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Renal Cell Carcinoma
additional 1cm margin of peri-tumour renal parenchyma to ensure a tumours ≤4 cm in experienced centres.
8
From a technical point of view,
true negative margin and decrease the risk of local recurrence. renal ischaemia time, parenchyma haemostasis, possible pelvico-
Indeed, removing a 1cm safety margin can make NSS more complex caliceal reconstruction and parenchyma renorraphy are the most
in some cases, causing an increased risk of urinary collecting system challenging steps of the procedure. In fact, while the techniques to
injuries, the need to clamp renal vessels, prolonged ischaemia times, reconstruct the renal parenchyma and control the haemostasis are
a higher risk of bleeding and potential injury to hylar vessels. standardised in open partial nephrectomy, the most appropriate
Moreover, the resection of a thick safety margin might reduce the technique in LPN is still under development and widespread use of
preserved parenchyma, negatively affecting the renal function of haemostatic biological agents has been reported. To date, only the use
patients with bilateral tumours or a single kidney. of gelatin-matrix thrombin sealant (FloSeal) has been shown to
significantly decrease haemorrhagic events.
15
In recent series of partial nephrectomy, the mean thickness of the
safety margin surrounding the tumour was 2.5–5mm but with The most frequent surgical complications reported in the literature
minimum values ranging between 0 and 1mm and maximum values were bleeding (1.5–10%), urine leak (1.4–10%), wound infection or
ranging between 7 and 23mm. Specifically, the safety margin ranges sepsis (0–3%), renal failure (0–2%) and vascular, organ or pleural injury
between 4 and 10mm at the area of the renal capsule and is reduced (0–2%). Medical complications range from 3 to 20%. From an
to 0–6mm at the bottom of the tumour bed.
11
However, data oncological point of view, local recurrence and cancer-specific survival
concerning recurrence rate clearly showed that the thickness of rates ranged from 0 to 1.7% and from 97 to 100% at follow-up,
the parenchyma surrounding the tumour does not affect long-term respectively (durations from 15 to 68 months in the different series).
16
progression-free survival in patients with negative surgical margins.
12
For this reason, the most recent version of the European Association Data from a non-systematic review of the literature showed that
of Urology (EAU) guidelines recommended the presence of only a ischaemia time was longer in patients who underwent LPN than
minimal tumour-free surgical margin of healthy renal parenchyma OPN. In larger series of OPN, the renal vessels were clamped in
surrounding the resected tumour in order to reduce the risk of local 50–99% of cases and the ischaemia time ranged between 14 and 20
relapse or progression, without specifying the exact minimum minutes. Vice versa, clamping of renal vessels is essential during LPN
thickness to be taken.
8
and the ischaemia times in the best hands ranged from 27 to 35
minutes without any decrease over time despite improvements
In this scenario, a very controversial point is the role of simple to the technique to control haemostasis and reconstruct the
enucleation in the conservative treatment of RCC. This surgical renal parenchyma.
16
Moreover, LPN is associated with higher
technique consists of the incision of the renal parenchyma within a few complication rates compared with open surgery and a steep learning
millimetres from the tumour and the blunt dissection of a space curve is required to reduce its morbidity. At the same time, although
between the pseudocapsule of the tumour and the normal renal tissue some comparative series reported similar oncological results at short-
without inclusion in the removed tissue of any visible normal renal term and intermediate follow-up,
15
the oncological outcomes will
parenchyma. Even though simple enucleation might be correctly used in remain difficult to compare until sufficient long-term data are available.
patients with bilateral kidney tumours and/or with solitary kidneys
preserving the most parenchyma possible, its use in patients with single RPN can be considered as the natural evolution and simplification of
tumours and contralateral normal kidney is more controversial the traditional LPN. In particular, the use of the da Vinci system can
considering the higher risk of local recurrences, particularly in patients simplify the manoeuvres needed to perform parenchyma
with neoplastic infiltration of the tumour pseudocapsule.
11
However, haemostasis, caliceal reconstruction and parenchyma renorraphy,
literature data show that simple enucleation provides similar oncological reducing warm ischaemia duration. At the same time, the learning
results to conventional NSS. In a series of 232 patients who had curve seems to be significantly shorter than for LPR.
17
In a very
undergone simple enucleation for ≤4cm RCC, Carini et al. reported five- interesting comparative study between LPR and RPN, Benway et al.
and 10-year cancer-specific survival rates of 96.7 and 94.7%, demonstrated a significant advantage in favour of RPN in terms of
respectively. Moreover, the authors observed no cases of positive warm ischaemia time (25 versus 18 minutes) and duration of in-
surgical margins or recurrence at the initial site of the tumour after a hospital stay (three versus 2.4 days). Positive surgical margins and
mean follow-up of 76 months.
13
Interestingly, the same authors recently recurrence rates were overlapping.
18
documented in the specimen of simple enucleation the presence of a
parenchymal tissue with a median thickness of 1mm (range 0.38–1.6) Expanding Indications for
lying beyond the tumour pseudocapsule with signs of chronic Nephron-sparing Surgery
inflammation. This precious microscopic layer of renal parenchyma Over the last few years some authors have proposed extending the
allows the presence of negative surgical margins also in patients with application of elective NSS beyond the treatment of small RCCs. A
tumours extending beyond the pseudocapsule.
14
Therefore, according to recent multicentre international study showed that the percentage of
the results of this recent and original study, it seems possible to consider NSS performed for tumours between 4 and 7cm increased from 8.1%
simple enucleation as a ‘minimal’ partial nephrectomy, in which very during the 1987–1991 period to 35.3% between 2004 and 2007.
7
In
little rime of peri-tumoural tissue is removed. Obviously, it is desirable 2004, two comparative, non-randomised studies reported similar
that those results are confirmed in the future. cancer-specific survival in patients who underwent NSS or radical
nephrectomy for RCC between 4 and 7cm in size.
6,19
Laparoscopic and Robotic Partial Nephrectomy
Laparoscopic partial nephrectomy (LPN) is considered to be a More recently, Antonelli et al. compared the oncological outcomes of
technically challenging procedure, and the EAU guidelines proposed 52 patients who underwent partial nephrectomy for renal tumours
this minimally invasive approach as an optional treatment for renal ≥4cm with those of 277 patients treated with radical nephrectomy. At
44 EUROPEAN UROLOGICAL REVIEW
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