SELECTED ABSTRACTS

Renal Cancer

107

Percutaneous Surgery for Upper Tract Transitional Cell Carcinoma: Long Term Follow Up

S.S. SANDHU*, M.J. KELLETT†, D. DEARNALEY* and C.R.J. WOODHOUSE*
*The Royal Marsden Hospital; †The Middlesex Hospital, UK

INTRODUCTION

Nephroureterectomy has been regarded as the standard therapy for upper tract transitional cell carcinoma (TCC). Renal pelvis TCC is a disease of the elderly, who would in some cases need dialysis after radical surgery. We have used percutaneous resection to manage this condition.

METHODS

Between 1984 and 2002, a total of 44 patients underwent percutaneous renal surgery. Follow up was available on 37 patients, with a mean age = 65 (range 37 to 92) years. Of these patients 10 had only a solitary kidney and 3 had bilateral tumours and therefore a total of 40 upper tracts were operated on.

RESULTS

The histology was as follows: benign in 5 pts, G1 pTa in 5 pts, G1 pT1in 2pts, G2 pTa in 12pts, G2 pT1 in 3pts, G3pT1 in 1pt, and G3 pT2in 2pts. Mean follow up of the patients was 4.2 years. 10 patients (31%) had a local recurrence (mean time to recurrence = 2.8 yrs). 5 patients had repeat resections; one of these and 3 other patients, including both patients with G3 disease, were managed with nephrouretrectomy. Two patients, who would have been rendered dialysis dependent, declined nephroureterectomy and had a palliative insertion of a nephrostomy tube. Two other patients (6%) developed systemic metastasis in the absence of local pelvic recurrence.

CONCLUSIONS

Percutaneous renal surgery leads to longterm recurrence free survival in the majority of patients (62%) and in 83% of cases renal preservation. In 37% of patients in our series, percutaneous surgery prevented unnecessary reliance on renal dialysis.

108

Laparoscopic Renal Cryoablation % 4-year Follow-up

W.A. HASAN, I.S. GILL, M. SPALIVIERO, M.M. DESAI, J.H. KAOUK and A.C. NOVICK
Cleveland Clinic Foundation, OH, USA

INTRODUCTION

Renal cryosurgery for tumor is now being offered at various institutions, however longterm oncologic follow-up data are currently lacking to date. We report our data on 40 patients undergoing LRC all of who have completed 4-year follow-up.

MATERIALS

Since September 1997, LRC has been performed in over 100 patients. Of these, 40 patients (44 tumours) have completed a follow-up of 4 years. Our postoperative follow-up protocol comprises serial MRI scans and additional CT scan-guided needle biopsy of the renal cryolesion.

RESULTS

Mean renal tumour size of 2.4 cm, mean intraoperative size of the created cryolesion was 3.7 cm. Sequential mean cryolesion size on MRI scanning at postoperative day 1, 3 months, 6 months, 1, 2, 3 and 4 years was 3.9 cm, 3 cm, 2.6 cm, 2 cm, 1.3 cm, 0.8 cm and 0.2 cm, respectively. This represents a percent reduction in cryolesion size by 23%, 33%, 49%, 67%, 80 and 95% at 3 months, 6 months, 1, 2, 3 and 4 years, respectively. At 4 years, 19 cryolesions (43%) had completely disappeared on MRI scanning. Postoperative needle biopsy identified locally persistent/ recurrent renal tumour in two patients (5%). Both patients underwent secondary laparoscopic radical nephrectomy and have no evidence of disease at last follow-up.

CONCLUSIONS

In 40 patients each with a minimum of 4-year follow-up, renal cryolesions decreased in size by 95%, completely disappeared in 43%, and needle biopsy identified locally persistent/ recurrent cancer in 5%. Complications were minimal. These ongoing oncologic data support the continued use of renal cryoablation in carefully selected patients.

109

Renal Cryoablation in von Hippel Lindau Disease

A. DOBLE, A. RIDDICK, P. HEGARTY and H. TAYLOR
Addenbrooke's NHS Trust, Cambridge, UK

INTRODUCTION

The natural history of renal tumours in von Hippel Lindau disease (VHLD) includes multiple metachronous tumours, often of low grade. Nephron-sparing surgery (NSS) achieves a 100% 5-year cancer specific survival in small renal adenocarcinomas. This pilot study assessed whether equivalent results could be achieved with in situ cryoablation therapy in VHLD patients.

PATIENTS AND METHODS

Ten VHLD patients with fourteen solid renal masses were studied. The lesions were all assessed by intraoperative ultrasound (IU/S) and needle biopsy prior to cryoablation. All patients were treated using 3-mm cryoprobes in a double freeze technique employing Argon and Helium, at open surgery in eight and under CT guidance in two. Sensors were placed at the periphery of the lesions to monitor tissue temperatures during treatment.

RESULTS

The mean lesion size was 2.6 cm, range 2-3.1 cm and histology confirmed Fuhrman 1 or 2 renal adenocarcinoma in 9 cases and Fuhrman 3 in one. The freeze time for each cycle was 10 min. Two patients dropped their Hb by > 2.5 g d/L. The median hospital stay was 4 days, range 3-6, and median follow up 16 months, range 6-30. In all patients, CT has shown non-enhancing lesions at 6-24 months post cryoablation with a decrease in lesion volume.

CONCLUSIONS

All treated tumours were amenable to thermal injury with limited morbidity. The treated lesions were rendered avascular. This technique merits further study in a randomized controlled trial with excisional NSS to evaluate tumour control, survival and morbidity.

110

Percutaneous Radiofrequency Ablation (RFA) of Small Renal Carcinoma (RCC) - Medium Term Outcome

J.P. DYER*, B. STEDMAN†, N. LYLE†, J.E. CAST†, M.C. HAYES* and D.J. BREEN*
*Department of Urology, Southampton General Hospital; †Department of Radiology, Southampton General Hospital, UK

INTRODUCTION

Incidental small renal cell carcinomas (RCC) are often identified in patients who are elderly and not fit for major surgery. This study aims to determine the safety and efficacy of percutaneous RFA in the management of these lesions.

METHODS AND MATERIALS

25 patients (mean age 78.2, range 60-89) underwent RFA of 29 tumours (mean 3.2, range 1.5 to 6.8 cm) between November 1999 and November 2003. Thirty treatment sessions were carried out. Treatments lasted 12 to 24 minutes and were guided by US 23, or CT 7. Patients were followed up clinically, biochemically and with early (<7 days) and sequential CT scanning.

RESULTS

Early post-procedural CT demonstrated complete tumour necrosis in 22 of 29 tumours. Five tumours required additional RFA. Two frail patients (aged 87, 88) were treated conservatively despite traces of viable tumour. Only minor complications have been identified. On case of self-limiting macroscopic haematuria and a minor asymptomatic thermal injury to the psoas muscle has occurred. No significant rise in creatinine was noted 21/25 (mean rise: 3.4 mmol/L, range -9.4 to +16.9 mmol/L). Follow up (mean 17.1 months, 427 patient months) revealed no evidence of local or distant recurrence in 22/25 patients.

CONCLUSION

Medium term experience suggests RFA is a safe, well tolerated and minimally invasive therapy for renal cell carcinoma. In the era of nephron sparing surgery, RFA may have a role in the management of small RCC.

111

Laparoscopic Partial Nephrectomy

P.V. KUMAR, T.H. WHITTLESTONE and M.P.J. WRIGHT
Bristol Royal Infirmary, UK

INTRODUCTION

Nineteen patients, age range 32-73 years, underwent Laparoscopic Partial Nephrectomy (LPN). Indications for surgery included six Bosniak 3 lesions and 13 solid renal lesions less than 4cm in diameter.

METHODS

Preoperative workup included spiral CT angiogram. Under anaesthetic an ipsilateral ureteric catheter was placed. A retroperitoneal balloon dilator was then used as an approach to the affected kidney. After placement of three 10-mm ports, the pedicle is then skeletalized and after the administration of mannitol a laparoscopic bulldog is placed across the pedicle. The lesion is then resected, a biopsy frozen section taken from the tumour base and the kidney reconstructed. Baseline CT scan performed at 1 month post op.

RESULTS

One patient had positive frozen biopsy and required synchronous nephrectomy. One patient had negative frozen biopsy and positive margins on subsequent formal histology and underwent an interval Nephrectomy. There were transfusions or conversion to open surgery.

CONCLUSIONS

LPN is a safe alternative to open partial nephrectomy with reduced trauma to the patient. Competency in intra-corporeal suturing is a prerequisite for this procedure

112

Laparoscopic Radical Nephrectomy for RCC: Safety, Oncological Effectiveness and Limiting Factors

A. ALHASSO*, L. MCLORNAN†, A. RAZA*, N. TOWNELL†, S.A. MCNEILL* and D.A. TOLLEY*
*Western General Hospital, †Ninewells Teaching Hospital, Dundee, UK

INTRODUCTION

Laparoscopic radical nephrectomy (LRN) for renal cell cancer (RCC) has been demonstrated to be safe and associated with long term outcomes similar to open nephrectomy (ON) for T1 RCC. The application of the approach to patients with more advanced disease requires further evaluation. We report our experience in LRN and discuss safety, oncological effectiveness and limitations of the procedure.

METHODS

Retrospective review of case notes for all patients undergoing LRN for RCC in two institutions.

RESULTS

Sixty-one patients (mean age 62 years, range 21-83) have undergone LRN.Pre-operative CT stage was T1a in 29 patients, T1b in 25 and T2 in 6. Operating time was 143.75, 145.26 and 161.83 min for T1a, T1b and T2 respectively (P = 0.001 Student's t-test). Pathological staging resulted in upstaging of two cases from T1a to pT3b, 4 cases from T1b to pT3b and 2 from T2 to pT3b. There were no major surgical complications and 8/61 (13%) suffered post-operative complications. Four cases (2.4%) required blood transfusion, and the median postoperative stay was 4 days (range 2-56). All specimens were removed intact and no positive surgical margins were reported. No recurrences have been reported in 37 patients with a mean follow-up of 36 months.

CONCLUSIONS

LRN for T1 RCC is a safe procedure. Negative surgical margins achieved in all cases provide encouraging evidence of satisfactory oncological effectiveness. In our T2 RCC group the operating time was significantly longer, suggesting that tumour size will be one of the main limiting factors for this approach.

113

Nephrectomy for Renal Cell Carcinoma with Nodal Metastases - Is It Worthwhile

A. KELKAR, S. SANDHU, M. GORE, T. EISEN and T.J. CHRISTMAS
The Royal Marsden Hospital, London, UK

INTRODUCTION

Metastatic renal cell carcinoma (RCC) is generally considered to have a poor prognosis but recent studies suggest that it is best to remove the primary before commencing immunotherapy. The aim of this study was to examine the prognosis of patients with lymph node metastases who underwent lymphadenectomy at the time of radical nephrectomy.

PATIENTS AND METHODS

A series of 275 RCC cases underwent radical nephrectomy with enbloc lymphadenectomy between 1992 and 2003. Lymph node metastases were present in 45(16%). Metastases were present in just the nodes in 19 but in the nodes and elsewhere in 26. Immunotherapy was only given to those with identifiable metastases.

RESULTS

13 (68%) of those with isolated nodal metastases are alive and those that are dead survived for a median of 24 months. In contrast, those with nodal and other metastases only 6 (23%) are alive. Of those that died, their median survival was only 5 months.

CONCLUSIONS

Lymphadenectomy at the time of radical nephrectomy for RCC appears worthwhile with surprising good survival results when metastases are present. Patients with metastases elsewhere do much worse after lymphadenectomy often with only short-time survival.

114

Trans-abdominal Approach to Resection of Vena Caval Thrombus From a Renal Cell Carcinoma. Surgical Pitfalls and Their Management

A. VAIDYA, G. CIANCIO and M. SOLOWAY
University of Miami, USA

INTRODUCTION

Patients with a renal tumor that extends into the vena cava (IVC) is often a challenge to the surgeon. The degree of difficulty depends upon the location of the thrombus in relation to the liver i.e. infra, retro or supra hepatic. The purpose of this abstract is to identify crucial steps where potential mishaps could take place, how to avoid them and if committed, to effectively manage them.

PATIENTS AND METHODS

From January 1999 to November 2003, 91 patients underwent resection of a caval thrombus using a transabdominal incision and piggyback technique of liver mobilization. Anatomico-surgical site-specific problems were identified and described.

RESULTS

Eleven patients had a thrombus extending into the atrium. Of these, cardio-pulmonary bypass was instituted in 6. Eighty-five patients underwent resection of the IVC thrombus without recourse to any form of bypass. Surgical site-specific areas of potential mishaps included the following: (a) Placement of the Rochard retractor could cause splenic or liver capsular tears. (b) Detaching the liver from its peritoneal attachments could lead to liver, diaphragmatic, adrenal, major hepatic vein, inferior phrenic vein, spleen and stomach injuries. (c) The piggyback technique of liver mobilization could result in tears in the IVC and the under surface of the IVC from 'ripping off' of the minor hepatic veins (d) Exposure and vascular isolation of the IVC could lead to thrombus displacement, tears in the lumbar veins and injury to the contralateral renal vein. (e) Removal of the thrombus after cavotomy could lead to tumor and air embolus. (f) Bypass could lead to problems from catheter placement and pump issues.

CONCLUSIONS

Excellent exposure of the IVC is the key to a trans-abdominal approach to these tumours. Understanding the potential areas of disaster will help urologists undertake this procedure with confidence.