Tomáš Ürge

Tumours in End-Stage Kidney

OBJECTIVE Patients with end-stage kidney disease (ESKD) show a greater risk for renal cell carcinoma (RCC), which tends to be multifocal and bilateral. The malignant potential is unclear. The question is whether to remove both kidneys in patients with a tumor on one side only diagnosed by computed tomography (CT). MATERIALS AND METHODS Kidney tumors were found in 14 patients with ESKD from January 2002 to December 2006. One was unfit for surgery. Thirteen patients underwent nephrectomy and 6 a bilateral procedure of whom only 2 had bilateral tumors on CT, 3 multiple tumors on the contralateral side, and 1 uncontrollable hypertension with tumors as an incidental finding. Tumors were found in all 19 specimens. RESULTS In 13 kidneys (68.4%), the tumors were multiple; in 6 (31.6%), solitary. The types of tumor were: 13 (68.4%) papillary RCCs (PRCC), 9 (47.4%) clear RCCs (CRCC), a combination of PRCC and CRCC in 4 (21.0%), and myxoid liposarcoma (with solitary PRCC contralaterally). The mean follow-up was short (19 +/- 15 months; maximum, 54 months). Only 1 patient died due to a tumor at 16 months after operation. CONCLUSIONS There is a high risk for bilateral involvement. Patients who undergo unilateral nephrectomy must be regularly followed and contralateral nephrectomy carefully considered, mainly in transplanted patients on immunosuppression. Further studies are needed to give a definitive answer about the indications for surgery and the indications for contralateral nephrectomy as well. To date, prophylactic contralateral nephrectomy should not be a therapeutic standard.

GreenLight (532 nm) laser partial nephrectomy followed by suturing of collecting system without renal hilar clamping in porcine model.

OBJECTIVES To assess the feasibility of partial nephrectomy (PN) without renal hilar clamping using the 80-W GreenLight (532 nm) laser with opening of the collecting system followed by its suture in a porcine model. METHODS We performed 12 open laser PNs in 6 farm pigs. We used the technique of incisional laser ablation of the lower pole of the right kidney. The pigs were kept alive, and 2 weeks later, underwent the same technique on the left kidney, followed by immediate killing. We recorded the acute and chronic outcomes. Renal parenchyma resection was achieved solely with the laser. The collecting system was opened with the laser in each procedure. All renal specimens underwent retrograde pyelography and histologic examination. RESULTS All procedures were completed without renal hilar clamping. The mean operative and laser time was 67.1 +/- 20.6 minutes (range 35-95) and 17.8 +/- 6.4 minutes (range 10-30), respectively. The mean resected kidney mass was 17% +/- 0.5% (range 10%-27%) of the total kidney mass. The mean blood loss was 142.5 +/- 88.9 mL (range 50-350). No evidence of urinary extravasation was seen after the acute procedures, but proven urinomas with decayed suture were found after all chronic procedures. CONCLUSIONS PN using the GreenLight laser is a feasible method for renal parenchyma incisional ablation. The laser hemostatic effect of interlobar vessel bleeding is safe and sufficient. The sutured collecting system after laser PN cannot heal in the thermically damaged tissue. The method is applicable to peripherally located lesions, without entering the collecting system. More prospective animal studies are necessary before application in humans.

End-stage kidney disease: gains of chromosomes 7 and 17 and loss of Y chromosome in non-neoplastic tissue.

The aim of this study was to determine the copy number changes of chromosomes 7, 17, 3p, and Y in a non-neoplastic tubular epithelium in end-stage kidney disease (ESKD). Seventeen kidneys from 11 patients with ESKD were retrieved from the archive files. Non-neoplastic kidney tissue in these cases was examined separately. Tissues containing papillary adenomas (PA), clear (CRCC) and papillary renal cell carcinomas (PRCC), and myxoid liposarcoma (LPS) were examined using the same probes and compared with non-neoplastic tissue. Tubular changes in the kidney parenchyma were classified into three types: (1) The vast majority of tubules were entirely atrophic; (2) Several tubules were hyperplastic, i.e., tubules with undifferentiated large epithelial cells, in which it was impossible to establish the specific type of a renal tubulus; (3) Dysplastic tubules were dilated, sometimes wrinkled. The basal membranes were lined by large eosinophilic epithelial cells with polymorphic nuclei and pseudostratification. Nucleoli were clearly visible. These tubular changes were multifocal with a haphazard distribution within the atrophic parenchyma. PA were detected in nine patients, of whom eight patients also revealed an additional tumor type(s) (4x CRCC, 3x PRCC, 1x PRCC, and CRCC). One patient had a CRCC only, another had a combination of PRCC and LPS. Chromosomal abnormalities were found in the second and third group of tubular changes, i.e., in hyperplastic and dysplastic tubules. Trisomy of chromosome 7 was detected in six cases, whereas trisomy of chromosome 17 in eight cases. A combination of both trisomies was found in five cases. Loss of chromosome Y was found in two cases. Fluorescence in situ hybridization on tissues containing papillary adenomas, renal cell carcinomas, and liposarcoma revealed expected results, i.e., trisomy of chromosomes 7 and 17 in all PAs and PRCC. No gains were present in CRCC and LPS. Loss of Y was found in six PA, five PRCC, and one LPS; loss of X was found in two CRCCs. We suggest that chromosomal changes typical of the papillary renal cell lesions, i.e., trisomies of chromosomes 7 and 17, are very frequent in non-neoplastic parenchyma of the end-stage kidney, and they have a tendency to a multifocal occurrence.

Position of laparo-endoscopic single-site surgery nephrectomy in clinical practice and comparison (matched case-control study) with standard laparoscopic nephrectomy

Introduction One way how to reduce morbidity and improve cosmesic of kidney surgery is single site laparoscopy. Relatively well described concept but without defined position in clincal practise. Aim To report of institutional experience with laparoendoscopic single-site surgery (LESS) nephrectomy (NE) and compare (matched case-control study) it with that of standard laparoscopic NE (LNE). Material and methods In the period 8/2011 to 10/2013, we performed 183 mini-invasive NE (132 tumours, 51 benign aetiology); 45 of them (24.6%) were LESS, the rest LNE. The main but not absolute indications for LESS were: non-obese men, and less advanced tumours. In 13 patients undergoing LESS-NEs (28.9%) there was a transumbilical approach. For the rest, a pararectal incision was performed and an accessory port was added in 31.1% (14) – 2/22 (9.1%) left sided, 12/23 (52.2%) right sided. Twenty-four LESS-NE were performed by a more experienced surgeon (mean operation time (MOT) 73.1 min), 21 LESS-NE by 4 other surgeons (MOT 132.8 min). These 24 were compared with 43 LNE done by the same surgeon before the period of LESS (1/2007–8/2011) and with similar characteristics of cases (body mass index (BMI) ≤ 35 kg/m2, less advanced tumour). Results We found no statistically significant differences in any of the parameters studied. The MOT 73.1 min vs. 75.0 min (p = 0.78), BMI 27.4 kg/m2 vs. 29.2 kg/m2 (p = 0.08), blood loss 54.7 vs. 39.2 (p = 0.47). Complications (4.2% vs. 11.6%) were only of internal character in origin. No conversion in either group. In LESS-NE, staplers were used more frequently (more expensive than clips) for division of renal hilar vessels (70.8% vs. 51.2%). The mean price of LESS-NE was €367 higher. Conclusions The LESS NE performed by an experienced surgeon is a safe and efficient method for the surgical treatment of both malignant and benign renal conditions in patients with BMI < 30 kg/m2 and with low-stage tumours. The LESS NE is more expensive compared to LNE.

MiT translocation renal cell carcinomas: two subgroups of tumours with translocations involving 6p21 [t (6; 11)] and Xp11.2 [t (X;1 or X or 17)]

IntroductionMiT translocation renal cell carcinomas (TRCC) predominantly occur in younger patients with only 25% of patients being over 40 years. TRCC contains two main subgroups with translocations involving 6p21 or Xp11.2. Herein we present 10 cases.MaterialsEight cases were treated at main author’s institution (identified among 1653 (0.48%) cases of kidney tumours in adults). Two cases were retrieved from the Pilsen (CZ) Tumour Registry.ResultsSix cases were type Xp11.2 and four 6p21; 7 female, 3 male patients; Xp11.2 4:2, 6p21 3:1. The mean age 49 years (range: 21–80), 5 patients (50%) over 40 years. The mean age of the group with Xp11.2 TRCCs was 55 (median 51) and 6p21 41 (32) years. One female with a 6p21 tumour (24 years) underwent nephrectomy at 4 months of pregnancy. Stage (UICC, 7th ed. 2009) was 5xI, 3xIII, 2xIV. The mean size of tumour was 80 (40–165) mm. The mean follow-up was 33.2 (1–92) months. In patients with 6p21 tumours, one (25%) died after 3 months due to widely metastatic disease. In patients with Xp11.2 tumours, 3 (50%) succumbed due to metastatic disease (range 1–8 months). Three patients with Xp11.2 are alive at 7, 52 and 92 months of follow-up, were diagnosed at early stage (T1a).ConclusionTRCCs were more common in females. Patient with 6p21 tumours were younger than those with Xp11.2. Both types have definitive malignant potential Type Xp11.2 seems to be a more aggressive neoplasm than 6p21. The case with metastatic 6p21 tumour is the 4th case described in the English literature.

Laparoscopic adrenalectomy for metachronous ipsilateral metastasis following nephrectomy for renal cell carcinoma

Introduction Although laparoscopic adrenalectomy (LA) is considered as a gold standard approach for adrenalectomy, there are minimal data describing options and outcomes of LA after previous ipsilateral nephrectomy (PIN). Aim To describe our results in a group of patients who underwent LA after PIN. Material and methods From August 2004 to October 2012 we performed at our institution 88 LA. Of this amount we performed 5 LA for metachronous metastasis of renal cell carcinoma (RCC) after PIN. This group was compared to a group without previous nephrectomy. Results The group comprised 4 men (80%) and 1 woman (20%); the mean age at the time of surgery was 66.8 ±8.5 (range: 60-77) years; the mean period between nephrectomy and adrenalectomy was 5.2 (range: 1.5-14) years; the operating time was longer in patients after PIN for 7 min; the mean blood loss was higher by 22 ml; duration of hospitalization was shorter by 1.3 days, paradoxically, compared with patients without PIN. There was no need for conversion to open surgery and we did not observe any other complications. Conclusions Laparoscopic adrenalectomy for metastasis of RCC after PIN is a technically feasible method in selected patients and it is associated with no significant differences in perioperative data in comparison with the group without prior nephrectomy. The patients benefit from minimally invasive surgery. The performance has required an experienced laparoscopic surgeon.

Morphological Characterization of Papillary Renal Cell Carcinoma Type 1, the Efficiency of Its Surgical Treatment.

Aim: Papillary renal cell carcinoma type 1 (pRCC1) represents the second most common type of malignant renal epithelial tumour. The origin of its characteristic appearance, its growth mechanism, and the long-term efficiency of its surgical treatment remain uncertain. Our aim was to determine typical characteristics of surgically treated pRCC1. Methods: pRCC1 was verified in 83 of 1,629 (5.1%) kidney tumours surgically treated in the period of January 2007-January 2016. The clinical and radiological characteristics, type of surgery, histopathology results and follow up data were recorded. Spearman correlation, Kruskal-Wallis analysis of variance, Fishers exact, and chi-square test were used to analyse appropriate variables. The overall survival rate was evaluated using the Gehan-Wilcoxon test and the Cox proportional hazards model. Results: The mean tumour size was 52.0 mm (15-180); 98.8% of the tumours showed a spherical shape and in 82.1%, exophytic growth was observed. Partial nephrectomy was performed in 80.7%. A majority (81.9%) were classified as pT1. Tumours, 89.2% of them, belonged to Fuhrman grade 1 or 2. The mean follow-up was 46.8 months. The overall survival was associated with pT category (p ≤ 0.0001). Conclusions: Typical signs of pRCC1 are a spherical shape, exophytic growth and low Fuhrmans grade. More than three-fourths of pRCC1 could be treated by the nephron-sparing surgery.

Managing urine leakage following laparoscopic radical prostatectomy with active suction of the prevesical space.

Introduction Urine leakage following laparoscopic radical prostatectomy (LRP) is a possible complication that may herald chronic urine incontinence. Intraoperative measures aiming to prevent this is not standardised. Aim Presentation of experience with active suction of the prevesical space in managing postoperative urine leakage. Material and methods At the Department of Urology, where laparoscopy of the upper abdomen and open RP were performed, a protocol for extraperitoneal LRP was established in 8/2008. Until 5/2011, 154 LRPs have been performed. Urine leakage from a suction drain appeared in 9 cases (5.8%). Permanent active suction (with a machine for Büllae thoracic drainage) of the prevesical space with negative pressure of 7-12 cm of H2O was started immediately. Results Urine leakage started after a mean of 0.9 (0-2) days postoperatively and stopped after a mean of 8.1 (15-42) days. Leakage stopped with only suctioning in 7 cases. In one case, open re-anastomosis was performed on the 7th postoperative day (POD). In another case, ineffective active suction was replaced on the 10th POD by needle vented suction without effect and the leakage stopped following gradual shortening of the drain up to the 15th POD. Conclusions Active suction of the prevesical space seems to be an effective intervention to stop postoperative urine leakage after laparoscopic radical prostatectomy.

Antegrade Mini-Invasive Nephroureterectomy: Laparoscopic Nephrectomy, Transurethral Excision of Ureterovesical Junction and Lower Abdominal Incision

Introduction: We describe another variant of nephroureterectomy – antegrade mini-invasive nephroureterectomy (AMNUE). Methods: AMNUE starts with a laparoscopic nephrectomy in the flank position. The specimen is enclosed in a bag without dividing the ureter, and the patient is positioned to the lithotomy position. Then the ureterovesical junction is excised transurethrally with a Collins knife. Finally, the specimen is removed and the ureter is plucked out through a short lower abdomen incision. Patients: From March 2005 to November 2008, 35 patients underwent nephroureterectomy: 7 as an open procedure, 8 as a laparoscopic nephrectomy with open ureterectomy, 8 as a complete laparoscopic nephroureterectomy, and 12 were admitted into the AMNUE group (7 men and 5 women, mean age 71 ± 7 years, range 54–81 years). Results: Tumors were found 6 times on both sides. The mean operation time was 165 ± 32 min (105–210 min), and the mean blood loss was 150 ± 91 ml (50–400 ml). Histology revealed 11 urothelial cancers and 1 papillary renal cell carcinoma. There was only 1 hematoma of the abdominal wall. Conclusion: AMNUE is a fast, safe and easily reproducible technique. It eliminates the risk of spillage of tumorous cells into the urine, which is possible in techniques where the ureter is excised with a Collins knife as the first procedure. The disadvantages of this approach are the necessary repositioning of the patient and that the long-term oncological results are currently unknown. AMNUE can be used when a complete laparoscopic nephroureterectomy is not technically feasible due to problems in the pelvis.

Complete laparoscopic nephroureterectomy with intravesical lockable clip.

Introduction We present a cohort of patients with low-stage pelviureteric neoplastic disease who underwent complete laparoscopic nephroureterectomy (CLNUE) with intravesical lockable clip (IVLC). Due to the absence of a standard technique of NUE, the study was not randomized. Materials From 1/2010 to 1/2012, 21 patients were subjected to CLNUE-IVLC. The first step was transurethral excision of the ureterovesical junction with Collins knife deep into the paravesical adipose tissue. The ureter was grasped with biopsy forceps and the distal end of the ureter was occluded with lockable clip. The applicator was introduced through a 5 mm port inserted as an epicystostomy. The patients were rotated to flank position and CLNUE followed. The endoscopically introduced clip on the distal ureter is proof of completion of the total ureterectomy. Results The mean operation time was 161 (115-200) min. In four (19.0%), the application of the clip failed and CLNUE was completed with non-occluded ureter. In three cases, subsequent laparoscopic nephrectomy was converted to open surgery. In two cases, the distal ureterectomy was completed with pluck technique through a lower abdominal incision that was also used for extraction of the specimen. There were four complications (Clavien II 2x, IIIb, V). Follow-up was available for all – mean 10.6 (range: 0-25) months. One died of disease generalization within 11 months. Conclusion CLNUE-IVLC is fast and safe. If needed, the endoscopic phase can be switched to open NUE. Disadvantages include: the need to change the position of the patient, the risk of inability to apply the clip on the distal ureter, and the risk of an unclosed defect of the urinary bladder.