A
69 yrs old male presented to our OPD with h/o left sided varicocele. A
known case of Diabetes, hypertension and bilateral medical renal
disease, he underwent MRI abdomen which revealed a large lower pole
lesion in left kidney with no renal vein or IVC thrombus. DTPA Scan
revealed a 61% function in the affected kidney. Due to his bilateral
medical renal disease and poorly functioning contra lateral kidney, he
was planned for Nephron Sparing Surgery / partial nephrectomy (L) and DJ
Stenting under cold ischaemia. Post op patient initially showed a rise
in creatinine levels which gradually settled down to pre operative
levels.
Before we go into the discussion of partial nephrectomy or nephron sparing surgery (NSS) in RCC, I would like to emphasize on the presenting complaint. Varicocele in the left side is one of the presentation of Left sided kidney mass, which occurs due to the drainage of the gonadal vein into the renal vein on the left side and generally indicates tumor thrombus in the venous system renal/ IVC, however in this case it was because of compression of left gonadal vein by the renal mass.
Renal tumors comprise approximately 3.8% of all new cancers with median age at diagnosis of 64 yrs. It is the third most common urological malignancy. The rate of RCC has increased by 1.6% per year for last 10 yrs, the reason of which is unknown. Majority of them are renal cell carcinomas and 80% of them are clear cell variety.
Smoking and obesity are high risk factors of RCC. Some genetic diseases are also associated with RCC, like Von Hippel Lindau (VHL) disease.
At presentation 25% are locally advanced. More often patient presents with metastatic disease (20%). Only a few patients present with Virchows Triad - the €too late triad' ( of hematuria, abdominal pain and flank mass). A CT Scan or MRI of the whole abdomen including pelvis clinches the diagnosis. A NEEDLE BIOPSY IS NOT NECESSARY BEFORE SURGERY IF THERE ARE CLEAR FINDINGS IN IMAGING. It is only required when non surgical intervention is planned or if the patient is planned to be kept under surveillance only.
Surgery is the only definitive curative treatment for renal cancer, either in the form of NSS/ Radical Nephrectomy. Any of the open, laparoscopic or robotic techniques may be employed for either of the two procedures; with each having its own advantages and disadvantages.Types of Partial Nephrectomy are Polar segmental resection, Wedge resection, Major transverse resection and Bench resection & auto transplant.
Indications for Open partial nephrectomy BOX 1
€ Solitary kidney
€ Large tumour
€ Central tumour
€ Multiple tumours
€ Requirement for cooling
€ Ischaemia > 30 min
Before we go into the discussion of partial nephrectomy or nephron sparing surgery (NSS) in RCC, I would like to emphasize on the presenting complaint. Varicocele in the left side is one of the presentation of Left sided kidney mass, which occurs due to the drainage of the gonadal vein into the renal vein on the left side and generally indicates tumor thrombus in the venous system renal/ IVC, however in this case it was because of compression of left gonadal vein by the renal mass.
Renal tumors comprise approximately 3.8% of all new cancers with median age at diagnosis of 64 yrs. It is the third most common urological malignancy. The rate of RCC has increased by 1.6% per year for last 10 yrs, the reason of which is unknown. Majority of them are renal cell carcinomas and 80% of them are clear cell variety.
Smoking and obesity are high risk factors of RCC. Some genetic diseases are also associated with RCC, like Von Hippel Lindau (VHL) disease.
At presentation 25% are locally advanced. More often patient presents with metastatic disease (20%). Only a few patients present with Virchows Triad - the €too late triad' ( of hematuria, abdominal pain and flank mass). A CT Scan or MRI of the whole abdomen including pelvis clinches the diagnosis. A NEEDLE BIOPSY IS NOT NECESSARY BEFORE SURGERY IF THERE ARE CLEAR FINDINGS IN IMAGING. It is only required when non surgical intervention is planned or if the patient is planned to be kept under surveillance only.
Surgery is the only definitive curative treatment for renal cancer, either in the form of NSS/ Radical Nephrectomy. Any of the open, laparoscopic or robotic techniques may be employed for either of the two procedures; with each having its own advantages and disadvantages.Types of Partial Nephrectomy are Polar segmental resection, Wedge resection, Major transverse resection and Bench resection & auto transplant.
Indications for Open partial nephrectomy BOX 1
€ Solitary kidney
€ Large tumour
€ Central tumour
€ Multiple tumours
€ Requirement for cooling
€ Ischaemia > 30 min
Indications for Minimally Invasive techniques BOX2
€ Small < 3cm
€ Non central lesion
€ Small < 3cm
€ Non central lesion
Originally
partial nephrectomy (NSS) was indicated only in the clinical settings
in which radical nephrectomy would make patient functionally anephric or
patient will require dialysis, like RCC in solitary kidney, but now it
is becoming more common. The absolute indications are Solitary kidney,
bilateral renal masses and Renal Impairment. There are also relative
indications like small unilateral tumors and hereditary RCC. Partial
nephrectomy has same oncological outcome till the stage 1B tumors, i.e,
till a size of 7 cm tumor. Node dissection has no survival advantage and
is a staging procedure only. At least 20% RCC cases are suitable for
NSS. Cold ischemia is preferred in those cases where we anticipate the
operative time following clamping of the renal artery to be prolonged.
If we clamp renal artery for more than 60 minutes in warm ischemia, then
the recovery is incomplete and 60-70% of the renal function is lost,
while the same for 20-30 minutes leads to complete renal recovery, and
in cold ischemia we can save the function of the kidney even till 60
minutes.
Studies with limited follow up reveal that the oncological outcome for laparoscopic Vs open partial nephrectomy appears to be similar. However, it was shown that operative and post operative complications are fewer in open surgery. Radical nephrectomy should not be employed when partial nephrectomy or NSS can be achieved (1) Pts with partial nephrectomy show better survival than radical nephrectomy. (2,3)
Surgical resection remains an effective therapy for clinically localized RCC, with options including radical nephrectomy (open, laparoscopic, robotic) or nephron sparing surgery. Each of these modalities is associated with its own benefits and risks, the balance of which should optimise long term renal function and expected cancer free survival.
Studies with limited follow up reveal that the oncological outcome for laparoscopic Vs open partial nephrectomy appears to be similar. However, it was shown that operative and post operative complications are fewer in open surgery. Radical nephrectomy should not be employed when partial nephrectomy or NSS can be achieved (1) Pts with partial nephrectomy show better survival than radical nephrectomy. (2,3)
Surgical resection remains an effective therapy for clinically localized RCC, with options including radical nephrectomy (open, laparoscopic, robotic) or nephron sparing surgery. Each of these modalities is associated with its own benefits and risks, the balance of which should optimise long term renal function and expected cancer free survival.
References:
1. Urology 2010;76:631-637.
2. JAMA 2012 apr 18;307(15):1629-35.
3. J Urology 2008; 179:468-471; discussion472-483
</ 3cm
1. Urology 2010;76:631-637.
2. JAMA 2012 apr 18;307(15):1629-35.
3. J Urology 2008; 179:468-471; discussion472-483
</ 3cm
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