F. Roos

Nephron Sparing Surgery for Renal Cell Carcinoma With Normal Contralateral Kidney: 25 Years of Experience

PURPOSE We report the long-term results of our consecutive series of 504 patients who underwent NSS for cancer suspicious, solid renal tumors in the presence of a normal opposite kidney at our institution since 1979. MATERIALS AND METHODS A total of 715 patients underwent NSS since 1969, including 504 for an elective indication, that is with a normal opposite kidney. Of these patients 381 (75.6%) had RCC, 123 (24.4%) had cancer suspicious benign lesions, including 53 (10.5%) with oncocytoma, 33 (6.5%) with angiomyo(lipo)ma, 23 (4.6%) with a complicated cyst and 13 (2.8%) with other benign lesions. Of the 381 patients with RCC 283 (74.3%) had clear cell, 68 (17.8%) had papillary and 30 (7.9%) had chromophobic RCC. Mean tumor diameter was 3.0 cm (range 0.5 to 11.0). Mean followup was 6.77 years (range 0.2 to 24.1). The oncological outcome was studied, including pathological features associated with tumor progression. RESULTS Estimated cancer specific survival rates at 5 and 10 years were 98.5% and 96.7%, respectively. Estimated survival rates free of distant metastasis at 5 and 10 years were 97.5% and 95.1%, respectively. Nine patients with localized RCC experienced local recurrence after NSS. Estimated survival rates free of local recurrence at 5 and 10 years were 98.3% and 95.7%, respectively. CONCLUSIONS The long-term results of our series support the concept of organ sparing surgery for RCC in the presence of a normal opposite kidney with excellent long-term survival and a low tumor recurrence rate.

Short-Term Functional and Oncologic Outcomes of Nephron-Sparing Surgery for Renal Tumours ≥7 cm

BACKGROUND Nephron-sparing surgery (NSS) for renal tumours preserves renal function and has become the standard approach for small renal tumours. Little is known about perioperative and oncologic outcomes of patients following NSS in renal tumours ≥ 7 cm in the presence of a healthy contralateral kidney. OBJECTIVE To analyse oncologic outcomes and perioperative morbidity in patients treated by NSS for renal tumours ≥ 7 cm. DESIGN, SETTING, AND PARTICIPANTS In total, 5767 patients were treated for renal tumours at two institutions from 1984 to 2009. In 91 patients, elective NSS was performed for renal tumours ≥ 7 cm. MEASUREMENTS Complication rates were assessed in detail and stratified using the Clavien-Dindo score (CDS). Oncologic outcomes for overall survival (OS), cancer-specific survival (CSS), and progression-free survival (PFS) were estimated using the Kaplan-Meier method. Logistic regression analysis was used to identify clinical risk factors for complications and prognosticators that have an oncologic impact on OS. RESULTS AND LIMITATIONS The median follow-up was 28 mo (range: 1-247 mo). Twenty-seven patients (29.6%) had perioperative complications and, of these, 89.1% had CDS grade 1 and 2. Twenty-seven percent of the 91 patients had benign lesions. Seven patients (10.6%) died from cancer-related causes. The 5- and 10-yr rates for OS, CSS, and PFS were 88% and 64%, 97% and 83%, and 91% and 78%, respectively. None of the analysed parameters had an impact on morbidity or OS in the univariate analysis. Limitations of this study were its retrospective nature and the relatively short follow-up period for oncologic outcome. CONCLUSIONS NSS for renal tumours ≥ 7 cm can be performed with acceptable complication rates and with oncologic outcomes comparable to radical nephrectomy studies. Our findings support NSS whenever technically feasible to reduce the loss of renal function.

Bilateral synchronous sporadic renal cell carcinoma: surgical management, oncological and functional outcomes

To analyse the functional and oncological outcomes of surgical treatment of bilateral synchronous sporadic renal cell carcinoma (RCC).

Oncologic Long-term Outcome of Elective Nephron-sparing Surgery Versus Radical Nephrectomy in Patients With Renal Cell Carcinoma Stage pT1b or Greater in a Matched-pair Cohort

OBJECTIVES To analyze the oncologic outcome and overall survival (OS) for patients with renal cell carcinoma (RCC) >4 cm undergoing radical nephrectomy (RN) or elective nephron-sparing surgery (NSS) in a matched-pair cohort. METHODS From 1988 to 2007, we identified 829 patients in our clinic treated with either RN (n = 641) or open NSS (n = 188) for renal masses >4 cm. After matching the cohort for age, time of surgery, grade, TNM stage, tumor size, and sex and excluding patients with metastases, benign lesions with an imperative indication, and those with missing records, 173 remained for oncologic analysis. OS, cancer-specific survival, and progression-free survival were estimated using the Kaplan-Meier method. The association with death was evaluated with Cox proportional hazards regression analysis. RESULTS At the last follow-up visit, 39 patients had died of any cause and 134 were alive at a median of 7.0 years. RN and elective NSS had been performed in 100 and 73 patients, respectively. The OS (P = .357), progression-free survival (P = .558), and cancer-specific survival (P = .239) were not significantly different between the elective NSS and RN groups using the Kaplan-Meier method. On univariate and multivariate Cox regression analysis, the type of surgery did not have an effect on OS (hazard ratio 1.35, 95% confidence interval 0.71-2.54, P = .359). CONCLUSIONS Our results suggest that it is oncologically safe to perform NSS for renal tumors >4 cm, for which the surgical feasibility according to the tumor location, rather than the tumor size, seemed to be the limiting factor.

Perioperative morbidity and renal function in young and elderly patients undergoing elective nephron‐sparing surgery or radical nephrectomy for renal tumours larger than 4 cm

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

Renal tumour surgery in elderly patients.

To analyse morbidity, renal function and oncological outcome in patients aged ≥80 years who had surgery for renal tumours, as in the elderly such surgery is controversial in relation to life‐expectancy and other causes of death.

Functional Analysis of Elective Nephron-sparing Surgery vs Radical Nephrectomy for Renal Tumors Larger than 4 cm

OBJECTIVE To preserve renal function, nephron sparing surgery (NSS) for renal tumors should be performed. Little is known about perioperative morbidity and long-term functional outcome of patients after elective NSS compared with radical nephrectomy (RN) in renal tumors >4 cm. MATERIALS AND METHODS Eight-hundred twenty-nine patients were treated with either RN (n = 641) or NSS (n = 188) for renal tumors >4 cm. After pairing the cohort for age, grading, TNM, size, gender, and preoperative renal function and excluding patients with imperative indication and metastases, 247 patients remained for functional analysis. Serum creatinine (SCr) values were used to estimate glomerular filtration rate (eGFR) via Modification of Diet in Renal Disease. Chronic kidney disease (CKD) was defined as eGFR <60 mL/min/1.73 m(2) and regression analyses were used to identify clinical risk factors for CKD and perioperative complications stratified by the Clavien-Dindo score. RESULTS The Charlson comorbidity index was similar between patients undergoing NSS (n = 101) and RN (n = 146) (P = .583). The complication rates did not differ significantly between both groups (P = .091). Age (OR 0.94, P = .009), ASA score 3+4 (OR 3.55, P = .004), RN (OR 10.75, P < .001), and preoperative eGFR (OR 1.06, P < .001) were independent risk factors for developing CKD postoperatively, whereas tumor size had no impact (OR 1.01, P = .245). Overall survival was comparable between the groups (P = .896). CONCLUSION Although overall survival was similar, patients undergoing RN for renal tumors >4 cm had a significantly higher risk of developing CKD than patients treated with NSS. Complication rate did not differ significantly between both groups, even for tumors >7 cm. Our findings support elective NSS for tumors >4 cm, whenever NSS is technically feasible for maintaining renal function.

Prognostic Factors of Papillary Renal Cell Carcinoma: Results From a Multi-Institutional Series After Pathological Review

PURPOSE We examined papillary renal cell carcinoma prognostic variables and validated the 2002 UICC TNM staging system in a multicenter analysis. MATERIALS AND METHODS From 10 urological institutions in Germany followup data were collected on a total of 675 patients with papillary renal cell carcinoma. Central pathological review was done to validate external histopathological diagnoses. The Kaplan-Meier method was used to derive cumulative cancer specific and overall survival, and the log rank test was used to compare the curves of 2 or more groups. For multivariate analysis of prognostic factors Cox regression analysis was done. All proportional hazard assumptions were systemically verified using the Grambsch-Therneau test. RESULTS Cancer specific survival was significantly related to TNM stage and histological grading on univariate and multivariate analyses. Five-year cancer specific survival in pT1b cases was significantly shorter than in pT1a cases (90.0% vs 98.3%, p = 0.017). No significant difference was found between pT1b and pT2 tumors. Patients with pT3 or greater disease were at high risk for metastasis (50.6%) while metastatic disease associated with pT2 or less tumors occurred in 7.8% (p <0.0001). After metastatic disease was present the prognosis was poor with 7.2% 5-year cancer specific survival. Age was associated with poor prognosis in the subgroup with pT3 or greater tumors on univariate analysis (p = 0.026) but not on multivariate analysis. CONCLUSIONS In its current form the 2002 UICC TNM staging system is not applicable to papillary renal cell carcinoma. Clinical and radiological followup should be offered at frequent intervals to patients with venous thrombus and/or locally advanced disease. The role of age remains unclear but should not be underestimated in risk stratification after surgery.

Bone Metastasis in Renal Cell Carcinoma is Preprogrammed in the Primary Tumor and Caused by AKT and Integrin α5 Signaling

PURPOSE Bone metastasis develops in 30% of all patients with renal cell carcinoma. We elucidated the mechanisms that lead to and predict bone metastasis of renal cell carcinoma. MATERIALS AND METHODS Nine renal cell carcinoma primary cell lines and 30 renal cell carcinoma tissue specimens (normal and tumor tissue) were collected from 3 patients with no metastasis and 10 with lung or bone metastasis within 5 years after nephrectomy. Cell migration was analyzed in a Boyden chamber and proliferation was assessed by bromodeoxyuridine incorporation. Adhesion to fibronectin, and collagen I and IV was determined after cell staining. The expression and/or activity of cellular signaling molecules was quantified by Western blot. RESULTS Compared to renal cell carcinoma cells from patients without metastasis, the migration of cells from patients with bone metastasis was enhanced 13.5-fold (p = 0.034), and adhesion to fibronectin and collagen I was enhanced 5.8-fold and 6.1-fold (p = 0.002 and 0.014, respectively). In general proliferation was decreased in metastasizing cells. In accordance with these results we detected higher activity of AKT (p = 0.011) and FAK (p = 0.054), higher integrin α5 expression (p = 0.052) and lower PTEN expression in primary cells from patients with bone metastasis compared to nonmetastasizing cells. An almost similarly altered expression pattern was also observed in the renal cell carcinoma tissue specimens and the normal renal tissue of patients with bone metastasis. CONCLUSIONS We describe evidence that molecular predispositions determine the potential for bone metastasis to develop in renal cell carcinoma, which may serve as prognostic markers after initial tumor detection.

[Colovesical fistula caused by diverticulitis of the sigmoid colon: diagnosis and treatment].

BACKGROUND Colovesical fistulas caused by diverticulitis of the sigmoid colon are a rare but complex disease for which there is so far no diagnostic and therapeutic algorithm. The goal of this retrospective study including long-term follow-up was to find an algorithm for the diagnosis and therapy of colovesical fistulas caused by diverticular disease. METHODS Between 1982 and 2010 a total of 54 patients (46 male and 8 female) were treated in this institute for a colovesical fistula caused by diverticulitis of the sigmoid colon. The validity of the following diagnostic procedures was considered: poppy seed test, abdominal computed tomography (CT), cystoscopy, coloscopy, cystography and colon enema. The one stage operation included resection of the inflamed colon and a two-lined hand sewn end to end anastomosis of the colon without protective colostomy. After excision of the fistula a two-lined closure of the bladder defect was carried out followed by insertion of a catheter for 7 days. During follow-up patients were examined for recurrence of diverticulitis and colovesical fistula. RESULTS At primary clinical presentation all patients showed clinical symptoms of recurrent urinary tract infections, 74.1% had pneumaturia and 53.7% fecaluria. Fistula detection rates were 94.8% for the poppy seed test, 58.7% for CT scanning, 19.4% for cystography, 38.6% for colon enema, 15.1% for cystoscopy and 9.6% for coloscopy. Of the patients 6 (11.1%) showed perioperative morbidity (3 pneumonia and 3 superficial wound infections) and mortality was 0%. After surgical intervention no recurring diverticulitis or fistulas were detected within a median follow-up period of 62 months (range 1-164 months). CONCLUSIONS The poppy seed test is the most reliable diagnostic method for the detection of colovesical fistulas. The one-stage resection of the fistula of the colon and bladder segment without protective colostomy is safe and feasible.