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.
UroToday – Renal Artery Occlusion During Nephron-Sparing Surgery: Retrospective Review of 301 Cases
The authors report on 301 patients who underwent nephron sparing surgery for a localized renal tumor. Of these, 181 patients had renal artery occlusion with cold ischemia, while the remaining 120 patients were managed with external compression alone to control hemorrhage. Mean tumor size was 3.56cm and there was a higher incidence of centralized tumors in the arterial occlusion group (p less than 0.05). The authors noted no difference in blood loss, transfusion rates, tumor size, or complications between the two groups. Two renal units (1.2%) were “lost” due to ischemic damage in the renal artery occlusion group, which was not a complication in the external compression group. More importantly, there was a significantly higher incidence of positive margins in the external compression group (4.2%) relative to the group with renal artery occlusion during resection (0.6%), (p less than 0.05).
Renal artery occlusion during partial nephrectomy may result in ischemic damage to the remaining renal parenchyma, particularly if prolonged, but is clearly superior for optimal visualization during tumor resection. This study demonstrates that external compression (the “grip of death”) does not significantly minimize morbidity over renal artery clamping, and may, in fact, be associated with an increased positive margin rate due to poor visibility during tumor resection.
UroToday – Positive Surgical Parenchymal Margin After Laparoscopic Partial Nephrectomy for Renal Cella: Oncological Outcomes Carcinom
Thursday, 15 March 2007
BERKELEY, CA (UroToday.com) – Positive margins following supposedly curative surgery can be devastating for patient and surgeon alike.
The implication that cancer was “left behind” implies a continued biologic threat, although little is known about the impact of positive margins following nephron sparing surgery, because, thankfully, it is a rare finding. Here, two leaders in laparoscopic renal surgery (Gill and Kavoussi) combine their experience to examine oncologic outcomes in patients undergoing laparoscopic partial nephrectomy found to have positive surgical resection margins.
These 2 surgeons are among the best in the world in minimally invasive partial nephrectomy. I would think that there margins were very close to being negative and management should be dictated by close followup of these patients if the surgeon felt he had removed the whole tumor. It is certainly a controversial topic.