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Renal function after partial nephrectomy following intra-arterial embolization of renal tumors



Laparoscopic Partial Nephrectomy (LPN) after intra-arterial Embolization of renal tumors (LPNE) in a hybrid operating room allows renal tumor enucleation without dissection and clamping of the renal pedicle. The purpose was to assess the potential negative impact of embolization on the renal function. This prospective monocentric study included all patients treated with LPNE between May 2015 and June 2019. Clinical data was collected and incorporated into the UroCCR database (NCT03293563). Glomerular Filtration Rate (GFR) and Computed Tomography Renal Volume (CTRV) were compared before and after 6 months following LPNE. The mean post-operative GFR was 86.6 mL/min (SD 22.9). The mean GFR loss was 9.4% (SD 15.1) and the median renal parenchyma loss was 21 mL (SD 20.6). Using a threshold of 25% GFR loss, age was the only significant predictive factor of renal function impairment according to bivariate (59.5 vs 69.3 years, p = 0.017) and multivariable analysis (OR 1.075, CI 1–1.2], p = 0.05). Significant renal function impairment was not correlated with the renal parenchymal volume loss (OR 0.987, CI [0.95–1.02], p = 0.435). Renal function impairment after LPNE seems to be comparable to other techniques of partial nephrectomy.
Scientic Reports | (2020) 10:21352 | 
Renal function
after partial nephrectomy
following intra‑arterial
embolization of renal tumors
Germain Bréhier 1*, Antoine Bouvier1, Louis Besnier1, Serge Willoteaux1,
Cosmina Nedelcu1, Thibaut Culty3, Christophe Aubé1,2 & Pierre Bigot3
Laparoscopic Partial Nephrectomy (LPN) after intra‑arterial Embolization of renal tumors (LPNE)
in a hybrid operating room allows renal tumor enucleation without dissection and clamping of the
renal pedicle. The purpose was to assess the potential negative impact of embolization on the renal
function. This prospective monocentric study included all patients treated with LPNE between
May 2015 and June 2019. Clinical data was collected and incorporated into the UroCCR database
(NCT03293563). Glomerular Filtration Rate (GFR) and Computed Tomography Renal Volume (CTRV)
were compared before and after 6 months following LPNE. The mean post‑operative GFR was
86.6 mL/min (SD 22.9). The mean GFR loss was 9.4% (SD 15.1) and the median renal parenchyma loss
was 21 mL (SD 20.6). Using a threshold of 25% GFR loss, age was the only signicant predictive factor
of renal function impairment according to bivariate (59.5 vs 69.3 years, p = 0.017) and multivariable
analysis (OR 1.075, CI 1–1.2], p = 0.05). Signicant renal function impairment was not correlated with
the renal parenchymal volume loss (OR 0.987, CI [0.95–1.02], p = 0.435). Renal function impairment
after LPNE seems to be comparable to other techniques of partial nephrectomy.
As a result of the increasing use of cross-sectional imaging, 40–50% of new renal cell carcinomas are now
detected at T1 stage (localized and size < 7cm) enabling a signicant reduction in mortality rates in developed
countries despite a worldwide increasing incidence1. Partial nephrectomy is now the standard surgical treat-
ment for these tumors, especially when smaller than 4cm (stage T1a)2. Improved knowledge and techniques
now allow nephron-sparing surgery, reducing the risk of cardiovascular events and morbi-mortality related to
impaired renal function3,4.
Feasibility and positive clinical outcomes of a new technique, Laparoscopic Partial Nephrectomy (LPN) aer
intra-arterial Embolization of renal tumors (LPNE) in a hybrid operating room, have been established in recent
studies5,6. Most importantly, pre-operative embolization avoids per-procedural hilar clamping commonly used
in partial nephrectomy procedures for bleeding control, since hilar clamping time is presumed to be a modi-
able surgical risk factor for decreased renal function aer partial nephrectomy7,8. While the eect of the dura-
tion of ischemia on renal function is still a matter of debate, post-operative renal function is clearly correlated
with the quality and quantity of the residual renal parenchyma 7,9. LPNE allows surgery with zero ischemia but
requires intra-arterial injection of an iodinated contrast medium and the sacrice of a small portion of healthy
e purpose of this study was to assess a potential signicant renal function impairment following LPNE and
to identify potential predictive factors for signicant impaired renal function.
Materials and methods
Population. e clinical data reports for the study were collected and incorporated into the UroCCR data-
base (French Research Network for Kidney Cancer, Identier NCT03293563), which is IRB-
approved (Comité Consultatif sur le Traitement de l’Information en Matière de Recherche dans le domaine de la
Santé) and obtained the CNIL (Commission Nationale de l’Informatique et des Libertés) authorization number
DR-2013-206. All methods were carried out in accordance with relevant guidelines and regulations. is pro-
            
      
 *
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spective monocentric study included all patients treated for a renal tumor between May 2015 and June 2019 by
e inclusion criterion was one single localized kidney tumor. e indication for partial nephrectomy was
validated by a multidisciplinary uro-oncologic board.
Patients who underwent Magnetic Resonance Imaging (MRI) instead of Computed Tomography (CT) scans
before surgery, patients who did undergo CT scans but not performed in our institution and patients with a
single kidney were excluded.
Procedure. All combined procedures were performed under general anaesthesia in a hybrid operating room
(Discovery IGS 730, GE Healthcare, Waukesha, WI). Concerning the unfolding of the procedure, rst of all,
an interventional radiologist performed a super-selective intra-arterial embolization of the renal tumor, then a
surgeon carried out the laparoscopic partial nephrectomy. All embolization and surgical procedures were con-
ducted as previously described (Fig.1)5.
Figure1. 44-year-old woman operated on for right kidney renal clear cell carcinoma (pT1a, complete
resection). (a) Selective arteriography shows a tumoral blush at the lower pole of right kidney (arrows). (b) Aer
embolization, the renal arteriography shows complete tumoral devascularization (arrows) with minimal defect
(arrowhead) of the peri-tumoral renal parenchyma. (c) Pre-operative CT scan shows the lower polar tumor
(arrowhead). (d) Sagittal sections of a tubular time CT scan 6months post-operatively show the operating area
with minimal cortical thinning (arrow) and hyperdense embolization material (arrowhead).
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Data and analysis. Pre-operative patient clinical data and tumor characteristics were retrieved: age, sex,
BMI, tumor size and renal tumor complexity score (R.E.N.A.L. nephrometry score; score of 4–6: low complexity;
score of 7–9: moderate complexity; score of 10–12: high complexity)10.
It is well established that the least invasive and most innocuous way to model renal function is the estimation
of the glomerular ltration rate (GFR) using standard formulas (according to Cockcro-Gault or MDRD) mainly
based on creatinine blood levels. Furthermore, excellent correlation has been shown between isotopic imag-
ing methods presumed to obtain accurate measurements of glomerular ltration rates and CT measured renal
volume (CTRV) used for pre-operative management and oncologic follow-up11. CT based volume assessment
techniques have already been used to calculate dierential kidney function, to show the dominant kidney prior
to kidney donation and even to estimate the risk of chronic kidney disease aer partial nephrectomy1214. We
therefore chose to use GFR (estimated by MDRD formula) and parenchymal renal volume (CTRV) as reective
of renal function.
Creatinine levels and MDRD clearance were collected as the pre-operative CT scans were performed and at
6months follow-up aer surgery. All CT scans were conducted according to a multiphasic protocol including an
initial non-contrast-enhanced phase followed by an arterial and/or parenchymal contrast-enhanced phase aer
intravenous injection of an iodinated contrast medium. All images were transferred to a workstation running
personal computer-based soware (SYNAPSE 3D, Fujilm Corporation, Tokyo, Japan) already used in previous
studies concerning renal volume calculation1517. Using enhanced CT phases, the aforementioned soware rst
performed an automatic extraction of the volume of both kidneys then adjusted by the operator using dier-
ent correction tools to obtain the denitive renal volume. All analysis was performed by a junior and a senior
radiologist. Ipsilateral and contralateral kidney volumes were measured excluding vessels, urinary tract, tumor
volume (in the pre-operative work-up), sequelar unenhanced areas or spontaneously hyperdense material cor-
responding to embolization devices (in the post-operative work-up).
Procedure-related data were collected: embolization procedure time, number of subsegmental arteries embo-
lized, volume of administrated iodinated contrast media, laparoscopy time, blood loss volume, requirement of
hilar clamping or embolization for secondary bleeding.
Statistical design plan. We compared data before and 6months aer LPNE. For comparison, the × 2 test
or Fisher’s test were used for qualitative variables, and Student’s t test was used for quantitative variables. Sig-
nicant GFR loss was considered when GFR was reduced by 25% aer surgery. is threshold was already used
in the elaboration of a nomogram to predict renal function loss aer partial nephrectomy for cancer18. Paired
T-test was used to compare kidney volumes before and aer surgery. Bivariate and multivariable logistic regres-
sion analysis were used to assess prognostic factors inuencing signicant GFR loss (> 25%). Only signicant
factors in the bivariate analysis were included in the multivariable analysis. e analyses were performed using
SPSS version 15.0 soware (IBM Analytics, USA). 95% Condence Interval (CI) and Odd-Ratio (OR) were used
to report results. Alpha risk was 5%.
Research involving human participants and/or animals. e clinical data reports for the study
were collected and incorporated into the UroCCR database (French Research Network for Kidney Cancer, Identier NCT03293563), which is IRB-approved (Comité Consultatif sur le Traitement de
l’Information en Matière de Recherche dans le domaine de la Santé) and obtained the CNIL (Commission Nation-
ale de l’Informatique et des Libertés) authorization number DR-2013-206.
Informed consent. Patients gave their informed consent.
Patient and tumor characteristics. During this period, 137 patients were treated by LPNE. We excluded
44 patients (12 with single kidney and 28 without pre or post-operative CT-scan). Mean age was 60.4years
(SD 12.3), mean BMI was 27.4kg/m2 (SD 5). According to R.E.N.A.L. tumor complexity score, 11 (11.8%), 46
(49.5%) and 36 (38.7%) tumors were respectively of high, moderate and low complexity. Mean tumor size was
3.4cm (SD 1.6). In 4 cases (4.3%) the surgical margins were positive. e histology of the tumors is detailed in
Peri‑operative data. Mean total operative time was 153.0min (SD 38). In 54 cases (58.1%) two or more
subsegmental arteries (up to 4) were embolized. Mean volume of administrated iodinated contrast media was
68.5mL (SD 68.5). Mean blood loss was 258.0mL (SD 459), no hilar clamping was necessary. No secondary
bleeding or embolization was reported. Perioperative data are reported on Table1.
Kidney function evolution. Pre-operative mean GFR-MDRD was 95.7mL/min (SD 23.7), mean GFR-
MDRD at 6months was 86.6mL/min (SD 22.9). Mean GFR-MDRD loss at 6months aer combined procedure
was 9.4% (CI [6.7–12.5], p value < 0.001). Signicant decrease of GFR-MDRD occurred in 10 patients (10.6%), 1
patient with no pre-operative kidney disease presented a new-onset chronic kidney disease. None of the patients
required dialysis.
Mean pre-operative global, ipsilateral and contralateral renal volume were respectively 332.0mL (SD 74.5),
164.0mL (SD 40) and 168.0mL (SD 39.2). Mean global, ipsilateral and contralateral renal volume at 6months
were respectively 315.6mL (SD 72.4), 143.0mL (SD 38.4) and 172.7mL (SD 41.6). Global renal volume, ipsilat-
eral and contralateral renal volume dierence of means were signicant, respectively −16.5mL (CI [10.2–22.7],
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p value < 0.001), −21.0mL (CI 16.8–25.3], p value < 0.001), + 4.7mL (CI [− 7.9; −1.5], p value = 0.004). Renal
function and volume evolution are reported on Table2.
Age was the only parameter significantly associated with > 25% loss of renal function (OR 1.075, CI
[1.0–1.155], p value = 0.05). e mean operative time (OR 1.01, CI [0.99–1.03], p value = 0.32) and the mean
parenchymal loss of operated kidney (OR 0.987, CI [0.95–1.02], p value = 0.435) were not correlated with signi-
cant loss of renal function. Bivariate and multivariable analysis of predictive factors of signicant renal function
decrease are respectively reported on Tables3 and 4.
is descriptive study of functional renal outcomes aer tumor vessels embolization and partial nephrectomy
showed encouraging results. We found a moderate rate of renal function loss at 6months estimated at 9.4%, con-
sidered to be in the high range but still comparable to known results aer partial nephrectomy: a meta-analysis
conducted in 2015 reported an average overall loss of renal function of about 10% aer partial nephrectomy for
Table 1. Patient and tumor characteristics, peri-operative data.
Patient characteristics
Mean age, year (SD) 60.4 (12.3)
Male, n (%) 57 (61.3)
Mean Body Mass Index, kg/m2 (SD) 27.4 (5)
Tumor characteristics
T stage, n (%)
T1a 63 (67.7)
T1b-2 30 (32.3)
R.E.N.A.L. tumor complexity, n (%)
Low (1–6) 36 (38.7)
Intermediate (7–9) 46 (49.5)
High (10 and more) 11 (11.8)
Mean tumor size, cm (SD) 3.4 (1.6)
Benign histology, n (%) 16 (17.2)
Oncocytoma 10 (10.7)
Angiomyolipoma 4 (4.3)
Cystic 1 (1)
Metanephric adenoma 1 (1)
Malignant histology, n (%) 77 (82.8)
Clear cell renal cell carcinoma 51 (54.8)
Chromophobe renal cell carcinoma 8 (8.6)
Papillary renal cell carcinoma 17 (18.3)
Carcinoma of collecting duct 1 (1)
Positive surgical margins 4 (4.3)
Table 2. Renal function and volume evolution.
Pre-operative Follow-up 6months
Mean GFR, mL/min (SD) 95.7 (23.7) 86.6 (22.9)
Dierence of means, mL/min (SD) [t-test] 9.6 (15.1) [p < 0.001]
Signicant renal function decrease, n (%) 10 (10.6)
Pre-operative chronic kidney disease, n (%) 4 (4.3%)
New chronic kidney disease, n (%) 1 (1)
Computed tomography renal volume
Mean global renal volume, mL (SD) 332 (74.5) 315.6 (72.4)
Dierence of means, mL/min [t-test] 16.5 [p < 0.001]
Mean treated renal volume, mL (SD) 164 (40) 143 (38.4)
Dierence of means, mL/min (SD) [t-test] 21 (20.6) [p < 0.001]
Mean contralateral renal volume, mL (SD) 168 (39.2) 172.7 (41.6)
Dierence of means, mL/min (SD) [t-test] 4.7 (15.5) [p = 0.004]
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patients with 2 kidneys19. We reported a moderate volume loss of the treated kidney at 6months (about 12.5%
i.e. 21.0mL), these results are supported by Takagi etal. study (volume loss of 18%) and Mir etal. study (volume
loss of 17%) aer partial nephrectomy20,21. We reported minimal compensatory hypertrophy of the contralat-
eral kidney of 2.9% (4.7mL), also comparable to the work of Takagi etal. (2.2%) and Mir etal. (5%), appearing
to be lower than in Jeon etal. (9.1%)2022. As marked compensatory hypertrophy is a marker of parenchymal
destruction of the operated kidney (contralateral hypertrophy of the order of 20% aer radical nephrectomy),
this minimal contralateral hypertrophy is an additional argument to conrm that embolization before partial
nephrectomy is to be considered a nephron-sparing technique.
Whether or not to perform renal arterial clamping during partial nephrectomy is still debated, one meta-anal-
ysis seemed to show a better preservation of renal function in the short and medium term with the "o-clamp"
technique, but another meta-analysis with a longer follow-up period showed that at 5years the dierence in renal
function was no longer signicant between the on-clamp and o-clamp methods23,24. However, if a clamp appears
necessary to control bleeding, its duration (< 25min) and selectivity will lead to better functional results25.
While arterial clamping remains controversial, preservation of the quantity and quality of renal parenchyma
is essential7,9. is preservation rst involves the surgical technique of tumor enucleation, which makes it pos-
sible to avoid removing healthy peritumoral parenchyma with acceptable oncological outcomes26. Second, this
preservation is also the result of performing superselective embolization, supported by state-of-the-art tools such
as CBCT, endovascular guidance soware, microcatheters and embolization devices. e absence of any nega-
tive impact of the number of embolized arteries on post-operative renal function is a good illustration of this.
Although the margin of healthy embolized parenchyma is minimal, it is nevertheless sucient to ensure
satisfying haemorrhagic control, as evidenced by the mean blood loss we reported (258.0mL), similar to that
observed (276.8mL) in a study performed with arterial clamping27. In this aforementioned study, despite the
presence of arterial clamping, 16 patients out of 289 presented secondary bleeding requiring embolization,
whereas no embolization for haemorrhage was reported in our work, conrming the results already published in
a previous study5,27. e choice of glue as embolization material, lling the lumen of the distal arterioles, allows
for immediate eective embolization and possibly more complete embolization than coils. ese elements may
explain the excellent control of bleeding shown in our work.
e multivariable analysis showed that only age is correlated with the occurrence of signicant impairment of
renal function, these results are corroborated by the results of Jeon etal. study22. Similarly, Lane etal. has shown
Table 3. Bivariate analysis of predictive factors of signicant renal function decrease.
< 25% RF loss ≥ 25% RF loss p
Mean age, year (SD) 59.5 (12) 69.3 (7.8) 0.017
Mean BMI (SD) 27.1 (5) 29.7 (4.3) 0.138
BMI > 30, n (%) 28 (34) 5 (50) 0.318
T stage, n (%) 0.72
T1a 57 (69) 6 (60)
T1b-2 26 (31) 4 (40)
R.E.N.A.L. tumor complexity, n (%) 0.136
Low (1–6) 32 (38) 4 (40)
Intermediate (7–9) 43 (52) 3 (30)
High (10 and more) 8 (10) 3 (30)
Mean tumor size, cm (SD) 3.3 (1.5) 3.7 (2) 0.56
Mean operative time, min (SD) 150.0 (37) 174.0 (39) 0.062
Mean Blood loss, mL (SD) 235.0 (451) 456.0 (497) 0.151
Number of arteries embolized, n (%) 0.86
1 35 (42) 4 (40)
2 or more 48 (58) 6 (60)
Mean iodinated contrast medium used, mL (SD) 68.4 (27) 68.8 (11) 0.97
Mean preoperative GFR, mL/min (SD) 95.7 (24) 95.4 (22) 0.96
Pre-operative Chronic kidney disease 3 (4) 1 (10) 0.371
Mean renal parenchyma loss, mL (SD) 19.0 (20) 31.0 (17) 0.077
Table 4. Multivariable analysis of predictive factors of signicant renal function decrease.
Mean age, year (SD) 1.075 1–1.155 0.05
Mean operative time, min (SD) 1.01 0.99–1.03 0.32
Mean renal parenchyma loss, mL (SD) 0.987 0.95–1.02 0.435
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that high age, among other non-modiable factors, is associated with decreased post-operative renal function9.
Elderly patients, regardless of the surgery performed, appear to have decreased renal function aer surgery,
probably related to a natural deterioration in renal function that would occur even if they did not undergo any
surgical procedure.
Even though this procedure requires two operators working successively, the total operating time (153.0min
[SD 38]) is similar to conventional procedures (for example 141.3min in George etal. work)27. is is possibly
explained by the injection of blue dye into the tumor vessels, that facilitates tumor spotting through the peri-renal
fat and the time saved due to the lack of renal hilum control6.
Considering the excellent control of haemorrhagic complications and observing the duration of hospitalisa-
tion, despite the cost of the material necessary for tumor vessels embolization, it would be interesting to compare
the cost-eectiveness of our combined procedure versus a robot-assisted procedure.
Our study limitations include rstly the relatively short follow-up time aer surgery. For our cohort it would
be interesting to collect GFR-MDRD results 2years aer surgery to assess if a delayed recovery of renal function
occurred as shown in Zabor etal. work which found that 2years aer surgery, 45% of patients had recovered
renal function similar to pre-operative function, with a more likely recovery in female patients, having a large
tumor size and an already impaired pre-operative renal function28. e second limitation is the small size of
the cohort, a larger sample size could have allowed other lines of statistical analysis, such as the occurrence of
new-onset chronic renal failure or a shi from moderate to severe chronic renal disease (GFR < 30mL/min).
Finally, we did not collect the presence or degree of albuminuria, which could have been of interest as a follow-
up parameter or as a prognostic factor, as pointed out in the Huang etal. study29.
e loss in GFR-MDRD and renal parenchyma volume (CTRV) aer LPNE seems to be comparable to results
already found in numerous published works in medical literature using other partial nephrectomy techniques.
ere was no correlation between the number of embolized arteries or renal parenchymal volume loss and renal
function loss. Age was the only parameter signicantly associated with > 25% loss of renal function. e main
interest of this surgical technique is to facilitate the tumor excision while reducing the risk of bleeding.
Data availability
The clinical data reported for the study were collected within the framework of the UroCCR project
Received: 20 July 2020; Accepted: 19 November 2020
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We thank all the patients and the team. e anesthesia team: Dr. A. Ter-Minassian, Dr. E. Rineau; the radiology
team: D. Dabli, D. Lefort, N. Leroy, C. Vrignaud; and the surgical team: P. Panayotopoulos, V. Le Corre.
Author contributions
Protocol/project development: P.B., A.B., G.B. Data collection or management: G.B., T.C. Data analysis: G.B.,
P.B., A.B. Manuscript writing/editing: G.B., P.B., A.B., L.B., S.W., C.N., T.C., C.A.
Competing interests
Pierre Bigot and Antoine Bouvier are consultants for GE Healthcare. Other authors do not have conict of
interest related to this study.
Additional information
Correspondence and requests for materials should be addressed to G.B.
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... Selective arterial embolization (SAE) is a widely studied method for decreasing the vascularity and volume of renal malignancies, thereby facilitating subsequent complete surgical tumor excision and limiting intraoperative bleeding [20][21][22][23]. In a nested matched case-control study, survival in 118 patients who underwent renal artery embolization before nephrectomy for renal cell carcinoma was 62% and 47% at 5 and 10 years, respectively, compared with 35% and 23% in 116 patients without pre-operative embolization [22]. ...
... In a nested matched case-control study, survival in 118 patients who underwent renal artery embolization before nephrectomy for renal cell carcinoma was 62% and 47% at 5 and 10 years, respectively, compared with 35% and 23% in 116 patients without pre-operative embolization [22]. A study of SAE followed by partial nephrectomy for renal tumors suggested that renal function impairment was similar to that after other partial nephrectomy techniques [23]. ...
Full-text available
The study’s purpose was to assess the safety, feasibility and efficiency of selective arterial embolization (SAE) using N-butyl cyanoacrylate (NBCA) glue before percutaneous cryoablation (PCA) of renal malignancies in patients whose tumor characteristics and/or comorbidities resulted in an unacceptable risk of bleeding. In this single-center retrospective study of 19 consecutive high-risk patients (median age, 74 years) with renal malignancies managed in 2017–2020 by SAE with NBCA followed by PCA, data about patients, tumor and procedures characteristics, complications, renal function and hemoglobin concentration before and after treatment, as well as recurrence were collected. Charlson comorbidity index was ≥4 in 89.5% of patients. Ten patients were treated by antiplatelet and/or anticoagulant therapy. Median tumor largest diameter was 3.75 cm (range, 1–6.5 cm) and R.E.N.A.L. nephrometry score was ≥7 in 80%, indicating substantial tumor complexity. No major complications were recorded and minor complications occurred in 7 patients. No residual tumor was found at 6-week imaging follow-up in 18/19 patients. Tumor recurrence was visible in 1/16 patients at 6-month imaging follow-up. No significant difference was found for renal function after treatment (p = 0.07), whereas significant decrease in hemoglobin concentration was noted (p = 0.00004), although it was relevant for only one patient who required only blood transfusion and no further intervention. SAE prior to PCA is safe and effective for managing renal malignancies in high-risk patients.
Aim We report the combined approach for the treatment of non-functioning moiety of a mal-rotated crossed fused kidney. Methods A 2 year-old boy presented with recurrent UTI and haematuria in the context of an anorectal malformation and a crossed fused ectopic right kidney with gross ureteric dilatation. Ultrasound, MRI and CT angiogram showed a complex renal unit in the right flank comprising of two moieties. The “posterior” non-functioning moiety gave rise to a markedly dilated refluxing ureter. The “anterior” larger moiety with more normal renal tissue had a non-dilated ureter. The CT revealed complex vascular pattern proving an excision of the moiety to be quite risky to the normal moiety. Selective embolization of the non-functioning moiety was performed by Interventional Radiology with 250-micron particles through an anti-reflux catheter and three detachable coils. 2 days later, he underwent an uneventful laparoscopic ureterectomy. Results There was a mild increase in serum creatinine post-embolization which returned to baseline after ureterectomy. Postoperative ultrasound with Doppler showed that the vascularity was preserved in the functioning residual anterior moiety. At 12 months follow-up he remains asymptomatic with no further haematuria or UTI. Conclusion Clinically indicated approach to removal of renal moieties in complex fusion anomalies requires a multimodal strategy. This is especially important when the intention is nephron sparing and should include appropriate post-embolization syndrome management.
Full-text available
Context: The optimal ischemia technique at partial nephrectomy (PN) for renal masses is yet to be determined. Objective: To summarize and analyze the current evidence about surgical, oncological, and functional outcomes after different ischemia techniques (cold, warm, and zero ischemia) at PN. Evidence acquisition: A computerized systematic literature search was performed by using PubMed (MEDLINE) and Science Direct. Identification and selection of the studies were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) criteria. Outcomes of interest were estimated blood loss (EBL), overall complications, positive surgical margins, local tumor recurrence, and renal function preservation. Meta-analysis and forest-plot diagrams were performed. Overall pooled estimates, together with 95% confidence intervals (CIs), of the incidence of all parameters were obtained using a random effect model (RE-Model) on the log transformed means (MLN), proportion, or standardized mean change, as deemed appropriate. Evidence synthesis: One hundred and fifty-six studies were included. No clinically meaningful differences were found in terms of EBL after cold (mean: 215.5; 95% CI: 154.2–276.8 m), warm (mean: 201.8; 95% CI: 175.0–228.7 ml), or zero (mean: 261.2; 95% CI: 171.0–351.3 ml) ischemia technique. Overall, postoperative complications were recorded in 14.1% (95% CI: 6.7–27.4), 11.1% (95% CI: 10.0–12.3), and 9.7% (95% CI: 7.7–12.2) of patients after cold, warm, and zero ischemia (p < 0.01), respectively. Positive surgical margins were recorded in 4.8% (95% CI: 1.9–10.9), 4.0% (95% CI: 3.4–4.8), and 5.6% (95% CI: 3.1–9.8) of patients after cold, warm, and zero ischemia (p < 0.01), respectively. Local recurrence was recorded in 3.2% (95% CI: 1.9–5.2) and 3.1% (95% CI: 0.7–11.5) of patients after warm and zero ischemia (p < 0.01), respectively. The log2 of estimated glomerular filtration ratio mean changes were–1.37 (95% CI:–3.42 to 0.68),–1.00 (–2.04 to 0.03), and–0.71 (–1.15 to–0.27) ml/min after cold, warm, and zero ischemia, respectively. Low level of evidence, retrospective nature of most of included studies, a high risk of selection bias, and heterogeneity within included studies limited the overall quality of the analysis. Conclusions: The effect of ischemia technique at PN is still debatable and subject to confounding by several factors, namely, patients’ selection criteria, surgical technique used, and percentage of functional parenchyma spared during surgery. These confounders bias available evidence and were addressed by only a small part of available studies. Unfortunately, the overall quality of literature evidences and the high risk of selection bias limit the possibility of any causal interpretation about the relationship between the ischemia technique used and surgical, oncological, or functional outcomes. Thus, none of the available ischemia technique could be recommended over the other. Patient summary: The present analysis shows that none of the available ischemia techniques, namely, cold, warm, or zero ischemia, is universally superior to the others, and other factors play a role in the surgical outcome. Ischemia technique at partial nephrectomy has no significant impact on surgical, oncological, and functional outcomes. No ischemia technique universally outperforms the others for all clinical scenarios, and the choice for a technique can be individualized and based on patient and tumor characteristics as well as on surgeon preferences.
Full-text available
Background: Ongoing efforts are focused on shortening ischemia intervals as much as possible during partial nephrectomy to preserve renal function. Off-clamp partial nephrectomy (off-PN) has been a common strategy for to avoid ischemia in small renal tumors. Although studies comparing the advantages between off-PN with conventional on-clamp partial nephrectomy (on-PN) have been reported, the impact on short- and especially long-term renal function of the two surgical methods has not been discussed seriously and remained unclear. Our purpose is to evaluate the impact on short- (within postoperative 3 months) and long-term (postoperative 6 months or longer) renal function of off-PN compared with that of on-PN. Methods: We comprehensively searched databases, including PubMed, EMBASE, and the Cochrane Library, without restrictions on language or region. A systematic review and cumulative meta-analysis of the included studies were performed to assess the impact of the two techniques on short- and long-term renal function. Results: A total of 23 retrospective studies and 2 prospective cohort studies were included. The pooled postoperative short-term decrease of estimated glomerular filtration rate (eGFR) was significantly less in the off-PN group (weighted mean difference [WMD]: 4.81 ml/min/1.73 m2; 95% confidence interval [CI]: 3.53 to 6.08; p < 0.00001). The short-term increase in creatinine (Cr) level in the on-PN group was also significant (WMD: - 0.05 mg/dl; 95%CI: - 0.09 to - 0.00; p = 0.04). Significant differences between groups was observed for the long-term change and percent (%) change of eGFR (p = 0.04 and p < 0.00001, respectively) but not for long-term Cr change (p = 0.40). The postoperative short-term eGFR and Cr levels, but not the postoperative long-term eGFR, differed significantly between the two groups. The pooled odds ratios for acute renal failure and postoperative progress to chronic kidney disease (stage≥3) in the off-PN group were found to be 0.25 (p = 0.003) and 0.73 (p = 0.34), respectively, compared with the on-PN group. Conclusions: Off-PN exerts a positive impact on the short- and long-term renal function compared with conventional on-PN. Given the inherent limitations of our included studies, large-volume and well-designed RCTS with extensive follow up are needed to confirm and update the conclusion of this analysis.
Purpose: To improve the tumor localization during laparoscopic surgery, we describe an innovative technique involving superselective intra-arterial injection of blue dye in tumoral vessels to color the tumor before surgical enucleation. Materials and Methods: The dye injection was performed at the same time as superselective embolization, immediately before laparoscopic surgery in a hybrid operating room. We used this new treatment sequence on 50 consecutive patients. Results: The selective intra-arterial injection of an emulsion of blue dye and lipiodol was feasible in 46 (92%) cases and well tolerated, followed by superselective embolization of the tumor vessels with glue or coils. The tumor was easily localized during surgery due to the blue coloration. Tumor coloration was not associated with postoperative complication, especially allergic reaction or renal failure. Pathologic analysis of the tumor was not modified by the coloration and all tumors had negative surgical margins. Conclusions: The preoperative dye localization is a feasible, safe, and accurate procedure. This combined approach reduces the difficulty of surgery and increases patient safety.
Purpose: To provide a contemporary understanding of chronic kidney disease (CKD) and its relevance to kidney cancer surgery. To resolve points of discrepancy regarding the survival benefits of partial nephrectomy (PN) vs radical nephrectomy (RN) by critically evaluating the results of prospective and retrospective studies in the urologic literature. Materials/methods: A comprehensive literature search for relevant articles listed in MEDLINE® (2002-2018) was performed using keywords radical nephrectomy, partial nephrectomy, glomerular filtration rate (GFR), kidney function, and chronic kidney disease. Selected review articles and society guidelines about CKD pertinent to urology and nephrology were also assessed. Results: Complete evaluation of the potential consequences of CKD involves assessment of cause, GFR level, and degree of albuminuria. CKD is commonly defined in the urologic literature solely as a GFR <60mL/min/1.73m2, thereby ignoring the significance of CKD cause and the presence/degree of albuminuria. Although this GFR level is relevant for preoperative assessment of patients undergoing surgery for kidney tumors, recent studies suggest that GFR <45mL/min/1.73m2 represents a more discerning postoperative prognostic threshold. Reported survival benefits of PN over RN demonstrated in retrospective studies are likely influenced by selection bias. The lack of survival benefit in the PN cohort of the only randomized trial of PN versus RN is consistent with data demonstrating that patients in both arms of the study had relatively low risk of mortality from CKD, when accounting for etiology of CKD and post-operative GFR levels. Conclusions: The prognostic risk of CKD for kidney cancer patients is increased whenever the preoperative GFR is <60 ml/min/1.73m2 or the postoperative GFR is <45mL/min/1.73m2. Additional factors including non-surgical causes of CKD and degree of albuminuria can also dramatically alter the consequences of CKD following kidney cancer surgery. Urologists must have a comprehensive knowledge of CKD in order to assess the risks/benefits of PN versus RN when managing tumors with increased complexity and/or oncologic aggressiveness.
Renal cancer represents 2% to 3% of all cancers, and its incidence is rising. The increased use of ultrasonography and cross-sectional imaging has resulted in the clinical dilemma of incidentally detected small renal masses (SRMs). SRMs represent a heterogeneous group of tumors that span the full spectrum of metastatic potential, including benign, indolent, and more aggressive tumors. Currently, no composite model or biomarker exists that accurately predicts the diagnosis of kidney cancer before treatment selection, and the use of renal mass biopsy remains controversial. The management of SRMs has changed dramatically over the last two decades as our understanding of tumor biology and competing risks of mortality in this population has improved. In this review, we critically assess published consensus guidelines and recent literature on the diagnosis and management of SRMs, with a focus on patient treatment selection and use of renal mass biopsy, active surveillance, and thermal ablation. Finally, we highlight important opportunities for leveraging recent research discoveries to identify patients with SRMs at high risk for renal cell carcinoma-related mortality and minimize overtreatment and patient morbidity.
Background: Decreased functional outcome after partial nephrectomy is associated with overall mortality. Objective: To create a model that predicts ≥25% reduction from baseline estimated glomerular filtration rate (eGFR) in patients undergoing robot-assisted partial nephrectomy (RAPN) and to investigate the role of acute kidney injury (AKI) in this patient population. Design, setting, and participants: A total of 999 patients were identified from a multi-institutional database. Renal function was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines for chronic kidney disease (CKD). AKI was defined as >25% reduction in eGFR from pre-RAPN period to discharge. Outcome measurements and statistical analysis: A nomogram to predict significant eGFR reduction (≥25% from baseline) in the time-frame between 3 and 15mo after RAPN was built based on the coefficients of Cox survival function that ultimately included age, sex, Charlson comorbidity index, baseline eGFR, RENAL nephrometry score, AKI in patients with normal baseline renal function, and AKI on CKD. Such landmark analysis was chosen in order to account for eGFR fluctuations occurring within the first 3mo of RAPN. The proportional hazard assumption was evaluated through the Schönfeld test. Internal validation was performed using the leave-one-out cross validation. Calibration was graphically investigated. The decision curve analysis (DCA) was used to evaluate the net clinical benefit. Results and limitations: Median (interquartile range [IQR]) age at surgery was 61yr (51, 68). Overall, 146 patients experienced significant eGFR reduction; median follow-up for survivors was 12.4mo. The 15-mo probability of significant eGFR reduction was 19%. All variables fitted into the model, including AKI in patients with normal renal function (hazard ratio [HR]: 4.51; 95% confidence interval [CI]: 3.12, 6.60; p<0.001) and AKI on CKD (HR: 4.90; 95% CI: 2.17, 11.1; p<0.001), emerged as predictors of significant eGFR reduction (all p≤0.048) and were considered to build a nomogram. The internally validated c index was 73%. The model demonstrated excellent calibration and a net benefit at the DCA with probabilities ≥4%. Conclusions: We developed a nomogram that accurately predicts significant eGFR reduction after RAPN. This model may serve as a tool for early identification of patients at high risk for significant renal function decline after surgery. Patient summary: We have developed a model for the prediction of renal function loss after partial nephrectomy for renal cancer.
Background: Stage T1a renal cell carcinoma (RCC) (tumors <4 cm) is usually curable. Nephron-sparing partial nephrectomy (PN) has replaced radical nephrectomy (RN) as the standard of care for these tumors. Radical nephrectomy remains the first alternative treatment option, whereas percutaneous ablation (PA), a newer, nonsurgical treatment, is recommended less strongly because of the relative paucity of comparative PA data. Objective: To compare PA, PN, and RN outcomes. Design: Observational cohort analysis using inverse probability of treatment-weighted propensity scores. Setting: Population-based SEER (Surveillance, Epidemiology, and End Results) cancer registry data linked to Medicare claims. Patients: Persons aged 66 years or older who received treatment for T1a RCC between 2006 and 2011. Interventions: PA versus PN and RN. Measurements: RCC-specific and overall survival, 30- and 365-day postintervention complications. Results: 4310 patients were followed for a median of 52 months for overall survival and 42 months for RCC-specific survival. After PA versus PN, the 5-year RCC-specific survival rate was 95% (95% CI, 93% to 98%) versus 98% (CI, 96% to 99%); after PA versus RN, 96% (CI, 94% to 98%) versus 95% (CI, 93% to 96%). After PA versus PN, the 5-year overall survival rate was 77% (CI, 74% to 81%) versus 86% (CI, 84% to 88%); after PA versus RN, 74% (CI, 71% to 78%) versus 75% (CI, 73% to 77%). Cumulative rates of renal insufficiency 31 to 365 days after PA, PN, and RN were 11% (CI, 8% to 14%), 9% (CI, 8% to 10%), and 18% (CI, 17% to 20%), respectively. Rates of nonurologic complications within 30 days after PA, PN, and RN were 6% (CI, 4% to 9%), 29% (CI, 27% to 30%), and 30% (CI, 28% to 32%), respectively. Ten percent of patients in the PN group had intraoperative conversion to RN. Seven percent of patients in the PA group received additional PA within 1 year of treatment. Limitations: Analysis of observational data may have been affected by residual confounding by provider or from selection bias toward younger, healthier patients in the PN group. Findings from this older study population are probably less applicable to younger patients. Use of SEER-Medicare linked files prevented analysis of patients who received treatment after 2011, possibly reducing generalizability to the newest PA, PN, and RN techniques. Conclusion: For well-selected older adults with T1a RCC, PA may result in oncologic outcomes similar to those of RN, but with less long-term renal insufficiency and markedly fewer periprocedural complications. Compared with PN, PA may be associated with slightly shorter RCC-specific survival but fewer periprocedural complications. Primary funding source: Association of University Radiologists GE Radiology Research Academic Fellowship and Society of Interventional Radiology Foundation.
We retrospectively analyzed the factors related to postoperative cardiovascular (CV) events in patients undergoing partial nephrectomy (PN) or radical nephrectomy (RN) for clinical T1 renal cell carcinoma (RCC). We identified 570 patients who underwent PN or RN for T1 renal cell carcinoma between January 1998 and December 2009 at our institution and related hospitals. We determined the cumulative incidence rate of CV events and overall survival (OS) using Kaplan-Meier survival curves with a log-rank test, and we evaluated the risk for an increase in CV events and OS using Cox proportional hazard regression. Of the 570 patients, 171 underwent PN and 399 underwent RN. The type of surgery was not significantly related with CV events. The only factor that significantly increased the risk of CV events in both the univariate (HR 2.67, p=0.006) and multivariate analyses (HR 2.14, p=0.044) was a postoperative estimated glomerular filtration rate (eGFR) <45 ml/min/1.73 m2. Postoperative eGFR was also a significant risk factor for OS in the univariate analysis (HR 2.38, p=0.0104), but not in the multivariate model. Postoperative renal function was a significant independent predictor of the incidence of subsequent CV events.
Purpose: To confirm the findings from a previous single-institution study of 572 patients from Memorial Sloan Kettering Cancer Center, in which we found that a significant proportion (49%) of patients recovered to their preoperative estimated glomerular filtration rate (eGFR) within 2 years following radical nephrectomy for renal cell carcinoma. Materials and methods: A multi-center retrospective study was conducted among 1928 patients using data contributed by three independent centers. The outcome of interest was postoperative recovery to preoperative eGFR. Data were analyzed using cumulative incidence and competing risks regression, with death from any cause treated as a competing event. Results: This study demonstrated that 45% of patients recovered to their preoperative eGFR by 2 years following radical nephrectomy. Furthermore, this study confirmed that recovery of renal function differs according to preoperative renal function, such that patients with lower preoperative eGFR have an increased chance of recovery. This study also suggested that larger tumor size and female sex are significantly associated with increased chance of renal functional recovery. Conclusions: In this multi-center retrospective study, we confirmed that over the long-term, a large proportion of patients recover to their preoperative renal function following radical nephrectomy for kidney tumors, and that recovery is more likely among those with lower preoperative eGFR.
Objective: To evaluate the clinical efficacy and safety of simple tumor enucleation (TE) for clinical T1 renal cell carcinoma. Materials and methods: A systematic search of PubMed, EMBASE, and Cochrane Central Register of Controlled Trials databases was performed to identify all trials that compared TE and traditional partial nephrectomy (PN) for patients with clinical T1 renal cell carcinoma. Results: A total of 7 studies involving 3,218 patients were identified and included in this meta-analysis. Compared with the PN group, the TE group had significantly shorter estimated operation times (mean difference [MD] = -21.93; 95% CI: -31.07 to -12.78; P< 0.001), shorter warm ischemia times (MD = -1.96; 95% CI: -3.80 to -0.13; P = 0.04), less blood loss (MD = -36.63; 95% CI: -57.49 to -15.77; P = 0.0006), and lower surgical complication rates (odds ratio [OR] = 0.66; 95% CI: 0.47-0.92; P = 0.02). Furthermore, there was no significant difference between the 2 groups in hospital stay duration (MD = -0.46; 95% CI: -0.93 to 0.02; P = 0.06), changes in estimated glomerular filtration rate (MD = 3.35; 95% CI: -2.78 to 9.48; P = 0.28), positive surgical margin rates (OR = 0.34; 95% CI: 0.10-1.14; P = 0.08), and local recurrence rates (OR = 0.71; 95% CI: 0.24-2.06; P = 0.52). Conclusion: Compared to traditional PN, TE is an effective and safe treatment for T1 renal tumors, and TE appears to have acceptable early oncology outcomes. Owing to the limited number of clinical trials and the predominantly retrospective data on this subject, there is a need for properly designed studies to confirm our findings.