Multiple Tumors

Renal cell carcinoma may be multifocal at presentation in 6.5-25% of cases, and satellite tumors may be detected in 15.6% of cases (67,68). Although many consider radical nephrectomy (open or laparoscopic) as the standard of care for such cases, consensus is lacking. A recent report demonstrated the feasibility of performing minimally invasive nephron-sparing surgery in the setting of multiple renal tumors. A total of 27 multiple tumors in 13 patients were treated by a combination of minimally invasive treatments (69). The indication for nephron-sparing surgery was imperative in 92% of patients. Minimally invasive treatments performed included en bloc excision of adjacent tumors during laparoscopic partial nephrectomy (three); individual laparoscopic partial nephrectomy of discrete, distant masses (two); laparoscopic partial nephrectomy of one mass and laparoscopic cryoablation of the other (two); and laparoscopic cryoablation of all masses (six). Mean tumor size treated by laparoscopic partial nephrectomy was 2.5 cm (range, 1-4.1), mean size of masses treated by cryotherapy was 1.8 cm (range, 0.9-3.2), mean operative time was 4.3 hours, and mean blood loss was 169 mL. Mean warm ischemia time was 40 minutes in patients treated with laparoscopic partial nephrectomy for adjacent masses, and 30 minutes in patients undergoing laparoscopic partial nephrectomy and cryotherapy. No intraoperative complications occurred. Postoperative complications included pneumonia (one), deep venous thrombosis treated with systemic anticoagulation and vena cava filter (one), and sepsis (one). Pathology confirmed renal carcinoma in 83% of all excised specimens with negative margins. Core needle biopsies before cryoablation showed renal carcinoma in 54% of specimens. After a mean follow-up of 16.4 months (range, 1-54), disease did not recur either locally or systematically in any patient. A new ipsilateral, distant from cryother-apy site, tumor developed in one patient 54 months postoperatively. The authors concluded that the judicious combination of complementary minimally invasive techniques was safe and efficacious.

TABLE 4 ■ Laparoscopic Partial Nephrectomy at the Cleveland Clinic: Single-Surgeon Experience in the Initial 300 Cases

Parameter

No. (%)

Median age (years)

62

Male

178 (59%)

Median body mass index

28.2

Median ASA score

3

Median preoperative S-creatinine (mg/dL)

1

Right side

133 (44%)

Tumor type on CT (n = 276)a

Exophytic

99 (36%)

Infiltrating up to sinus

86 (31%)

Infiltrating not up to sinus

80 (29%)

Completely intrarenal

11 (4%)

Tumor location (n = 259)a

Peripheral

180 (69%)

Central

79 (31%)

Tumors abutting hilum (n = 211)a

13 (6%)

Laparoscopic approaches

Transperitoneal

201 (67%)

Retroperitoneal

99 (33%)

Intraparenchymal extension (intraoperative

1.4

ultrasonography) (n = 202)a (cm)

Median operative time (hours)

3.3

Median warm ischemia time (minutes)

32

En bloc clamping of renal hilum (laparoscopic Satinsky clamp)

215 (72%)

Median blood loss (mL)

150

Median % of tumor excision (surgeon perception)

20

Heminephrectomy

66 (22%)

Pelvicalyceal suture repair

236 (78%)

Overall intraoperative complication

17 (6%)

Hemorrhage

8 (2.7%)

Inferior epigastric artery injury

2 (0.7%)

Other

7 (2.3%)

Overall postoperative complication

34 (12%)

Hemorrhage

6 (2%)

Atelectasis

5 (1.7%)

Urine leak

4 (1.3%)

Atrial fibrillation

3 (1%)

Deep vein thrombosis

2 (0.6%)

Pleural effusion

2 (0.6%)

Pneumonia

2 (0.6%)

Renal insufficiency

3 (1%)

Other

7 (2.3%)

Overall late complications

30 (10 %)

Hemorrhage

9 (3%)

Urine leak

6 (2%)

Congestive heart failure

2 (0.6%)

Deep vein thrombosis

2 (0.6%)

Renal insufficiency

2 (0.6%)

Sepsis

2 (0.6%)

Wound infection

2 (0.6%)

Other

5 (1.6%)

Hospital stay (days)

2.6

Renal cell carcinomas on pathology

211 (71%)

Positive surgical margin

3 (1%)

RCC

2 (0.6%)

Oncocytoma

1 (0.3%)

aData were considered "not available" if the parameter was not clearly described in the CT report, intraoperative ultrasound report, or operative note. Source: From Ref. 66.

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