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1.  Outcome of embolised vascular metastatic renal cell tumours causing spinal cord compression 
European Spine Journal  2013;22(Suppl 1):27-32.
To present the results of the surgical management of metastatic renal cell tumours of the spine with cord compression who underwent pre-operative embolisation.
We conducted a retrospective cohort study of all embolised vascular metastatic renal cell tumours of the spine that underwent urgent surgical intervention over a 7-year period (2005–2011). All medical notes, images and angiography/embolisation details were studied. We recorded the timing (immediate vs. delayed) and grade of embolisation and compared this to the estimated blood loss (EBL); extent of metastatic spinal cord compression (using the Tomita score and Bilsky scores) was also compared to EBL. Finally, neurological (Frankel grade), surgical outcome and complications were reviewed in all patients.
During the study period, we operated on 25 emergency patients with metastatic renal cell carcinoma causing spinal cord compression who had received pre-operative embolisation (mean age 59.6 (24–78) years; 8 females, 17 males). All but one of our patients had hypervascularisation/arterio-venous fistulae on angiography. We were able to achieve greater than 90 % embolisation in the majority (17/25, 68 %) The estimated blood loss was 1,696 (400–5,000) ml; mean operating time was 276 (90–690) min and an average of 2.3 (0–7) units of whole blood was transfused. Nine patients had a posterior only decompression/stabilisation, nine patients had a posterior decompression ± cement augmentation, six had combined anterior/posterior procedures and one had anterior corpectomy/reconstruction alone. There was no statistical difference in the EBL between immediate versus delayed surgery after embolisation or the grade of embolisation. Immediate surgery after embolisation and interestingly less complete embolisation showed a trend towards less EBL. The extent of the tumour as graded by the Bilsky score correlated with increased EBL (p = 0.042). No complications occurred during the embolisation procedure. The surgical complication rate was 32 % (8/25) including two major complications (septicaemia (1) and metal work failure (2)) and five minor complications. Postoperatively, 52 % (13/25) had no change in neurological status, 36 % (9/25) improved by at least one Frankel grade and 12 % (3/25) had neurological deterioration by one Frankel grade. The average survival following surgery was 14.1 (0.5–72) months.
Blood loss (mean 1,696 ml) and complications (32 %) remain a concern in the operative treatment of vascular metastatic spinal cord compression. Most patients remained the same neurologically or improved by at least 1 grade (22/25, 88 %). Paradoxically, greater embolisation showed a trend to more blood loss which could be due to more extensive surgery in this group, a rebound ‘reperfusion’ phenomena or even the presence of arterio-venous fistulae. Interestingly, we also found that the extent of the tumour, as graded by the Bilsky score, correlated with increased blood loss suggesting that more extensive cord compression by metastases could lead to more blood loss intra-operatively.
PMCID: PMC3578518  PMID: 23328874
Embolisation; Vascular metastatic spinal tumours
2.  Correlation of percentage changes in platelet counts with recurrence rate following radical nephrectomy 
To categorize and correlate percentage changes in platelets counts - an objective approach with recurrence rate following radical nephrectomy.
Materials and Methods:
All consecutive patients who had radical nephrectomy for localized renal tumor in the period from January 1997 to December 2005 have been included in this study. The data was collected retrospectively. The primary outcome of this study was over all and cancer- specific survival and its correlation with percentage change in platelet count from pre-surgical level. Change in platelets counts was categorized as less than or more than 0-10%, 10-20% and more than 20% from base line (pre-surgery). This was correlated with the follow-up recurrence and disease free survival. Survival distribution were estimated using Kaplan-Meier method, univariate and multivariate regression analyses were performed using Cox proportional hazards models to address the impact of different prognostic factors on survival.
Of the 237 patients treated with radical nephrectomy, pT1, pT2, pT3, and pT4 accounted for 116 (49%), 44 (18.5%), 68(28.7%), and nine (3.8%) cases respectively. The mean tumor size was 6.3 cm (Range: 4-17 cm; SD: 3). The pre-operative platelet count ranged from 82 to 1573 (Mean: 327.5; SD: 171.7). The overall follow-up time ranged from 1-102 months (Mean: 39 months; SD: 27months). There was significant correlation between the recurrence rate and increase in platelets count of more than 20% following radical nephrectomy (P value- 0.0001).
Categorization of platelets changes following radical nephrectomy for localized renal cell carcinoma, in particular, a change in more than 20% can accurately predict recurrence and cancer specific survival following radical nephrectomy for localized renal cell carcinoma.
PMCID: PMC2938539  PMID: 20877593
Platelets; radical nephrectomy; renal cancer
3.  Renal Oncocytosis: Management and Clinical Outcomes 
The Journal of urology  2011;185(3):795-801.
Renal oncocytosis is an extremely rare pathological condition in which renal parenchyma is diffusely involved by numerous oncocytic nodules, in addition to showing a spectrum of other oncocytic changes. Our aim was to describe our experience with renal oncocytosis, focusing on management and outcomes.
Materials and Methods
Twenty patients with a final pathologic diagnosis of renal oncocytosis from July 1995 through June 2009 were included in the analysis. Patient demographics, intraoperative variables and postoperative outcomes are reported.
The median age at nephrectomy was 71 years. Fifteen patients (75%) had bilateral disease. There were 23 operations performed on 20 patients. Thirteen (57%) were partial nephrectomies and 10 (43%) were radical nephrectomies. The median diameter of the dominant tumor mass was 4.1 cm (range 1–14.6). The most common dominant tumor histology was hybrid tumor between oncocytoma and chromophobe renal cell carcinoma in 13 of 23 specimens (57%), followed by chromophobe RCC in 6 (26%), oncocytoma in 3 (13%) and conventional RCC in 1 (4%). Ten patients (50%) had pre-existing chronic kidney disease before nephrectomy and 5 more developed CKD after surgery. After a median follow-up of 35 months, no patient developed metastatic disease.
Patients with renal oncocytosis usually present with multiple and bilateral renal nodules. Half of the patients had CKD at diagnosis and 25% developed new-onset of CKD. No patient developed distant metastatic disease during follow-up.
Our management approach is to perform a partial nephrectomy when possible and then employ careful surveillance of the remaining renal masses.
PMCID: PMC4203377  PMID: 21239013
renal oncocytosis; kidney neoplasms; chromophobe renal cell carcinoma; oncocytoma; nephrectomy
4.  Renal Histologic Parameters Influencing Postoperative Renal Function in Renal Cell Carcinoma Patients 
Korean Journal of Pathology  2013;47(6):557-562.
Pre-existing non-neoplastic renal diseases or lesions may influence patient renal function after tumor removal. However, its description is often neglected or omitted in pathologic reports. To determine the incidence and clinical significance of non-neoplastic lesions, we retrospectively examined renal tissues obtained during 85 radical nephrectomies for renal cell carcinoma.
One paraffin-embedded tissue block from each case containing a sufficient amount of non-tumorous renal parenchyma was cut and processed with hematoxylin and eosin and periodic acid-Schiff methods. Non-neoplastic lesions of each histological compartment were semi-quantitatively and quantitatively evaluated.
Among the various histologic lesions found, tubular atrophy, arterial intimal thickening, and glomerulosclerosis were the most common (94.1%, 91.8%, and 88.2%, respectively). Glomerulosclerosis correlated with estimated glomerular filtration rate at the time of surgery, as well as at 1- and 5-years post-surgery (p=.0071), but tubulointerstitial fibrosis or arterial fibrous intimal thickening did not. Post-hoc analysis revealed that glomerulosclerosis of more than 20% predicted post-operative renal function. However, its significance disappeared when gender and age were considered.
In conclusion, non-neoplastic lesions, especially with regard to glomerulosclerosis percentage, should be described in pathology reports to provide additional information on renal function decline.
PMCID: PMC3887158  PMID: 24421849
Nephrectomy; Carcinoma, renal cell; Glomerular filtration rate; Histology
The Journal of urology  2009;182(6):2601-2606.
Recent observations suggest that partial nephrectomy for small renal tumors may be associated with improved survival compared with radical nephrectomy. We evaluated survival in patients with renal tumors 4-7cm using a bi-institutional collaboration.
Combining institutional databases from Mayo Clinic and Memorial Sloan-Kettering, we identified 1,159 patients with sporadic, unilateral, solitary and localized renal masses 4.1–7.0 cm who underwent radical or partial nephrectomy between 1989 and 2006. Patient outcome was compared using Cox proportional hazards regression models.
Among the 1,159 patients, 873 (75%) and 286 (25%) were treated with radical and partial nephrectomy, respectively. Patients treated with partial (vs radical) nephrectomy were significantly more likely to have a solitary kidney (10% vs 0.2%, p<0.001) and chronic kidney disease (15% vs 7%, p<0.001). Median duration of follow-up for survivors was 4.8 years (range 0-19). There was not a significant difference in overall survival when comparing patients treated with radical and partial nephrectomy (p=0.8). Interestingly, in a subset of 943 patients with RCC, those treated with radical nephrectomy were significantly more likely to die from RCC compared with those treated with partial nephrectomy (hazard ratio 2.16; 95% CI 1.04–4.50; p=0.039) although this association only approached statistical significance in a multivariable analysis (hazard ratio 1.97; 95% CI 0.92–4.20; p=0.079).
Our results suggest that overall and cancer-specific survival is not compromised when partial nephrectomy is utilized for patients with 4-7cm renal cortical tumors. With the benefit of preserving renal function, our results support the use of partial nephrectomy whenever technically feasible for renal tumors up to 7cm.
PMCID: PMC4171846  PMID: 19836797
Kidney neoplasms; Nephrectomy; Carcinoma; renal cell; Survival; Treatment outcome
6.  Renal Artery Embolization Using a New Liquid Embolic Material Obtained by Partial Hydrolysis of Polyvinyl Acetate (Embol): Initial Experience in Six Patients 
Korean Journal of Radiology  2000;1(3):121-126.
To evaluate the therapeutic efficacy of a new liquid embolic material, Embol, in embolization of the renal artery.
Materials and Methods
Embol is a new embolic material obtained by partial hydrolysis of polyvinyl acetate mixed in absolute ethanol and Iopromide 370 and manufactured by Schering Korea, Kyonggido, Korea. Six patients who underwent embolization of the renal artery using Embol were evaluated. Four were male and two were female and their ages ranged from 11 to 70 (mean, 53) years. Clinical and radiologic diagnoses referred for renal artery embolization were renal cell carcinoma (n = 3), renal angiomyolipoma (n = 2) and pseudoaneurysm of the renal artery (n = 1). After selective renal angiography, Embol was injected through various catheters, either with or without a balloon occlusion catheter. Changes in symptoms and blood chemistry which may have been related to renal artery embolization with Embol were analyzed.
The six patients showed immediate total occlusion of their renal vascular lesions. One of the three in whom renal cell carcinoma was embolized with Embol underwent radical nephrectomy, and the specimen thus obtained revealed 40% tumor necrosis. In the two patients with angiomyolipomas, the tumors decreased in size and abdominal pain subsided. Bleeding from pseudoaneurysm of the renal artery was successfully controlled. Four patients showed symptoms of post-embolization syndrome, and one of these also showed increased levels of blood urea nitrogen and creatinine. One patient experienced transient hypertension.
Embol is easy to use, its radiopacity is adequate and it is a safe and effective embolic material which provides immediate and total occlusion of renal vascular lesions.
PMCID: PMC2718180  PMID: 11752942
Arteries, therapeutic blockade; Embolism, therapeutic; Kidney, interventional procedure; Interventional procedures, technology
7.  Surgical management of haemorrhaging renal angiomyolipoma in pregnancy 
•We report the case of a 25-week pregnant woman that had a ruptured AML.•This is the first case of nephrectomy in late second trimester with the foetus left in-utero.•We present a literature review of the management of bleeding AML in pregnancy.
Renal angiomyolipoma (AML) is a benign mesenchymal tumour of the kidney with a tendency of aneurysm formation at risk of rupturing. Due to increased maternal circulation and hormonal influences, rupture risk is greater in pregnancy, often leading to a vascular emergency and premature delivery or termination.
Presentation of case
A 24-weeks pregnant woman (45 years old, G6P1) presented with haematuria and flank pain. CT showed AML with acute haemorrhage. The patient became haemodynamically unstable and underwent urgent embolisation and follow-on total radical nephrectomy with the foetus being left in-utero. This involved a multidisciplinary team (urologist, vascular surgeon, interventional radiologist and obstetrician). The procedure was uncomplicated and the pregnancy went to term with a healthy girl delivered at 38 weeks.
The incidence of AML is 0.13% in the general population. 21 reports of haemorrhaging AML in pregnancy have been published in the last 35 years. Mean gestational age was 29.6 weeks. Eight were treated conservatively to term, one underwent exploratory laparotomy with evacuation of haematoma only, five were embolised, and seven were managed with nephrectomy. Of the nephrectomy subgroup, one was preceded by vaginal delivery and five underwent concurrent caesarean section (one with pre-op embolisation). There were two associated foetal deaths.
This case demonstrates that with a multidisciplinary approach, it is possible to successfully leave a foetus undelivered whilst performing a radical nephrectomy for a large bleeding AML in a woman carrying a late second trimester pregnancy.
PMCID: PMC4336430  PMID: 25598402
Angiomyolipoma; Pregnancy; Haemorrhage; Nephrectomy; Therapeutic embolisation
8.  Systematic classification and prediction of complications after nephrectomy in patients with metastatic renal cell carcinoma (RCC) 
BJU international  2012;110(9):1276-1282.
To evaluate and identify factors predictive for morbidity after radical nephrectomy in patients with metastatic renal cell carcinoma (mRCC).
Patients and methods
We identified patients with mRCC who underwent nephrectomy at Memorial Sloan-Kettering Cancer Center (MSKCC) between 1989 and 2009.
Postoperative complications were characterised using a modified version of the Clavien-Dindo classification system.
Patient and disease characteristics, including a previously validated MSKCC risk-stratification system using calcium, haemoglobin (Hb), lactate dehydrogenase, and Karnofsky Performance Status (KPS), were evaluated as predictors of postoperative complications using univariate and multivariable logistic regression models.
The area under the receiver operating characteristic curve (AUC) was calculated for each model to assess predictive accuracy and corrected for overfit using 10-fold cross validation.
Over the study period, 195 patients with mRCC underwent nephrectomy; 53 (27%) developed grade ≥2 complications within 8 weeks of surgery.
Pulmonary, thromboembolic events and anaemia requiring transfusion were the most common types of complications after nephrectomy in the metastatic setting.
In univariate analysis, age, low albumin, low KPS, high corrected serum calcium, low serum Hb, and unfavourable MSKCC risk score were predictive of complications.
Patients who sustained postoperative complications were less likely to receive systemic therapy within 56 days (odds ratio [OR] 0.32; 95% confidence interval [CI] 0.12–0.86; P = 0.024).
A multivariable model containing KPS (OR 14.5; 95%CI 4.34–48.6; P < 0.001) and age (OR 1.04; 95%CI 1.01–1.08; P = 0.014) showed the greatest predictive accuracy (corrected AUC 0.72; 95%CI 0.63–0.80) for postoperative complications.
Postoperative complications after radical nephrectomy in the setting of mRCC are common and occur frequently in older patients and those with worse KPS.
These complications are important because they may delay or deny receipt of subsequent systemic therapy.
PMCID: PMC3985128  PMID: 22554107
renal cell carcinoma; metastatic; nephrectomy; sunitinib; complications; Clavien
9.  Prolonged survival after sequential multimodal treatment in metastatic renal cell carcinoma: two case reports and a review of the literature 
In this case series and short review of the literature, we underline the impact of nephrectomy combined with sequential therapy based on cytokines, antiangiogenic factors, and mammalian target of rapamycin inhibitors along with metastasectomy on overall survival and quality of life in patients with metastatic clear cell renal carcinoma.
Case presentation
In the first of two cases reported here, a 53-year-old Caucasian man underwent a radical left nephrectomy for renal cell cancer and relapsed with a bone metastasis in his right humerus. He was treated with closed nailing and cytokine-based chemotherapy. For 5 years, the disease was stable and he had great improvement in quality of life. Subsequently, the disease relapsed in his lymph nodes, lung, and thorax soft tissue. He was then treated with antiangiogenic factors and mammalian target of rapamycin inhibitors. The disease progressed until September 2009, when he died of allergic shock during a blood transfusion, 9 years after the initial diagnosis of renal cell cancer.
In the second case, a 54-year-old Caucasian man underwent a radical left nephrectomy for renal cell cancer. A year later, the disease progressed to his neck lymph nodes, and cytokine-based chemotherapy was initiated. While he was on cytokines, a solitary pulmonary nodule appeared and he underwent a metastasectomy. Nine months later, magnetic resonance imaging of his brain revealed a focal right occipitoparietal lesion, which was resected. After two years of active surveillance, the disease relapsed as a pulmonary metastasis and he was treated with an antiangiogenic factor. Further progressions presenting as enlarged axillary lymph nodes, chest soft tissue lesions, and thoracic spine bone metastases were sequentially observed. He then received a first-generation mammalian target of rapamycin inhibitor, an antiangiogenic factor, and later a second-generation mammalian target of rapamycin inhibitor and palliative radiotherapy. Ten years after the initial diagnosis of renal cell cancer, his disease is stable and he is on a third antiangiogenic factor and leads an active life.
One multidisciplinary approach to patients with metastatic renal cell cancer combines nephrectomy, metastasectomy, and radiotherapy (when feasible) with medical therapy based on cytokines and targeted treatment employing agents inhibiting angiogenesis, other receptor tyrosine kinases, and mammalian target of rapamycin. This approach could prolong survival and improve quality of life.
PMCID: PMC3459787  PMID: 22978809
Metastatic renal cell carcinoma; prolonged survival; sequential therapy; quality of life
10.  Description of a multicenter safety checklist for intraoperative hemorrhage control while clamped during robotic partial nephrectomy 
The adoption of robotic assistance has contributed to the increased utilization of partial nephrectomy for the management of renal tumors. However, partial nephrectomy can be technically challenging because of intraoperative hemorrhage, which limits the ability to identify the tumor margin and may necessitate the conversion to open surgery or radical nephrectomy. To our knowledge, a comprehensive safety checklist does not exist to guide surgeons on the management of hemorrhage during robotic partial nephrectomy. We developed such an safety checklist based on the cumulative experiences of high volume robotic surgeons.
A treatment safety checklist for the management of hemorrhage during robotic partial nephrectomy was collaboratively developed based on prior experiences with intraoperative hemorrhage during robotic partial nephrectomy.
Reducing the risk of hemorrhage during robotic partial nephrectomy begins with reviewing the preoperative imaging for renal vasculature and tumor anatomy, with a focus on accessory vessels and renal tumor proximity to the renal hilum. During hilar exposure, an attempt is made to identify additional accessory renal arteries. The decision is then made on whether to clamp the hilum (artery +/- vein). If bleeding is encountered during resection, management is based on whether the bleeding is suspected to be arterial or from venous backbleeding. Operative maneuvers that may increase the chance of success are highlighted in safety checklists for arterial and venous bleeding.
Safely performing robotic partial nephrectomy is dependent on attention to prevention of hemorrhage and rapid response to the challenge of intraoperative bleeding. Preparation is essential for maximizing the chance of success during robotic partial nephrectomy.
PMCID: PMC3342085  PMID: 22471921
Kidney neoplasms; Robotics; Nephrectomy; Hemorrhage; Patient safety
11.  Robotic Retroperitoneal Partial Nephrectomy: A Four-Arm Approach 
A fourth arm during robotic retroperitoneal partial nephrectomy may provide optimal traction on target tissues and may decrease complications and positive margins secondary to impaired exposure.
Robotic partial nephrectomy is an effective alternative to laparoscopic partial nephrectomy. The 3-arm and 4-arm transperitoneal robotic approaches are well described in the literature. However, a retroperitoneal robotic technique has yet to be fully described. We report our technique and initial experience with robotic retroperitoneal partial nephrectomy with a novel 4-arm approach.
Materials and Methods:
We reviewed our current experience with the robotic retroperitoneal approach. Descriptive statistics on patient characteristics, operative parameters, and oncologic outcomes are reported.
A total of 67 robotic-assisted partial nephrectomies were performed by one surgeon between October 2009 and October 2010. The 4-arm retroperitoneal approach was used in 8 patients (12%) with no complications. Median tumor size was 2cm. All were posterior renal tumors, with 5 located in the upper pole. The median operative time, warm ischemia time, estimated blood loss, and length of stay were 202 minutes, 18 minutes, 100cc, and 2 days, respectively. Pathology indicated renal cell carcinoma (RCC) in 7 patients with negative margins.
The 4-arm robotic approach to retroperitoneal partial nephrectomy is safe, reproducible, and easily used. The fourth arm provides optimal traction on target tissues in key maneuvers and may decrease complications and positive margins secondary to impaired exposure.
PMCID: PMC3481227  PMID: 23477167
Robotics; Nephrectomy; Renal cell carcinoma; Retroperitoneum
12.  Risk Score and Metastasectomy Independently Impact Prognosis in Patients with Recurrent Renal Cell Carcinoma 
The Journal of urology  2008;180(3):873-878.
To evaluate the prognostic roles of metastasectomy and an established risk stratification system for patients experiencing a disease recurrence following nephrectomy for non-metastatic renal cell carcinoma (RCC).
A retrospective analysis was performed on 129 patients with localized RCC treated by partial or radical nephrectomy and subsequently diagnosed with disease recurrence. At the time of recurrence, a previously validated risk score based on Karnofsky performance status, interval from nephrectomy, and serum hemoglobin, calcium, and lactate dehydrogenase levels was used to categorize patients as favorable, intermediate, or poor-risk. Survival from recurrence was assessed based on risk categorization and metastasectomy
Median time from nephrectomy to recurrence was 16 months. Median and two-year survival rates were strongly associated with the risk score (favorable-risk: 73 months and 81%; intermediate-risk: 28 months and 54%; poor-risk: 6 months and 11%; log-rank<0.001). Metastasectomy was performed in 44 patients (34%) and found to be of clinical benefit across the various risk categories (interaction analysis, p=0.8). On multivariate analysis, a better risk category (p<0.001) and undergoing a metastasectomy (p<0.001) were each independently associated with a more favorable survival and when combined provided six different risk categories with an estimated two-year survival ranging from 0 – 93%.
The clinical course for patients with an RCC recurrence following nephrectomy can be variable and is independently impacted by an objectively obtained risk score and whether the patient undergoes a metastasectomy.
PMCID: PMC2570431  PMID: 18635225
renal cell carcinoma; disease recurrence; nephrectomy; surveillance; prognosis; metastasectomy
13.  Complicated variation of simple renal cyst usually means malignancy: results from a cohort study 
Currently, simple renal cysts (SRCs) are not considered to warrant follow-up or specific treatment unless a patient presents symptomatically. By demonstrating malignant transformation of SRCs, we urge regular follow-up and timely surgical treatment in affected patients.
From September 2002 to September 2010, we treated 31 cases of renal cell carcinoma derived from SRCs. Among these patients, in 14 cases a SRC was radiographically detected by computed tomography (CT) or magnetic resonance imaging (MRI) prior to operation, and malignant tumors were detected by pathological analysis following laparoscopic cyst decortication; 13 of these patients received supplementary radical nephrectomy within 2 months, whereas one patient chose to receive active surveillance. The other 17 patients exhibited SRCs and were monitored by ultrasound for over 6 months; surgical treatment was chosen if a complicated variation of SRCs was found during surveillance, detected by ultrasound, and confirmed by CT or MRI. Median follow-up was 60 months (30 to 126 months). All data analyzed were collected with informed consent, and the study was approved by the ethical committee of our institute.
Pathological studies confirmed early-stage clear-cell renal cell carcinoma in all of the cases, with Fuhrman grade I to III. In decortication-detected malignancies, supplementary radical nephrectomy exhibited residual tumor in 7 out of 13 cases; the patient who chose active surveillance remains free of recurrence for 78 months, and all other patients survived without disease at the last follow-up.
Renal cell carcinoma may be detected incidentally in SRCs, and more attention should be paid to complicated variations of SRCs during surveillance, owing to the extremely high probability of malignancy. This interesting but alarming phenomenon might urge regular follow-up and timely surgical treatment in affected patients.
PMCID: PMC4201697  PMID: 25315064
diagnosis; kidney neoplasm; renal cell carcinoma; simple renal cyst; treatment
14.  Percutaneous Ureteral Elevation in Laparoendoscopic Single-Site Radical Nephrectomy 
Laparoendoscopic single-site radical nephrectomy may be feasible in select patients. Suture-assisted retraction of the ureteral and lower pole attachments facilitate safe dissection.
Background and Objectives:
To describe our technique of suture-assisted ureteral retraction during Laparoendoscopic Single-Site (LESS) radical nephrectomy.
Materials and Methods:
A healthy, 39-year-old woman with an incidental 5-cm enhancing left renal mass elected to undergo radical nephrectomy. A 2-cm skin incision was made in the left upper quadrant of the abdomen, and a Covidien SILS port was introduced using standard Hasson techniques. Straight and angled laparoscopic instruments were used to mobilize the kidney outside of Gerota's fascia. To place the renal vessels on stretch and facilitate hilar dissection, the ureter and lower pole attachments were encircled with a 0-Vicryl suture inserted percutaneously via a disposable fascial closure device. The kidney was bagged and removed intact.
The procedure was performed without complication with a total operative time of 265 minutes. EBL was minimal at 25mL. The patient was discharged home on postoperative day 1, and final pathology revealed stage pT1b chromophobe renal cell carcinoma with negative surgical margins.
LESS radical nephrectomy is feasible in select patients. Suture-assisted retraction of the ureter and lower pole attachments using a fascial closure device facilitates safe dissection and control of the renal hilum.
PMCID: PMC3041051  PMID: 21333208
Laparoendoscopic single-site surgery; Laparoscopy; Nephrectomy
15.  Utilization of Systemic Therapy and Factors Impacting Survival for Patients Undergoing Cytoreductive Nephrectomy 
BJU international  2009;106(2):218-223.
Prospective randomized trials have demonstrated a survival benefit for nephrectomy in patients with metastatic renal cell carcinoma treated with immunotherapy. These data have been extrapolated to support cytoreductive nephrectomy in the targeted therapy era as well. However, the likelihood that patients with metastatic kidney cancer who undergo nephrectomy will receive systemic treatment postoperatively remains poorly defined. We present a multi-institutional experience evaluating the utilization of systemic therapy in patients undergoing cytoreductive nephrectomy.
141 patients who underwent cytoreductive nephrectomy between 1990 and 2008 were identified from our Institutional Kidney Cancer Registries. Kaplan Meier analyses and Cox regression models were used to assess the impact of clinicopathological and perioperative variables on patients’ subsequent receipt of systemic therapy and postoperative survival.
Overall, 98/141 patients (69.5%) received postoperative systemic treatment, at a median of 2.5 months (range 0.1–61.5) after nephrectomy. In this group, 52 (53%) patients received immunotherapy, 34 (35%) targeted agents, and 12 (12%) other regimens. By contrast, 43 patients (30.5%) did not receive systemic therapy, because of rapid disease progression (n=13, 30%), decision for surveillance by medical oncology (n=9, 21%), patient refusal (n=10, 23%), perioperative mortality (n=8, 19%), and unknown reasons in three patients (7.0%). Median survival following cytoreductive nephrectomy was 16.7 months (range 0–120). The risk of death after surgery correlated with the number of metastatic sites (p=0.012) and symptoms (p=0.001) at presentation, poor performance status (p=0.001), high tumor grade (p=0.006), and presence of sarcomatoid features (p<0.024).
Nearly one-third of patients undergoing cytoreductive nephrectomy did not receive systemic treatment. While some were electively observed or declined therapy, others did not receive treatment due to rapidly progressive disease. Further investigation is warranted to identify those patients at highest risk for rapid post-operative disease progression who might benefit instead from an initial approach to treatment with systemic therapy.
PMCID: PMC2906619  PMID: 19922542
renal cell carcinoma; metastases; nephrectomy; systemic therapy; targeted therapy
16.  Surgical resection for locally invasive renal cell carcinoma: Is it worthwhile? 
Many patients with renal cell carcinoma (RCC) present with disease involving the adjacent viscera. Although survival in such patients is poor, surgery remains the only proven modality of treatment. We describe our experience with radical nephrectomy for locally invasive RCC over a five-year period.
Study Design:
A retrospective analysis of the records of all patients who had undergone surgery for locally invasive RCC between January 1999 and December 2004 at our institute.
Materials and Methods:
During the study period, 102 patients with RCC underwent surgery at our institute, out of which 18 (17.6%) patients had adjacent organ involvement. The survival and outcomes in terms of symptom relief are described.
Statistical Analysis:
The survival rates were calculated by the Kaplan-Meier method using EGRET statistical software package.
Of the 18 patients, two patients had inoperable disease. Fifteen out of the 18 patients succumbed to their disease after a median period of 7.5 months. Three patients are still alive, having survived for 13, 16 and 25 months. Most patients derived considerable benefit with respect to relief of symptoms, which was long-lasting.
For selected patients with locally invasive RCC, radical nephrectomy with en bloc resection of involved organs may provide the opportunity for long-term survival. In others, it may provide considerable symptomatic relief.
PMCID: PMC2721599  PMID: 19718323
Locally invasive; radical nephrectomy; renal cell carcinoma
17.  Incidental giant renal oncocytoma: a case report 
Large renal oncocytomas are not very rare entities. To the best of our knowledge, we report one of the largest oncocytomas in the English literature. The tumor was incidentally diagnosed and, based on the preoperative clinical and radiographic findings, was therefore considered to be a renal cell carcinoma.
Case presentation
A 48-year-old Caucasian diabetic man had an abdominal ultrasound for chronic abdominal discomfort, which revealed a large mass on the left kidney. An abdominal computed tomography scan revealed a contrast enhancing, well defined, heterogenous large mass (16.5 × 13.9 cm) originating from the left lower pole with cystic and solid areas. A magnetic resonance imaging scan was performed with no evidence of renal vein or caval thrombus or embolus. A radical nephrectomy was performed through a left flank intercostal incision and the pathology diagnosed renal oncocytoma. The postoperative course was uneventful and the patient was discharged six days later.
Several reports have characterised this essentially benign renal histiotype, which represents 5% to 7% of all solid renal masses. Unfortunately, most renal oncocytomas cannot be differentiated from malignant renal cell carcinomas by clinical or radiographic criteria. Central stellate scar and a spoke-wheel pattern of feeding arteries are unreliable diagnostic signs and are of poor predictive value. These tumors are treated operatively with radical or partial nephrectomy or thermal ablation, depending on the clinical circumstances. We report on, to the best of our knowledge, the fourth largest lesion of this type of renal pathology.
PMCID: PMC2990760  PMID: 21059248
18.  Laparoscopic Radical Nephrectomy for Renal Masses 7 Centimeters or Larger 
To report our operative experience and oncologic outcomes for the laparoscopic management of large renal tumors.
All laparoscopic and hand-assisted laparoscopic radical nephrectomies performed at our institution were reviewed. Thirty patients with tumors ≥7cm and a pathologic diagnosis of renal cell carcinoma were included.
Mean operative time was 175.7±24.5 minutes, and mean estimated blood loss was 275.5±165.8 mL. No case required conversion to open radical nephrectomy. The mean hospital stay was 2.4±1.6 days. Four patients (13%) had minor complications. Of the 30 tumors, 18 were pathologic stage T2, 9 were stage T3a, 2 were stage T3b, and one was stage T4. At a mean follow-up of 30 months (range, 10 to 70), 22 patients (73%) were alive without evidence of recurrence, and 5 patients (17%) were alive with disease. One patient (3%) died of complications related to renal cell carcinoma, and 2 patients (7%) died from other causes. Overall survival was 90%, cancer-specific survival was 97%, and recurrence-free survival was 80%.
Laparoscopic radical nephrectomy for large tumors is a technically challenging operation. However, in experienced hands, it is a reasonable therapeutic option for the management of larger RCC neoplasms.
PMCID: PMC3015927  PMID: 19660207
Renal cell carcinoma (RCC); Kidney neoplasm; Large tumors; Minimally invasive surgery
19.  Treatment of patients with metastatic renal cell carcinoma undergoing hemodialysis: case report of two patients and short literature review 
BMC Nephrology  2013;14:84.
Renal cell carcinoma (RCC) may involve both kidneys. When bilateral nephrectomy is necessary renal replacement therapy is mandatory. Treating such patients with sequential therapy based on cytokines, antiangiogenic factors and mammalian target of rapamycin (mTOR) inhibitors is challenging.
Case presentation
The first case, a 50-year-old Caucasian female, underwent a radical right nephrectomy for RCC. Twelve years later she underwent a radical left nephrectomy along with total hysterectomy including bilateral salpingo-oophorectomy for RCC involving the right kidney and ovary. Hemodialysis was necessary because of bilateral nephrectomy. She relapsed with pulmonary metastases and enlarged mediastinal lymph nodes and received cytokine based therapy along with bevacizumab. Therapy was discontinued despite the partial response because of hemorrhagic gastritis. Therapy was switched to an antiangiogenic factor but the patient manifested a parietal brain hematoma and stopped therapy. Subsequently disease relapsed with malignant pleural effusion and pulmonary nodules and a mammalian target of rapamycin inhibitor was administered which was withdrawn only at patient’s deteriorating performance status. The patient died of the disease 13 years after the initial diagnosis of RCC.
The second case, a 51-year-old, Caucasian male, underwent a radical right nephrectomy for a chromophobe RCC. Six months later he underwent a radical left nephrectomy for RCC that proved to be a clear cell RCC. Due to bilateral nephrectomy hemodialysis was obligatory. Following disease recurrence at the anatomical bed of the right kidney therapy with antiangiogenic factor was administered which led to disease regression. However the patient experienced a left temporal-occipital brain hematoma. A radical excision of the recurrence which histologically proved to be a chromophobe RCC was not achieved and the patient received mTOR inhibitor which led to disease complete response. Nine years after the initial diagnosis of RCC he is disease free and leads an active life.
Patients with RCC are in significant risk to manifest bilateral disease. Renal insufficiency requiring hemodialysis poses therapeutic challenges. Clinicians must be aware of the antiangiogenic factors’ adverse effects, especially bleeding, that may manifest in higher frequency and more severe in this setting.
PMCID: PMC3637452  PMID: 23587009
Bilateral renal cell carcinoma; Hemodialysis; Nephrectomy; Targeted agents; Tyrosine kinase inhibitor
20.  Surgical Management of Renal Cell Carcinoma 
Surgical resection of renal cell carcinoma (RCC) is the benchmark for long-term cure of the disease. Although open or laparoscopic radical nephrectomy is considered the gold standard for stage T1b-T4 tumors, nephron-sparing surgery is the preferred operative modality for small renal masses demonstrating equivalent oncologic efficacy and improved renal function outcomes compared with complete nephrectomy. With the advance of minimally invasive surgery, nephron-sparing procedures can safely be conducted laparoscopically with or without robotic assistance. RCC with intravenous tumor thrombus presents a surgical challenge, but multidisciplinary surgical approaches can provide long-term benefit in these patients. The role of cytoreductive nephrectomy and metastasectomy in patients with metastatic RCC (mRCC) is controversial, but seems to be beneficial for patients in the era of targeted therapy.
PMCID: PMC3930656  PMID: 24596437
renal cell carcinoma; surgical management; radical nephrectomy; nephron-sparing surgery
21.  Minimal changes in the systemic immune response after nephrectomy of localized renal masses1 
Urologic oncology  2014;32(5):589-600.
Renal cell carcinoma (RCC) is an immunogenic tumor, and multiple immunostimulatory therapies are in use or under development for patients with inoperable tumors. However, a major drawback to the use of immunotherapy for RCC is that renal tumors are also immunosuppressive. As a result, current immunotherapies are curative in <10% of patients with RCC. To better understand the systemic immune response to RCC, we performed a comprehensive examination of the leukocyte and cytokine/chemokine composition in the peripheral blood of patients with localized clear cell renal tumors pre- and post-nephrectomy.
Methods and materials
Peripheral blood samples were taken from 53 consented subjects with renal masses before cytoreductive nephrectomy and again at clinic visits approximately 30 days after nephrectomy. Samples were also obtained from 10 healthy age- and gender-matched controls. Blood samples from clear cell RCC subjects were analyzed by multi-parameter flow cytometry to determine leukocyte subset composition and multiplex array to evaluate plasma proteins.
Pre-nephrectomy, clear cell tumors were associated with systemic accumulations of both “exhausted” CD8+ T cells, as indicated by surface BTLA expression, and monocytic CD14+HLA-DRnegCD33+ myeloid-derived suppressor cells (MDSC). Subjects with T3 clear cell RCC also had a unique pro-tumorigenic and inflammatory cytokine/chemokine profile characterized by high serum concentrations of IL-1β, IL-2, IL-5, IL-7, IL-8, IL-17, TNF-α, MCP-1 and MIP-1β. At an early post-nephrectomy time point (~30 d), we found the systemic immune response to be largely unaltered. The only significant change was a decrease in the mean percentage of circulating BTLA+CD8+ T cells. All other cellular and soluble immune parameters we examined were unaltered by the removal of the primary tumor.
In the first month following surgery, nephrectomy may relieve systemic CD8 T cell exhaustion marked by BTLA expression, but continuing inflammation and MDSC presence likely counteract this positive effect. Future determination of how this systemic immune signature becomes altered during metastatic progression could provide novel targets for neoadjuvant immunotherapy in RCC. r 2014 Elsevier Inc. All rights reserved.
PMCID: PMC4124886  PMID: 24768357
Carcinoma; Renal cell; Immunity; Immune suppression; Inflammation
22.  Prognostic utility of pre-operative circulating osteopontin, carbonic anhydrase IX and CRP in renal cell carcinoma 
British Journal of Cancer  2012;107(7):1131-1137.
Objectively measured circulating biomarkers of prognosis complementing existing clinicopathological models are needed in renal cell carcinoma (RCC).
Blood samples collected from 216 RCC patients in Leeds before nephrectomy (median follow-up 7 years) were analysed for C-reactive protein (CRP), osteopontin (OPN) and carbonic anhydrase IX (CA9) and prognostic significance determined.
CA9, OPN and CRP were univariately prognostic for overall survival (OS), cancer-specific survival (CSS) and disease-free survival (DFS) with CRP and CA9 being independently prognostic for OS/CSS and OS, respectively. Including CA9, OPN and CRP with other conventional prognostic factors gave a superior predictive capacity when compared with a previously published pre-operative clinical nomogram (Karakiewicz et al, 2009). Osteopontin outperformed this nomogram and the post-operative SSIGN score for OS but not for CSS, being significantly predictive for non-cancer deaths. Osteopontin, CRP and CA9 outperformed stage (c-index 76% compared with 70% for stage) and OPN or CA9 identified several subsets of poor prognosis patients including in T1 patients, who may benefit from adjuvant therapy and increased surveillance.
Circulating CA9, OPN and CRP add value to existing clinicopathological prognostic factors/models and support further studies to investigate their potential use in improving the clinical management of RCC.
PMCID: PMC3461155  PMID: 22918393
osteopontin; renal cancer; carbonic anhydrase IX; prognosis; RCC; CRP
23.  Development of a surgical safety checklist for the performance of radical nephrectomy and tumor thrombectomy 
The surgical management of renal cell carcinoma with invasion of the renal vein or inferior vena cava is associated with significant rates of perioperative morbidity and mortality. In this report we propose a surgical checklist aimed at reducing adverse events associated with the resection of these tumors.
This review describes the development of an evidence- and experience-based surgical checklist aimed at improving the perioperative safety of patients undergoing radical nephrectomy and tumor thrombectomy.
Reducing the risk of complications during the surgical management of renal tumors with venous invasion begins with appropriate pre-operative imaging aimed at defining the cranial extent of the tumor thrombus, thus facilitating accurate preoperative planning. Other key elements of the checklist are aimed at ensuring clear and precise pre-, intra- and postoperative communication between members of the multidisciplinary-care team.
A standardized surgical checklist may help to increase the perioperative safety of patients undergoing radical nephrectomy and tumor thrombectomy. Future validation studies are required to determine the clinical feasibility and post-implementation safety profile of this new checklist.
PMCID: PMC3546874  PMID: 23241448
Checklist; Renal cell carcinoma; Inferior vena cava; Tumor thrombus
24.  Feasibility and Outcomes of Laparoscopic Renal Intervention After Prior Open Ipsilateral Retroperitoneal Surgery 
Journal of Endourology  2013;27(2):196-201.
Background and Purpose
Treating patients with renal-cell carcinoma (RCC) after previous retroperitoneal surgery (renal or adrenal) is technically challenging. We present our initial experience with laparoscopic renal interventions (LRI) after previousopen retroperitoneal surgery in patients needing ipsilateral renal intervention. We report on feasibility, functional and oncologic outcomes of LRI after previous open retroperitoneal surgery.
Patients and Methods
We reviewed records of patients undergoing attempted laparoscopic or robot-assisted renal intervention after at least one previous open ipsilateral retroperitoneal surgery. We identified 34 patients who underwent 39 staged attempted LRI after 48 previous open ipsilateral renal or adrenal surgeries. The LRI included 20 minimally invasive partial nephrectomies (MIPN), 11 laparoscopic radiofrequency ablations (LRFA), and 8 laparoscopic nephrectomies (LTN). Demographic, perioperative, renal functional, and oncologic outcome data were collected. Statistical analyses were performed to identify risks for conversion to open surgery.
No attempted nephron-sparing procedure resulted in kidney loss. Overall conversion rate of the cohort was 28% and was highest in the MIPN group (40%). On univariate analysis, only multiple tumors that were treated significantly increased chances of open conversion (P<0.01). Subset analysis demonstrated similar rates of blood loss, operative times, and conversion rates in patients undergoing partial nephrectomy having previous open partial nephrectomy compared with previous open adrenal surgery only. There was no significant difference in preservation of renal function between MIPN and LRFA, with more than 85% of preoperative renal function preserved. Mean follow-up of 11.9 months (range 1–97.5 mos) metastasis-free survival and overall survival was 94.1% and 97%, respectively.
LRI after previous open ipsilateral retroperitoneal surgery is feasible. Repeated partial nephrectomy has the highest conversion risks among the laparoscopic renal interventions and appears to be independent of previous renal or adrenal procedure. Attempting repeated LRI for multiple tumors is a significant risk factor for open conversion. Renal functional and oncologic outcomes are encouraging at early follow-up.
PMCID: PMC3573724  PMID: 22963658
25.  Prognostic benefit of surgical management in renal cell carcinoma patients with thrombus extending to the renal vein and inferior vena cava: 17-year experience at a single center 
BMC Urology  2013;13:47.
Management of renal cell carcinoma (RCC) with tumor thrombus extending to the renal vein and inferior vena cava (IVC) is challenging. The aim of this study was to evaluate the benefit of surgical management in such patients.
From February 1995 to February 2013, 520 patients were treated for RCC at Hirosaki University Hospital, Hirosaki, Japan. The RCC patients with tumor thrombus extending to the renal vein (n = 42) and IVC (n = 43) were included in this study. The records of these 85 patients were retrospectively reviewed to assess the relevant clinical and pathological variables and survival. Prognostic factors were identified by multivariate analysis. The benefit of surgical management was evaluated using propensity score matching to compare overall survival between patients who received surgical management and those who did not.
RCC was confirmed by pathological examination of surgical or biopsy specimens in 74 of the 85 patients (87%). Sixty-five patients (76%) received surgical management (radical nephrectomy with thrombectomy). Distant metastasis was identified in 45 patients (53%). The proportion of patients with tumor thrombus level 0 (renal vein only), I, II, III, and IV was 49%, 13%, 18%, 14%, and 5%, respectively. The estimated 5-year overall survival rate was 70% in patients with thrombus extending to the renal vein and 23% in patients with thrombus extending to the IVC. Multivariate analysis identified thrombus extending to the IVC, presence of distant metastasis, surgical management, serum albumin concentration, serum choline esterase concentration, neutrophil-lymphocyte ratio, and Carlson comorbidity index as independent prognostic factors. In propensity score-matched patients, overall survival was significantly longer in those who received surgical management than those who did not.
Surgical management may improve the prognosis of RCC patients with thrombus extending to the renal vein and IVC.
PMCID: PMC3852853  PMID: 24125174
Renal cell carcinoma; Radical nephrectomy with thrombectomy; Tumor thrombus; Prognostic factors

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