Sara L. Best

Radiofrequency Ablation Versus Partial Nephrectomy in Patients with Solitary Clinical T1a Renal Cell Carcinoma: Comparable Oncologic Outcomes at a Minimum of 5 Years of Follow-Up

BACKGROUND Long-term comparative outcomes for radiofrequency ablation (RFA) versus partial nephrectomy (PN) for the primary treatment of clinical T1a renal cell carcinoma (RCC) have not previously been reported. OBJECTIVE Report comparative 5-yr oncologic outcomes for RFA versus PN in patients with clinical T1a RCC. DESIGN, SETTING, AND PARTICIPANTS Observational single-institution cohort study, involving consecutive patients with a solitary histologically confirmed T1a RCC treated by RFA or PN and followed for a minimum of 5 yr. Those presenting with synchronous multiple, metachronous, bilateral, and/or metastatic disease, a history of hereditary RCC syndromes, a family history of RCC, and with post-treatment follow-up <5 yr were excluded from analysis. MEASUREMENTS The Kaplan-Meier method was used to determine 5-yr overall survival (OS), cancer-specific survival (CSS), local recurrence-free survival (local RFS), overall disease-free survival (DFS), and metastasis-free survival (MFS) for RFA versus PN. Survival curves were compared using the log-rank test. A p value ≤ 0.05 was considered statistically significant. RESULTS AND LIMITATIONS A total of 37 patients in each group met the selection criteria. The RFA cohort was significantly older and had more advanced comorbidities, but other patient characteristics were similar. For RFA versus PN, median follow-up was 6.5 yr (interquartile range [IQR]: 5.8-7.1) versus 6.1 yr (IQR: 5.4-7.3) (p = 0.68), respectively. The 5-yr OS was 97.2% versus 100% (p = 0.31), CSS was 97.2% versus 100% (p = 0.31), DFS was 89.2% versus 89.2% (p = 0.78), local RFS was 91.7% versus 94.6% (p = 0.96), and MFS was 97.2% versus 91.8% (p = 0.35), respectively. Study limitations are retrospective data analysis, loss to follow-up, limited statistical power, and limited generalizability of our data. CONCLUSIONS In appropriately selected patients, RFA is an effective minimally invasive therapy for the treatment of cT1a RCC, yielding comparable long-term oncologic outcomes to nephron-sparing surgery.

Long-Term Outcomes of Renal Tumor Radio Frequency Ablation Stratified by Tumor Diameter: Size Matters

PURPOSE Renal tumor size influences the efficacy of radio frequency ablation but identification of confident size cutoffs has been limited by small numbers and short followup. We evaluated tumor size related outcomes after radio frequency ablation for patients with adequate (greater than 3 years) followup. MATERIALS AND METHODS We identified 159 tumors treated with radio frequency ablation as primary treatment. Disease-free survival was defined as the time from definitive treatment to local recurrence, detection of metastasis or the most recent imaging showing no evidence of disease. Patients were evaluated with contrast enhancing imaging preoperatively, and at 6 weeks, 6 months and at least annually thereafter. RESULTS Median tumor size was 2.4 cm (range 0.9 to 5.4) with a median followup of 54 months (range 1.5 to 120). Renal cell carcinoma was confirmed in 72% of the 150 tumors that had pre-ablation biopsy (94%). The 3 and 5-year disease-free survival was comparable at 92% and 91% overall, and was dependent on tumor size, being 96% and 95% for tumors smaller than 3.0 cm and 79% and 79%, respectively, for tumors 3 cm or larger (p=0.001). Most failures (14 of 18) were local, either incomplete ablations or local recurrences. This is an intent to treat analysis and, therefore, includes patients ultimately found to have benign tumors, although outcomes were comparable in patients with cancer. CONCLUSIONS Radio frequency ablation treatment success of the small renal mass is strongly correlated with tumor size. Radio frequency ablation provides excellent and durable outcomes, particularly in tumors smaller than 3 cm. Of tumors 3 cm or larger, approximately 20% will recur such that alternative treatment techniques should be considered. However, most treatment failures are local and are often successfully treated with another ablation session.

Patient-reported body image and cosmesis outcomes following kidney surgery: Comparison of laparoendoscopic single-site, laparoscopic, and open surgery

BACKGROUND Laparoendoscopic single-site surgery (LESS) is reported to result in superior cosmesis versus alternative surgical approaches, based solely on surgeon assessment or anecdotal evidence. OBJECTIVE Evaluate patient-reported body image and cosmesis outcomes following kidney surgery. DESIGN, SETTING, AND PARTICIPANTS We conducted a prospective and retrospective observational cohort study involving patients who underwent kidney surgery (n=114) via LESS (n=35), laparoscopic (n=52), or open (n=27) approaches. Cosmesis was evaluated using a comprehensive survey administered ≥3 mo postoperatively. MEASUREMENTS Survey components were a body image questionnaire (BIQ) consisting of body image and cosmesis subscales, a photo-series questionnaire (PSQ) assessing scar preferences after knowledge of scar outcomes for alternative surgical approaches, and query of preference for future surgical approach using a trade-off method. Body image, cosmesis, and PSQ scales ranged from 5 to 20, 3 to 24, and 1 to 10, respectively. RESULTS AND LIMITATIONS Median BIQ component scores did not significantly differ across surgical approaches. Median ratings for the LESS, laparoscopy, and open scar photographs were 8, 5, and 5, respectively (p=0.0001). Before viewing photographs, median self-scar ratings for LESS, laparoscopy, and open approaches were 9, 5, and 6.5, respectively (p=0.02); after photographs, ratings were 9, 7, and 7, respectively (p=0.008). Assuming equivalent surgical risk among the approaches, overall preference for future LESS, laparoscopy, or open surgery was 39%, 33%, or 4%, respectively. As theoretical risk of LESS was raised, preference for LESS decreased, whereas preference for laparoscopy and open surgery increased. Study limitations are a nonrandomized design and the use of a nonvalidated scale. CONCLUSIONS Urologic patients favor LESS cosmesis outcomes over those for laparoscopy or open surgery. Considering the superior scar satisfaction among LESS patients, who were younger and more likely to be undergoing surgery for benign disease, we infer that this demographic most values the cosmetic advantages of LESS.

Perioperative Comparison of Robotic Assisted Laparoendoscopic Single-Site (LESS) Pyeloplasty Versus Conventional LESS Pyeloplasty

BACKGROUND Conventional laparoendoscopic single-site (C-LESS) pyeloplasty is technically challenging due to instrument clashing, loss of triangulation, and difficulty sewing. Application of the da Vinci S or Si robotic platforms could potentially overcome these challenges. OBJECTIVE Compare our initial experience with robotic assisted laparoendoscopic single-site (R-LESS) pyeloplasty to our latter experience with C-LESS pyeloplasty (ie, after the initial 15 patients). DESIGN, SETTING, AND PARTICIPANTS This single-institution retrospective observational cohort study involved consecutive patients who presented with symptomatic ureteropelvic junction obstruction and who were deemed suitable for single-incision pyeloplasty by the treating surgeon. MEASUREMENTS Demographic, clinical, perioperative, and early postoperative comparative outcomes. RESULTS AND LIMITATIONS Ten patients each underwent R-LESS or C-LESS pyeloplasty by a single surgeon between March 2009 and July 2011. For R-LESS and C-LESS groups, age, gender distribution, body mass index, proportion of patients with prior abdominal surgery, estimated blood loss, and hospital length of stay were statistically similar. Mean operative time was significantly longer for R-LESS (226 vs 188 min; p=0.007). C-LESS pyeloplasty alone required an accessory port for the anastomosis in 10 of 10 cases. Two conversions to standard laparoscopy and two postoperative complications occurred in 3 of 10 patients in the C-LESS group, compared with no conversions and one postoperative complication in the R-LESS group (p=0.26). Study limitations are a retrospective design, a modest number of patients, and a lack of quantification of subjective outcomes such as instrument clashing and maneuverability. CONCLUSIONS Adaptation of the da Vinci Si robotic surgical platform to laparoendoscopic single-site pyeloplasty appears to reduce the physical learning curve for this complex procedure. Future prospective, comprehensive evaluation of additional outcomes including subjective parameters, cosmesis, and longer term functional outcomes will help better define its role in minimally invasive dismembered pyeloplasty and better estimate its associated learning curve.

Importance of cosmesis to patients undergoing renal surgery: a comparison of laparoendoscopic single-site (LESS), laparoscopic and open surgery

Study Type – Therapy (case series)

Complications during the initial experience with laparoendoscopic single-site pyeloplasty

Study Type – Therapy (case series)

Assessment of Renal Oxygenation During Partial Nephrectomy Using Hyperspectral Imaging

PURPOSE DLP® hyperspectral imaging is a technology that can be used to construct a highly sensitive, noninvasive, real-time tissue hemoglobin saturation map. This almost video rate technology may be a tool to monitor renal perfusion/oxygenation during hilar occlusion and kidney recovery. We describe our initial experience using hyperspectral imaging to assess renal hemoglobin saturation parameters during open partial nephrectomy for renal cortical tumors in humans. MATERIALS AND METHODS Hyperspectral images were collected intraoperatively during open partial nephrectomy. The kidney was actively illuminated using a hyperspectral imaging camera with visible light consisting of a chemometrically predetermined spectrum (520 to 645 nm) for hemoglobin. Spectroscopic reflectance images were captured by a focal plane array, which were digitally processed to visualize the percent of oxyhemoglobin at each image pixel. RESULTS Hyperspectral imaging was done in 21 patients with a mean age of 56 years who were undergoing partial nephrectomy. Mean clamp time was 37.0 minutes. Median baseline percent of oxyhemoglobin in all patients was 74.6%. Hyperspectral imaging revealed a median 20.0% decrease from normalized pre-occlusion baseline at a median 10.3 minutes of hilar occlusion, where it plateaued for the duration of kidney ischemia. Upon reperfusion the percent of oxyhemoglobin returned to baseline at a median of 5.8 minutes. CONCLUSIONS Hyperspectral imaging is a real-time noninvasive method to assess renal oxyhemoglobin saturation intraoperatively throughout the kidney. A nadir percent of oxyhemoglobin is attained within 10 minutes of hilar occlusion. This knowledge may allow future surgical or pharmacological interventions that titrate or minimize ischemic injury in real time.

Self-retaining barbed suture for parenchymal repair during laparoscopic partial nephrectomy; Initial clinical experience

Study Type – Therapy (case series)

Radiofrequency Ablation of Incidental Benign Small Renal Mass: Outcomes and Follow-up Protocol

OBJECTIVE To review our 10-year experience with radiofrequency ablation, focusing on the outcomes for the incidental benign renal tumor. Tumor ablation is an alternative minimally invasive approach for the treatment of small renal masses (SRMs), with published series appropriately emphasizing the outcomes for the renal cell carcinoma subset of treated tumors. However, just as with partial nephrectomy, approximately 20% of SRMs are benign. The intermediate- to long-term outcome of the incidentally ablated benign tumor and its appropriate follow-up protocol is unknown. METHODS All SRMs treated with temperature-based radiofrequency ablation from 2001 to 2011 were reviewed. Of a total of 280 enhancing SRMs biopsied at radiofrequency ablation, 47 were confirmed as benign tumors. Ablation success was defined as the lack of enhancement on the initial postablation axial imaging. Recurrence was defined as tumor growth and enhancement on follow-up axial imaging. RESULTS Of the 47 benign tumors, 32 were treated percutaneously and 15 laparoscopically. The histologic biopsy finding was angiomyolipoma in 10 and oncocytoma in 37. The median tumor size was 2 cm (range 1-3.6), and the mean follow-up was 45 months. No recurrences developed, and all lesions required only 1 treatment session. The median pre- and postoperative glomerular filtration rate was 77 mL/min/1.73 m(2) (range 39-137) and 68 mL/min/1.73 m(2) (range 36-137). The present study was limited by its retrospective nature and small sample population. CONCLUSION Radiofrequency ablation of SRMs <3.5 cm found to be benign on concurrent biopsy can be efficaciously treated with a single treatment session. Long-term follow-up imaging might not be required if successful ablation is determined at the initial post-treatment cross-sectional imaging study.

Clinical, Pathologic, and Functional Outcomes After Nephron-Sparing Surgery in Patients with a Solitary Kidney: A Multicenter Experience

BACKGROUND AND PURPOSE Surgical management of a renal neoplasm in a solitary kidney is a balance between oncologic control and preservation of renal function. We analyzed patients with a renal mass in a solitary kidney undergoing nephron-sparing procedures to determine perioperative, oncologic, and renal functional outcomes. PATIENTS AND METHODS A multicenter study was performed from 12 institutions. All patients with a functional or anatomic solitary kidney who underwent nephron-sparing surgery for one or more renal masses were included. Tumor size, complications, and recurrence rates were recorded. Renal function was assessed with serum creatinine level and estimated glomerular filtration rate. RESULTS Ninety-eight patients underwent 105 ablations, and 100 patients underwent partial nephrectomy (PN). Preoperative estimated glomerular filtration rate (eGFR) was similar between the groups. Tumors managed with PN were significantly larger than those managed with ablation (P<0.001). Ablations were associated with a lower overall complication rate (9.5% vs 24%, P=0.01) and higher local recurrence rate (6.7% vs 3%, P=0.04). Eighty-four patients had a preoperative eGFR ≥60 mL/min/1.73 m(2). Among these patients, 19 (23%) fell below this threshold after 3 months and 15 (18%) at 12 months. Postoperatively, there was no significant difference in eGFR between the groups. CONCLUSIONS Extirpation and ablation are both reasonable options for treatment. Ablation is more minimally invasive, albeit with higher recurrence rates compared with PN. Postoperative renal function is similar in both groups and is not affected by surgical approach.