Khaled S. Hafez

LONG-TERM RESULTS OF NEPHRON SPARING SURGERY FOR LOCALIZED RENAL CELL CARCINOMA: 10-YEAR FOLLOWUP

PURPOSE Partial nephrectomy is effective for renal cell carcinoma when preservation of renal function is a concern. We present the 10-year followup of patients treated with nephron sparing surgery at our institution. MATERIALS AND METHODS Partial nephrectomy was performed in 107 patients with localized sporadic renal cell carcinoma before December 1988. Tumors were symptomatic in 73 patients (68%) and indications for surgery were imperative in 96 (90%). Of the patients 42 (39%) had renal insufficiency preoperatively. All patients were followed a minimum of 10 years or until death. RESULTS At the end of the followup interval 32 patients (30%) had no evidence of recurrence, 28 (26%) died of metastatic renal cell carcinoma and 46 (42%) died of unrelated causes. Cancer specific survival was 88.2% at 5 and 73% at 10 years, and was significantly affected by tumor stage, symptoms, tumor laterality and tumor size. Long-term renal function was stable in 52 patients (49%). CONCLUSIONS Partial nephrectomy is effective for localized renal cell carcinoma, providing long-term tumor control with preservation of renal function.

NEPHRON SPARING SURGERY FOR LOCALIZED RENAL CELL CARCINOMA: IMPACT OF TUMOR SIZE ON PATIENT SURVIVAL, TUMOR RECURRENCE AND TNM STAGING

PURPOSE We studied the impact of tumor size on patient survival and tumor recurrence following nephron sparing surgery for localized sporadic renal cell carcinoma. In addition, we evaluated the usefulness of the new TNM staging system in which T1 versus T2 tumor status is delineated by tumor size 7 or less versus more than 7 cm., respectively. MATERIALS AND METHODS The results of nephron sparing surgery for localized sporadic renal cell carcinoma in 485 patients treated before 1997 were reviewed. Patients were divided into groups according to tumor size as 1--2.5 or less (142), 2--2.5 to 4.0 (168), 3--more than 4 to 7 (125) and 4--more than 7 cm (50). Mean postoperative followup was 47 months. RESULTS Overall and cancer specific 5-year survival for the entire series was 81 and 92%, respectively. Of 44 patients with recurrent renal cell carcinoma 16 (3.2%) had local recurrence and 28 (5.8%) had metastatic disease. There was no difference in 5-year cancer specific survival or tumor recurrence between groups 1 and 2 or groups 3 and 4. However, these outcome measures were significantly more favorable in groups 1 and 2 combined (tumors 4 cm. or less) compared to groups 3 and 4 combined (tumors more than 4 cm.) (p = 0.001). CONCLUSIONS Following nephron sparing surgery for localized sporadic renal cell carcinoma cancer-free survival is significantly better in patients with tumors 4 cm. or less compared to those with larger tumors. The usefulness of the current TNM staging system can be improved by subdividing T1 tumors into T1a (4 cm. or less) and T1b (4 to 7 cm.).

Patterns of Tumor Recurrence and Guidelines for Followup After Nephron Sparing Surgery for Sporadic Renal Cell Carcinoma

PURPOSE We delineated patterns of tumor recurrence and developed guidelines for followup after nephron sparing surgery for sporadic renal cell carcinoma. MATERIALS AND METHODS Before December 1994, 327 patients underwent nephron sparing surgery for sporadic localized renal cell carcinoma at our clinic. Mean postoperative followup was 55.6 months. The course and outcome for patients with postoperative recurrent renal cell carcinoma were reviewed in detail. RESULTS Renal cell carcinoma recurred after nephron sparing surgery in 38 patients (11.6%), including 13 (4.0%) who had local tumor recurrence with (7) or without (6) metastatic disease and 25 (7.6%) who had metastatic disease without local tumor recurrence. Recurrent renal cell carcinoma was detected by associated symptoms in 25 patients and by a followup chest x-ray or abdominal computerized tomography (CT) in 13. The respective incidences of postoperative local tumor recurrence and metastatic disease according to initial pathological tumor stage were 0 and 4.4% for stage T1, 2.0 and 5.3% for stage T2, 8.2 and 11.5% for stage T3a, and 10.6 and 14.9% for stage T3b disease. The peak postoperative intervals until local tumor recurrence were 6 to 24 months (7 of 10 patients with stage T3 renal cell carcinoma) and longer than 48 months (all 3 with stage T2 disease). Patients with isolated local tumor recurrence had better survival compared to those with local tumor recurrence and metastatic disease or metastases only. CONCLUSIONS Followup for recurrent malignancy after nephron sparing surgery for renal cell carcinoma can be tailored according to the initial pathological tumor stage. All patients should be evaluated yearly with a medical history, physical examination and select laboratory studies. Patients with stage T1 renal cell carcinoma require no additional monitoring, while those with stage T2 disease should also undergo a yearly chest x-ray and abdominal CT every 2 years. The same recommendations are offered for patients with stage T3 renal cell carcinoma except that abdominal CT should be done every 6 months for the first 2 years postoperatively.

Comparison of direct hospital costs and length of stay for radical nephrectomy versus nephron-sparing surgery in the management of localized renal cell carcinoma

OBJECTIVES Recent work has demonstrated comparable surgical results and 5-year cancer-specific survival rates between radical nephrectomy and nephron-sparing surgery (NSS) in the treatment of patients with small (4 cm or smaller) solitary renal cell carcinomas (RCCs). However, differences exist in the intraoperative management and postoperative care of patients undergoing NSS versus radical nephrectomy, and we sought to compare direct hospital costs and length of stay (LOS) between these two groups to determine whether either treatment imparts a specific cost advantage. METHODS Data were retrieved from medical records and administrative data sets containing billing encounters for all costs incurred during hospitalization at the Cleveland Clinic Foundation. Individual costs were grouped together using nine cost center categories encompassing every aspect of direct hospital care, including anesthesiology, laboratory, radiology, nursing, pharmaceutical, and emergency services, and medical care, surgical care, and miscellaneous costs. Each cost center was further subdivided, and a total of 52 cost subcategories were assessed. The total direct costs of hospitalization were compared using a multivariate regression model in which patient demographics and tumor characteristics, type and year of surgery, LOS, and cost center categories were assessed as single and interactive factors. Postoperative complication and cancer-specific survival rates were also compared to identify any potential therapeutic differences between the two groups. RESULTS Between 1991 and 1995, 80 patients underwent surgery at the Cleveland Clinic Foundation for solitary RCCs 4 cm or smaller, including 52 partial and 28 radical nephrectomies. We found no difference in the postoperative complication rate or cancer-specific survival rate between the two surgical groups. Total direct hospital costs and LOS were not statistically different between the NSS and radical nephrectomy groups (P >0.05). This was further supported by our multivariate model, which accounted for 61% of the observed variance in the total costs (F = 12.11, P = 0.0001). The type of surgery was not associated with total cost when controlling for all other factors, including age, sex, year of surgery, tumor size, grade, and stage, and postoperative complications (P = 0.7). There was no significant interaction between the type of surgery and the LOS (P = 0.5). CONCLUSIONS This study demonstrated that elective NSS can be performed with equivalent direct hospital costs and LOS when compared with patients undergoing radical nephrectomy for small solitary RCCs. These data have significant economic implications for the comparison of competing surgical treatment strategies for localized RCC.

LAPAROSCOPIC INTRACORPOREALLY CONSTRUCTED ILEAL CONDUIT AFTER PORCINE CYSTOPROSTATECTOMY

PURPOSE We present our technique of laparoscopic ileal conduit creation after cystoprostatectomy in a porcine model performed in a completely intracorporeal manner. METHODS AND METHODS After developing the technique in 5 acute animals laparoscopic cystoprostatectomy with intracorporeally performed ileal conduit urinary diversion was performed in 10 surviving male pigs. A 5-port transperitoneal technique was used. All steps of the technique applied during open surgery were duplicated intracorporeally. Specifically cystectomy, isolation of an ileal conduit, restoration of bowel continuity and mucosa-to-mucosa stented bilateral ileoureteral anastomosis formation were performed by exclusively intracorporeal laparoscopic techniques. RESULTS Surgery was successful in all 10 study animals without intraoperative or immediate postoperative complications. Blood loss was minimal and average operative time was 200 minutes. Stenosis of the end ileal stoma specifically at the skin level was noted in 6 animals. Three deaths occurred 2 to 3 weeks postoperatively. At sacrifice renal function was normal in all surviving animals. No ileo-ureteral anastomotic strictures were noted on pre-sacrifice radiography of the loop or at autopsy examination of the anastomotic sites. CONCLUSIONS Laparoscopic ileal conduit urinary diversion after cystoprostatectomy may be performed completely intracorporeally in the porcine model. Clinical application of this technique is imminent.

Contemporary management of renal cell carcinoma with coexistent renal artery disease : Update of the cleveland clinic experience

OBJECTIVES To treat concurrent renal cell carcinoma (RCC) and renal artery disease (RAD), which pose an unusual and challenging management dilemma. METHODS Before June 1998, 48 patients presented with localized RCC and RAD affecting all the functioning renal parenchyma. These patients were grouped into four distinct categories: group 1, a solitary kidney with RCC and RAD (n = 8); group 2, bilateral RCC and coexistent RAD (n = 9); group 3, unilateral RCC and contralateral RAD (n = 15); and group 4, unilateral RCC and bilateral RAD (n = 16). The most common cause of RAD was atherosclerosis (n = 40), followed by medial fibroplasia (n = 5), renal artery aneurysm (n = 2), and arteriovenous malformation (n = 1). RESULTS All patients underwent complete surgical excision of RCC. A nephron-sparing operation was performed preferentially (44 patients), and bilateral renal cancer operations were staged. Eleven patients underwent surgical renal vascular reconstruction in conjunction with either partial (n = 9) or radical (n = 2) nephrectomy. In 2 patients, renal revascularization was accomplished by percutaneous transluminal angioplasty before tumor excision. No perioperative deaths occurred. Postoperatively, preservation of renal function was achieved in 47 patients; 1 patient required chronic dialysis. The overall and cancer-specific 5-year patient survival rates in this series were 66% and 90%, respectively. At a mean follow-up of 58 months, 28 patients were alive with no evidence of malignancy. Six patients died of metastatic RCC, and 14 died of unrelated causes with no evidence of malignancy. CONCLUSIONS Nephron-sparing surgery combined with selective renal arterial reconstruction can yield gratifying results in this complex patient population.

Renal hemodynamic effects of lovastatin in a renal ablation model

OBJECTIVES Patients with renal mass reduction of more than 50% are at increased risk for progressive renal failure. Lipid-lowering agents have been shown to preserve renal function in various models of chronic renal failure. This study was performed to evaluate the hemodynamic effects of lovastatin, a 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitor, in the remnant kidney model. METHODS Two groups of animals were studied. Group 1 (n = 9) served as controls and group 2 (n = 14) received lovastatin, 15 mg/kg/day orally, for 2 weeks after renal ablation. Glomerular filtration rate (GFR, inulin clearance), renal blood flow (RBF, ultrasonic flow probe), and 24-hour protein excretion were measured in anesthetized rats. RESULTS Two weeks after renal ablation, GFR was 0.28 +/- 0.09 mL/min/gkw (gram kidney weight) in group 1, whereas in group 2, lovastatin preserved GFR at 0.58 +/- 0.3 mL/min/gkw (P < 0.05). RBF in group 1 was 1.2 +/- 0.2 mL/min/gkw and increased to 2.1 +/- 0.4 mL/min/gkw in group 2 (P < 0.05), representing a 43% increase. Protein excretion decreased significantly to 13 +/- 1.7 mg/24 hr in group 2. The lovastatin-treated group had a lower serum cholesterol (59 +/- 3 mg/dL versus 71 +/- 2 mg/dL, P < 0.05), but serum triglyceride levels were not different between the two groups. CONCLUSIONS Lovastatin preserves renal function in a renal ablation model after 2 weeks of treatment. It specifically increased total RBF. Therefore, in addition to its known cholesterol lowering effect, lovastatin also has the direct renal hemodynamic effect of increasing RBF and maintaining GFR.