Morbidity of tumour enucleation for renal cell carcinoma (RCC): results of a single‐centre prospective study

Abstract

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Nephron sparing surgery is the standard treatment for RCC up to a diameter of 7 cm, but it’s intra and postoperative morbidity is not negligable. Tumour enucleation is a nephron sparing technique with a demonstrated oncological efficacy while no prospective study evaluated its surgical results and postoperative morbidity to date. Our study adds a prospective evaluation of tumour enucleation morbidity. Our results showed that this technique has a low incidence of postoperative complications, especially of urinary fistula. Major tumour dimension and endorenal tumour growth resulted predictors of postoperative complications. OBJECTIVE To evaluate the incidence and risk factors of adverse events (AEs) after tumour enucleation (TE). PATIENTS AND METHODS Between 2006 and 2009, clinical, surgical and functional data were prospectively gathered from 200 consecutive patients who had open TE. TE was done by blunt dissection using the natural cleavage plane between the tumour capsule and normal parenchyma. All the AEs were stratified for severity according to the National Cancer Institute Common Toxicity Criteria version 2.0 grading system. Risk factors for AEs were determined by univariate analysis. RESULTS The mean (range) tumour size was 3.2 (0.8–10.0) cm, and mean (range) warm ischaemia time (WIT) was 16.5 (5–31) min. Overall, 32 AEs (six grade I, 20 grade II, and six grade III) occurred after TE in 30 patients and of those 27 were surgical (13.5%) and five were medical AEs (2.5%). On univariate analysis, imperative/relative surgical indication was the only predictive factor for the development of medical AEs. Statistically significant predictors of overall surgical AEs and urinary fistula were clinical tumour dimension, completely endorenal tumour growth and a positive tumour relationship with the urinary collecting system (UCS). A completely endorenal tumour growth and a positive tumour relationship with the UCS also correlated with bleeding requiring transfusions. Completely endorenal tumour growth was significantly associated with major (grade III) AEs. CONCLUSIONS The TE technique was associated with a 16% AE rate and of those only 3% required re‐intervention (grade III). Urinary fistula occurred in six patients (3%) and ureteric stenting was required in 0.5% of cases.

Endoscopic robot-assisted simple enucleation (ERASE) for clinical T1 renal masses: description of the technique and early postoperative results

“…In a prospective series of 200 consecutive patients who had open SE, we reported a low rate of Clavien grade III surgical complications such as urinary fistula requiring JJ stent positioning, that was 0.5 %, and postoperative bleeding requiring superselective embolization of renal artery, that occurred in 2 % of cases [18]. These data compare favorably with the rates reported after standard PN in the best available evidence, that is 4.4 % for urinary fistula and 3.1 % for severe postoperative bleeding [23].…”

“…It represents the robotic translation of the SE technique, developed in our center over 25 years ago and become the standard of care for NSS either open and laparoscopically [5,6,[16][17][18].…”

The safety and efficacy of sonidegib for the treatment of locally advanced basal cell carcinoma

“…In these latter cases, when the depth of the lesion or the proximity to important vascular structures makes the procedure more challenging, the adoption of the TE technique can be decisive, as the blunt dissection provides a clear dissection plane identification, helping the surgeon to discriminate the natural cleavage plane existing between the tumor and the renal parenchyma. Moreover, TE provides maximal parenchymal preservation and minimizes incidental calyceal tearing or vascular injuries [32][33][34].…”

Tumour enucleation vs partial nephrectomy: Long term results

“…It is has been reported a possible advantage using SE especially when facing tumors with most unfavourable nephrometry (PADUA ≥ 10; RENAL ≥ 10, totally endorenal tumors, cT1b with endophytic growth into the medulla and close to main intrarenal vessels and collecting system). However, the majority of the studies on the perioperative results of TE does not analyse subgroups of challenging tumors [6][7][8]. In a recent study, that assessed the perioperative results of SE in 244 patients, a substantial 21% had a PADUA score ≥10 thus confirming that SE might wide the technical indications of NSS including the most challenging cases [9].…”

“…Indeed, SE showed in single center prospective series a low incidence of postoperative complications requiring reintervention, a low rate of urinary fistulas and of ureteral stenting [7,9]. However, in a large multicenter prospectively derived dataset (RECORd project), a matched-pair comparison of 396 patients showed that SE and standard PN are associated with similar WIT and similar incidence of overall, surgical and medical complications [8].…”