4 cm endophytic renal tumour in a
60 year old diabetic male :
Treatment of choice IS NOT partial
nephrectomy
Dr Souvik Dey
Complications of Partial
Nephrectomy
• Urinary Fistulae
• Postoperative Bleeding
• Renal Insufficiency
Urinary Fistulae
• Incidence – 4-21%
• Risk factors – large tumor and endophytic tumor
• Endophytic location of the tumor increased possibility of opening
PCS increased possibility of urinary leak
Post Operative Bleeding
• Incidence of bleeding after partial nephrectomy-
• 4.2% - 6% for laparoscopic partial nephrectomy
• 6 % and for open partial nephrectomy
• 8.1% for robot assisted procedure
• Management
• Blood transfusion renal/segmental artery angioembolization surgical re
exploration
• Central tumor location correlates with increased risk of postoperative
haemorrhage
Van Poppel H, Bamelis B, Oyen R, Baert L. Partial nephrectomy for renal cell carcinoma can achieve long-term
tumor control. J Urol. 1998; 160(3 Pt 1):674–678.
Renal Insufficiency
• Decline in function after PN averages about 20% in the operated
kidney and 10% globally for patients with 2 kidneys
• Due to ischemic insult, loss of nephron mass related to parenchymal
excision or collateral damage during reconstruction
Mir MC, Ercole C, Takagi T, Zhang Z, Velet L, Remer EM, Demirjian S, Campbell SC. Decline in renal function
after partial nephrectomy: etiology and prevention. J Urol. 2015 Jun;193(6):1889-98.
More complications with endophytic
tumors
Conclusion: Increasing tumor complexity is associated with the development of major
complications after PN
More complications with endophytic
tumors
• 390 patients undergoing PN divided, based on nephrometry score,
divided into 3 groups – low, moderate and high complexity.
• Major complication (CD III – V) rates differed significantly (6.4 vs 11.1
vs 21.9%; p = 0.009) among tumor complexity groups.
• Thirty-five patients (54.7%) in the high NS group suffered from a
postoperative complication (minor or major) within 30 d of surgery
Ablation therapy
Treatment options
• Cryoablation - Argon gas based probes, target temp -40 C
• Radiofrequency ablation - Monopolar alternating electric current
molecular friction heat production protein denaturation, target
temperature 70C
Similar oncological outcome for cT1a
Mayo Clinic and Mayo Medical School, Rochester, MN, USA
Conclusion - With mature follow-up at a single institution, percutaneous ablation
appears to have acceptable results for cT1 renal tumors
• 1422 cT1a patients –
• NSS - 1055, Median clinical follow-up of 9.4 yrs
• RFA - 180, Median clinical follow-up of 7.5 yrs
• Cryoablation – 187, Median clinical follow-up of 6.3 yrs
• Five-year CSS was 99%, 96%, and 100% for PN, RFA, and cryoablation
respectively
Conclusion - With mature follow-up at a single institution, percutaneous ablation appears to have acceptable
results for cT1 renal tumors
Conclusion: IGA is potentially as good as LPN in oncological durability. IGA
preserves kidney function significantly better than LPN.
Results
• A total of 296 (238 T1a, 58 T1b) consecutive patients were identified; 103, 100, and 93 patients underwent
CRYO, RFA, and LPN, respectively Median follow-up time was 75, 98 and 71 months, respectively.
• On univariate analysis, all oncological outcomes were comparable amongst CRYO, RFA, and LPN (p > 0.05).
• On multivariate analysis, T1a patients undergoing RFA had improved local recurrence-free survival (HR
0.002, 95% CI 0.00–0.11, p = 0.003) and metastasis-free survival (HR 0.002, 95% CI 0.00–0.52, p = 0.029)
compared to LPN.
• Patients undergoing CRYO and RFA had a significantly smaller median decrease in eGFR post-operatively
compared to LPN (T1a: p < 0.001; T1b: p = 0.047).
Partial Nephrectomy vs ablation
therapy
Conclusion:
• PN is associated with higher overall survival and local control over ablative therapies, but results did not
translate into significantly better cancer-specific mortality.
• Ablative therapies were superior to PN regarding complications and renal function.
Better safety profile
• Avoids ischemic injury to the kidneys Preservation of renal function
• Faster post operative recovery
• Better perioperative outcomes
Chan, V.WS., Osman, F.H., Cartledge, J. et al. Long-term outcomes of image-guided ablation and laparoscopic partial nephrectomy for T1 renal cell carcinoma. Eur Radiol 32, 5811–5820 (2022).
Renal function preservation
NSS requires a period of overall renal ischemia
Prolonged duration of ischemia (endophytic tumor)
Ischemic insult to kidneys (already at risk in view of DM)
Hemorrhage and decreasing renal function (increased risk of CKD)
Renal function preservation
The mean eGFR decline in the RFA group was significantly lower than that in the PN group
Peri operative outcomes
Ablation therapy has -
• Less duration of hospital
stay
• Less major complication
Benign renal mass in cT1a
Benign tumors in around 20% cases.
• AML
• Oncocytoma
• Metanephric adenoma
• Leiomyoma
Standard of care
Radical Partial ?Ablation
nephrectomy nephrectomy therapy
Thank you
