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There are limited reports of laparoscopic nephron sparing surgery (LNSS) in children and none where a 3D model facilitated oncological resection. There are also limited reports discussing the use of cis-retinoic acid in bilateral diffuse hyperplastic perilobar nephrogenic rests (DHPLNR). We report the first case of a 3D model facilitated zero-ischemia LNSS in children and the first following treatment with cis-retinoic acid. The patient was a 3-year-old girl with bilateral DHPLNR who had recurrent disease following standard therapy. She had suspicious lesions in the upper pole of the left kidney. Both were completely excised and histologically described as hyperplastic nephrogenic rests.

The current standard treatment for stage I Wilms' tumor is open radical nephrectomy. Patients with WAGR syndrome and Wilms' tumor have risk of contralateral tumor and are a group of patients benefitted by nephron-sparing surgery (NSS). Whereas laparoscopic NSS has been attempted in such patients, due to the inherent technical limitations it has failed to gain popularity. Robotic approach for NSS overcomes limitations of movement and dexterity occurring with laparoscopic approach. However, the existing literature in robotic NSS in children is very limited. We present the first report of robotic approach for NSS in a child with WAGR syndrome.

To analyze the impact of gender on the clinicopathologic features and survival of patients with surgically treated papillary renal cell carcinoma (papRCC) using a comprehensive international multicenter database.Data of 2325 patients undergoing surgery for unilateral papRCC between 1984 and 2015 in 17 European and North American centers were retrospectively collated. The impact of clinicopathologic features on the likelihood of nephron-sparing surgery (NSS) was evaluated using a multivariable logistic regression model. The influence on cancer-specific mortality (CSM) and other-cause mortality was analyzed by multivariable competing-risk regression models. Finally, subgroup analyses were conducted for organ-confined (n = 2075) and non-organ-confined tumors (n = 250). The median follow-up was 47 months.The study cohort included 1782 (77%) male patients (male-to-female ratio 3.3:1.0). Considering age, symptoms at presentation, performance status, pathologic tumor size, stage, and grade, we observed that there were no significant gender-specific differences. In contrast, female patients underwent NSS significantly less frequently (P .001). On multivariable analysis, the likelihood of NSS was 72% higher in male patients after adjusting for all relevant cofactors (P .001). No significant gender-specific differences in terms of CSM and other-cause mortality were demonstrated, but CSM was 59% lower in female patients in the subgroup of organ-confined tumors (P = .001).No impact of gender on survival was found analyzing this large cohort of patients undergoing surgery for papRCC. However, CSM appears to be lower in female patients with organ-confined disease. In this context, it is interesting that the likelihood of NSS seems to be significantly higher in male patients.

Denys-Drash syndrome (DDS) is a combination of genital and urinary anomalies that are mostly associated with renal and gonadal malignancies. We report 2 patients who presented with genital ambiguity and were diagnosed as 46-XY DDS. Both patients had renal masses during follow-up and underwent partial nephrectomy aiming to have transplant at older age.

Objective To discuss the presenting features, imaging findings, and recommended management of patients with Metanephric adenoma (MA) focusing on the diagnostic challenges and indications for follow up. Materials and Methods In this case report, we present a case of a 10-year-old female with MA who eventually underwent nephron sparing surgery with a partial nephrectomy. We performed a literature review of previous cases of metanephric adenoma and their respective management and follow-up. Results Renal ultrasound demonstrated a heterogeneous, echogenic mass measuring 3.8 cm at the upper pole of the right kidney. Further investigations consisted of computed tomography scan, magnetic resonance imaging, and magnetic resonance angiography. The patient underwent robotic-assisted partial nephrectomy. The immunohistochemical staining pattern, gross, and microscopic appearance of the lesion were consistent with the diagnosis of MA. The combination of CK7, EMA, and S-100 negativity and WT1 and CD57 positivity is considered characteristic of metanephric adenoma as described in the literature. Conclusion MA is a rare benign tumor and especially in the pediatric population can cause significant concern over a possible malignant lesion. Although, no follow-up recommendations currently exist in cases of completely resected MA, we standardly perform postoperative surveillance. Although Metanephric Adenoma is difficult to diagnose preoperatively, given the advances in nephron sparing surgery and the utilization of nonionizing radiation modalities for follow up, we can manage these patients safely and with lower morbidity by preserving renal parenchyma.

We present a case of bilateral multifocal Wilms tumor in a nonsyndromic 12-month-old male. Our management approach included 12 weeks of preoperative chemotherapy for maximal tumor shrinkage and, despite the central location of the tumors, successful staged bilateral nephron-sparing surgery. We advocate for a broader application of nephron-sparing surgery in Wilms tumor cases with the goal of preserving renal function without compromising oncologic outcomes.

Objective To assess perioperative morbidity and margins after conventional clamped partial nephrectomy (PN) while also using volumetric analysis to differentiate the contributions of parenchymal volume loss and recovery from ischemia. Materials and Methods The study analyzed 163 patients who underwent PN with appropriate studies to allow analysis of function and parenchymal mass specifically in the operated kidney. Recovery from ischemia (glomerular filtration rate saved/volume saved) would be 100% if all nephrons recovered from ischemia. Precision (postoperative parenchymal volume/predicted parenchymal volume, presuming loss of a 5-mm rim of parenchyma related to excision and reconstruction) reflects efforts to optimize the amount of vascularized parenchyma saved with the PN. Trifecta was defined as negative margins, no Clavien grade 3-5 or urologic complications, and both recovery ≥80% and precision ≥80%. Results An open procedure was performed in 82 patients (50%), and 59 (36%) had a solitary kidney. Warm ischemia was used in 96 patients (59%). The RENAL nephrometry score (radius, exophytic/endophytic properties of the tumor, nearness of tumor deepest portion to the collecting system or sinus, anterior/posterior descriptor, and the location relative to polar lines) was intermediate in 74 (45%) and high complexity in 38 (23%). Median recovery from ischemia was 95% and was ≥80% in 143 patients (88%). Median precision of excision/reconstruction was 93% and was ≥80% in 138 patients (85%). All tumors had negative surgical margins. Perioperative complications occurred in 13 patients (9%). Trifecta was achieved in 113 patients (69%). Multivariable analysis identified solitary kidney as the only significant predictor of trifecta. Conclusion Given careful patient selection and commensurate surgical expertise, excellent outcomes can be obtained with conventional clamped PN. Analysis of parenchymal volumes is necessary to facilitate comprehensive evaluation of functional outcomes after PN, allowing differentiation of nephron loss vs failure to recover from ischemia.

Objective To better understand the impact of nephron-sparing surgery (NSS) on renal function in patients with nonsyndromic unilateral Wilms tumor (uWT), a group of such patients treated with NSS were compared with a stage-matched cohort managed with radical nephrectomy (RN). The recommended management of nonsyndromic uWT is RN. However, NSS may decrease the risk of long-term renal disease and associated comorbidities. Materials and Methods An international, multi-institutional review was conducted of nonsyndromic uWT cases managed with NSS and compared with a stage-matched RN cohort. Data were collected on demographics, oncologic characteristics and outcomes, serum creatinine, and estimated glomerular filtration rate (eGFR) calculated via Schwartz formula. Results Fifteen patients who underwent NSS (6 females and 9 males) met study criteria and were diagnosed at a median age of 2.5 years (range, 0.2-8.2 years) and followed for a median of 8.4 years (range, 0.5-31.8 years). The stage-matched RN cohort consisted of 15 patients (8 females and 7 males) diagnosed at a median age of 3.7 years (0.3-7.4) and followed for a median of 2.1 years (0.6-10.5 years). The median preoperative eGFR was 91.7 (39.4-237.7) and 149.9 (93.8-215.9) for NSS and RN, respectively, P = .026. The median eGFR at last follow-up was 135.3 (57.5-185.8) and 131.0 (98.6-161.2) for NSS and RN, respectively, P = .95. The median change in eGFR during the study period was a gain of 28.6 (−51.9 to 83.0) for the NSS cohort vs a loss of 19.1 (−54.7 to 25.2) for the RN cohort, P = .007. Conclusion In a highly selected patient population with nonsyndromic uWT, NSS provides excellent renal function preservation when compared with RN. These data require validation via prospective investigation on a larger scale.

Objective To evaluate quick-staining cytology as an alternative method to intraoperative frozen sectioning after nephron-sparing nephrectomy. Materials and Methods Eighty-two partial nephrectomies were performed with intraoperative quick-staining cytology and frozen section evaluation. The results of both were compared with permanent histology as the gold standard. Results After partial nephrectomy, permanent histologic surgical margins were positive in 8 of 82 (9.7%), cytology in 10 of 82 (12%), and frozen sectioning in 4 of 82 (5%). In comparison with permanent histologic examination, sensitivity of the cytologic examination was 87.5%, positive predictive value 70%, specificity 95.9%, and negative predictive value 98.6%. Kappa values (κ) revealed a good level of agreement between intraoperative cytology and final histologic examination (κ = 0.751; P

To evaluate whether surgeon factors, such as training and experience, have a strong impact on selection of surgical approach for treating renal cancers. Nephron-sparing surgery (NSS) has become the reference standard for tumors that are amenable to such an approach. Tumor size and configuration are important predictors of usage of NSS. The RENAL nephrometry score (RNS) has been developed to standardize reporting of tumor complexity, but the performance of this method within individual surgeons' practices, particularly in the community-based setting, has not been evaluated previously.Clinical data and RNS were collected retrospectively for 300 cases performed by 5 different surgeons with varying NSS usage rates (31-74%).Mean RNS for patients undergoing NSS (6.0) and radical nephrectomy (RN) (9.3) differed significantly (P.0001), as did tumor size (2.8 vs 6.3 cm, P.0001). RNS was a better predictor of surgery type (R(2) = .55) than was tumor size (R(2) = .43) for all 5 surgeons. In univariable analysis, individual surgeon, surgery year, glomerular filtration rate, tumor size, RNS, and each RNS component predicted NSS vs RN (each P.05). In multivariable analysis, surgeon, tumor size, exophytic amount, and nearness to collecting system were independent predictors of NSS usage (P.001).Despite significant variation in NSS usage by individual surgeons at a community-based health system, RNS appears to be valid for both low and high usage. With increasing usage of NSS worldwide, RNS appears to reflect current patterns and may inform future practice for surgeons of all backgrounds.

To compare the characteristics and predictors of cancer-specific survival (CSS) of 2 rare distal nephron tumors--medullary renal cell carcinoma (MRCC) and collecting duct carcinoma (CDC).All cases of histologically verified MRCC and CDC reported to The Surveillance, Epidemiology and End Results (SEER) database between 1995 and 2007 were considered. A number of characteristics were compared by tumor histology. Subset analyses were performed for metastatic patients and those managed surgically. CSS was analyzed using Cox proportional hazard models.Overall, 21 cases of MRCC and 227 cases of CDC met the criteria for analysis. Patients with MRCC were younger (median 24 vs 63 years, P.001), more often black (71.4% vs 22.7%, P.001), metastatic at presentation (71.4% vs 27.8%, P.001), and less likely to undergo surgery (61.9% vs 85.6%, P = .015) compared with patients with CDC. Tumor size was similar between MRCC and CDC (median 6 vs 5 cm, P = .70). Median survival was 5 months for MRCC and 30 months for CDC (P.001). In metastatic MRCC and CDC patients, surgery predicted CSS (HR 4.61 and 2.24, both P ≤.05) despite having larger primary tumors than those managed nonsurgically (median 7.5 vs 5.0 cm, P.01).Patients with MRCC present younger, at a later stage, and are more often black than patients with CDC. The stage migration toward localized kidney cancer is not apparent for these tumors. Although both cancers have a poor prognosis, the clinical and survival characteristics are distinct. Patients selected for cytoreductive surgery have improved survival.

Objectives To review our perioperative complications during the first decade of using hand-assisted laparoscopic nephrectomy using a sleeve (HALN). HALN is a minimally invasive procedure first reported by our group in 1997. Methods After institutional review board approval, the charts of the patients who had undergone HALN, hand-assisted laparoscopic partial nephrectomy, or hand-assisted laparoscopic nephroureterectomy from 1997 to 2007, at our institution, were retrospectively reviewed. Standard laparoscopic procedures were not included. The relevant patient characteristics, operative details, American Society of Anesthesiologists score, body mass index, comorbidities, medications, and complications were recorded. Results A total of 227 consecutive patients had undergone Hand-assisted laparoscopic renal surgery, and all their charts were reviewed. Of these 227, 134 were radical HALN, 37 were nonradical HALN, 42 were hand-assisted laparoscopic partial nephrectomy, and 15 were hand-assisted laparoscopic nephroureterectomy. Complications developed in 59 patients (26%): 8% major and 18% minor. The procedure-specific complication rate was 29% for radical HALN, 27% for nonradical HALN, 33% for hand-assisted laparoscopic nephroureterectomy, and 17% for hand-assisted laparoscopic partial nephrectomy. Complications included blood transfusion in 6%, urinary retention in 4%, ileus in 4%, and wound infection in 4%. From 2003 through 2007 (n = 163), our overall complication rate was 22% (8% major and 13% minor). From 1997 to 2002 (n = 65), the overall complication rate was 38% ( P = .02). The American Society of Anesthesiologists score and the use of systemic steroids were associated with the occurrence of perioperative complications. Conclusions Our results have shown that hand assistance provides a safe, minimally invasive laparoscopic procedure. Our complications rates were comparable to those with other standard and hand-assist series, although the spectrum of complications varied. Hand-assisted laparoscopic renal surgery could be a method by which to improve patient access to minimally invasive nephron-sparing surgery.

To evaluate LRN as treatment for high risk patients. Laparoscopic radical nephrectomy (LRN) is performed for renal tumors not amenable to nephron-sparing treatments. Indications are increasing to include higher risk patients including those with end-stage renal disease (ESRD) necessitating dialysis.We performed a retrospective analysis of a patient cohort with clinical stage T1 renal tumors undergoing transperitoneal LRN. Parameters examined included patient demographics, medical comorbidities, tumor characteristics, operative outcomes, and complications.One hundred eighty-nine patients underwent 195 LRN. Sixteen patients (8.5%) had preexistent ESRD requiring dialysis. A higher American Society of Anesthiologists score (P.05), higher age-adjusted Charlson comorbidity index (P=.003), higher incidence of previous abdominal surgery (P=.012), and higher incidence of hypertension (P=.025) were found for the ESRD group. Mean blood loss was 153.0 and 132.0 mL (P=.71) in the ESRD patients and non-ESRD patients, respectively. A longer stay (P=.02) was noted for ESRD patients. Mean tumor size in the ESRD patients and non-ESRD patients was 2.6 and 4.2 cm (P.05), respectively. Renal cell carcinoma was the most common pathology in 14 of 20 (70.0%) ESRD patient renal units and 167 of 175 (95.4%) non-ESRD patient renal units (P=.001). Intraoperative and postoperative complication rates were 6.3% and 31.3% respectively for ESRD patients (P=.05), and 8.7% and 21.4% respectively for non-ESRD patients (P=.35). Most postoperative complications were minor.LRN, for the treatment of renal tumors in ESRD patients requiring dialysis, is feasible and safe with acceptable intraoperative and postoperative complication rates. Patients with ESRD may require longer hospital stay after LRN.

Objectives To define the rate of positive surgical margins (PSMs) and analyze the outcome of patients with PSMs. The outcome and proper management of patients with positive PSMs during nephron sparing surgery (NSS) are questionable. In this study we define the clinical outcomes of PSMs at NSS and suggest management. Methods Clinical records of 114 renal units who underwent open NSS for a renal mass between May 1995 and September 2005 were reviewed. Results PSMs were suspected on frozen section in 17 of 114 renal units (15%). Tumors with suspected PSMs at frozen section were smaller (2.9 ± 1.6) in comparison to those with negative surgical margins (3.4 ± 1.8 cm) (P = .001). Nine of 17 (53%) cases underwent total nephrectomy (5 immediately, 4 delayed). In 4 (24%), immediate re-excision of the renal crater was performed. A total of 4 (24%) that were followed up clinically were with no evidence of disease. Therefore, in 13 of 17 (77%) cases, the presence of tumor cells at the remaining side of the kidney could be evaluated histologically. In 2 cases from the immediate response group, tumor cells were found in the side opposite to the resection. There was no residual tumor in any case subjected to delayed nephrectomy. At median follow-up of 71 months, 15 of 17 patients are alive and with no evidence of disease. Two patients died because of unrelated causes. The overall 5-year survival rate is 98.2% and there is no cancer-specific mortality. Conclusions The true PSM rate is in the range of 1.75%-5.26%. No disease progression or deaths attributable to renal cell carcinoma were associated with PSMs. Total nephrectomy should be avoided as a response to PSMs.

Objective To evaluate the role of the surgical technique used for the treatment of benign renal tumors, with regard to renal function and overall survival (OS) in patients without cancer-related mortality. Patients and methods The study included 506 patients, mean age of 63.3 years, with histologically proven benign renal lesions originating from 5 European centers. Retrospective data from each hospital were retrieved and merged into a common database for analyses. OS, American Society of Anesthesiology score, and renal functions were measured in relation to surgical technique. The Mann-Witney U -test, the paired t -test, and Cox's multivariate analysis were used. Results Patients treated with radical nephrectomy had significantly reduced renal function postoperatively compared with nephron sparing surgery (NSS). OS was significantly reduced after radical nephrectomy compared with NSS ( P = .012), a survival difference that remained significant [hazard ratio (HR) 0.042, 95% confidence interval (CI) 0.221-0.972, P = .042] in multivariate analysis, together with age at diagnosis (HR 1.065, 95% CI 1.026-1.106, P = .001) and American Society of Anesthesiology score (HR 2.361, 95% CI 1.261-4.419, P = .007). Also renal function assessed by estimated glomerular filtration rate significantly correlated to survival in univariate analysis, but did not remain independent after multivariate analysis. Oncocytoma was the most frequent benign lesion, followed by angiomyolipoma. Conclusion The present study in patients with benign renal tumors shows that the remaining renal function and OS correspond to the choice of surgical procedure. Our results support the recommendation to perform NSS whenever possible when surgery is performed for patients with renal masses. The limitations of the study are the retrospective design and the selection bias for the surgical approach.

Objectives Temporary occlusion of the renal artery during nephron-sparing surgery may facilitate complete tumor resection and reduce operative bleeding. However, it may also entail a greater risk of ischemic kidney damage. In contrast, when vascular occlusion is not applied, the risk of bleeding, as well as the risk of positive margins, may be increased. To study these issues, we retrospectively evaluated our results with nephron-sparing surgery for kidney masses using renal artery occlusion compared with patients in whom vascular occlusion was not applied. Methods From 1988 to 2003, 301 consecutive patients underwent nephron-sparing surgery for a kidney mass at our institutions. At the surgeons’ discretion, the renal artery was temporarily occluded in 181 patients (60%) and was not in 120 (40%). Results No statistically significant differences were found between the two groups regarding blood loss, transfusion rates, and overall complication rates. The loss of the renal unit because of ischemia was noted in 2 patients (1.2%) after renal artery occlusion and in none of the nonoccluded group. Positive tumor margins were found in 5 patients (4.2%) in the nonoccluded group and in 1 patient (0.6%) in the vascular occlusion group. Conclusions Our results suggest that although vascular occlusion during nephron-sparing surgery may increase the risk of permanent kidney damage, patients with no vascular occlusion may have a greater risk of positive tumor margins after surgery. These two factors should be taken into consideration and could be discussed with the patient when attaining informed consent.

Objectives To determine the feasibility of using serum albumin glutaraldehyde tissue adhesive (BioGlue) to achieve hemostasis and prevent urine leakage during nephron-sparing surgery (NSS). Methods From February 1993 to April 2005, 174 NSS operations were performed for renal cell carcinoma at our institute. A total of 143 patients underwent NSS with the traditional suturing technique (suture group) and 31 patients underwent a sutureless BioGlue sealing-only procedure (BioGlue group). We compared the two groups for clinical and tumor characteristics and surgical outcome. Results The patient and tumor characteristics were similar in both groups. The average maximal tumor diameter was 4.21 cm (range 2.2 to 7) for the suture group and 3.67 cm (range 2 to 6.8) for the BioGlue group. The use of BioGlue reduced the mean warm ischemic time by 8.8 minutes (17.2 versus 26 minutes, P = 0.002). The mean estimated blood loss was 45.1 mL in the BioGlue group and 111.7 mL in the suture group ( P = 0.001). Blood transfusion was required in 1 patient (3.2%) of the BioGlue group and 24 (17%) in the suture group ( P = 0.014). None of the patients treated with BioGlue developed urinary fistula compared with three (2%) in the suture group. Conclusions Albumin glutaraldehyde tissue adhesive (BioGlue) alone provided adequate hemostasis during NSS, significantly decreasing the blood loss and transfusion rate, as well as the renal ischemic and operative times. BioGlue was easy to use and safe for sealing the kidney during partial nephrectomy. Future prospective clinical trials are necessary to validate its role during renal surgery.

Objectives To describe 3 cases of tumors located in the kidney that may relate collecting (Bellini) duct carcinoma (CDC) to urothelial cell carcinoma (UC). We hypothesized that these distinct tumor types may share a common origin. CDC is a subtype of renal cell carcinoma associated with a highly aggressive course, poor prognosis, and limited response to immunotherapy, behaving similarly to UC. Methods We present 2 cases of CDC and 1 case of UC of the renal papilla. We compared the clinical presentation and survival rate, together with the radiologic, histologic, and immunostaining (including p53) findings, with strong emphasis on the similarities. Results One patient with CDC had a previous history of grade 3, Stage Ta bladder UC.The urothelial carcinoma from the kidney papilla (case 3) presented carcinoma in situ of the adjacent urothelium and displayed mixed characteristics with CDC, namely location, positive staining for Ulex europaeus and pyelonephritic changes. p53 staining showed marked positivity in the tumor of patient 2. Disease progression was rapid, with a median survival of 5.6 months (range 5 to 7). Conclusions The results of this study suggest that the broad category of renal cell carcinoma includes a spectrum of lesions. In this range of diseases, CDC might be distinct from conventional renal cell carcinoma but share biologic features with UC, with the consequent implications for management. This association between CDC and UC may reflect the common embryologic origin of collecting duct and urothelial cells, since they derive from progressive branching of the mesonephric (wolffian) duct. Furthermore, the differential cytogenetic expression profiles suggest that the molecular events underlying the development of distal nephron and proximal tubule renal cancers are distinct.

Objectives To review our experience with laparoscopic nephron-sparing surgery in the management of two or more synchronous, ipsilateral renal masses. Minimally invasive nephron-sparing procedures are increasingly used for the treatment of select patients with a single, small renal tumor. Methods Since 1998, we have performed laparoscopic nephron-sparing surgery in 288 consecutive patients, including laparoscopic partial nephrectomy (n = 200) and renal cryotherapy (n = 88). Of these, 13 patients (4.5%) were treated for synchronous ipsilateral renal masses. Results A total of 27 renal tumors were treated in 13 patients. The patients were divided into four groups on the basis of the treatment. Group 1 (n = 3) underwent en-bloc laparoscopic partial nephrectomy encompassing both tumors; group 2 (n = 2) underwent individual laparoscopic partial nephrectomy of discrete masses during the same procedure; group 3 (n = 2) had one mass treated with partial nephrectomy and the other mass treated with cryotherapy; and group 4 (n = 6) had all tumors treated with cryotherapy. All cases were completed successfully without conversion to open surgery or laparoscopic nephrectomy. The mean overall operative time was 4.3 hours, and the mean blood loss was 169 mL. No intraoperative complications occurred. Three patients had postoperative complications, none requiring re-exploration. One patient in group 4 developed de novo tumors in the treated kidney, located distant from the cryoablated sites. Conclusions Laparoscopic partial nephrectomy is an emerging, efficacious laparoscopic treatment option for select patients. Laparoscopic cryotherapy is a useful alternative or adjunct to partial nephrectomy. The judicious combination of these complementary techniques further extends the scope of minimally invasive nephron-sparing surgery.

Objectives To examine the relationship between the width of the resection margin and disease progression in renal cell carcinoma (RCC) after nephron-sparing surgery (NSS). During NSS for RCC, it is standard practice to excise the tumor along with a surrounding margin of normal parenchyma (margin of resection) to ensure complete resection of the neoplasm. However, no agreement has been reached on how wide the margin of resection should be. Methods We retrospectively reviewed the histopathologic sections and medical records of 69 patients with localized RCC who had undergone NSS between 1976 and 1988 to determine whether the resection margin, tumor size, TNM stage, and Fuhrman nuclear grade were associated with disease progression (defined as local tumor recurrence or metastasis). The mean postoperative follow-up interval was 8.5 years. Results No association was found between the width of the resection margin and disease progression (P = 0.98, log-rank test). Both TNM stage and Fuhrman nuclear grade correlated with disease progression. Patients with T1-T2 tumors had lower progression (P

To compare the effect of radical with partial unilateral nephrectomy on the development of atherosclerosis in the apolipoprotein E (apoE(-/-))-deficient mouse model.Male apoE(-/-) mice were randomly assigned to the following 3 groups: (1) radical left nephrectomy (RNX, 15 mice), (2) partial left nephrectomy (PNX, 15 mice), and (3) left kidney sham operation (sham-op, 12 mice). The right kidney was left intact in all groups. At 16 weeks after surgery, mice were killed, and atherosclerotic surface area and plaque composition were evaluated in the aortic root and the descending aorta using a quantitative morphologic image processing method.At killing, RNX mice had significantly higher serum urea, total cholesterol, and triglyceride concentrations than PNX and sham-op groups (P.05, P.001, and P.0001, respectively). Atherosclerotic lesions in the aortic root and the descending aorta were significantly increased in the RNX mice compared with those in the PNX and sham-op mice (P.05 and P.001, respectively). In addition, aortic plaques of RNX mice showed a significant increase in nitrotyrosine expression (P.02) and collagen content (P.05), whereas the degree of macrophage infiltration was comparable between the groups.We show for the first time that PNX, as compared with RNX, slows the progression of vascular disease in a mouse model of severe atherosclerosis. This effect was mediated by the prevention of chronic kidney disease-induced increases in oxidative stress and lipid disturbances. Our finding can be interpreted as being in support of an expanded use of nephron-sparing techniques in atherosclerosis-prone patients who need to undergo kidney cancer surgery.

To analyze the influence of preoperative renal function on postoperative renal outcomes after radical nephrectomy (RN) and nephron-sparing surgery (NSS) for malignancy in patients stratified according to preoperative chronic kidney disease (CKD) stage and surgical extent (NSS vs RN).Retrospective review of patients undergoing renal surgery for localized renal masses stratified by surgical extent and preoperative CKD stage based on glomerular filtration rate (GFR) level: stage I (90 mL/min/1.73 m(2)), stage II (60-89 mL/min/1.73 m(2)), and stage III (30-59 mL/min/1.73 m(2)). Survival analysis for significant renal impairment was based on freedom from the development of new-onset GFR30 or45 mL/min/1.73 m(2).A total of 1306 patients were included in the analysis with preoperative CKD stage I (27.9%), II (52.1%), and III (20.1%); 41.3% and 58.7% underwent NSS and RN, respectively. NSS was associated with a lower annual rate of GFR decline in preoperative CKD stage-I (P = .028) and stage-II patients (P = .018), but not in CKD stage-III patients (P = .753). Overall, 5.0% and 15.0% developed new-onset GFR30 mL/min/1.73 m(2) and45 mL/min/1.73 m(2), respectively. There was no difference in the probability of developing significant renal impairment between NSS and RN in CKD stage-I or -III patients, whereas only in CKD stage-II patients was the surgical extent independently associated with development of significant renal impairment (RN: odds ratio, 9.0; P = .042 for GFR30 mL/min/1.73 m(2) and odds ratio, 2.3; P = .003 for GFR45 mL/min/1.73 m(2)).Compared with RN, NSS is associated with a lower rate of GFR decline for preoperative CKD stage-I and -II patients, but only CKD stage-II patients demonstrated a decreased risk of developing significant renal impairment.

Objectives. To determine whether a 1-cm margin is necessary for cancer control during nephron-sparing surgery (NSS) for renal cell carcinoma (RCC). Methods. A retrospective review of 67 patients who underwent NSS for RCC between 1990 and 2000 was conducted. The data collected included patient demographics, tumor size and location, histologic type and grade, margin status (positive or negative), and the shortest distance of normal parenchyma (in millimeters) around the tumor in the final pathologic specimen. Recurrence was determined from the clinical follow-up, which included physical examination, ultrasonography or computed tomography, and various laboratory tests. Results. Fifty-five cases were performed open and 12 laparoscopically. The mean follow-up was 60 months (range 5 to 124). The mean tumor size was 3.0 cm (range 0.9 to 11.0). Seven patients were found to have a positive margin; 1 died of metastatic RCC, 1 was alive with systemic recurrence, and 5 had no evidence of disease. Of 11 patients with a negative margin distance of less than 1 mm, 9 were recurrence free, 1 had simultaneous local and pulmonary relapse, and the other had pulmonary recurrence only. The remainder of the study patients (n = 49) had negative margins greater than 1 mm, and all were alive without evidence of disease at the last follow-up. Conclusions. This review questions the necessity of a 1-cm margin to prevent recurrence after NSS for RCC. Additional studies to determine the optimal margin distance should be conducted.

There is controversy concerning the management of small unilateral renal cell carcinomas. The present study was undertaken to evaluate the relative efficacy of radical nephrectomy versus nephron-sparing surgery in such patients.Patients with a single, small (less than 4 cm), localized, unilateral, sporadic renal cell carcinoma (RCC) were identified from an institutional registry. From 1975 to 1992, 88 patients fulfilling these criteria were treated with either radical nephrectomy (n = 42) or nephron-sparing surgery (n = 46). The mean postoperative follow-up interval is 48 +/- 29 months.The radical and nephron-sparing surgical groups were well matched for patient age, sex, renal function, diabetes, hypertension, tumor size, tumor location, and tumor stage. All patients in both groups had low pathologic stage RCC. There was no difference between the two groups in terms of the mean hospital stay, the requirement for blood transfusions, or the occurrence of surgical complications. There was no difference in the mean preoperative and postoperative serum creatinine levels for patients in the nephron-sparing surgery group. However, the mean postoperative serum creatinine levels were significantly higher than the mean preoperative levels for patients in the radical nephrectomy group (P0.001). A single patient in each group developed recurrent RCC postoperatively. The cancer-specific 5-year survival rate for patients in the radical and nephron-sparing surgical groups is 97% and 100%, respectively.Radical nephrectomy and nephron-sparing surgery each provide safe and effective curative treatment for patients with a single, small, unilateral localized RCC. The long-term renal functional advantage of nephron-sparing surgery in this setting is not established.

Objective To assess the impact of laparoscopy on usage of partial nephrectomy (PN) by comparing national usage trends in patients undergoing surgery for localized renal tumors. Methods Using linked Surveillance, Epidemiology, and End Results (SEER)–Medicare data, we retrospectively examined trends in procedure usage from 1995 to 2007 for patients undergoing surgery for localized (stage I/II) renal masses. Procedures were classified as open radical nephrectomy (ORN), laparoscopic radical nephrectomy (LRN), open partial nephrectomy (OPN), and laparoscopic partial nephrectomy (LPN). Patients were further stratified by tumor size (≤4 cm, >4– ≤7 cm, >7 cm). Data were primarily analyzed using logistic regressions. Results Patients (n = 11,689, mean age 74.4 ± 5.7 years, 56% male) with a mean tumor size of 4.7 ± 3.3 cm met the inclusion criteria. From 1995 to 2007, ORN rates decreased and for each year successive year patients were more likely to be treated with OPN (odds ratio [OR] 1.17, 95% confidence interval [CI] 1.14-1.19), LRN (OR 1.44, CI 1.41-1.47), and LPN (OR 1.75, CI 1.68-1.83). Although the increased usage of OPN (7.5% vs 13.6%, P < .001) and LPN (0% vs 14.2%, P < .001) reached statistical significance, this was offset by a marked increase in LRN over the same time period (3.0% vs 43.0%, P < .001). Conclusion Despite increasing emphasis on nephron preservation, PN usage rates remain low. Compared with a 40% increase in LRN, use of PN increased by only 20% from 1995 to 2007. As a result, 72% of identified Medicare beneficiaries with localized tumors were managed with radical nephrectomy (RN) in 2007. The trade-off of minimally invasive surgery for nephron preservation may have adverse long-term consequences.

Reninoma is an extremely rare, renin-secreting, benign kidney tumor that can cause hypertension. We present a case of hypertension secondary to reninoma treated with laparoscopic nephron-sparing surgery in a 15-year-old girl and review some relevant published literature. Laparoscopic retroperitoneal nephron-sparing surgery was performed and the tumor was removed intact. The histopathologic examination showed the characteristic of reninoma with positive CD34 staining immunohistochemically. The patient's blood pressure and level of serum potassium remained normal at 1-month follow-up examination.

Objective To assess our institution's experience with the management of pathologic stage T3bNxM0 renal cell carcinoma with tumor thrombus confined to the renal vein treated with nephron-sparing surgery (NSS). Methods Of the 492 patients who have undergone NSS at Columbia University from 1998 to 2009, 8 patients were found to have stage T3bNxM0 renal cell carcinoma (RCC) on final pathology. Records were reviewed for indication for NSS, imaging studies, perioperative management, surgical details, pathology, and both functional and disease-specific outcomes. Postoperative renal function was estimated by most recent glomerular filtration rate using Modification of Diet in Renal Disease formula. Recurrence of RCC was monitored using serial axial imaging. Results The 8 patients were presumed to be clinical stage T1aN0M0 RCC before surgery; however, tumor thrombus was identified in the renal vein intraoperatively and on final pathology in 4, and 4 cases, respectively, corresponding to stage T3bNxM0 RCC by current American Joint Committee on Cancer–Tumor-Necrosis-Metastasis 2002 criteria. After a median follow-up of 19.8 months, the patients experienced a mean decrease in estimated glomerular filtration rate of 27.1%. One patient developed new-onset renal failure, defined as an estimated glomerular filtration rate below 30 mL/min/1.73 m 2 . Clean surgical margins were obtained in 7 patients. Carcinoma was identified at the parenchymal margin in 1 patient. No patients have evidence of recurrence of RCC by serial axial imaging. Conclusions NSS does not seem to have had a negative impact on a small series of patients with pathologic stage T3bNxM0 RCC limited to the renal vein and may be a feasible option when the clinical situation indicates a need for preservation of renal function.

OBJECTIVES To explore whether mini-margin nephron-sparing surgery (NSS) is clinically safe and effective for renal cell carcinoma (RCC) of 4 cm or less with a normal contralateral kidney. METHODS A total of 115 patients with sporadic, pathologically confirmed RCC of 4 cm or less (Stage T1a), with a normal contralateral kidney, were treated by NSS using a mini-margin of less than 5 mm from 1998 to 2006. The surgical margin status was evaluated by both frozen and permanent paraffin section studies. The patients were followed up, and the data were analyzed. RESULTS The mean and median tumor diameter was 3.3 and 3.5 cm (range 1.0 to 4.0). None of the patients had positive surgical margins detected at either frozen section or final paraffin section analysis. The mean margin width was 2.2 mm (median 2.0, range 0 to 6). Of the 115 patients, 114 had margins of 5 mm or less (99.1%), 97 (84.3%) had margins of 3 mm or less, and 26 had margins of 0 mm (22.6%). At a mean follow-up of 65 months (median 66, range 9 to 105), all patients were alive. No distant metastasis was detected. Local recurrence was detected in 1 patient (0.9%) at a different site in the kidney. No major surgical complications, such as hemorrhage or urinary leakage/urinoma requiring reoperation, occurred. Considering only the 97 patients with follow-up of more than 3 years in the analysis, the mean and median follow-up time was 73 and 69 months (range 37 to 105), respectively. All 97 patients were alive with no evidence of disease at the last visit. CONCLUSIONS The results of our study have shown that mini-margin NSS is a safe and effective approach for treating early localized RCC of 4 cm or less.

Objectives To determine the feasibility of nephron-sparing surgery (NSS) in patients with centrally located tumors. Methods A retrospective cohort study of 118 patients who underwent NSS between 1993 and 2002 (35 patients with centrally located tumors and 83 with peripherally located tumors) was performed. Kaplan-Meier curves were constructed to evaluate freedom from local recurrence and disease-specific survival in patients with conventional histologic subtype tumors. The Wilcoxon test was used to compare the curves (two-tailed P ≤0.05 was considered to be statistically significant). Results Intraoperatively, in patients with centrally located tumors, the need to close the collecting system ( P = 0.035) and for blood transfusions ( P = 0.033) was greater. Two perioperative deaths occurred in patients with peripherally located tumors. Two patients with centrally located tumors subsequently underwent nephrectomy. Of the patients with centrally located tumors, 1 patient had a positive margin, 2 patients had local recurrence, and 1 patient developed metastasis. No positive surgical margins or local recurrence was found in patients with peripherally located tumors, although 4 patients developed distant metastasis. Kaplan-Meier curves for patients with conventional histologic subtype tumors demonstrated a statistically significant difference for local recurrence ( P = 0.04), but not for survival ( P = 0.71). The mean follow-up time was 38.8 and 43.8 months for patients with centrally located and peripherally located tumors, respectively. Conclusions NSS can be used to postpone, or eliminate the need for, nephrectomy in 94.3% of patients with centrally located tumors and can achieve oncologic disease control similar to that for exophytic lesions. These data indicate that NSS should be considered even for patients with centrally located tumors, taking into account that performing such surgery is a challenging task.

A 14-year-old hypertensive boy was evaluated in our clinic. The physical examination was essentially normal except for his high blood pressure. Laboratory findings showed increased plasma renin activity. Abdominal ultrasonography detected a hypoechoic, 2-cm mass in right kidney. Contrast-enhanced computed tomography of the abdomen revealed a well-circumscribed, solid, hypoenhancing cortical lesion in the middle of the right kidney. Magnetic resonance angiography documented bilateral normal renal arteries. With a preoperative diagnosis of reninoma, the patient underwent nephron-sparing surgery. Intraoperative frozen section analysis revealed a benign lesion. Subsequently, histopathologic examination and electron microscopy confirmed the diagnosis of juxtaglomerular cell tumor. The patient remained normotensive in the postoperative period. Follow-up intravenous urography showed bilateral normally functioning kidneys.