Feasibility and Outcomes of Repeat Partial Nephrectomy

Abstract

Purpose-Despite the proven efficacy of nephron sparing surgery, patients with hereditary renal cancer remain at risk for tumor recurrence. Management options for recurrent tumors include completion nephrectomy, ablation, and repeat partial nephrectomy (RPN). We examine the feasibility and outcomes of RPN performed on the same renal unit.Materials and Methods-We retrospectively reviewed the records of 51 attempted RPN cases on 47 patients from 1992 to 2006. Demographic information as well as intraoperative, perioperative, and renal functional outcome data were collected. Comparison of pre-and postoperative renal function was performed using the two tailed T-test.Results-Major perioperative complications or reoperations occurred in 10 of 51 (19.6%) cases that included one perioperative mortality (1.9%). In cases of successful RPN, there was a statistically significant increase in postoperative serum creatinine (1.35 vs. 1.16 mg/dL, p <0.05) and a significant decrease in creatinine clearance (84.6 mL/min vs. 95.3mL/min, p = 0.05) and renogram split function (52.3% vs. 54.8%, p <0.05). Two patients required long term hemodialysis (3.9%). Ten of the 51 renal units (19.6%) in our study required subsequent operations for additional local recurrence or de novo tumor formations with a median time to subsequent surgery of 50 months. Forty-six of fortyseven patients are alive at median follow up of 56 months.Conclusions-RPN is technically feasible. Although there is a statistically significant decrease in postoperative renal functional studies, most patients retained sufficient function to avoid hemodialysis. RPN may provide acceptable oncologic control despite the anticipated development of locally recurrent or de novo tumors. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. While repeat partial nephrectomy may maintain the balance between tumor control and renal preservation, the feasibility as well as functional and oncologic outcomes of patients undergoing RPN are not well established. There are a few reports of patients with hereditary kidney cancer that have undergone repeat NSS. [4][5][6] However, most of these series report limited numbers which may restrict the ability to make conclusions regarding repeat partial nephrectomy. Our ongoing clinical experience in patients with hereditary kidney cancer who are at risk for metachronous tumor formation has provided a unique opportunity to evaluate the feasibility and outcomes of repeat partial nephrectomy. Keywords NIH Public Access MATERIALS AND METHODSBetween 1992 and 2006, 51 cases of planned RPN on the same renal unit ...

Repeat Robotic Partial Nephrectomy: Characteristics, Complications, and Renal Functional Outcomes

“…21 Furthermore, both Kowalczyk and coworkers and Johnson and coworkers report postoperative complication rates of 50% and 43.2%, respectively, in their series of open repeat partial nephrectomies (oRPNx). 2,17 The overall complication rate for this series is comparable to the repeat open series previously reported.…”

“…However, in the repeat open series by Johnson and coworkers, the overall EBL of 2400 mL and transfusion rate of 64.7% were substantially higher than the 145 mL and 19.2% transfusion rate in our series. 2 Furthermore, the series reported by Bratslavsky and associates had an average EBL of 1200 mL greater than ours. 6 No significant differences were found in median clamp time between the two groups ( p = 0.65) ( Table 2).…”

“…17,18 Similar surgical challenges have previously been reported for open and laparoscopic surgery following previous renal surgery. 2,3,6 In our experience, the robotic approach to these challenges is similar, if not identical, to that of open surgical techniques used to address dense scarring around the kidney and vasculature. For example, isolation of individual vessels at the renal hilum is often eschewed in favor of en bloc mobilization and en bloc clamping of the hilum if indicated.…”

“…The multiple surgeries required is associated with higher morbidity and long-term risk of needing renal replacement therapy. 2,3 Robot-assisted partial nephrectomy has been shown to be a safe and feasible procedure for hereditary kidney cancer patients with multiple renal masses. The procedure has been shown to minimally impact renal functional outcomes in our patient population.…”

“…Repeat and salvage open renal surgeries are often quite difficult and result in higher blood loss and complication rates compared to first time renal surgery. 2,3,6 Such surgeries also have a higher risk of renal unit loss. As such, most surgeons tend to avoid minimally invasive techniques in this setting of repeat renal surgery.…”