6th Macedonian Urological Symposium State of the art lecture Nephron sparing surgery Chr. Leiber,...

6th Macedonian Urological Symposium

State of the art lecture

Nephron sparing surgery

Chr. Leiber, W.Schultze-Seemann, G. Dimitriadis

Freiburg i. Br., Thessaloniki

History of renal surgery/nephron sparing surgery

1861 (Walcott) and 1867 (Spiegelberg) – parts of the kidney were removed mistakenly - both patients died

1869 first planned nephrectomy by Simon (for urinary fistula)

- a kidney can be extirpated safely from a human being

- a patient can survive with only one kidney

1870 partial nephrectomy by Simon for hydronephrosis

1884 Wells accidentally removed a third of a kidney (perirenal fibrolipoma)

1887 Czerny did the first partial resection for a tumor (angiosarcoma)

1950 – Vermooten – foundation of modern nephron sparing surgery

„ there are certain instances, when, for the patients well being, it is unwise to do a nephrectomy, even in the presence of a malignant growth involving the kidney. The question is, whether such a procedure is ever justifiable when the opposite kidney is normal.

I am inclined to think that in certain circumstances it may be“


State of the art - Nephron sparing surgery

Standard indications for nephron sparing surgery fall into three categories

Absolute anephric patient postop., need for dialysis

Relative impaired renal function on the contralateral kidney,bilateral tumors, heriditary cancer

Elective localized unilateral RCC and a normal contralateral kidney (size ? [<4cm], cortical, clearly localized)



TNM-Classification of Renal Cell Carcinoma

1987 1997 2002

T 1 <2,5cm <7cm T1a <4cm T1b 4,1-7cmT2 >2,5cm >7cm >7cmT3a infiltration perirenal fat, adrenal glandT3b infiltration of renal vein, vena cavaT3c infiltr. of thoracic v. cavaT4 tumor outside gerota‘s fascia



Reassessment of the 1997 TNM classification in pT1 (a/b) RCC

Database of 1324 pts with RCC who had a RN between 1960 and 1991

Patients with stage I disease were stratified by size cut-offs ranging from 2,5-7cm in 5mm increments

5 year disease specific survival was estimated in each subgroup

The most discriminating cut-off was identified

233 had TNM 1997 stage I disease

tumor <5cm tumor >5cm p

Cancer spec. surv. 94,6% 79,2% 0,003

Nonorgan confined dis. 16,2% 36,8%

„patients with pT1 tumor >5cm had the same survival as patients with stage II disease.

… the subclassification into T1a/b (AJCC 6.edition) may not be optimal“Elmore,JM et al. Cancer 98,2329:2003



Radical nephrectomy/ nephron sparing surgery 2746 patients – between 1970 and 2000

812 deaths from RCC

5year cancer specific survival rate based on the 2002 classification by the American Joint Committee on Cancer were

pT1a 97%

pT1b 87%

pT2 71%

pT3a 53%

pT3b 44%

pT3c 37%

pT4 20%

„excellent subclassification of pT1 tumors in pT1a and pT1b“

Blute,F. et al. J. Urol. 173,1889:2005



Percentage of NSS

Mayo Clinic 7,1 16,1 29,3 48,3

USA 4 7

Freiburg 25 35

Type of nephrectomy - Mayo Clinic

1970-79 1980-89 1990-99 2000-02

RN 650 946 1269 362

NSS 50 182 527 338



Nationwide Inpatient sample + American Hospital Association Survey

4914 patients for RCC surgery

open nephrectomy 3310 (67,4 %)

open partial nephrectomy 784 (15,9 %)

laparoscopic parital nephrectomy 820 (16,7%)

Miller D. et al. Abstract 637 AUA 2007

Type of nephrectomy - U. S. A. 2003



Nephron sparing surgery in tumors between 4 and 7cm

932 patients with pT1b tumors (RCC) between 1970 and 2000

NSS – 91 cases RN – 841 cases

cancer spec. Surv(5y) 98% 86%

(n.s. after adjusting for features associated with death – stage, grade, histol. tumor necrosis, histol. subtype)

distant metast. free 94% 83%

(n.s. after adjusting for features associated with death – stage, grade, histol. tumor necrosis, histol. subtype)

local recurrence RR 0,32

„NSS results in excellent outcome in appropiately selected patients“

Leibovich,BC et al. J. Urol. 171,1066:2004



Nephron sparing surgery – Freiburg 1990-3/2007

438 partial nephrectomies

- 333 sporadic RCC Pathol. – pT1a - 87%

- 66 heriditary cancer (VHL) pT1b - 10%

- 39 benign tumors pT2 - 0,3%

Median follow-up 69 months pT3a - 2%

Mean age 61 years pT3b - 0,7%

Mean number of tumors 1,1 indication elective 82%

Mean tumor size 3,5cm imperat. 18%

Cold ischaemia 84,6%

Mean time of ischaemia 28 min (6-120 min.)

Mean op. time 110 min.

Mean blood loss 175ml



Tumor enucleation in nephron-sparing surgery?

108 patients underwent NSS between 1989 and 2000 (enucleation)Mean follow-up – 88,3 monthsMean tumor size 2,7 cmpT1a – 95%, pT1b – 4%, pT3a – 1%

Cancer specific survival : 5 years – 99% 10 years – 97,8%Progression free survival : 5 years – 98,1% 10 years – 94,7%Local progression : 2pt (1,9%)

– 1 alone, 1associated with distant metastases

„enucleation is not associated with an increased risk of local recurrence compared with partial nephrectomy“

Lapini A. J.Urol.174,57:2005



Nephron-sparing surgery - Can it be done laparoscopical?

Comparison open (OPN) versus laparoscopic (LPN) partial nephrectomy

Cleveland clinic + 2 other centers

1800 patients (1029 OPN, 771 LPN)

Bias to open group (more patients symptomatically, reduced Karnofsky Index, more tumors > 4 cm and centrally located.

LPN shorter OP-time, reduced blood loss, shorter hospital stay.

Intraoperative complication rate comparable.

But, LPN longer ischemia time, more postoperative complications, increased number of subsequent procedures.

Gill I. et al. Abstract 495 AUA 2007



Nephron-sparing surgery - Can it be done laparoscopical?

557 laparoscopic partial nephrectomy at Cleveland clinicbut only 56 patients with follow-up > 60 monthsMean tumor size 2,9 cmpT1a – 86%, pT1b – 14%

Cancer specific survival : 5 years – 100%

Overall survival : 5 years – 86%

Local recurrence : 1 patient

„At our center laparoscopic partial nephrectomy is an established alternative to open partial nephrectomy“

Lane R. + Gill I. Abstract 496 AUA 2007





von Hippel-Lindau Disease

Nephron sparing surgery – Freiburg 1990-2007heriditary tumors (VHL)

Evidence for heriditary cancer (VHL)

- young patient (20-40 years)

- concomittant cysts (cyst cystadenoma carcinoma)

- concomittant or known history of pheochromocytoma

- bilateral tumors

- pos. family history of RCC

indication for nephron sparing surgery without genetic proof






inherited, autosomal-dominant

de novo mutations in 1-3% of the cases

penetrance approx. 100%

responsable are mutations of the vHL-gene tumor-suppressor-gene on the short arm of chromosome3 (3p25)

cytoplasmatic proteine (213 amino acids, 28-30 kDa) expression in nearly every tissue the vHL gene is mutated as well in 80% of the sporadic RCC

[Latif et al, "Identification of the vHL disease tumor suppressor gene", Science, 260,

1993]




1. Hemangioblastoma of the CNS 60-80%

2. Cysts and Tumors of the Pancreas 60-80%

3. Hemangioblastoma of the Retina 50-60%

4. Renal Cysts and RCC 30-60%

5. Cystadenoma of the Epididymis 20-54%

6. Pheochromocytoma 11-24%

7. Tumors of the Saccus endolymphaticus 2-11%

Maddock et al, "A genetic register for vHL disease", J Med Genet, 33, 1996 Maher et al, "Clinical features and natural history of vHL disease", Q J Med, 77, 1990 Richard et al, "Haemangioblastoma of the central nervous system in vHL disease. French VHL study group", J Intern Med, 243, 1998

Nephron sparing surgery – Freiburg 1990-2007

66 heriditary cancer (VHL)

Mean age 36 years

Number of tumors removed 1-55

Mean number of tumors 10

Median number of tumors 7

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postop. Bleeding 15%

urinary leakage 3%

op. revision 12%

mean op. time 155 min.

mean blood loss 320ml

6th Macedoian Urological Symposium


Freiburg technique of nephron sparing surgery- open retroperitoneal access- (cold) ischaemia by vessel loops



Freiburg technique of nephron sparing surgery- resection of the peritumoral fat



Freiburg technique of nephron sparing surgery- open retroperitoneal access- (cold) ischaemia by vessel loops and in situ hypothermia by ice



Freiburg technique of nephron sparing surgery- partial resection in sporadic RCC, enucleation in heriditary cancer (all tumors and cysts)- no frozen sections- haemostasis of the bigger vessels by absorbable sutures, Argon-cauterization



Freiburg technique of nephron sparing surgery- haemostasis of the bigger vessels by absorbable sutures, Argon-cauterization



Freiburg technique of nephron sparing surgery- Haemostyptics (Tachosil®, Floseal® or Bioglue®)



Freiburg technique of nephron sparing surgery- no adaptation of the parenchyma (decompression after tumor resection)



Frozen section in nephron-sparing surgery?

172 patients underwent NSS between 1988 and 2003Mean tumor size 3,56 cmFrozen section was routinely done during surgery

Positive tumor margins in 2 cases – both central tumorsImmediate nephrectomy was performed in both – no residual tumor

Paraffin sections disclosed 4 more positive margins 1 nephrectomy for tumor recurrence after 9 months

in 3 cases no recurrence (26, 59 and 120 months)

„frozen section analysis during nephron sparing surgery has minimal clinical significance“

Duvdevani,M. J.Urol.173,385:2005



Freiburg technique of nephron sparing surgery- In selected cases photodynamic diagnostic by aminolevulinic acid



Nephron sparing surgery – Freiburg 1990-2007 – long term results

333 sporadic RCC

cancer spec. Surv. (5yr) overall survival

% %

3 years 100 94

5 years 97 89

10 years 97 84



Nephron sparing surgery – Summary

Nephron sparing surgery (NSS) and radical nephrectomy provide equally effective treatment for patients with a single, small, clearly localized T1 tumor

Cancer free survival is much better in tumors smaller than 4cm (5cm?) compared to patients with greater tumors (cut-off)

The results of NSS are less satisfactory in patients with greater than T1 tumors

The morbidity of NSS is acceptable

Renal function after NSS remains stable in >95% of the patients

NSS is mandatory in all cases of heriditary RCC



6th Macedonian Urological Symposium State of the art lecture Nephron sparing surgery Chr. Leiber,...

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