considered ECOG performance status, mode of presentation, kind of surgery, pathological size, pathological stage (TNM, 2002), venous and urinary tract involvement, Fuhrman nuclear grading and tumour necrosis. The log rank test was used for univariate analysis. The Cox proportional hazard model was used to perform multivariate analysis.

RESULTS: The patients mean age was 60.16±12.8 years (range 25-84). 72 patients (83.7%) were male and 14 (16.3%) female. ECOG performance status was “0” in 77 (89.5%); “1” in 8 (9.3%) and “2” in a single case (1.2%). 49 tumours (57%) were incidentally detected; 37 (43%) were symptomatic. In 61 patients (70.9%) we performed radical nephrectomy; in 18 (20.9%) an elective nephron-sparing surgery (NSS) and in 7 (8.1%) an imperative NSS. The mean pathological size was 5.1±2.4 cm (range 1-13). The pathological stage of the primary tumour was pT1a in 33 cases (38.4%), pT1b in 28 (32.6%), pT2 in 12 (14%), pT3a in 11 (12.8%) and pT3b in 2 (2.3%). Lymph nodes involvement (pN+) was present in 3 cases (3.5%). 5 patients (5.8%) were metastatic at the time of initial presentation. Fuhrman nuclear grading (available only in 59 patients) was G1 in 6 cases (10.2%); G2 in 31 (52.5%) and G3 in 22 (37.3%). Tumour necrosis was present in 3 out of the 57 patients in whom the data was available (3.5%). Venous involvement was present in 2 cases (2.3%). The 5 and 10-year cancer specific survival probability were respectively 83.2% and 81.1%. Once performed univariate analysis, pathological stage of the primary tumour (p=0.0000), lymph nodes involvement (p=0.0000) and the presence of metastases (p=0.0002) were included in a multivariate model. Only the pathological stage of the primary tumour was significant at multivariate analysis (HR1.844).

CONCLUSIONS: Papillary RCC is localized in a large percentage of cases (81.4%). This explains the high 5 and 10-year cancer specific survival rates. In this cohort of patients the primary tumour local extension resulted the most powerful predictive variable.

689

UPPER URINARY TRACT TUMOURS AFTER CYSTECTOMY FOR INVASIVE BLADDER CANCER

Akkad T.¹, Pelzer A.², Pinggera G.², Berger A.², Rehder P.², Bartsch G.², Hoeltl L.²

¹University Hospital Innsbruck, Urology, Innsbruck, Austria, ²University Hospital Innsbruck, Department of Urology, Innsbruck, Austria

INTRODUCTION & OBJECTIVES: Tumour recurrence in the upper urinary tract after radical cystectomy is a rare but possible event. We analyzed our patients concerning the occurrence and risk factors of secondary upper urinary tract tumours.

MATERIAL & METHODS: Between 1/1992 and 6/2002, 356 patients (83 females, 273 males) with muscle invasive bladder cancer underwent radical cystectomy. Mean age at operation was 63.3 years (range 24-82 years, SD 9.77). Frozen section of the distal ureter was negative for tumour and CIS in all patients. Follow up in 6-monthly intervals consisted of clinical and blood examinations, urine cytology and radiographic evaluation with either ultrasound and chest x-ray or CT scan.

RESULTS: Seven patients (5 right, 2 left) out of 356 (1.9%) developed upper urinary tract tumours after a mean time of 23.4 months (range 5 to 76). All of the patients had undergone radical cystectomy with multifocal high grade invasive TCC of the bladder (³T1) and in one patient with concomitant CIS. Tumours occurred in the renal pelvis (RP) only in 1, in the RP in combination with the proximal ureter in 4 patients and 2 patients, who had already metastases at time of diagnosis, had tumours only in the distal ureter. 5 patients with local disease underwent nephroureterectomy out of whom 3 are currently alive with a mean recurrence free survival of 49 months. 1 patient died due to a secondary malignancy (NHL) 32 months after nephroureterectomy, one patient developed metastatic disease 1.5 months after nephroureterectomy and died within 4 months. The two patients with metastatic disease at diagnosis received chemotherapy (Gemcitabine/Cisplatin) but died 3 and 4 months after diagnosis.

Table: m/f: gender; RU: right ureter; LU: left ureter, RP: right renal pelvis

CONCLUSIONS: In our series all patients who developed secondary upper urinary tract TCC had multifocal tumours. Tumour stage was not a reliable risk factor, as even 2 patients with T1 lesions and without CIS developed upper urinary tract tumours. All secondary tumours were high stage and high grade carcinomas. Although a rare occurrence, upper urinary TCC after cystectomy represents a substantial aggressive finding. 28.5% of our patients had metastasis at time of diagnosis, making regular controls for early diagnosis necessary.

699

PHASE II TRIAL OF PACLITAXEL AND CARBOPLATIN IN ADVANCED/METASTATIC TRANSITIONAL CELL CANCER

Johannsen M., Wille A., Roigas J., Schnorr D., Loening S.

University Hospital Charité, Department of Urology, Berlin, Germany

INTRODUCTION & OBJECTIVES: Treatment of advanced or metastatic transitional cell cancer (TCC) still represents a major challenge in urologic oncology. Limited longterm benefit and high toxicity of conventional treatment regimes like MVAC have led to the evaluation of new agents with comparable efficacy and lower toxicity. Paclitaxel (Taxol) has been demonstrated to be an active drug in the treatment of TCC and is characterized by low toxicity. We investigated the effect of a combination therapy with Taxol and Carboplatin in patients with advanced / or metastatic disease.

MATERIAL & METHODS: From 6/1997 to 2/2003 27 patients with advanced measurable TCC of the urothelium with or without prior systemic therapy or radiotherapy were entered onto this trial. Patients were treated once weekly with a combination therapy of Taxol (100 mg/m2) and Carboplatin (AUC of 2, according to the Calvert formula). Therapy courses were administered once weekly for six weeks. After 2 cycles, a re-staging was carried out to evaluate response.

RESULTS: Overall, 6 complete (CR, 22.2%) and 13 partial remissions (PR, 48.1%) were noted, whereas 5 patients had stable disease (SD, 18.5%) and 3 patients progressed (PD, 11.1%). Mean progression-free interval was 7.5 months (2 - 34) and median survival was 11 months (2 - 51). Comparing responders (CR/PR) with non-responders (SD/PD), overall survival was 17 vs. 6 months (p=0.09). Side effects were moderate with no case of neutropenic fever or severe thrombocytopenia. All patients had alopecia while 50% of patients reported nausea at the day of administration of chemotherapy. Mild peripheral neurotoxic symptoms were present in 60% of cases. 80% of cycles were administered in less than 2 days allowing patients to be treated on an outpatient basis.

CONCLUSIONS: Combination therapy with Taxol and Carboplatin is a promising approach in the management of advanced TCC. Toxicity and side effects are moderate and therapy can be given on an outpatient basis. Moreover, the combination of Taxol and Carboplatin appears to be a suitable regimen for patients with impaired renal function and / or considerable co-morbidity, who would not tolerate Cisplatin-based chemotherapy regimens.

765

LAPAROSCOPIC PARTIAL NEPHRECTOMY FOR RENAL TUMOURS WITH AND WITHOUT ISCHEMIA - A RETROSPECTIVE COMPARISON INCLUDING 130 PATIENTS

Jeschke K.¹, Wakonig J.¹, Bugelnig J.¹, Meixl H.¹, Peschel R.², Bartsch G.²

¹General Hospital Klagenfurt, Department of Urology, Klagenfurt, Austria, ²University Innsbruck, Department of Urology, Innsbruck, Austria

INTRODUCTION & OBJECTIVES: The technique of laparoscopic partial nephrectomy for renal tumours is still evolving. We retrospectively compared patients operated with and without hilar clamping in terms of complications and patients outcome.

MATERIAL & METHODS: Between 2/1996 and 7/2001 we performed 68 laparoscopic partial nephrectomies in patients with renal tumours without hilar clamping. A retroperitoneal approach was predominant. The resection itself was done by simultaneous cutting and coagulating with bipolars or harmonic scalpel. No endoscopic suturing was applied and haemostasis was achieved by coagulation and fibrin glue. From 7/2001 in 62 patients laparoscopic partial nephrectomy for renal tumours was done with hilar clamping, mainly by a retroperitoneal approach. In 5 of these patients we did additional parenchymal cooling by in situ perfusion of the kidney via arterial Seldinger catheter placed preoperatively. Tumour excision was done sharply with endoscalpel and shears. The collecting system was sutured if necessary and haemostasis was achieved either by central sutures and fibrin glue, or by closing the defect with parenchymal sutures. There was no difference in both groups in terms of patients mean age (61 Years) tumour location and tutor size (2.3 cm).

RESULTS: None of the operations had to be converted to open surgery. Mean operating time was 116 (70 - 200) minutes without and 77 (50 - 150) minutes with hilar clamping. Major complications occurred in 8 patients (12%) in group 1 (4 postoperative bleedings and 4 urinary fistulas), that required open reoperation in 5 patients. In group 2 we observed major complications in 3 patients (4.8%). None of them had an open reintervention. Histology showed RCC in 55 cases (80%) in group 1. One patient had a positive margin and had subsequent nephrectomy. In the group with hilar clamping RCC was found in 54 patients (87%), all with negative margins. Median follow up in group 1 is 38 (25 - 81) months and 11 (1 - 25) months in group 2. All patients show NED so far.

New techniques in laparoscopic partial nephrectomy, mimicking open surgery, as hilar clamping, parenchymal cooling by in situ perfusion, endoscopic suturing of the collecting system and parenchymal sutures for haemostasis make the procedure more clear and reduce perioperative morbidity, operating time and risk for positive surgical margins.

766

ROBOTIC ASSISTED LAPAROSCOPIC PARTIAL NEPHRECTOMY

Peschel R.¹, Neururer R.¹, Bartsch G.¹, Blute M.², Gettman M.²

¹University Hospital Innsbruck, Department of Urology, Innsbruck, Austria, ²Mayo Clinic, Department of Urology, Rochester, United States

INTRODUCTION & OBJECTIVES: The Da Vinci system has been introduced with the goal of simplifying complex laparoscopic procedures. We reviewed our initial clinical results with the Da Vinci assisted partial nephrectomy.

MATERIAL & METHODS: From February 2003 through August 2003 13 patients with renal tumours underwent Da Vinci partial nephrectomy. Tumour size was 2 - 6 cm (mean 3.5). After exposure of the kidney and the tumour via either a transperitoneal or retroperitoneal approach the renal artery was clamped. In 8 cases a renal cooling via an intra-arterial catheter was performed. The tumour was excised with cold scissors and the vessels and the collecting system were suture repaired. A surgical cushion was fixed with interrupted sutures and the renal artery was unclamped.

RESULTS: In 9 cases the whole procedure was done by the Da Vinci system. In 4 cases the exposure of the kidney and the hilum was done with conventional laparoscopy. The mean operative time including placement of the renal artery catheter was 215 min (130 - 262). Warm ischaemia time was 22 min (15-29). Cold ischaemia time ranged from 18 to 43 min. The mean estimated blood loss was 170 cm (50 - 300) Postoperative hospital stay was 4.3 days (2-7). The pathology showed oncocytoma in two cases, benign cyst in 1 case, all others were RCC. In one case of a 6 cm lower pole tumour a positive margin occurred despite negative frozen sections; laparoscopic tumour nephrectomy was performed showing no evidence of tumour.

CONCLUSIONS: The initial results for the robotic assisted laparoscopic partial nephrectomy are encouraging. An experienced scrubbed assistance is mandatory for this technique. The 3D-vision and the ability of perfect intracorporeal suturing allow a repair of the kidney as in open surgery.

770

RADIOFREQUENCY INTERSTITIAL ABLATION (RITA) OF RENAL CANCER DOES NOT PRODUCE THE COMPLETE TUMOUR DESTRUCTION: RESULTS OF A PHASE II STUDY

Brausi M.¹, Castagnetti G.², Gavioli M.², Peracchia G.², De Luca G.², Olmi R.²

¹Estense- Sant' Agostino Institute, Department of Urology, Modena, Italy, ²Ramazzini Hospital, Department of Urology, Carpi, Italy

INTRODUCTION & OBJECTIVES: RITA has been recently proposed by many urooncological centres for treatment of renal tumours. However there are few reports on the histopathological changes and /or tumour destruction occurring after RITA. The objectives of our phase II study was to evaluate the pathological changes and the rate of necrosis after intraoperative RITA performed immediately before surgery and to observe side effects.

MATERIAL & METHODS: Between February and June 2002 8 patients with renal tumours scheduled to undergo partial or radical nephrectomy were recruited for the study after ethical committee approval and patient informed consent. Inclusion criteria were: presence of radiographically documented (ultrasound or CT) renal neoplasm, ability to undergo radical or partial nephrectomy life expectancy> 12 months, ASA scores less than 4. Surgery was conducted via a flank incision in 2 patients and or midline abdominal incision in 6 patients. The RITA needle with 7 tines was inserted to the centre of the tumour mass under direct vision and ultrasound control. Tines were desployed to possibly include all the tumour mass and were retracted and reinserted in order to reach the normal surrounding parenchyma. An electrosurgical generator was connected to the needle to reach a tissue temperature of 90°-100° C. The mean patient age was 57.3 (30-71), the number of tumours treated was 8, and the mean tutor diameter was 4.4 cm (2-7.1 cm). Tumour ablation time varied from 18 to 30 minutes (mean 24.7’).Tissue temperature reached was 100° C in all cases but 2 (angiomyolipoma and a large tumour mass). All tumours were resected: 3 patients received radical and 5 patients partial nephrectomy. Specimens were preserved in formalin and pathological examination was performed using haematoxylin-eosin staining protocol. The percentage of obtained tumours necrosis was defined by pathologist on slides.

RESULTS: Intraoperative ultrasound revealed the formation of gas bubbles with increased echogenicity of treatment area during RITA. Final pathological examination showed viable cells of adenocarcinomas in 7 patients and angiomyolipoma in 1 patient. Tumours necrosis was present in all tumours but one (angiomyolipoma). However coagulative necrosis of the tumour was present from 15% to 90% of the specimen (mean tumour necrosis rate 60%) and was always incomplete. Complications: mild bleeding was observed from angiomyolipoma not requiring blood transfusion.

CONCLUSIONS: RITA was ineffective for total destruction of renal tumour and the procedure alone should not be considered curative. RITA could be indicated in old, high risk patients with renal tumours not eligible for surgery.

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