Comparison of the functional state of the renal parenchyma when performing tumor enucleation with standard partial nephrectomy

• Pogosyan R.R.
• Elena V. Zaklyazminskaya
• Vasilchenko A.V.
• Igor V. Semeniakin

Abstract

Background. Tumor enucleation (TE) optimizes parenchyma retention and may provide better function than standard partial nephrectomy (PN), although evidence for this is inconsistent.

Aim - to compare functional results when choosing a strategy between TE and PN.

Material and methods. The study included patients who underwent partial nephrectomy (PN) with the necessary data to analyze the preservation of ipsilateral parenchymal mass (IPM) and glomerular filtration rate (GFR). All studies were performed <2 months before and 3-12 months after surgery. Patients with a single kidney or multicentric tumors were excluded. Vascularization of the ipsilateral parenchymal mass (IPM) was evaluated by CT scans with bolus contrast before and after surgery. Serum creatinine-based GFR levels were also obtained at the same time.

Results. The analysis included 19 TE and 90 cases of PN. The median of preoperative GFR was comparable in TE and PN (75 and 78 ml/min/1.73 m²; p=0.6). Theme and tumor size was 3.0 cm for TE and 3.3 cm for PN (p=0.03). The average RENAL score was 7 in both groups. For TE, warm ischemia and zero ischemia were used in 51 and 49% of cases, respectively. For PN, warm ischemia and zero ischemia were used in 72 and 28% of patients, respectively. Capsule closure was performed in 46% of TE cases and in 100% of PN cases (p<0.001). Positive surgical margins were found in 5.26% of patients with TE and 5% of patients with PN (p=0.2). The median of the vascularized parenchymal mass remained at 95% [interquartile range (MR) 91-100%] for TE and 84% (MR 76-92%) for PN (p<0.001). The median GFR was 101% (MR 93-111%) and 89% (MR 81-96%) for TE and PN, respectively (p<0.001). In a multi-parameter analysis: the partial nephrectomy strategy, preoperative GFR and saved vascularized IPM were reliably related (p<0.001) with a "new" postoperative GFR. Limitations include retrospective design and lack of data on partial nephrectomy results.

Conclusion. Our analysis shows that TE has a potentially greater ability to save IPM compared to PN and can provide optimal functional recovery. Further research will be required to assess the clinical significance of these results. TE in kidney cancer involves dissection of a long the capsule of the tumor, which all ows optimal preservation of normal renal tissue and contributes to a better recovery of function. Significance of this approach in various clinical settings and different genetic tumor origin requires further investigation.

Keywords:robot-assisted partial nephrectomy, kidney tumor, Хр11.7/TFE3 fusion gene

References 

1. Demirjian S., Lane B.R., Derweesh I.H., Takagi T., Fergany A., Campbell S.C. Chronic kidney disease due to surgical removal of nephrons: relative rates of progression and survival. J Urol. 2014; 192: 1057–62.

2. Lane B.R., Demirjian S., Derweesh I.H., et al. Survival and functional stability in chronic kidney disease due to surgical removal of nephrons: importance of the new baseline glomerular fi ltration rate. Eur Urol. 2015; 68: 996–1003.

3. Mir M.C., Campbell R.A., Sharma N., et al. Parenchymal volume preservation аnd ischemia during partial nephrectomy: functional and volumetric analysis. Urology. 2013; 82: 263–8.

4. Volpe A., Blute M.L., Ficarra V., et al. Renal ischemia and function after partial nephrectomy: a collaborative review of the literature. Eur Urol. 2015; 68: 61–74.

5. Ginzburg S., Uzzo R., Walton J., et al. Residual parenchymal volume, not warm ischemia time, predicts ultimate renal functional outcomes in patients undergoing partial nephrectomy. Urology. 2015; 86: 300–5.

6. Mir M.C., Ercole C., Takagi T., et al. Decline in renal function after partial nephrectomy: etiology and prevention. J Urol. 2015; 193: 1889–98.

7. Zhang Z., Zhao J., Dong W., et al. Acute kidney injury after partial nephrectomy: role of parenchymal mass reduction and ischemia and impact on subsequent functional recovery. Eur Urol. 2016; 69: 745–52.

8.    Uzzo R.G., Novick A.C. Nephron sparing surgery for renal tumors: indications, techniques and outcomes. J Urol. 2001; 166: 6-18.

9.    Russo P. Open partial nephrectomy: personal technique and current outcomes. Arch Esp Urol. 2011; 64: 571-93.

10.    Kaouk J.H., Khalifeh A., Hillyer S., Haber G.P., Stein R.J., Autorino R. Robot-assisted laparoscopic partial nephrectomy: step-by-step contemporary technique and surgical outcomes at a single high-volume institution. Eur Urol. 2012; 62: 553-61.

11.    Dong W., Zhang Z., Zhao J., et al. Excised parenchymal mass during partial nephrectomy: functional implications. Urology. 2017; 103: 129-35.

12.    Bahler C.D., Dube H.T., Flynn K.J., et al. Feasibility of omitting cortical renorrhaphy during robot-assisted partial nephrectomy: a matched analysis. J Endourol. 2015; 29: 548-55.

13.    Gupta G.N., Boris R.S., Campbell S.C., Zhang Z. Tumor enucleation for sporadic localized kidney cancer: pro and con. J Urol. 2015; 194: 623-5.

14.    Blackwell R.H., Li B., Kozel Z., et al. Functional implications of renal tumor enucleation relative to standard partial nephrectomy. Urology. 2017; 99: 162-8.

15.    Carini M., Minvervini A., Masieri L., Lapini A., Ser-ni S. Simple enucleation for the treatment of pT1a renal cell carcinoma: our 20 year experience. Eur Urol. 2006; 50: 1269-71.

16.    Mukkamala A., Allam C.L., Ellison J.S., et al. Tumor enucleationvs sharp excision in minimally invasive partial nephrectomy: technical benefit without impact on functional or oncologic outcomes. Urology. 2014; 83: 1294-9.

17.    Longo N., Minervini A., Antonelli A., et al. Simple enucleation versus standard partial nephrectomy for clinical T1 renal masses: perioperative outcomes based on a matched-pair comparison of 396 patients (RECORd project). Eur J Surg Oncol. 2014; 40: 762-8.

18.    Dong W., Lin T., Li F., et al. Laparoscopic partial nephrectomy for T1 renal cell carcinoma: comparison of two resection techniques in a multi-institutional propensity score-matching analysis. Ann Surg Oncol. 2016; 23: 1395-402.

19.    Minervini A., di Cristofano C., Lapini A., et al. Histopathologic analysis of peritumoral pseudocapsule and surgical margin status after tumor enucleation for renal cell carcinoma. Eur Urol. 2014; 55: 1410-8.

20.    Schiavina R., Serni S., Mari A., et al. A prospective, multicenter evaluation of predictive factors for positive surgical margins after nephron-sparing surgery for renal cell carcinoma: the RECORd1 Italian project. Clin Genitourin Cancer. 2015; 13: 165-70.

21.    Garcia A.G., Leon T.G. Simple enucleation for renal tumors: indications, techniques, and results. Curr Urol Rep. 2016; 17: 7.

22.    Minervini A., Campi R., Sessa F., et al. Positive surgical margins and local recurrence after simple enucleation and standard partial nephrectomy for malignant renal tumors: systematic review of the literature and meta-analysis of prevalence. Minerva Urol Nefrol. 2017; 69 (6): 523-38. DOI: http://doi.org/10.23736/S0393-2249.17.02864-8

23.    Levey A.S., Bosch J.P., Lewis J.B., Greene T., Rogers N., Roth D. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease study group. Ann Intern Med. 1999; 130: 461-70.

24.    Levin A., Stevens P.E. Summary of KDIGO 2012 CKD guideline: behind the scenes, need for guidance, and a framework for moving forward. Kidney Int. 2014; 85: 49-61.

25.    Campbell S.C., Uzzo R.G., Allaf M.E., et al. Renal mass and localized renal cancer: AUA guideline. J Urol. 2017; 198 (3): 520-9. URL: http://doi.org/10.1016/j.juro.2017.04.100

26.    Ljungberg B., Bensalah K., Bex A., et al. EAU guidelines on renal cell carcinoma. European Association of Urology, 2016. URL: https://uroweb.org/wp-content/uploads/EAU-Guidelines-Renal-Cell-Carcinoma-2016.pdf

27.    Minervini A., Carini M., Uzzo R.G., Campi R., Smaldone M.C., Kutikov A. Standardized reporting of resection technique during nephronsparing surgery: the surface-intermediate-base margin score. Eur Urol. 2014; 66: 803-5.

28.    Maurice M.J., Ramirez D., Malkop E., et al. Predictors of excisional volume loss in partial nephrectomy: Is there still room for improvement? Eur Urol. 2016; 70: 413-5.

29.    Dong W., Wu J., Suk-Ouichai C., et al. Devascu-larized parenchymal mass associated with partial nephrectomy: predictive factors and impact on functional recovery. J Urol. 2017; 198 (4): 787-94. DOI: http://doi.org/10.1016/j.juro.2017.04.020

30.    Satkunasivam R., Tsai S., Syan S., et al. Robotic unclamped «minimal-margin» partial nephrectomy: ongoing refinement of the anatomic zero-ischemia concept. Eur Urol. 2015; 68: 705-12.

31.    Cheng X., He J., Gan W., Fan X., Yang J., Zhu B., et al. Pseudocapsule of renal cell carcinoma associated with Xp11.2 translocation/TFE3 gene fusion: a clue for tumor enucleation? Int J Clin Exp Pathol. 2015; 8 (5): 5403-10.

32.    Nguyen K.A., Syed J.S., Espenschied C.R., La-Duca H., Bhagat A.M., et al. Advances in the diagnosis of hereditary kidney cancer: Initial results of a multigene panel test. Cancer. 2017; 123 (22): 4363-71.

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