Der Urologe

, Volume 57, Issue 3, pp 280–284 | Cite as

Standardoperationen bei kleinen Nierentumoren (<4 cm)

  • S. K. Frees
  • R. Mager
  • H. Borgmann
  • W. Jäger
  • C. Thomas
  • A. Haferkamp
Leitthema
  • 49 Downloads

Zusammenfassung

Hintergrund

In den letzten Jahren entwickelten sich eine Vielzahl neuer Therapieoptionen für die Behandlung kleiner Nierentumoren (mit einem Durchmesser < 4 cm). Hier reicht die Bandbreite von der aktiven Überwachung bis hin zu ablativen Verfahren. Welches konkrete Vorgehen für den einzelnen Patienten das beste Outcome bringt, bleibt bis zum heutigen Zeitpunkt unklar und muss anhand weiterer Studien geklärt werden. Bis dato verbleibt die operative Therapie als Goldstandard. Während früher die Nephrektomie als Therapie der Wahl galt, sollte heute für alle Patienten ein nierenerhaltendes Verfahren angestrebt werden.

Ergebnisse

Neben der offenen Nierenteilresektion, die immer noch in den Leitlinien als Standardprozedur empfohlen wird, zeigte sich in den letzten Jahren ein Trend zum vermehrten Einsatz minimal-invasiver Techniken – auch bei nierenerhaltendem Vorgehen. Es scheint, als würden diese Techniken mit gewissen Vorteilen wie geringerem Blutverlust einhergehen. Für das robotisch assistierte Verfahren konnten die nachteiligen Ergebnisse des laparoskopischen Verfahrens mit längerer warmer Ischämie, längeren Operationszeiten und postoperativen Einschränkungen der Nierenfunktion nicht gezeigt werden. Bei entsprechender Expertise des Operateurs können auch minimal-invasive Verfahren angeboten werden. Unabhängig von der Wahl des Verfahrens sollten die komplette Resektion des Tumors sowie eine möglichst kurze Ischämiezeit im Vordergrund stehen.

Schlüsselwörter

Nephrektomie, radikale Robotisch assistierte Verfahren Laparoskopische Verfahren Minimal-invasive Verfahren Resektion 

Standard surgery for small renal masses (<4 cm)

Abstract

Background

Several new treatment strategies have emerged in the treatment of small renal masses (<4 cm in diameter). Active surveillance and ablative techniques have been introduced but it remains unclear which patients will benefit the most from these new treatment options. A surgical approach remains standard of care. In recent decades, radical nephrectomy has been replaced by nephron-sparing surgery for the management of small renal masses.

Results

In addition to the open partial nephrectomy, which is considered the standard approach, the number of surgeries performed using minimally invasive techniques is increasing. Recent data show that there might be some benefits such as less blood loss. The disadvantages shown by laparoscopic partial nephrectomy such as prolonged warm ischemia, longer operation times, and postoperative renal impairment might be negligible for the robotic approach. Therefore, current guidelines allow these approaches in addition to open partial nephrectomy if sufficient surgical expertise is given.

Keywords

Nephrectomy, radical Robotic surgical procedures Laparoscopic surgical procedures Minimally invasive surgical procedures Resection 

Notes

Einhaltung ethischer Richtlinien

Interessenkonflikt

S.K. Frees, R. Mager, H. Borgmann, W. Jäger, C. Thomas und A. Haferkamp geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

Literatur

  1. 1.
    American Cancer Society (2015) Cancer Facts & Figures 2015Google Scholar
  2. 2.
    Benway BM, Bhayani SB, Rogers CG et al (2009) Robot assisted partial nephrectomy versus laparoscopic partial nephrectomy for renal tumors: a multi-institutional analysis of perioperative outcomes. J Urol 182:866–872CrossRefPubMedGoogle Scholar
  3. 3.
    Blom JH, Van Poppel H, Marechal JM et al (2009) Radical nephrectomy with and without lymph-node dissection: final results of European organization for research and treatment of cancer (EORTC) randomized phase 3 trial 30881. Eur Urol 55:28–34CrossRefPubMedGoogle Scholar
  4. 4.
    Butler BP, Novick AC, Miller DP et al (1995) Management of small unilateral renal cell carcinomas: radical versus nephron-sparing surgery. Urology 45:34–40 (discussion 40–31)CrossRefPubMedGoogle Scholar
  5. 5.
    Capitanio U, Suardi N, Matloob R et al (2014) Extent of lymph node dissection at nephrectomy affects cancer-specific survival and metastatic progression in specific sub-categories of patients with renal cell carcinoma (RCC). BJU Int 114:210–215CrossRefPubMedGoogle Scholar
  6. 6.
    Choi JE, You JH, Kim DK et al (2015) Comparison of perioperative outcomes between robotic and laparoscopic partial nephrectomy: a systematic review and meta-analysis. Eur Urol 67:891–901CrossRefPubMedGoogle Scholar
  7. 7.
    Chow WH, Devesa SS, Warren JL et al (1999) Rising incidence of renal cell cancer in the United States. JAMA 281:1628–1631CrossRefPubMedGoogle Scholar
  8. 8.
    D’armiento M, Damiano R, Feleppa B et al (1997) Elective conservative surgery for renal carcinoma versus radical nephrectomy: a prospective study. Br J Urol 79:15–19CrossRefPubMedGoogle Scholar
  9. 9.
    Desai MM, De Castro Abreu AL, Leslie S et al (2014) Robotic partial nephrectomy with superselective versus main artery clamping: a retrospective comparison. Eur Urol 66:713–719CrossRefPubMedGoogle Scholar
  10. 10.
    George AK, Herati AS, Srinivasan AK et al (2013) Perioperative outcomes of off-clamp vs complete hilar control laparoscopic partial nephrectomy. BJU Int 111:E235–E241CrossRefPubMedGoogle Scholar
  11. 11.
    Gill IS, Eisenberg MS, Aron M et al (2011) “Zero ischemia” partial nephrectomy: novel laparoscopic and robotic technique. Eur Urol 59:128–134CrossRefPubMedGoogle Scholar
  12. 12.
    Gill IS, Kavoussi LR, Lane BR et al (2007) Comparison of 1,800 laparoscopic and open partial nephrectomies for single renal tumors. J Urol 178:41–46CrossRefPubMedGoogle Scholar
  13. 13.
    Gong K, Zhang N, He Z et al (2008) Multilocular cystic renal cell carcinoma: an experience of clinical management for 31 cases. J Cancer Res Clin Oncol 134:433–437CrossRefPubMedGoogle Scholar
  14. 14.
    Gratzke C, Seitz M, Bayrle F et al (2009) Quality of life and perioperative outcomes after retroperitoneoscopic radical nephrectomy (RN), open RN and nephron-sparing surgery in patients with renal cell carcinoma. BJU Int 104:470–475CrossRefPubMedGoogle Scholar
  15. 15.
    Herr HW (2008) Surgical management of renal tumors: a historical perspective. Urol Clin North Am 35(4):543–549.  https://doi.org/10.1016/j.ucl.2008.07.010 CrossRefPubMedGoogle Scholar
  16. 16.
    Huang WC, Elkin EB, Levey AS et al (2009) Partial nephrectomy versus radical nephrectomy in patients with small renal tumors – is there a difference in mortality and cardiovascular outcomes? J Urol 181:55–61 (discussion 61–52)CrossRefPubMedGoogle Scholar
  17. 17.
    Jabaji R, Palazzi KL, Mehrazin R et al (2014) Determinants of renal functional decline after open partial nephrectomy: a comparison of warm, cold, and non-ischemic modalities. Can J Urol 21:7126–7133PubMedGoogle Scholar
  18. 18.
    Kane CJ, Mitchell JA, Meng MV et al (2004) Laparoscopic partial nephrectomy with temporary arterial occlusion: description of technique and renal functional outcomes. Urology 63:241–246CrossRefPubMedGoogle Scholar
  19. 19.
    Kaneko G, Miyajima A, Kikuchi E et al (2012) The benefit of laparoscopic partial nephrectomy in high body mass index patients. Jpn J Clin Oncol 42:619–624CrossRefPubMedGoogle Scholar
  20. 20.
    Kates M, Badalato GM, Pitman M et al (2011) Increased risk of overall and cardiovascular mortality after radical nephrectomy for renal cell carcinoma 2 cm or less. J Urol 186:1247–1253CrossRefPubMedGoogle Scholar
  21. 21.
    Kim SP, Abouassaly R (2016) Treatment of patients with positive margins after partial nephrectomy. J Urol 196:301–302CrossRefPubMedGoogle Scholar
  22. 22.
    Lane BR, Gill IS (2010) 7‑year oncological outcomes after laparoscopic and open partial nephrectomy. J Urol 183:473–479CrossRefPubMedGoogle Scholar
  23. 23.
    Lane BR, Russo P, Uzzo RG et al (2011) Comparison of cold and warm ischemia during partial nephrectomy in 660 solitary kidneys reveals predominant role of nonmodifiable factors in determining ultimate renal function. J Urol 185:421–427CrossRefPubMedGoogle Scholar
  24. 24.
    Lane BR, Tobert CM, Riedinger CB (2012) Growth kinetics and active surveillance for small renal masses. Curr Opin Urol 22:353–359CrossRefPubMedGoogle Scholar
  25. 25.
    Maclennan S, Imamura M, Lapitan MC et al (2012) Systematic review of perioperative and quality-of-life outcomes following surgical management of localised renal cancer. Eur Urol 62:1097–1117CrossRefPubMedGoogle Scholar
  26. 26.
    Marconi L, Desai MM, Ficarra V et al (2016) Renal preservation and partial nephrectomy: patient and surgical factors. Eur Urol Focus 2:589–600CrossRefPubMedGoogle Scholar
  27. 27.
    Marszalek M, Meixl H, Polajnar M et al (2009) Laparoscopic and open partial nephrectomy: a matched-pair comparison of 200 patients. Eur Urol 55:1171–1178CrossRefPubMedGoogle Scholar
  28. 28.
    Masson-Lecomte A, Yates DR, Hupertan V et al (2013) A prospective comparison of the pathologic and surgical outcomes obtained after elective treatment of renal cell carcinoma by open or robot-assisted partial nephrectomy. Urol Oncol 31:924–929CrossRefPubMedGoogle Scholar
  29. 29.
    Mellon MJ, Lucas SM, Kum JB et al (2013) A comparison of pathologic outcomes of matched robotic and open partial nephrectomies. Int Urol Nephrol 45:381–385CrossRefPubMedGoogle Scholar
  30. 30.
    Muramaki M, Miyake H, Sakai I et al (2013) Prognostic factors influencing postoperative development of chronic kidney disease in patients with small renal tumors who underwent partial nephrectomy. Curr Urol 6:129–135CrossRefPubMedGoogle Scholar
  31. 31.
    Porpiglia F, Bertolo R, Amparore D et al (2017) Nephron-sparing suture of renal parenchyma after partial nephrectomy: which technique to go for? Some best practices. Eur Urol Focus.  https://doi.org/10.1016/j.euf.2017.08.006 PubMedGoogle Scholar
  32. 32.
    Rais-Bahrami S, George AK, Herati AS et al (2012) Off-clamp versus complete hilar control laparoscopic partial nephrectomy: comparison by clinical stage. BJU Int 109:1376–1381CrossRefPubMedGoogle Scholar
  33. 33.
    Shah PH, Moreira DM, Okhunov Z, Patel VR, Chopra S, Razmaria AA, Alom M et al (2016) Positive surgical margins increase risk of recurrence after partial nephrectomy for high risk renal tumors. J Urol 196(2):327–334.  https://doi.org/10.1016/j.juro.2016.02.075 PubMedGoogle Scholar
  34. 34.
    Shikanov S, Lifshitz D, Chan AA et al (2010) Impact of ischemia on renal function after laparoscopic partial nephrectomy: a multicenter study. J Urol 183:1714–1718CrossRefPubMedGoogle Scholar
  35. 35.
    Smaldone MC, Kutikov A, Egleston BL et al (2012) Small renal masses progressing to metastases under active surveillance: a systematic review and pooled analysis. Cancer 118:997–1006CrossRefPubMedGoogle Scholar
  36. 36.
    Spaliviero M, Power NE, Murray KS et al (2017) Intravenous Mannitol versus placebo during partial nephrectomy in patients with normal kidney function: a double-blind, clinically-integrated, randomized trial. Eur Urol.  https://doi.org/10.1016/j.eururo.2017.07.038 PubMedGoogle Scholar
  37. 37.
    Steinestel J, Steffens S, Steinestel K et al (2014) Positive surgical margins in nephron-sparing surgery: risk factors and therapeutic consequences. World J Surg Oncol 12:252CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Sun M, Becker A, Tian Z et al (2014) Management of localized kidney cancer: calculating cancer-specific mortality and competing risks of death for surgery and nonsurgical management. Eur Urol 65:235–241CrossRefPubMedGoogle Scholar
  39. 39.
    Thompson RH, Atwell T, Schmit G et al (2015) Comparison of partial nephrectomy and percutaneous ablation for cT1 renal masses. Eur Urol 67:252–259CrossRefPubMedGoogle Scholar
  40. 40.
    Thompson RH, Hill JR, Babayev Y et al (2009) Metastatic renal cell carcinoma risk according to tumor size. J Urol 182:41–45CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Thompson RH, Lane BR, Lohse CM et al (2010) Every minute counts when the renal hilum is clamped during partial nephrectomy. Eur Urol 58:340–345CrossRefPubMedGoogle Scholar
  42. 42.
    Tugcu V, Bitkin A, Sonmezay E et al (2011) Transperitoneal versus retroperitoneal laparoscopic partial nephrectomy: initial experience. Arch Ital Urol Androl 83:175–180PubMedGoogle Scholar
  43. 43.
    Van Poppel H, Da Pozzo L, Albrecht W et al (2011) A prospective, randomised EORTC intergroup phase 3 study comparing the oncologic outcome of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma. Eur Urol 59:543–552CrossRefPubMedGoogle Scholar
  44. 44.
    Vricella GJ, Murray S, Boncher NA et al (2011) External validation of a model for tailoring the operative approach to minimally invasive partial nephrectomy. BJU Int 107:1806–1810CrossRefPubMedGoogle Scholar

Copyright information

© Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2018

Authors and Affiliations

  • S. K. Frees
    • 1
  • R. Mager
    • 1
  • H. Borgmann
    • 1
  • W. Jäger
    • 1
  • C. Thomas
    • 1
  • A. Haferkamp
    • 1
  1. 1.Klinik und Poliklinik für Urologie und KinderurologieUniversitätsmedizin MainzMainzDeutschland

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