The Surgical Management of RCC From Robson to Radiofrequency Ablation f q y Tony Finelli, MD, MSc, FRCSC University Health Network y University of Toronto
Backgro nd Background • Renal cell carcinoma (RCC) is 9 th most (RCC) is 9 most common malignancy - 4600 new cases/yr (Can ) - 4600 new cases/yr. (Can.) • ~ 700+ surgeries/yr. 700+ s rgeries/ r (Ontario)
Renal Cell Carcinoma in Canada • 3% of malignancies; peaks in 6th and 7th decades • 3:2 male-to-female incidence • Extent of disease at diagnosis: • • local 60–70%; regional 15–20%; local 60–70%; regional 15–20%; • metastatic 15–20% • Common symptoms: � Hematuria (50%) � Weakness (28%) � Weight loss (28%) g ( %) � Anemia (21%) � Fever (7%) � Paraneoplastic syndromes (up to 25%) Paraneoplastic syndromes (up to 25%) 1. Canadian Cancer Stats, 2006. Available at: http://www.cancer.ca. 2. Cavalli F, Hansen HH, Kaye SB, eds. Textbook of Medical Oncology. 3rd ed. London, UK: Martin Dunitz; 2004:221-226.
RCC Staging : Stage I Tumor < 7 cm in greatest dimension and Tumor < 7 cm in greatest dimension and limited to kidney; 5-year survival, 95% Stage II Tumor > 7 cm in greatest dimension and limited to kidney; 5-year survival, 88% Stage III Tumor in major veins or adrenal gland, tumor within Gerota’s fascia, or 1 regional lymph node involved; 5 5-year survival, 59% i l 59% Stage IV Tumor beyond Gerota’s fascia or Tumor beyond Gerota’s fascia or > 1 regional lymph node involved; 5-year survival, 20% Cohen HT, McGovern FJ. N Engl J Med. 2005;353:2477-2490.
Localized RCC – TNM (2002) ) (
Surgery for Kidney Cancer Robson, Churchill, Anderson Robson, Churchill, Anderson J Urol 1969;101;297 J Urol 1969;101;297 301 J Urol 1969;101;297 J Urol 1969;101;297-301 301 301
Conventional Nephrectomy
Large Flank Incision
Partial Nephrectomy Novick Stewart Straffon Novick Stewart Straffon Novick, Stewart, Straffon Novick, Stewart, Straffon J Urol 1977;118;932 J Urol 1977;118;932
Open Partial Nephrectomy • 1981 marked the beginning of the elective 1981 marked the beginning of the elective NSS era • Licht and Novick (1993) – 241 cases of elective NSS 241 f l i NSS – Early evidence of oncologic efficacy
Open Partial Nephrectomy • Fergany, Hafez, and Novick (1999) – 10 yr. followup after elective NSS – Equivalent to oncologic results to radical Equivalent to oncologic results to radical nephrectomy for tumours < 4 cm
Expanding Indications for Elective p g Partial Nephrectomy
Elective Partial Nephrectomy: T Tumours 4 – 7 cm 4 7 • Retrospective review of NSS and RN for • Retrospective review of NSS and RN for tumors 4 -7 cm at the Mayo Clinic • Results: • Results: – After adjusting for stage, grade, necrosis, type: – 5 yr cancer specific survival was similar 5 yr. cancer specific survival was similar – 5 yr. metastases-free survival equivalent – Local recurrence no different for < 4 or 4 -7 cm Local recurrence no different for < 4 or 4 7 cm • Elective NSS can be applied to tumors 4 -7 cm especially if exophytic cm especially if exophytic
Contemporary Complication Rates with Open Partial Nephrectomy
Contemporary Complication Rates with Open Partial Nephrectomy • 1985 to 2001 (compare ’85-95, ’96-01) • N = 823 open NSS N 823 open NSS • Intraop blood loss (550 v. 350cc, p<0.001) • CRF (14.6 v 8.1%, p=0.003) CRF (14 6 8 1% 0 003) • Early comp (13.4 v 6.9%, p=0.002) • Late comp (32.4 v 24.6%, p=0.014)
Emerging Data on L Long-term Renal Function R l F i • 662 patients w/ 2 kidneys and normal function • RN or PN for a solid cortical tumour < 4cm • CRF defined as: – GFR < 60 ml/min or < 45 ml/min/1.73m 2
Long-term Renal Function g • 3-year probability of freedom from “CRF”: – GFR < 60: 80% vs. 35% for PN and RN, resp. – GFR < 45: 95% vs. 64% for PN and RN, resp. • Multivariate analysis – procedure independent predictor of CRF di t f CRF • Median time to GFR < 60 was 18 months for RN RN, not reached for PN t h d f PN • No patient in this cohort has gone on to dialysis
Is partial nephrectomy underutilized? Is partial nephrectomy underutilized? J Urol, Mar. 2006 l • 1988 – 2001 1988 2001 • SEER database review • N = 14,647 (primary tumour < 7 cm)
Tumours < 2 cm
Tumours 2 – 4 cm
Is partial nephrectomy underutilized? O Ontario i 1995 – 1998 Partial Nx 166 (5.7) Radical Nx 2743 (94.3) ( ) 1999 – 2002 Partial Nx 345 (10.1) ( ) Radical Nx 3078 (89.9) 2003 – 2007* Partial Nx 284 (14.1) Radical Nx 1731 (85.9) Abouassaly et al. (unpublished)
Laparoscopic Radical Nephrectomy y p p p
Flank B lge Flank Bulge Chatterjee et al., Urol Onc 22: 36-9. (2004) • Historically 3% • N=70 (1996 – 2000) N 70 (1996 2000) • 50% of patients reported a flank bulge • 24% experienced durable flank pain 24% i d d bl fl k i • Median pain magnitude = 5/10 • Pain persisted greater than 1 year • Impacted QOL especially in those < 60 yrs Impacted QOL, especially in those < 60 yrs.
Flank B lge Flank Bulge Y hi Yoshimura et al., J Urol (169): 182-5, Jan 2003 t l J U l (169) 182 5 J 2003
Radical Nephrectomy Laparoscopic nephrectomy: initial case report. Clayman RV, Kavoussi, LR, Soper NJ, Dierks SM, Meretyk S, Darcy MD, et al. J Urol, 146:278, 1991
Laparoscopic Radical Nephrectomy • Diminished: – postoperative pain, analgesic requirement – length of hospital stay and convalescence • Equivalent: q – Rate of complications* – Blood loss* – Surgical time* – Oncologic results
Laparoscopic Radical Nephrectomy p p p y Transperitoneal
Port Placement (Left) Port Placement (Left)
Left Renal Hilar Dissection
LAPAROSCOPIC RADICAL NEPHRECTOMY Specimen Extraction
Evidence Supporting LRN Evidence Supporting LRN
Equal cancer-specific outcomes for 3 years.
Portis et al.
LRN LRN – Oncologic Outcomes Oncologic O tcomes P Portis et al., J Urol (167): 1257-62, Mar 2002 ti t l J U l (167) 1257 62 M 2002
LRN – Tumours > 7cm St i b Steinberg, Finelli, Desai et al, J Urol (172):2172-6, Dec 2004 Fi lli D i t l J U l (172) 2172 6 D 2004
LRN – Oncologic Outcomes g pT2-3b RCC Stage Specific Survival g p 1.0 .8 STAGE .6 Survival pT3b .4 pT3a .2 pT2 0.0 0 12 24 36 48 60 72 84 Months From Nephrectomy Finelli et al. (unpublished)
Laparoscopic Cytoreductive Nephrectomy
Laparoscopic Cytoreductive Laparoscopic Cytoreductive N N Nephrectomy Nephrectomy h h t t
Laparoscopic Cytoreductive Laparoscopic Cytoreductive N N Nephrectomy Nephrectomy h h t t
Conclusions • LRN has been performed for > 10 years • Oncologic outcomes equivalent Oncologic outcomes equivalent • Diminished morbidity • Indications are expanding I di i di • Caution in selecting patients
LRN LRN • Standard of care for T2 RCC in the Standard of care for T2 RCC in the absence of imperative indications for NSS NSS • Caution: – Large hilar tumour – Hilar adenopathy – > 12 cm – Multiple parasitic vessels p p
LAPAROSCOPIC PARTIAL LAPAROSCOPIC PARTIAL LAPAROSCOPIC PARTIAL LAPAROSCOPIC PARTIAL NEPHRECTOMY NEPHRECTOMY
Laparoscopic Partial Nephrectomy p p p y Laparoscopic partial nephrectomy is L i i l h i NOT new... • Winfield, et al , 1995 • Gill, et al, 1995 • McDougall, et al, 1998 • Janetschek, et al, 2000 • Harmon et al, 2000
Laparoscopic Partial Nephrectomy p p p y RETROSPECTIVE COMPARISON J Urol 170:64 J Urol 170:64- -8, July 2003 8, July 2003 Laparoscopy vs. Open (n=200) Laparoscopy vs. Open (n=200)
• 33% had > 1 complication • Overall 18% had a urologic complication Overall 18% had a urologic complication • Hemorrhage – 9.5% (3.5, 2, and 4%) • Urine leak – 4.5% i l k 4 % • Open conversion – 1% • Reoperation – 2%
Oncologic Outcomes • N = 100 • Mean tumour size – 3.1 cm Mean tumour size 3.1 cm • Mean WIT – 27 minutes • 2 positive margins (oncocytoma, RCC) 2 iti i ( t RCC) • Median f/u – 42 months – 86 % survival, 100% cancer specific survival
Laparoscopic Partial Laparoscopic Partial Nephrectomy
Laparoscopic Partial Nephrectomy Laparoscopic Partial Nephrectomy • The most demanding laparoscopic procedure • Potential for hemorrhage g • Time pressure of warm ischemia • Requires complete comfort with lap • Requires complete comfort with lap • Must master suturing angles • Set-up is critical • Requires efficient intracorporeal suturing
Laparoscopic Partial Nephrectom Laparoscopic Partial Nephrectomy • Initially LPN was applied to: – Small tumours Small tumours – Solid tumours – Exophytic tumours E h ti t – In the setting of two kidneys
Expanding the Application of Laparoscopic Partial Nephrectomy i i l h
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