Nephron-Sparing Treatments Underused in CKD Patients – Renal and Urology News

Of particular concern, the researchers noted, is that patients with pre-existing chronic kidney disease (CKD) had a nearly twofold increased likelihood of undergoing RN than NSM compared with patients without CKD. Even though NSM use increased over the study period, most CKD patients still received RN, the investigators found.

via Nephron-Sparing Treatments Underused in CKD Patients – Renal and Urology News.

This study looked at data from the 1998-2008 and found that most renal masses were being treated by removing the entire kidney, even in patients with kidney disease.  I have been performing partial nephrectomies for renal masses that were less than 4cm since I was at Indiana in 1997.  Over the last 5 years, I have performing partial nephrectomies for tumors as large as 9cm if the location would allow it.

Partial Nephrectomy Offers Better Renal Preservation, Survival – Renal and Urology News

The median follow-up for patients still alive at the last follow-up was 8.3 years. The estimated overall survival rates at 10 and 15 years were 69% and 53%, respectively, for RN compared with 80% and 74%, respectively, following PN. Compared with PN-treated patients, patients who underwent RN were 75% more likely to die from any cause and more than four times more likely to develop stage IV chronic kidney disease, after adjusting for covariates, according to findings published online in European Urology. All of these differences between the RN and PN group were significant.

via Partial Nephrectomy Offers Better Renal Preservation, Survival – Renal and Urology News.

There have been several studies that concluded that patients that have kidney tumors and have only part of their kidney removed (partial nephrectomy) vs. the entire kidney removed (total or radical nephrectomy) have less kidney problems in the future.  They patients with nephron sparing surgery (partial) lived longer as well.

Not all patients are candidates for removing only part of the kidney, but most with tumors under 4cm and most with tumors not in the middle of the kidney should have a partial nephrectomy as a consideration.

At Newark Beth Israel, I have been performing robotic partial nephrectomy since 2005.  In 2007 I started using intraoperative renal ultrasound to better show the kidney anatomy.  In 2012 I started using firefly to help me perform more accurate kidney surgery for suspected kidney cancer.

Kidney Cancer & Treatment

Men and women normally have 2 kidneys that function to filter our blood. Urine is created and brought to the bladder before it is eliminated through the urethra.

Kidneys can develop masses that may be cancerous. Some of the signs and symptoms of kidney cancer are blood in the urine, pain in the back, and weight loss. Fortunately many masses are found in the kidney before they cause symptoms. These masses are found when people have abdominal ultrasounds, MRIs, or CT scans for other complaints.

2021 U.S. Kidney Cancer Statistics

Estimated New Cases (76,080)
Estimated Deaths (13,780)

Source: National Cancer Institute (NCI)

Treatment Options

If you have an early diagnosis of kidney cancer, there is usually a range of treatment options. These may include:

  • Conservative management (surveillance)
  • Minimally invasive therapy including cryosurgery and radiofrequency ablation, or
  • Surgical removal of part of the kidney or the whole kidney

Your treatment options will depend on a number of factors, including the size and location of the tumor, your age and health, and the skill of your surgeon.

Learn More:

Information on robotic kidney surgery

Is the Complication Rate of Radical Cystectomy Predictive of the Complication Rate of Other Urological Procedures?

Source: UroToday

A higher hospital radical cystectomy volume appears to lead to a lower risk of complications only after other common urological oncological procedures, namely radical prostatectomy and nephrectomy, but not after nononcological urology procedures.

This abstract found that hospitals that performed radical cystectomy (removal of the bladder and surrounding tissue for bladder cancer) had less complcations for kidney and prostate cancer surgery as well.

I have been perfoming radical cystecomies my whole career and started perfoming these robotically 3 1/2 years ago. Although I thought performing the more complex surgery helpe me in other surgeries, I didnt realize that a study would show less complications for these other procedures.

Robotic Partial Nephrectomy Study

Journal of Robotic Surgery, Volume 2, Number 3 / September, 2008

We report a large, multi-institutional series of RPN for renal tumors, confirming safety and feasibility reported in previous small, single-institution studies. Although we report the initial experience in RPN at each center, immediate oncologic results and perioperative outcomes approached those of more mature laparoscopic series. Robotic assistance may facilitate the technical challenges of precise tumor resection and renal reconstruction within acceptable warm ischemia times. Long-term outcomes are needed to establish the role of RPN in nephron-sparing surgery.

This was a large multi-institutional study that I was part of. This was the largest robotic partial nephrectomy study reported.

Robotic Partial Nephrectomy Versus Laparoscopic Partial Nephrectomy for Renal Cell Carcinoma: Single-Surgeon Analysis of >100 Consecutive Procedures

Source: UroToday
The mean total operative time (140 vs 156 minutes, P = .04), warm ischemia time (19 vs 25 minutes, P = .03), and length of stay (2.5 vs 2.9 days, P = .03) were significantly shorter for RPN than for LPN, respectively.
RPN can produce results comparable to LPN but has disadvantages, such as cost and assistant control of the renal hilum. Additional randomized trials are needed.
A friend and expert robotic renal surgeon, Dr Bhayani, discusses his results with robotic partial nephrectomy.
The most important finding is the improvement in warm ischemia time, the amount of time the kidney is not receiving blood supply.
Another important finding is that the operation can be done quicker robotically, which can translate into a cost savings that will partially offset the increased cost of the robotic equipment.

Kidney Cancer Cells Tricked Into Killing Themselves

Source: NPR

A researcher has found a potential therapy for patients with kidney cancer, which historically hasn’t responded well to other therapies, such as radiation and chemotherapy.
Most cancerous kidney cells — also known as renal cells – have lost a gene called VHL, says Amato Giaccia, a cancer researcher at the Stanford University School of Medicine. And as he reports in the journal Cancer Cell, Giaccia has found a new compound, STF-62247, that causes death to kidney cancer cells missing VHL.
The drug works by altering a natural process inside cells. All cells have a kind of internal recycling process, called autophagy, where compounds inside the cell are broken down and their chemicals re-used. But Giaccia says there is normally a balance.

This is likely many years away, but likley will be the future for treatment of various cancers. This particular therapy is a medicine, but I believe that gene therapy, vaccines, and targetted medicines will one day be able to cure many cancers without the need for surgery or radiation.

Best of AUA Orlando 2008 for Prostate Cancer

Source: Urology Times
Robotic Surgery
Presented by Ashutosh K. Tewari, MD,
Weill-Cornell Medical College, New York.

* Robot-assisted laparoscopic partial nephrectomy is associated with shorter hospital stay and less bleeding, but the warm ischemia time is still around 30 minutes.

* Studies comparing robot-assisted laparoscopic cystectomy and open radical cystectomy show similar oncologic outcomes. At a high-volume tertiary care center, the robotic technique was more cost-efficient, but that finding needs to be confirmed at other centers. Other remaining issues regarding the robotic procedure include the need to define how the reconstruction should be performed, the extent of the lymphadenectomy, and ensuring clear margins at lateral areas.

* A study of almost 4,000 patients reaffirms the safety of robotic-assisted laparoscopic prostatectomy (RALP). Rates of major surgical, major medical, and minor medical complications were all ≤0.7%, and the rate of minor surgical complications was 3.3%.

* Studies comparing open and RALP show the surgeon is the most important variable in determining outcome.

* Extended lymph node dissection should be performed in high-risk prostate cancer patients, and can be done with RALP.

* A total reconstruction procedure including anterior and posterior restoration of the vesicourethral junction is associated with early return to continence and improvement in overall continence rates.

Some of the highlights from the AUA
Of interest is the growing application of robotic surgery for smaller kidney cancers (partial nephrectomy) and bladder cancer, which I have been performing since 2005 myself.

The other very important adaption is the posterior and anterior reconstruction of the urinary tract during robotic prostatectomy, which I have performing for over a year after attending Dr Tewari’s conference.

New for kidney cancer: robotic surgery

Source: Washington University Website

“Robotic surgery is more efficient and precise than either open or laparoscopic surgery for tumors confined to the kidney,” says Bhayani, assistant professor of surgery and a leader in the field of robotic surgery. “Rather than operate with two hands, I can simultaneously control four robotic instruments with mechanical “wrists” that rotate more than 360 degrees, giving me far greater maneuverability than human hands or laparoscopic instruments.” Bhayani led a team at Washington University to develop the procedure for kidney tumors.

Dr Bhayani is a friend and excellent surgeon. Check out his website for a video clip of the partial nephrectomy. I was recently invited as a guest faculty at his conference (First Annual World Robotic Renal Symposium) and had the privilege of watching him perform 2 live surgeries, a robotic nephrectomy and a robotic partial nephrectomy. Both went very well.

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