Littérature scientifique sur le sujet « Renal cell carcinoma, radical nephrectomy, partial nephrectomy, renal function »

Renal preservation therapy has been a promising concept for the treatment of localized renal cell carcinoma (RCC) for 20 years. Nowadays partial nephrectomy (PN) is well accepted to treat the localized RCC and the oncological control is proved to be the same as the radical nephrectomy (RN). Under the result of well oncological control, minimal invasive method gains more popularity than the open PN, like laparoscopic partial nephrectomy (LPN) and robot assisted laparoscopic partial nephrectomy (RPN). On the other hand, thermoablative therapy and cryoablation also play an important role in the renal preservation therapy to improve the patient procedural tolerance. Novel modalities, but limited to small number of patients, include high-intensity ultrasound (HIFU), radiosurgery, microwave therapy (MWT), laser interstitial thermal therapy (LITT), and pulsed cavitational ultrasound (PCU). Although initial results are encouraging, their real clinical roles are still under evaluation. On the other hand, active surveillance (AS) has also been advocated by some for patients who are unfit for surgery. It is reasonable to choose the best therapeutic method among varieties of treatment modalities according to patients' age, physical status, and financial aid to maximize the treatment effect among cancer control, patient morbidity, and preservation of renal function.

Chronic kidney disease risk is increased among patients with renal cell carcinoma, particularly for those with preexisting chronic kidney disease (including proteinuria) but also for those with comorbidities such as diabetes mellitus, hypertension, and obesity. Among those with small renal masses without complex disease, partial nephrectomy should be prioritized given favorable pathologic prognosis and mortality related to cardiovascular disease or chronic kidney disease. Nephrologists should actively participate in a multidisciplinary team to help formulate individualized treatment which will help preserve residual kidney function where possible.

AIM: To study the hemodynamics and functional state of the renal tissue of the contralateral kidney in the early postoperative period after surgical treatment of kidney cancer. MATERIALS AND METHODS: The prospective study included 58 patients with renal cell carcinoma, 36 (62.1%) of whom underwent radical nephrectomy, and 22 (37.9%) underwent partial nephrectomy. Tumor sizes ranged from 1.0 to 12.0 cm. All patients before surgery and in the early postoperative period underwent ultrasound examination of the structure and size of the kidneys, Doppler ultrasonography of the renal vessels, biomicroscopy of the bulbar conjunctiva, measured peripheral blood pressure, determined the glomerular filtration rate (GFR) and performed a coagulogram. The control group included 16 healthy adults. RESULTS: In 83.3% of patients after radical nephrectomy and in 13.6% of patients after partial nephrectomy a tendency towards an increase in blood pressure compared with the initial values was noted by the 2-4th day after the operation. By the 5th day after surgery, the volume of the only kidney remaining after radical nephrectomy increased by an average of 4% (from 126.1 1.4 to 131.2 2.1 cm3, p 0.05), while after partial nephrectomy has not changed reliably. After surgery, a decrease in GFR was detected in 34 (58.6%; p 0.05) patients, including after radical nephrectomy (n = 28) up to 73.4 8.2 ml / min / 1.73 m2, after partial nephrectomy (n = 6) up to 98.2 3.4 ml / min / 1.73 m2. Doppler ultrasonography of the vessels of a single kidney in patients after radical nephrectomy showed a moderate increase in linear blood flow, an increase in the resistance index in the main trunk of the renal artery, and a decrease in the pulsation index in the segmental and arc arteries. In patients after partial nephrectomy in the contralateral kidney these changes were not observed. When performing biomicroscopy of the bulbar conjunctiva in 83.3% of patients after radical nephrectomy and in 13.6% of patients after partial nephrectomy, changes in the microvasculature were revealed: narrowing of arterioles, expansion of venules, slowing of venular and capillary blood flow. Before the operation and in the early postoperative period, the content of fibrinogen and soluble fibrin-monomer complex in the blood of patients with renal cell carcinoma was significantly higher than in the control group. CONCLUSIONS: In patients with renal cell carcinoma, changes in the contralateral kidney in the early postoperative period after radical nephrectomy are significantly more pronounced than after partial nephrectomy, and are accompanied by changes in systemic and local hemodynamics and kidney function. The results of the study confirm the feasibility of performing organ-preserving surgeries in patients with renal cell carcinoma.

Renal cell carcinoma (RCC) is often detected incidentally andearly. Currently, open partial nephrectomy and laparoscopic totalnephrectomy form competing technologies. The former is invasive,but nephron-sparing; the other is considered less invasive but withmore loss of renal mass. Traditionally, emphasis has been placedon oncologic outcomes. However, a patient with an excellentoncologic outcome may suffer from morbidity and mortality relatedto renal failure. Animal models with hypertension and diabeticrenal disease indicate accelerated progression of pre-existing diseaseafter nephrectomy. Patients with RCC are older and they havea high prevalence of diabetes and hypertension. The progressionof renal failure may also be accelerated after a nephrectomy. Ouranalysis of the available literature indicates that renal outcomes inRCC patients after surgery are relatively poorly defined. A strategyto systematically evaluate the renal function of patients with RCC,with joint discussion between the nephrologist and the oncologicteam, is strongly advocated.L’hypernéphrome est souvent décelé fortuitement et au stade précoce.Actuellement, la néphrectomie partielle par voie ouverteet la néphrectomie totale par laparoscopie sont des technologiesconcurrentes. Tandis que la première est plus invasive, mais permetl’épargne des néphrons, la seconde est moins invasive maisentraîne une perte plus importante de masse rénale. Par le passé,on a mis l’emphase sur les résultats d’un point de vue oncologique.Cependant, un patient pour qui la chirurgie donne d’excellents résultatsen matière d’élimination de la tumeur pourrait présenter unemorbidité et une mortalité en lien avec une insuffisance rénale. Desmodèles animaux de néphropathie avec hypertension et diabèteindiquent une évolution accélérée des maladies préexistantes aprèsla néphrectomie. Les patients présentant un hypernéphrome sontplus âgés; la prévalence du diabète et de l’hypertension est élevée.L’évolution de l’insuffisance rénale peut aussi être accélérée aprèsla néphrectomie. Notre analyse des articles publiés montre que lesrésultats sur le plan de la fonction rénale après une chirurgie pourtraiter un hypernéphrome sont relativement mal définis. Une stratégiefondée sur une évaluation systématique de la fonction rénale despatients atteints d’hypernéphrome, avec discussion entre le néphrologueet l’équipe de soins oncologiques, est fortement encouragée.

OVERVIEW: The incidental renal mass represents a heterogeneous group that contains both benign and malignant pathologies. The majority of renal cell carcinomas are discovered incidentally, without the presence of symptoms directly related to the mass, and are closely associated with the term small renal masses because of the discovery before the onset of symptoms. In general, small renal masses are defined as 4 cm or smaller, and may account for greater than half of renal cell carcinoma diagnosis. The use of renal mass biopsy may offer additional pathological information but the clinician must be reminded of the technical and diagnostic limitations of renal mass biopsy. Patient-dependent factors, such as life expectancy and comorbidities, guide the management of small renal masses, which include active surveillance, partial nephrectomy, radical nephrectomy, and ablative techniques (cryoablation and radiofrequency ablation). Partial nephrectomy has demonstrated durable oncologic control for small renal masses while preserving renal function and, if feasible, is the current treatment of choice. In the other extreme of the renal cell carcinomas spectrum and in the presence of metastatic disease, the removal of the renal primary tumor is termed cytoreductive nephrectomy. Two randomized trials (SWOG 8949 and EORTC 30947) have demonstrated a survival benefit with cytoreductive nephrectomy before the initiation of immunotherapy. These two studies have also been the motivation to perform cytoreductive nephrectomy in the targeted therapy era. Currently, there are two ongoing randomized prospective trials accruing to investigate the timing and relevance of cytoreductive nephrectomy in the contemporary setting of targeted therapy.

Objective: To evaluate renal function (GFR) after radical nephrectomy compared to partial nephrectomy in stage T1 renal cell carcinoma patients between 2005 and 2015. Material and Method: Retrospective chart review of 409 patients who were diagnosed with renal cell carcinoma (T1) and treated with radical nephrectomy (RN) or partial nephrectomy (PN) between 2005 and 2015 (RN=136, PN=92); 228 patients with pathologically confirmed pT1 remained for analysis and were then evaluated for their estimated glomerular filtration rate (eGFR) after the surgery. Results: There were a total of 228 (149 males and 79 females) T1 RCC patients; 136 patients were T1a with RN (57.8%) and 92 with PN (42.2%). Median follow-up was 58 months and 35 months for the RN and PN groups. From the analysis, post-operative eGFR of the RN group was decreased from 77.49 to 59.61 ml/min/1.73m2 and the PN group was decreased from 78.85 to 69.9 ml/min/1.73m2. The comparative eGFR between the 2 groups at 1 month had a significant difference (p-value<0.05). eGFR at 3 months (50.24 in RN vs 64.67 in PN), 6 months (47.98 vs 64.51), 3 years (48.79 vs 67.22) and 5 years (52.63 vs 73.59) were also significantly altered between the 2 groups. The tumor recurrence rate was not significantly different between RN and PN. Conclusion: We found that patients treated with PN had superior post-operative renal function compared with RN. However, there was no difference in the tumor recurrence rate between the 2 groups after a follow-up of 10 years.

Renal cell carcinoma (RCC) accounts for 3.9 % of all cancers. In 2018, 24,291 and 63,990 new cases of RCC were recorded in Russia and the US, respectively. The most common approach to early stage RCC treatment consists in either radical or partial nephrectomy. This article presents a clinical case of the successful treatment of a localized renal cell carcinoma T3аN0M0 in a 65-year-old man. 8 weeks after the performed kidney resection, the biochemical blood parameters and glomerular filtration rate did not significantly differ from the initial values (p > 0.05). A control CT examination of the abdominal cavity and the retroperitoneal space (after 12 weeks) detected no enlarged regional, paraaortic and paracanal lymph nodes. Partial nephrectomy is considered to be an alternative surgical treatment of localized RCC forms due to its potential for maximal organ preservation. Partial nephrectomy should be a method of choice in cases where it is technically and strategically feasible, since this type of surgical intervention provides for a better preservation of renal function under a lower risk of postoperative complications.

Background/Aim. In renal cell carcinoma (RCC) the choice of surgical technique, radical (RN) or partial nephrectomy (PN) is still centre dependant because there still are no absolute recommendations for this approach. This study aims to analyze the oncological aspects, time until recurrent disease appears and cancer-specific survival in patients with RCC in T1bN0?0 depending on the type of surgical procedure partial or radical nephrectomy. Methods. A clinical observational study of a series of cases was conducted that analyzed data of 154 patients operated in our institution with a mean follow up a period not less than five years. The inclusion criteria included: renal tumours 4-7 cm, histopathological confirmation of RCC, absence of metastasis and normal serum creatinine. Exclusion criteria included: the presence of other malignancies, solitary functional kidney or comorbidities that can compromise renal function, bilateral tumours or unilateral multiple tumours. Results. The study analyzed data of 154 patients, 97 radical nephrectomies and 57 patients that underwent partial nephrectomy. Analyzing cancer-specific survival in four patients with RN there was a disease advancement that led to a lethal outcome, one PN patient died as a result of local relapse and distant metastasis. Conclusion. Based on our results PN is a good and safe treatment option for patients with RCC in T1b stadium. Partial nephrectomy offers a similar tumour control and better cancer-specific survival.

385 Background: Partial nephrectomy (PN) has reported equivalent oncologic outcomes with superior renal function outcomes when compared to radical nephrectomy (RN) for treatment of localized renal cell carcinoma (RCC). Whether PN provides adequate cancer control in high risk disease is unclear. To clarify, survival outcomes were compared between those who underwent RN and PN for high risk RCC. Methods: Using the Surveillance, Epidemiology, and End Results database patients with RCC who underwent PN or RN for a localized tumor ≤ 7cm were identified. Cancer-specific (CSS) and overall survival (OS) were compared between those with high risk disease (defined as poorly or undifferentiated grade and/or pathologic stage T3) who underwent PN or RN. Results: Of 51,183 patients with localized RCC ≤ 7cm, 24.9% had high risk disease, 85.2% and 14.8% of which underwent RN and PN, respectively. Five-year CSS was superior in the PN group vs. the RN group (93.3% vs. 86.0%, p<0.001). On multivariable analysis undergoing RN was no longer predictive of CSS (HR 1.23, p=0.08). Similarly, 5-year OS was superior in the PN versus RN group (79.5% vs. 70.1%, p<0.001). RN remained independently associated with poor OS on multivariable analysis (HR 1.16, p=0.031). Propensity analysis accounting for factors affecting selection for type of nephrectomy produced similar results. RN did not influence CSS but portended a 20% increased risk of death from all causes (p=0.008). Conclusions: In patients with high risk RCC, partial nephrectomy is associated with improved OS and does not compromise cancer control as compared to radical nephrectomy.

INTRODUÇÃO: A nefrectomia radical está associada com algum grau de comprometimento da função do rim remanescente em pacientes com câncer renal. A etiologia da insuficiência renal crônica (IRC) nesses casos é complexa, tem prevalência relativamente alta e existem poucas alternativas terapêuticas quando ela se estabelece. Métodos que permitem prever o aparecimento desse quadro e possibilitem condutas terapêuticas que minimizem e retardem a perda de função renal são altamente desejáveis. OBJETIVOS: Em pacientes submetidos à nefrectomia radical: 1. Objetivo primário: Avaliar o impacto de alterações do parênquima renal não neoplásico, dados demográficos, clínicos e laboratoriais sobre o desenvolvimento de insuficiência renal crônica. 2. Objetivo secundário: Correlacionar alterações do parênquima renal não neoplásico, dados demográficos, clínicos e laboratoriais com a variação da taxa de filtração glomerular estimada pré e pós-operatória. MÉTODOS: Foram selecionados 65 pacientes submetidos à nefrectomia radical por quadros de carcinoma de células renais. Nesses casos, procedeu-se a análise histológica do parênquima renal não neoplásico e as alterações encontradas foram correlacionadas com o aparecimento subsequente de IRC. Para avaliação da função renal, foi utilizada a taxa de filtração glomerular estimada (TFGe) por meio da fórmula MDRD (Modification of Diet in Renal Disease) pré-operatória e última consulta. O estado do parênquima renal não neoplásico foi avaliado por meio de parâmetros histológicos: 1. Presença de glomerulosclerose, calculada pelo número total de glomérulos escleróticos dividido pelo número total de glomérulos avaliados, e expressa em porcentagem e presença de glomérulos hialinizados; 2. Alterações vasculares com a presença de arteriolosclerose. A extensão da oclusão arterial foi quantificada em três grupos: menos de 25%, 26% a 50% e acima de 50%. 3. Presença de fibrose intersticial e atrofia tubular. O impacto destas alterações no comportamento da função renal foi avaliado por meio do desenvolvimento IRC, definida com uma TFGe menor que 60ml/minuto/1,73m2 na avaliação mais recente e de acordo com os protocolos do Kidney Disease Outcomes Quality Initiative. RESULTADOS: Após um seguimento médio de 49,06 meses, foi observado uma queda média de 26,52% na função renal nos pacientes submetidos à nefrectomia radical. Trinta e cinco dos 65 pacientes evoluíram para IRC. Em uma análise univariada, presença de glomerulosclerose (OR=3,8), arteriosclerose (OR=3.3), fibrose intersticial (OR=3.8), hipertensão arterial (OR=3.7), Diabetes Mellitus (OR=11.6) e idade maior que 60 anos (OR=3.4) associaram-se à evolução para IRC (p < 0.05). Em uma regressão logística multivariada, índice de comorbidade de Charlson (OR= 2,3), GS (OR= 1,2) e TFGe pré-operatória (OR= 0,96) foram estatisticamente significantes. Para cada 2,5% de aumento de alterações glomérulos, houve uma diminuição percentual de 28% da TFGe. CONCLUSÕES: Alterações histológicas do parênquima renal não neoplásico e parâmetros clínicos podem ser utilizados para predizer pacientes que evoluirão para IRC após uma nefrectomia radical
INTRODUCTION: Radical nephrectomy is inevitably associated with a variable renal function decrease. Chronic Kidney disease (CKD) is highly prevalent and there are few options for treatment in end stage CKD. The goal, as urologist, should be on optimizing renal function after surgery and not just avoiding dialysis. OBJECTIVES: In patients submitted to radical nephrectomy: 1. Primary objective: Assess the association of histopathological parameters in non-neoplastic renal parenchyma with new onset chronic kidney disease after surgery. 2. Secondary objective: Assess the association of demographic and clinical parameters with new onset chronic kidney disease after surgery. METHODS: Data were extracted from 65 patients who underwent radical nephrectomy. Using The MDRD (Modification of Diet in Renal Disease) formula, we calculated the estimated glomerular filtration rate preoperatively and at last follow-up. The study end point was development of CKD, defined as an estimated glomerular filtration rate (eGFR) of less than 60ml/minute/1,73m2. A renal pathologist assessed three histological features in the nonneoplastic parenchyma, including global glomerulosclerosis, arteriosclerosis, interstitial fibrosis and tubular atrophy. For glomerulosclerosis assessment, the percent of affected glomeruli was determined. Arteriosclerosis or the extent of arterial luminal occlusion was graded into three groups, including 1-0% to 25%, 2-26% to 50% and 3-greater than 50%. Interstitial fibrosis and tubular atrophy were evaluated as absent/present. RESULTS: After a mean follow-up of 49,06 months, the eGFR rate decreased 26,52% after radical nephrectomy. Thirty five patients developed CKD. In a univariate analysis, the incidence of CKD was associated with glomerulosclerosis (OR=3,8), interstitial fibrosis (OR=3,8), arteriosclerosis (OR=3,3), hypertension (OR=3,7), Diabetes Mellitus (OR=11,6) and age (OR=3,4) after surgery. In a multivariate analysis, Charlson comorbidity index (OR= 2,3), glomerulosclerosis (OR= 1,2) and baseline eGFR(OR= 0,96) were associated with new onset CKD after radical nephrectomy. For each 2,5% increase in glomerular abnormality the eGFR rate decreased 28% from baseline. CONCLUSIONS: Histologic findings in the nonneoplasic tissue, in addition to clinical parameters, can be used to predict which patients are more likely to develop CKD after radical nephrectomy

Background: La nefrectomia parziale ad oggi rappresenta il trattamento gold standard in pazienti con neoplasie renali clinicamente localizzate. Il progetto RECORD2 nasce dall’esigenza di fornire evidenze più robuste nel setting della chirurgia per tumori renali ed in particolare di fornire modelli predittivi di rischio dei più importanti outcomes postoperatori dopo chirurgia renale. Scopo dello studio: 1) Analizzare la distribuzione della nefrectomia radicale (RN) e della nefrectomia parziale (PN) nei centri aderenti al progetto RECORD 2 per pazienti con diagnosi di neoplasia renale non metastatica (cT1-4N0M0). 2) Valutare gli outcomes peri- e post-operatori in pazienti trattati con nefrectomia parziale per tumore del rene localizzato (cT1-T2N0M0). Confrontare i risultati peri- e postoperatori ad un follow-up a lungo termine in pazienti sottoposti a PN e RN per neoplasie renali in stadio clinico T1N0M0. Materiali e Metodi: L'Italian REgistry of COnservative and Radical surgery for cortical renal tumor Disease (RECORD 2 project) è un progetto multicentrico, osservazionale prospettico promosso dalla Società Italiana di Urologia (SIU). Nello studio sono stati inclusi 4325 pazienti sottoposti, tra il 2013 e il 2016, a chirurgia per tumori renali corticali in 34 centri urologici italiani. Di questi, 2584 pazienti sono stati trattati con nefrectomia parziale e 1712 con nefrectomia radicale. Sono state eseguite regressioni logistiche univariate e multivariate per valutare i possibili predittori di outcomes perioperatori e funzionali, nel caso in cui gli outcomes fossero valutati come variabile nominale ad un tempo predefinito per ogni paziente. Sono state effettuate analisi di sopravvivenza mediante l’utilizzo di curve di Kaplan-Meier. La valutazione di possibili predittori di outcomes di sopravvivenza è stata effettuata mediante l’utilizzo di analisi univariate e multivariate secondo Cox. Sono stati generati nomogrammi come rappresentazione grafica di modelli di regressione logistica multivariata. In caso di analisi di confronto tra gruppi con caratteristiche statisticamente significative al baseline è stato effettuato un propensity score matching analysis. Risultati: La distribuzione dei centri ha interessato in maniera pressoché completa tutte le regioni italiane, con limitate eccezioni. L’intervento conservativo è stato largamente più utilizzato rispetto a quello radicale. Se però ci soffermiamo ad analizzare la distribuzione dei due approcci in relazione al centro di provenienza, osserviamo che in alcuni centri il numero di nefrectomie radicali ha raggiunto o superato quello delle nefrectomie parziali. Durante gli anni di inclusione per gli interventi di nefrectomia parziale e radicale, l’approccio open è progressivamente diminuito, quello laparoscopico è rimasto pressoché costante, l’approccio robotico è progressivamente aumentato. Inoltre, durante gli anni nei pazienti sottoposti a nefrectomia parziale, è aumentato il numero delle masse complesse trattate, le indicazioni di necessità relativa ed assoluta. Infine, l'enucleazione è stata significativamente più utilizzata negli ultimi anni rispetto alle altre tecniche resettive. Il tasso di complicanze chirurgiche postoperatorie dopo nefrectomia parziale era del 10,2% con un tasso di complicanze maggiori del 2.5%. Secondo il modello multivariato completo, età (OR 1,01, p = 0.03), ASA score (OR 1.281, p = 0.046), stadio T2 rispetto allo stadio T1a (OR 2.03, p = 0,01), PADUA score (OR 1,16, p = 0,001), anemia preoperatoria (OR 2,20, p <0,001), approccio open (O 2,87, p <0,001) e laparoscopico (OR 1,73, p = 0,01) rispetto al robotico sono risultati essere fattori predittivi di complicanze chirurgiche postoperatorie. È stato costruito un nomogramma predittivo con una predittività del 73.1% alle analisi post-hoc. È stata effettuata un’analisi in un sottogruppo di pazienti trattati con accesso mininvasivo che ha dimostrato che l’accesso retro- e trans-peritoneale presentano outcomes perioperatori comparabili, ma il primo accesso è associato ad un tempo di degenza significativamente minore. Una dettagliata analisi dei fattori predittivi di rischio di complicanze chirurgiche in paziente con masse renali complesse PADUA score ≥10 e trattati con PN è stata riportata nel testo. Complessivamente il 25% dei pazienti sottoposti a nefrectomia parziale hanno sviluppato insufficienza renale acuta (AKI) durante la degenza postoperatoria. All'analisi multivariata, l’età (OR 1,03; p <0,0001), l’eGFR preoperatorio (OR: 1,02; p = 0,003), lo stadio clinico T1b (OR: 1,88; p = 0,0004), tumori PADUA 7-8 (OR: 1,55; p = 0,11) e PADUA 9 (OR: 1,70; p = 0,058) erano associati ad un aumento del rischio di AKI. Al contrario, la chirurgia laparoscopica (OR: 0,46; p = 0,009) e robotica (OR: 0,39; p <0,0001) hanno mostrato una minore probabilità di AKI rispetto alla chirurgia open. I coefficienti del modello multivariato sono stati utilizzati per costruire un nomogramma di predizione. Dei pazienti trattati con nefrectomia parziale, 2076 hanno presentato neoplasie maligne all’analisi istopatologica. Lo stadio patologico T1a, T1b, T2 e T3a è stato attribuito nel 68,7%, 22,6%, 2,1% e 6,6% dei pazienti, rispettivamente. Un coinvolgimento nodale patologico (pN1) è stato trovato nello 0,4% dei casi. Il tasso di margini chirurgici positivi è stato del 16,5%. Sono stati effettuati due modelli multivariati, uno clinico e uno clinico-patologico, per determinare i fattori predittivi di margini chirurgici positivi. Il modello multivariato su base clinica ha rivelato che lo stadio clinico (cT1a vs cT2), il PADUA score, la casistica del centro (< 60 PN/anno vs ≥ 60 PN/anno)e l’approccio chirurgico (laparoscopica vs open) sono predittori indipendenti di margini chirurgici positivi (AUC: 0,66). Il modello clinico-patologico multivariato ha rivelato che lo stadio clinico, la casistica del centro, l’indicazione (assoluta vs elettiva), l’approccio chirurgico, l’invasione linfovascolare e l’upstaging a pT3a sono erano predittori indipendenti di margini chirurgici positivi (AUC: 0,70). I coefficienti delle variabili incluse nel modello clinico sono stati usati per sviluppare il nomogramma di predizione di margini positivi. È stata eseguita una subanalisi nella popolazione dei pazienti con diagnosi di neoplasia renale in stadio cT1N0M0 trattati con nefrectomia radicale (645) e parziale (2600), nei centri inclusi. Il confronto della popolazione è stato eseguito anche dopo aver condotto una selezione matched-pair su 600 pazienti in entrambi i gruppi con caratteristiche al baseline comparabili. I pazienti sottoposti a RN presentavano un tasso significativamente maggiore di complicanze chirurgiche e mediche intraoperatorie e di AKI postoperatoria significativamente maggiore rispetto a quelli sottoposti a PN. Il tasso di complicanze postoperatorie chirurgiche è risultato comparabile tra i due gruppi. Il tasso di margini chirurgici in tumori maligni dei pazienti sottoposti a PN è risultato significativamente maggiore rispetto ai pazienti trattati con RN. Il confronto degli outcomes di sopravvivenza e funzionali ad un follow-up di 48 mesi nelle due coorti selezionate di pazienti (post-matching) ha confermato che i pazienti sottoposti a PN presentavano una migliore preservazione della funzionalità renale sia nel breve sia nel lungo termine rispetto alla controparte trattata con RN a parità di outcomes oncologici a lungo termine. Conclusioni: La nefrectomia parziale rappresenta ad oggi la terapia chirurgica di scelta nei pazienti con neoplasia renale in stadio cT1N0M0. Nonostante le attuali linee guida non raccomandino uno specifico approccio nell’esecuzione della nefrectomia parziale, il presente studio conferma che l’approccio robotico possa ridurre la morbilità postoperatoria riducendo significativamente il tasso di complicanze, l’incidenza di danno renale acuto. Tuttavia, numerosi fattori devono essere considerati nello stratificare la tipologia d’approccio ottimale, in particolare le caratteristiche della malattia e quelle del paziente, al fine di poter bilanciare rischi e benefici di un intervento conservativo ed identificare il candidato ottimale per una

The incidence of localized renal cell carcinoma (RCC) has increased due to the widespread use of abdominal imaging, often for unrelated conditions. Despite improved understanding of the natural history of slow growth in many tumours and the impact of ageing and co-morbidities on patient survival, RCC is still the most lethal of genitourinary cancers and surgery remains the mainstay of treatment. Localized RCC is defined as stages T1-2 N0 M0. The relatively safe needle core biopsy is increasingly used, especially for small renal masses (SRMs), as we now know that up to 30% are benign and that RCC subtypes differ in biology and behaviour. Radical nephrectomy, either performed by open or laparoscopic technique, is indicated for stage T2 tumours or when partial nephrectomy (PN) is not believed to be feasible.

Robot-assisted partial nephrectomy (RAPN) has been accepted as the standard treatment recommended for relatively small renal mass or even the T2 renal carcinoma in experienced hospitals as Nephron Sparing Surgery. To obtain better RAPN surgical outcomes, the understanding of surgical anatomies such as the position of intra-renal structure and the positional relationship of each structure should be detailed in a three-dimensional (3D) manner. The 3D virtual surgical simulation for partial nephrectomy based on the image segmentation method with high-resolution CT can provide the 3D anatomical details of the renal tumor focusing on their relationships with the arterial and venous branches as well as with the intrarenal portion of the urinary collecting system. This imaging application is also used as image guidance during the surgery, and it indicated that it provides the improvement of clinical outcomes such as the duration of hospitalization, transfusion, and major postoperative complications as well as conversion to radical nephrectomy or open partial nephrectomy. In this chapter, we describe the basics of the 3D imaging assistance methods for partial nephrectomy and the benefit of 3D virtual surgical simulation in optimizing the outcome of the RAPN.