Simple enucleation for the treatment of highly complex renal tumors: Perioperative, functional and oncological results

Abstract

Aim: To assess the role of simple enucleation (SE) for the treatment of highly complex renal tumors. Methods: Overall, 96 Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) classification score 10 to 13 renal tumors were treated with SE at our institution. All conventional perioperative variables, surgical, functional and oncological results were gathered in a prospectively maintained database. Survival curves were generated using a KaplaneMeier method. Univariate analysis assessed the outcome differences. Results: Mean (AE1s.d.) clinical tumor diameter was 4.8 (AE1.6 cm). 70.8% of patients had !cT1b stage. The PADUA score was recorded as 10, 11, 12 and 13 in 57.3%, 29.2%, 11.5%, and 2.1% of tumors respectively. Overall, 76 patients were treated with an open approach and 20 robotically. Mean warm ischemia time (WIT) was 19.2 min, and WIT greater than 25 min occurred in 14.6% of cases. Positive surgical margin (PSM) rate was 3.6% and trifecta was achieved in 64.3% of patients. Postoperative surgical complications occurred in 24% of patients, with 14.6% Clavien-Dindo grade 1e2, 8.3% grade 3, and 1% grade 4. Five-year cancer specific survival (CSS), recurrent free survival (RFS), and overall survival (OS) rates resulted 96.1%, 90.8% and 88.0%, respectively. Overall, 4.2% of patients experienced progressive disease. At follow-up, the mean decrease of eGFR from preoperative value was 13.9 ml/min. This was not significantly correlated with PADUA score (p ¼ 0.69). The surgical approach was neither a predictor of Trifecta outcome, nor of postoperative complications, WIT >25 min or PSM rate. Conclusions: SE is an effective treatment for highly-complex renal tumors, with a potential key role to widen the NSS (nephron sparing surgery) indications according to guidelines.

Outcomes of robot-assisted simple enucleation of renal masses

“…[6,18] Moreover, by conducting the dissection through the natural cleavage, which is an avascular plane, the renal artery clamping might be omitted or eventually deferred. [8,12] …”

Predictive factors of overall and major postoperative complications after partial nephrectomy: Results from a multicenter prospective study (The RECORd 1 project)

“…1 Historically, partial nephrectomy (PN) was exclusive for small renal masses or patients with reduced renal function, but with advances of surgical skills, its indications have broaden out to high-complex tumors such as hilar, completely endophytic and clinical T1b renal masses. 2,3 PN has been associated, in observational and retrospective studies, with reduced mortality for cardiovascular accidents compared to radical nephrectomy. Concurrently, postoperative surgical complications represent the prominent concern of PN, as they have been reported in up to 30% of cases, with a major (Clavien 3e4) complication rate of 3e6%.…”

“…These factors seem to be dependent on patients' clinical characteristics, nephrometry parameters, surgical approach and technique. 3,7 The aim of this study is to analyze postoperative complications of PN and to assess for significant predictive factors in T1 renal tumors by the retrospective analysis of a prospective multicentre cohort (RECORd1 Project).…”

Standardized Reporting of Microscopic Renal Tumor Margins: Introduction of the Renal Tumor Capsule Invasion Scoring System

“…3 Recently, a tumor enucleation approach has become more prevalent in the surgical management of sporadic renal masses with promising initial results. 4,5 Renal tumor enucleation takes advantage of the renal tumor pseudocapsule, consisting of a fibrous band of compressed renal parenchyma that isolates the tumor from the surrounding healthy renal parenchyma and provides a natural dissection plane during surgery ( Figure 1). 6 When compared to healthy margin partial nephrectomy for RCC, tumor enucleation has demonstrated comparable oncological outcomes in some series.…”