A. Tuccio

Histopathologic Analysis of Peritumoral Pseudocapsule and Surgical Margin Status after Tumor Enucleation for Renal Cell Carcinoma

BACKGROUND The oncologic safety of blunt tumor enucleation (TE) of renal cell carcinoma (RCC) depends on the presence of a continuous pseudocapsule (PS) around the tumor and on the possibility of obtaining negative surgical margins (SMs). OBJECTIVE To investigate the PS and SMs after TE to define the real need to take a rim of healthy parenchyma around the tumor to avoid the risk of positive SMs. The risk of PS invasion related to other clinical and pathologic variables was also evaluated. DESIGN, SETTING, AND PARTICIPANTS Between September 2006 and December 2007, data were gathered prospectively from 187 consecutive patients who had kidney surgery. Overall, 90 consecutive patients who had TE for RCC were eligible for the study. All specimens were evaluated using an image analyzer by a dedicated uropathologist. INTERVENTION TE was done by blunt dissection using the natural cleavage plane between the tumor and the normal parenchyma. MEASUREMENTS PS, SM, and routinely available clinical and pathologic variables were recorded. RESULTS AND LIMITATIONS In 60 RCC tumors (67%) the PS was intact and free from invasion (PS-) while in 30 (33%) there were signs of penetration within its layers, with or without invasion beyond it. Indeed, 26.6% had PS that had been penetrated on the parenchymal side and 6.6% had penetration on the perirenal fat tissue side. The odds of having PS penetration increased significantly with an increase in clinical tumor size. PS penetration was also significantly associated with pathologic tumor dimensions and grade. In all cases the SMs were negative after TE. The present patients, followed for >2 yr, will enable us to correlate the risk of local recurrence with PS status. CONCLUSIONS The risk of PS penetration is associated with clinical and pathologic tumor dimensions and grade. If there is PS invasion into normal parenchyma, the presence of a thin layer of tissue allows for negative SM even if a TE is performed.

Pathological characteristics and prognostic effect of peritumoral capsule penetration in renal cell carcinoma after tumor enucleation

OBJECTIVE To evaluate the pathological characteristics of peritumoral capsule (PC) and the prognostic effect of capsule penetration on tumor recurrence in patients treated with tumor enucleation for clinically intracapsular renal cell carcinomas (RCCs). METHODS AND MATERIALS PC status was analyzed in 304 consecutive patients with single intracapsular RCC. Degree and side of capsule penetration if present were evaluated. Mean (median, range) follow-up was 49 months (46, 25-69). Local recurrence rate, progression-free survival (PFS), and cancer-specific survival were the main outcomes. Statistical analyses included the Kaplan-Meier method, log-rank test, and univariate and multivariate Cox regression models. RESULTS Overall, 51% of RCCs had intact PC and free from neoplastic invasion (PC-), 34.9% had capsular penetration on the parenchymal side (PCK), and 14.1% had tumor invasion on the perirenal fat tissue side (PCF). None of the patients had positive surgical margins. The 5-year PFS rates for tumors PC-, PCK, and PCF were 97.5%, 96.7%, and 77.1%, respectively (P<0.0001). The multivariate Cox model showed PCF to be the sole significant independent predictor of PFS, whereas patients who had PCK did not present a significant increased risk in developing recurrence. CONCLUSIONS Tumor enucleation is an oncologically safe nephron-sparing surgery technique. PCF is a significant and independent predictor of tumor recurrence in patients with clinically intracapsular RCCs scheduled for nephron-sparing surgery. PCK does not predict the risk of recurrence.

Local recurrence after tumour enucleation for renal cell carcinoma with no ablation of the tumour bed: results of a prospective single‐centre study

Study Type – Therapy (individual cohort) 
Level of Evidence 2b

Morbidity of tumour enucleation for renal cell carcinoma (RCC): results of a single‐centre prospective study

Study Type – Therapy (case series) Level of Evidence 4

Sutureless Hemostatic Control During Laparoscopic NSS for the Treatment of Small Renal Masses

Background. This study aimed to evaluate the safety and efficacy of a sutureless hemostatic control during laparoscopic nephron sparing surgery (LNSS) for the treatment of small renal masses. Methods. Between November 2007 and August 2010, 245 patients underwent nephron sparing surgery. Overall, 100 patients (41%) had LNSS. Hemostasis was controlled either by a knot-tying suture repair (standard-LNSS) or by a sutureless technique (s-LNSS). The s-LNSS was done using a bipolar cauterization of the resection bed, followed by Floseal apposition. Operative and warm ischemia time (WIT), intraoperative blood loss, hospital stay, blood tests, and perioperative complications were recorded. Results. In 32 cases (32%) hemostasis was controlled by the sutureless technique. The s-LNSS was the treatment of choice for small tumors ≤1.5 cm, and it was also used for the treatment of tumors between 1.6 and 2.5 cm, aside from their spatial extension. Indeed, the mean (range; interquartile range) clinical dimension of the tumors in the s-LNSS group was 1.9 (1-3.5; 1.5-2.1) cm. On the contrary, the vast majority of tumors >2.5 cm were treated with standard-LNSS. Mean (range; interquartile range) WIT in the s-LNSS group was 16 (8-22; 12-16) minutes. The mean (range) intraoperative blood loss in the s-LNSS group was 107 cc (25-205). No postoperative early and late bleeding were reported in the s-LNSS group, and the mean (range) time to drainage removal and time to discharge were 3 (2-5) and 4 (3-7) days, respectively. Conclusions. The sutureless technique with bipolar cauterization of the surgical bed and Floseal apposition is safe and effective for the hemostatic control in the treatment of small cortical masses. It can be always used for tumors ≤1.5 cm and can be a valid option also for tumors between 1.6 and 2.5 cm, aside from their spatial extension.

Florence robotic intracorporeal neobladder (FloRIN): a new reconfiguration strategy developed following the IDEAL guidelines.

To describe our step‐by‐step technique for robotic intracorporeal neobladder configuration, including the stages of conception, development and exploration of this surgical innovation, according to the Idea, Development, Exploration, Assessment, Long‐term follow‐up (IDEAL) Collaboration guidelines.

Tumor–parenchyma interface and long-term oncologic outcomes after robotic tumor enucleation for sporadic renal cell carcinoma

OBJECTIVE Tumor enucleation has been shown to be oncologically safe for elective treatment of renal cell carcinoma (RCC); yet, evidence on long-term oncologic outcomes after robotic tumor enucleation is lacking. In this study we provide a detailed histopathological analysis of tumor-parenchyma interface and the long-term oncologic outcomes after robotic tumor enucleation for sporadic RCC in a high-volume referral center. MATERIALS AND METHODS We selected consecutive patients undergoing robotic tumor enucleation for sporadic RCC by experienced surgeons with at least 4 years of follow-up. Pattern of pseudocapsule (PC) invasion, thickness of healthy renal margin removed with the tumor, margin status and recurrence rate were the main study endpoints. Multivariable models evaluated independent predictors of PC invasion. RESULTS Overall, 140 patients were eligible for the study. Of these, 127 (91%) had complete data available for analysis. Median thickness of healthy renal margin was 0.57 mm (interquartile range [IQR] 0.24-103). A distinct peritumoral PC was present in 121/127 (95%) tumors with a median thickness of 0.28 mm (IQR 0.14-0.45). In 24/121 (19.8%) cases, RCC showed complete PC invasion. At multivariable analysis, increasing tumor diameter, endophytic rate > 50% and papillary histology were significantly associated with complete PC invasion. Positive surgical margins were reported in 3/127 (2.4%) cases. At a median follow-up of 61 months (range 48-76), one patient died due to metastatic RCC. Among patients alive at follow-up, no cases of recurrence at the enucleation site were recorded, while three cases (2.4%) of renal recurrence (elsewhere in the ipsilateral kidney) and three cases (2.4%) of systemic recurrence were found. CONCLUSIONS Distinct RCC-related features were associated with complete PC invasion. By providing a microscopic layer of healthy renal margin in almost all cases, robotic tumor enucleation achieved negative surgical margins in the vast majority of patients, even in case of complete PC invasion. At long-term follow-up, no recurrences were found at the enucleation site. Although our findings need to be confirmed by larger studies with longer follow-up, robotic tumor enucleation appears oncologically safe in experienced hands for the treatment of sporadic RCC.

643 Clamp vs clampless endoscopic robot-assisted simple enucleation (ERASE) for the treatment of clinical T1 renal masses: Analysis of surgical and functional outcomes from a matched-paired comparison

MATERIAL & METHODS: A matched-pair comparison of 120 clamp vs. 120 clampless over 350 patients treated with ERASE was performed matching for side, polar tumor location, clinical size score, urinary collecting system and renal sinus dislocation. Perioperative and functional outcomes were compared between groups. Renal function was calculated using biochemical markers (Sr Creatinine, eGFR using MDRD and chronic kidney disease (CKD) stage according to eGFR).

415 Endoscopic robot-assisted simple enucleation (ERASE) vs open simple enucleation (OSE) for the treatment of clinical T1 renal masses: Analysis of predictors of trifecta outcome

Aim: The aim of this study was to analyse the intraand postoperative complications, as well as the predictive factors of Trifecta outcome in patients submitted to endoscopic robotassisted simple enucleation (ERASE) and open simple enucleation (OSE) for clinical T1 renal masses. Materials and Methods: Overall, 634 cases treated with OSE (n=290) and ERASE (n=344) were prospectively recorded in our Department between 2006 and 2014. Trifecta was defined as simultaneous ischemia time <25 min, no surgical complication and negative surgical margin. A univariate analysis and multivariate logistic regression were performed for Trifecta. Results: The two groups were comparable for body mass index (BMI), comorbidity, tumor side, clinical T score, tumor diameter, surgical indication, pre-operative renal function, pre-operative hemoglobin and hematocrit. A significant difference was found between the OSE and the ERASE groups in operative time (115 (96-130) vs. 150 (120180) minutes, p<0.0001), pedicle clamping (93.8% vs. 69.2%, p<0.0001), estimated blood loss (EBL) (150 (100200) vs. 100 (100-143) cc, p<0.0001) and intraoperative complications (3.4% vs. 1.7%, p=0.02). The two groups were comparable for warm ischemia time (WIT) ≥25 min. A significant difference was found between OSE and ERASE in overall (16.6% vs. 5.5%, p<0.0001), Clavien 2 (11.7% vs. 4.4%, p=0.02) and Clavien 3 (3.1% vs. 1.7%, p=0.04) postoperative surgical complications, length of stay (6.0 (5.0-7.0) vs. 5.0 (4.0-6.0) days, p<0.0001), pre-operative 1st day delta creatinine (0.3 (0.2-0.4) vs. 0.15 (0.1-0.2) mg/dl, p<0.0001), positive surgical margins (2.1% vs. 1.5%, p=0.04), and Trifecta achievement (73.8% vs. 85.5%, p<0.0001). At univariate analysis, a higher median clinical diameter, a higher mean age, a higher median Charlson comorbidity index (CCI), endophytic tumor growth pattern, renal sinus and calyceal dislocation of the tumor, a higher median PADUA score and OSE were predictive factors of Trifecta achievement. At multivariate analysis, CCI lost significance (p=0.26), while age (odds ratio (OR)=1.02, 95% confidence interval (95% CI)=1.00-1.04, p=0.001), clinical diameter (OR=1.22, CI=1.05-1.42, p=0.008), PADUA score (OR=1.23, CI=1.07-1.41, p=0.004) and OSE (OR=1.74, CI=1.13-2.68, p=0.01) were confirmed predictive factors for Trifecta failure. Conclusion: The ERASE is a feasible and safe technique, which shows a comparable WIT, together with a significantly lower EBL, surgical complications’ rate, length of stay and a significantly higher Trifecta achievement compared to OSE. Age, comorbidity, tumor diameter and PADUA score, in association with surgical approach, represent significant predictive factors of Trifecta failure.

730 PSA kinetics parameters are predictive of PET features worsening in patients with biochemical relapse after prostate cancer treatment with radical intent: Results from a longitudinal cohort study

MATERIAL & METHODS: This longitudinal cohort study comprised 103 consecutive patients. All patients underwent two 18FC PET/CT: one at baseline (PET 1) and one after 6 months (PET 2). Total PSA (tPSA), PSA velocity (vPSA), PSA doubling time (dtPSA), absolute variation of PSA values between PET2 and PET1 (∆PSA), percentage variation of PSA between the two PSA measurements were measured from each patients (PSA%). Progression of disease on 18FC PET/CT findings were compared with the PSA kinetics parameters. The major outcome measures were the disease progression at the PET.