RCC: Surgery  Hein Van Poppel UZ Gasthuisberg  Leuven, Belgium Lugano 2011 ECCLU 2011 is held under the auspices of the  E...
Risk factors for RCC <ul><li>Smokin g </li></ul><ul><li>Obesit y </li></ul><ul><li>H yp ertension </li></ul><ul><li>Fruit ...
1963 Increasing Incidence of Small RCC Events per 100,000U.S. population HOLLINGSWORTH, JCI 98:1333, 2006 < 2cm  2-4cm  4-...
Mortality for RCC and all causes  Up to 5 y. after surgical therapy Hollingsworth et al. Cancer 2007 Survival non RCC mort...
Kidney Cancer Treatment  through the years <ul><li>Every solid mass….Radical Nephrectomy </li></ul><ul><li>Imperative Neph...
WHAT ABOUT RADICAL NEPHRECTOMY ?
Radical nephrectomy <ul><li>No longer golden standard treatment for SRMs </li></ul><ul><li>Limited to cases not amenable t...
Extended LND for RCC R L Crispen et al., Eur.Urol.,2011 8
Dilemma in RCC <ul><li>LND in cN+ pts  - Poor prognosis (7-17% 5 yr survival) - Often but not always metastatic - Does LND...
Reassessing the Lymph  Node Staging for RCC Terrone C et al. Eur Urol 2006; 49: 324-331 <ul><ul><li>(618 Rad.Nephr.+LND) <...
Reassessing the Lymph  Node Staging for RCC Terrone C et al. Eur Urol 2006; 49: 324-331 <ul><ul><li>(618 Rad.Nephr.+LND) <...
Reassessing the Lymph  Node Staging for RCC Dimashkieh HH et al. J Urol 2006; 176: 1978-1983 ENE =Extranodal extension 12
Tumour, Nodes, Metastases  Staging System  Nx   Regional Lymphnodes    Idem   cannot be assessed N0  Regional lymphnodes I...
What to do in cN+ patients ? Radical Nephrectomy  and  Robson-LND 14
Rad.Nx Part.Nx Tachosil 15
Lymphnode Dissection? <ul><ul><li></=4 vs. >4 LNs involved (p=0.02) </li></ul></ul><ul><ul><li>- Patients without primary ...
Performance of LND  1989 to 2004 <ul><li>Despite stage migration and increasing number of resections : no better OS or PFS...
Performance of Adrenalectomies 1989 to 2004 P.Russo  et al., Cancer, 2008 RCC patients  Adrenalectomy No Yes
RCC Incidence      RCC Mortality  Lipworth et al. J Urol 176:2353, 2006 19
20
21
WHAT ABOUT PARTIAL NEPHRECTOMY ?
P.Russo  et al., Cancer, 2008 Numbers of Radical or Partial Nephrectomies
NEPHRON-SPARING 24
Elective  Nephron-sparing  Surgery for Localized RCC  Valdez-Mendoza, 2008 N° pts 5-y  DFS (% ) Local recurr. (% ) Median ...
Overall Survival Cure rates of Partial and Radical Nx for small RCC are similar Eur.Urol. 2011 26
Partial vs. Radical Nx <ul><li>Complication rate of partial Nx is higher </li></ul><ul><li>Length of stay, hospital cost c...
Partial Nephrectomy for  Small Renal Masses   D.C. Miller, 2006. SEER Data Part. Nx  in 9.6% of cases of RCC (1988-2001)  ...
Partial Nephrectomy: An underutilized procedure <ul><li>Urologists fear the higher complication rate </li></ul><ul><li>Ope...
30
Enucleation  Enucleoresection NSS 31
Pure Enucleation 32
33
Wedge resection  Polar Nephrectomy NSS 34
Wedge resection 35
Polar resection 36
37
WHAT ABOUT THE MARGINS ? 38
Intact PseudoCapsule in most RCC’s 39
1 cm RCC Pseudocapsule?? 40
PseudoCapsular Perforation No PseudoCapsule 41
Multifocality as reason  for recurrence 42
SIZE of the MARGIN in NSS <ul><li>Czerny : margin? </li></ul><ul><li>1950   Vermooten :  margin 1 cm </li></ul><ul><li>Mar...
Margin size and  local recurrence   <ul><li>232 patients mean tumor size 2,8 cm  </li></ul><ul><li>mean follow-up 76 month...
Enucleation with ablation  of the tumour base <ul><li>97 patients,  only 1 local recurrence </li></ul><ul><li>A.Kutikov et...
Positive Surgical Margins  Oncological Outcomes <ul><li>Positive margins ≠ adverse prognosis  </li></ul><ul><li>Vigilant m...
WHAT ABOUT LARGER TUMORS ? 47
OPEN  PARTIAL  NEPHRECTOMY  SURVIVAL  vs. TUMOR  DIAMETER  0 12 24 36 48 60 72 84 96 108 120 < 4 cm  310 PATS. > 4 cm  175...
T1b Midpole  Wedge to Enucleation 49
Larger Tumors : NSS <ul><li>Homburg  : 69 elective NSS >4cm   </li></ul><ul><li>Stockle,  Eur.Urol. 2006   </li></ul><ul><...
cT1b Partial Nephrectomy   <ul><li>71 patients mean tumor size  4 - 7 cm  </li></ul><ul><li>mean follow-up 74 months </li>...
T1b  -  T3a  Upper Pole 52
Conclusions on NSS for T1b <ul><li>-  Surgically feasible </li></ul><ul><li>Local cancer control good </li></ul><ul><li>Ca...
WHAT ABOUT CENTRAL  TUMORS ? 54
Centrally located tumors   NSS ? Rad.Nx 55
Intra-operative Ultrasound 56
Planning intra-renal tumor 57
Hilar (A-V) Clamping Surface Cooling 58
T1a  Intrarenal  Enucleation 59
WHAT ABOUT MULTIFOCAL   TUMORS ? 60
And Multifocal RCC ? 60
61
Open Partial Nephrectomy <ul><li>From controversial to well accepted </li></ul><ul><li>Allows difficult resections with lo...
Partial Nephrectomy (Cleveland Clinic) 0 50 100 150 200 250 1995 1996 1997 1998 2000 2001 2002 2003 2004 Open Laparoscopic...
Lap. or Open Partial Nx? <ul><ul><li>LPN (at expert centres) compares to OPN </li></ul></ul><ul><ul><ul><li>- Equal short ...
Ischemic renal damage after NSS  <ul><li>Warm ischemic time of ≥ 25 min caused </li></ul><ul><li>irreversible damage </li>...
C L AMP ING  ECHO 66
Hemostasis 67
Laparoscopic  Partial Nephrectomy <ul><li>Expert centers reproduce open surgery </li></ul><ul><li>Hilar clamping, cooling,...
Management of Renal Tumors (JOHNS  HOPKINS) 1998 2000 2001 1999 1997 2005 0 40 60 80 100 20 ORN OPN LRN LPN LRA PRA % PEMP...
WHAT ABOUT  ABLATIVE  THERAPIES ? 70
<ul><li>“ The best Focal Therapy for  RCC    … is Surgery” </li></ul>H.Van Poppel, Focal Therapy Meeting Amsterdam, 2009 71
Energy ablative therapies <ul><li>Thermal ablation : cryoablation and RFA  </li></ul><ul><ul><li>Reasonable option for sma...
Percutaneous RFA 73
RFA 74
Laparoscopic Cryoablation 75
PERCUTANEOUS  CRYO  J. RICHIE, BRIGHAM,  BOSTON 76
HIFU 20-40 W/cm 2 1600-2000 W/cm 2 DEPT. UROLOGY, UNIVERSITY OF VIENNA Still experimental 77
Energy ablative therapies <ul><li>At this time </li></ul><ul><ul><li>Insufficient data to compare  Cryo/RFA </li></ul></ul...
RFA and CRYO <ul><li>SAFE  AND  LOW  MORBIDITY  IN  LOW  RISK,  PERIPHERAL  TU. < 3cm </li></ul><ul><li>Can be repeated </...
Renal Cancer Treatment Kim, J Urol ‘03  McDougall, J Urol ‘96 Corman, Br J Urol ‘00 Lotan, Br J Urol ‘05 Kercher, Surg End...
Conclusion <ul><li>Increasing number of small renal masses are diagnosed </li></ul><ul><li>1/2  renal tumours are < 4cm at...
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H. Van Poppel - Kidney cancer - Surgery (including nephron-sparing surgery)

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  • SRMs: small renal masses NSS: nephron-sparing surgery
  • In conclusions,
  • In conclusions,
  • In conclusions,
  • Moving to locally advanced RCC, As you know, they are classified as pT3 and pT4. The former group includes tumours invading perirenal fat and/or ipsilateral adrenal gland, T3a, as well as those presenting with thrombosis within the renal vein or the vena cava below or above the diaphragm. Moreover, T4 RCC were characterized by tumours extending beyond the gerota fascia.
  • LPN: laparoscopic partial nephrectomy OPN: open partial nephrectomy
  • RFA: radiofrequency ablation MINS: minimally invasive nephron-sparing AS: active surveillance
  • RFA: radiofrequency ablation HIFU:High Intensity Focused Ultrasound MWT: Microwave Thermotherapy LITT: Laser Interstitial Thermal Therapy PCU: Pulsed Cavitational Ultrasound
  • H. Van Poppel - Kidney cancer - Surgery (including nephron-sparing surgery)

    1. 1. RCC: Surgery Hein Van Poppel UZ Gasthuisberg Leuven, Belgium Lugano 2011 ECCLU 2011 is held under the auspices of the European School of Urology
    2. 2. Risk factors for RCC <ul><li>Smokin g </li></ul><ul><li>Obesit y </li></ul><ul><li>H yp ertension </li></ul><ul><li>Fruit and ve g etable consumption: linked </li></ul><ul><li>Occu p ational factors: no definite proof </li></ul>(Lipworth et al., J Urol 176:2353, 2006)
    3. 3. 1963 Increasing Incidence of Small RCC Events per 100,000U.S. population HOLLINGSWORTH, JCI 98:1333, 2006 < 2cm 2-4cm 4-7cm > 7cm 1985 1987 1989 1991 2001 1993 1995 1997 1999 n=34.503
    4. 4. Mortality for RCC and all causes Up to 5 y. after surgical therapy Hollingsworth et al. Cancer 2007 Survival non RCC mortality RCC mortality .
    5. 5. Kidney Cancer Treatment through the years <ul><li>Every solid mass….Radical Nephrectomy </li></ul><ul><li>Imperative Nephron Sparing Surgery </li></ul><ul><li>Elective Nephron Sparing Surgery </li></ul><ul><li>Laparoscopic Radical - Partial Nephrectomy </li></ul><ul><li>Ablative techniques </li></ul><ul><li>Observation – Watchful Waiting </li></ul><ul><li>Never a randomized trial has compared any of these treatments </li></ul>
    6. 6. WHAT ABOUT RADICAL NEPHRECTOMY ?
    7. 7. Radical nephrectomy <ul><li>No longer golden standard treatment for SRMs </li></ul><ul><li>Limited to cases not amenable to NSS </li></ul><ul><li>Extended lymphnode dissection </li></ul><ul><ul><li>Patients with detectable LN: </li></ul></ul><ul><ul><li>no improved survival </li></ul></ul><ul><ul><li>Can be restricted to staging purposes ? </li></ul></ul><ul><ul><li>In cN0: a small subgroup could benefit </li></ul></ul><ul><li>Adrenalectomy </li></ul><ul><ul><li>Only mandatory in selected cases in which there are risk factors for adrenal involvement (Grade B) </li></ul></ul>7
    8. 8. Extended LND for RCC R L Crispen et al., Eur.Urol.,2011 8
    9. 9. Dilemma in RCC <ul><li>LND in cN+ pts - Poor prognosis (7-17% 5 yr survival) - Often but not always metastatic - Does LND bring any benefit ? </li></ul><ul><li>- Nevertheless LND is not debated in these cases </li></ul><ul><li>LND in cN0 pts - All survivors had only microscopic nodal disease </li></ul><ul><li>- Can we safely omit LND in cN0 patients? </li></ul><ul><li>- Risk factors that predict nodal invasion </li></ul>9
    10. 10. Reassessing the Lymph Node Staging for RCC Terrone C et al. Eur Urol 2006; 49: 324-331 <ul><ul><li>(618 Rad.Nephr.+LND) </li></ul></ul>10
    11. 11. Reassessing the Lymph Node Staging for RCC Terrone C et al. Eur Urol 2006; 49: 324-331 <ul><ul><li>(618 Rad.Nephr.+LND) </li></ul></ul>p=0.02 11
    12. 12. Reassessing the Lymph Node Staging for RCC Dimashkieh HH et al. J Urol 2006; 176: 1978-1983 ENE =Extranodal extension 12
    13. 13. Tumour, Nodes, Metastases Staging System Nx Regional Lymphnodes Idem cannot be assessed N0 Regional lymphnodes Idem negative N1 Metastasis to a 4 or less positive nodes single node (no extranodal invasion) N2 Metastasis in > > 4 positive nodes 1 Lymph node (extranodal invasion) TNM, 2002 TNM, ?? V.Ficarra 13
    14. 14. What to do in cN+ patients ? Radical Nephrectomy and Robson-LND 14
    15. 15. Rad.Nx Part.Nx Tachosil 15
    16. 16. Lymphnode Dissection? <ul><ul><li></=4 vs. >4 LNs involved (p=0.02) </li></ul></ul><ul><ul><li>- Patients without primary LND can develop LN recurrence only </li></ul></ul>C.Terrone et al ,Eur Urol. 2006 There is a rationale for prophylactic LND in cN0 16
    17. 17. Performance of LND 1989 to 2004 <ul><li>Despite stage migration and increasing number of resections : no better OS or PFS </li></ul>P.Russo et al., Cancer, 2008 RCC patients undergoing LND through the years No Yes
    18. 18. Performance of Adrenalectomies 1989 to 2004 P.Russo et al., Cancer, 2008 RCC patients Adrenalectomy No Yes
    19. 19. RCC Incidence RCC Mortality Lipworth et al. J Urol 176:2353, 2006 19
    20. 20. 20
    21. 21. 21
    22. 22. WHAT ABOUT PARTIAL NEPHRECTOMY ?
    23. 23. P.Russo et al., Cancer, 2008 Numbers of Radical or Partial Nephrectomies
    24. 24. NEPHRON-SPARING 24
    25. 25. Elective Nephron-sparing Surgery for Localized RCC Valdez-Mendoza, 2008 N° pts 5-y DFS (% ) Local recurr. (% ) Median FU (mos) Van Poppel et al . (1998) [44] 51 98 0 75 Herr (1999) [9] 70 97 1.5 120 Hafez et al . (1999) [10] 45 100 0 35 Lee et al . (2000) [4] 37 100 0 40 Lau (2000) [23] 189 98 1 44 Filipas et al . (2000) [49] 180 98 1.6 56.4 McKiernan et al . (2002) [22] 117 100 1.2 25 Kural et al . (2003) [51] 50 100 0 33.1 Patard et al . (2004) [11] 379 97.8 0.8 51
    26. 26. Overall Survival Cure rates of Partial and Radical Nx for small RCC are similar Eur.Urol. 2011 26
    27. 27. Partial vs. Radical Nx <ul><li>Complication rate of partial Nx is higher </li></ul><ul><li>Length of stay, hospital cost comparable </li></ul><ul><li>Creatinine failure and dialysis need much lower </li></ul><ul><li>° Adkins J.Urol 2003, Huang Lancet Oncol.2006 </li></ul><ul><li>Quality of life significantly better </li></ul><ul><li>° Poulakis Urology 2003, Lesage Eur Urol 2007 </li></ul><ul><li>Still an underutilized procedure </li></ul><ul><li>° Miller J.Urol 2006 </li></ul>27
    28. 28. Partial Nephrectomy for Small Renal Masses D.C. Miller, 2006. SEER Data Part. Nx in 9.6% of cases of RCC (1988-2001) % 4 28
    29. 29. Partial Nephrectomy: An underutilized procedure <ul><li>Urologists fear the higher complication rate </li></ul><ul><li>Open radical nephrectomy for small lesions is often easy, curative and not-complicated </li></ul><ul><li>Laparoscopic radical nephrectomy became popular and is now standard for T1 tumors ! </li></ul><ul><li>There is an obvious need for better training </li></ul>29
    30. 30. 30
    31. 31. Enucleation Enucleoresection NSS 31
    32. 32. Pure Enucleation 32
    33. 33. 33
    34. 34. Wedge resection Polar Nephrectomy NSS 34
    35. 35. Wedge resection 35
    36. 36. Polar resection 36
    37. 37. 37
    38. 38. WHAT ABOUT THE MARGINS ? 38
    39. 39. Intact PseudoCapsule in most RCC’s 39
    40. 40. 1 cm RCC Pseudocapsule?? 40
    41. 41. PseudoCapsular Perforation No PseudoCapsule 41
    42. 42. Multifocality as reason for recurrence 42
    43. 43. SIZE of the MARGIN in NSS <ul><li>Czerny : margin? </li></ul><ul><li>1950 Vermooten : margin 1 cm </li></ul><ul><li>Marberger : no reference margin </li></ul><ul><li>1992 Hohenfellner : enucleation </li></ul><ul><li>+ coagulation tumor bed </li></ul><ul><li>Carini : simple enucleation </li></ul><ul><li>What is a safe margin? </li></ul>43
    44. 44. Margin size and local recurrence <ul><li>232 patients mean tumor size 2,8 cm </li></ul><ul><li>mean follow-up 76 months (12-225) </li></ul><ul><li>PURE ENUCLEATION </li></ul><ul><li>margin size: 0,0 mm </li></ul><ul><li>3 local recurrences elsewhere in the kidney </li></ul><ul><li>No local recurrence at the level of the enucleation </li></ul><ul><li>Carini et al, Eur.Urol., 2006 </li></ul>44
    45. 45. Enucleation with ablation of the tumour base <ul><li>97 patients, only 1 local recurrence </li></ul><ul><li>A.Kutikov et al. BJU Int 2008: 102; 699-691 </li></ul><ul><li>Experts’ Editorial comment: </li></ul><ul><li> pure blunt TE, without the need to coagulate </li></ul><ul><li>A. Minervini et al. Eur Urol 2008: 54; 1347-1444 </li></ul>
    46. 46. Positive Surgical Margins Oncological Outcomes <ul><li>Positive margins ≠ adverse prognosis </li></ul><ul><li>Vigilant monitoring </li></ul><ul><li>O. Yossepowitch et al. (from MSKCC), J Urol 2008: 179; 2158-2163 </li></ul>46
    47. 47. WHAT ABOUT LARGER TUMORS ? 47
    48. 48. OPEN PARTIAL NEPHRECTOMY SURVIVAL vs. TUMOR DIAMETER 0 12 24 36 48 60 72 84 96 108 120 < 4 cm 310 PATS. > 4 cm 175 PATS. Months Ca. specific survival % HAFEZ, J.UROL. 162:1930, 1999 48 0 20 40 60 80 100
    49. 49. T1b Midpole Wedge to Enucleation 49
    50. 50. Larger Tumors : NSS <ul><li>Homburg : 69 elective NSS >4cm </li></ul><ul><li>Stockle, Eur.Urol. 2006 </li></ul><ul><li>Florence : 71 simple enucleations 4-7cm </li></ul><ul><li>Carini, J.Urol. 2006 </li></ul><ul><li>Mayo and MSKCC : 1159 T1b </li></ul><ul><li>Thompson, J.Urol. 2009 </li></ul><ul><li>Mayo Clinic : 69 stage T2 or greater </li></ul><ul><li>Breau, J.Urol. 2010 </li></ul>50
    51. 51. cT1b Partial Nephrectomy <ul><li>71 patients mean tumor size 4 - 7 cm </li></ul><ul><li>mean follow-up 74 months </li></ul><ul><li>PURE ENUCLEATION </li></ul><ul><li>margin size: 0,0 mm </li></ul><ul><li>3 local recurrences: </li></ul><ul><li>- 1 kidney recurrence: second partial Nx </li></ul><ul><li>- 2 local recurrence with M+ </li></ul><ul><li>5 and 8 y CSS = 85.1 and 81.6% </li></ul>Carini et al., J.Urol.,2006 51
    52. 52. T1b - T3a Upper Pole 52
    53. 53. Conclusions on NSS for T1b <ul><li>- Surgically feasible </li></ul><ul><li>Local cancer control good </li></ul><ul><li>Cancer specific survival is OK </li></ul><ul><li>Prognosis is defined by M+ </li></ul>Note: EAU ‘08, Patard: NSS to be systematically considered regardless of size 53
    54. 54. WHAT ABOUT CENTRAL TUMORS ? 54
    55. 55. Centrally located tumors NSS ? Rad.Nx 55
    56. 56. Intra-operative Ultrasound 56
    57. 57. Planning intra-renal tumor 57
    58. 58. Hilar (A-V) Clamping Surface Cooling 58
    59. 59. T1a Intrarenal Enucleation 59
    60. 60. WHAT ABOUT MULTIFOCAL TUMORS ? 60
    61. 61. And Multifocal RCC ? 60
    62. 62. 61
    63. 63. Open Partial Nephrectomy <ul><li>From controversial to well accepted </li></ul><ul><li>Allows difficult resections with low morbidity </li></ul><ul><li>Intra-operative ultrasound easily applicable </li></ul><ul><li>Cooling, clamping, etc. no technical problems </li></ul><ul><li>Kidney closure mostly easily achieved, if not hemostatic techniques are easily applied </li></ul><ul><li>Duration of surgery is very short </li></ul><ul><li>Cost for technical tools very low </li></ul>62
    64. 64. Partial Nephrectomy (Cleveland Clinic) 0 50 100 150 200 250 1995 1996 1997 1998 2000 2001 2002 2003 2004 Open Laparoscopic I . GILL, AAGUS, 2006 63
    65. 65. Lap. or Open Partial Nx? <ul><ul><li>LPN (at expert centres) compares to OPN </li></ul></ul><ul><ul><ul><li>- Equal short and long-term outcomes </li></ul></ul></ul><ul><ul><ul><li>Decreasing complication profile </li></ul></ul></ul><ul><ul><ul><li>LPN to include most renal tumours hitherto reserved for OPN </li></ul></ul></ul><ul><ul><li>Larger LPN series needed </li></ul></ul><ul><ul><ul><li>Longer follow-up </li></ul></ul></ul><ul><ul><ul><li>Possibly a prospective randomised trial </li></ul></ul></ul>64
    66. 66. Ischemic renal damage after NSS <ul><li>Warm ischemic time of ≥ 25 min caused </li></ul><ul><li>irreversible damage </li></ul><ul><li> Y. Funahaski et al. Eur Urol 2009: 55; 209-216 </li></ul><ul><li>Is renal warm ischemia over 30 minutes during laparoscopic partial nephrectomy possible? </li></ul><ul><li>Kidney damage during LPN when warm ischemia is > 30 min </li></ul><ul><li> F. Porpiglia et al. Eur Urol 2007: 52; 1170-1178 </li></ul>65
    67. 67. C L AMP ING ECHO 66
    68. 68. Hemostasis 67
    69. 69. Laparoscopic Partial Nephrectomy <ul><li>Expert centers reproduce open surgery </li></ul><ul><li>Hilar clamping, cooling, intraoperative ultrasound…all have been developed </li></ul><ul><li>Hemostasis and warm ischemia are the most important issues </li></ul><ul><li>The complication rate is higher than that of open surgery </li></ul><ul><li>Open Partial Nx remains the gold standard </li></ul>68
    70. 70. Management of Renal Tumors (JOHNS HOPKINS) 1998 2000 2001 1999 1997 2005 0 40 60 80 100 20 ORN OPN LRN LPN LRA PRA % PEMPONGKOSOL, BJUInt 98:751, 2006 2002 2003 2004 1996 1995 1994 1993 1992 1991 1621 PATIENTS Open Radical Lap.Radical Open Partial Lap.Partial RFA WW ? 69
    71. 71. WHAT ABOUT ABLATIVE THERAPIES ? 70
    72. 72. <ul><li>“ The best Focal Therapy for RCC … is Surgery” </li></ul>H.Van Poppel, Focal Therapy Meeting Amsterdam, 2009 71
    73. 73. Energy ablative therapies <ul><li>Thermal ablation : cryoablation and RFA </li></ul><ul><ul><li>Reasonable option for small (< 3 cm) low grade RCC in frail patients, who are not candidates for AS and who accept long-term radiographic surveillance </li></ul></ul><ul><li>Percutaneous tumour core biopsy </li></ul><ul><li>prior to ablation </li></ul><ul><li>Posttreatment biopsies </li></ul><ul><ul><li>When recurrence or incomplete ablation is suspected </li></ul></ul><ul><li>Minimal impact on renal function </li></ul>72
    74. 74. Percutaneous RFA 73
    75. 75. RFA 74
    76. 76. Laparoscopic Cryoablation 75
    77. 77. PERCUTANEOUS CRYO J. RICHIE, BRIGHAM, BOSTON 76
    78. 78. HIFU 20-40 W/cm 2 1600-2000 W/cm 2 DEPT. UROLOGY, UNIVERSITY OF VIENNA Still experimental 77
    79. 79. Energy ablative therapies <ul><li>At this time </li></ul><ul><ul><li>Insufficient data to compare Cryo/RFA </li></ul></ul><ul><ul><li>Ablation reserved for carefully selected </li></ul></ul><ul><ul><li>high surgical risk pts with SRMs < 4 cm (Grade C) </li></ul></ul><ul><li>Other minimally invasive techniques </li></ul><ul><ul><li>Use of HIFU, radiosurgery, MWT, LITT and PCU should be considered experimental </li></ul></ul>HIFU:High Intensity Focused Ultrasound LITT: Laser Interstitial Thermal Therapy MWT: Microwave Thermotherapy PCU: Pulsed Cavitational Ultrasound 78
    80. 80. RFA and CRYO <ul><li>SAFE AND LOW MORBIDITY IN LOW RISK, PERIPHERAL TU. < 3cm </li></ul><ul><li>Can be repeated </li></ul><ul><li>LESS RELIABLE THAN (MORE INVASIVE) PARTIAL NEPHRECTOMY </li></ul><ul><li>Not experimental, but developmental </li></ul>79
    81. 81. Renal Cancer Treatment Kim, J Urol ‘03 McDougall, J Urol ‘96 Corman, Br J Urol ‘00 Lotan, Br J Urol ‘05 Kercher, Surg End ‘03 80 Rad Nx Open Part.Nx Lap Part.Nx Ablation Morbidity 15% 16% 20% 2-6% Recovery 35 days 33 days 12 days 1 day Mortality 2% 1.6% <1% <0.5% Hospital Stay 5 days 3 days 1.9 days 0.5-1 day Cost $31,000-35,000 $26,000-32,000 $26,000-32,000 $5,000-10,000
    82. 82. Conclusion <ul><li>Increasing number of small renal masses are diagnosed </li></ul><ul><li>1/2 renal tumours are < 4cm at detection </li></ul><ul><li>If nephrectomy is indicated, laparoscopic radical nephrectomy is standard care in T1 - T2 tumours </li></ul><ul><li>NSS is an established treatment in tumors < 4cm, in 4-7 cm in expert centers in selected cases </li></ul><ul><li>Open PN is still standard care – laparoscopic PN should be limited to high volume/experienced centers </li></ul><ul><li>Radical nephrectomy in T1-T2 tumours will increase the risk of renal insufficiency with time compared to NSS </li></ul><ul><li>Minimal invasive modalities could be considered in elderly patients not suitable for PN </li></ul>81

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