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Concept: Nephrectomy

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BACKGROUND: To evaluated the prognostic significance of the pre-operative C-reactive protein (CRP) serum level in patients with renal cell cancer (RCC). METHODS: We evaluated 1,161 RCC patients with complete patient and tumour specific characteristics as well as information about their pre-operative CRP-level, who had undergone either radical nephrectomy or nephron-sparing surgery at two German high-volume centres (University Hospitals of Hannover and Ulm). The mean follow-up was 54 months. RESULTS: The CRP-level, stratified to three subgroups (CRP <= 4, 4--10, and >10 mg/l), correlated significantly with tumour stage (p < 0.001), the risk of presenting nodal disease (2.1, 3.1, and 16.4%) and distant metastasis (2.9, 8.6, and 30.0%; p < 0.001). The Kaplan-Meier 5-year cancer specific survival (CSS) rates were 89.4, 77.9, and 49.5%, respectively (p < 0.001). Multivariate analysis identified CRP as an independent prognosticator for CSS as well as overall survival (p < 0.001). Patients with a CRP of 4--10 and >10 mg/l had a 1.67 and 2.48 fold higher risk of dying due to their RCC compared to those with a pre-operative CRP <=4 mg/l, respectively. CONCLUSIONS: A high preoperative serum CRP level is an independent predictor of poor survival in patients with RCC. Its routine use could allow better risk stratification and risk-adjusted follow-up of RCC patients.

Concepts: Cancer staging, Kidney cancer, Renin, Nephrectomy, Lung cancer, Renal cell carcinoma, C-reactive protein, Cancer

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The role of cytoreductive nephrectomy (CN) in metastatic renal cell carcinoma (mRCC) has become unclear since the introduction of targeted therapies (TT). We sought to evaluate contemporary utilization rates of CN and to examine the survival benefit of CN compared with non-CN patients treated with TT.

Concepts: Nephrectomy, Lung cancer, Oncology, Cancer, Renal cell carcinoma

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AIM: The renal medulla plays an important role in the control of water and salt balance by the kidney. Outer medullary descending vasa recta (OMDVR) are microscopic vessels providing blood flow to the renal medulla. Data on the physiology of human vasa recta are scarce. Therefore we established an experimental model of human single isolated perfused OMDVR, and characterized their vasoactivity in response to angiotensin II and to pressure changes. Methods: Human non-malignant renal tissue was obtained from patients undergoing nephrectomy due to renal cell carcinoma. OMDVR were dissected under magnification and perfused using concentric microscopic pipettes. The response of OMDVR to angiotensin II and pressure changes was quantified in serial pictures. All patients signed a consent form prior to surgery. Results: OMDVR constricted significantly after bolus applications of angiotensin II. OMDVR constriction to angiotensin II was also concentration dependent. Response to luminal pressure changes were different according to the diameter of vessels, with larger OMDVR constricting after pressure increase, while smaller ones did not. Conclusion: OMDVR constrict in response to angiotensin II and pressure increases. Our results show that OMDVR may take part in the regulation of medullary blood flow in humans. Our model may be suitable for investigating disturbances of renal medullary circulation in human subjects. Acta Physiologica © 2013 Scandinavian Physiological Society.

Concepts: Vasa recta, Endocrine system, Renin-angiotensin system, Blood pressure, Nephrectomy, Physiology, Loop of Henle, Kidney

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To describe a case of robotic assisted radical nephrectomy with level III retrohepatic vena caval tumor thrombectomy (11cm) and extended retroperitoneal lymph node dissection (RPLND) for renal cell carcinoma (RCC).

Concepts: Squamous cell carcinoma, Lymph, Lymph node, Nephrectomy, Cancer, Lymphadenectomy, Renal cell carcinoma, Kidney

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Prolonged operative time (ORT) is often considered a drawback to minimally invasive surgery (MIS) due to increased morbidity. Limited data exist comparing long laparoscopic ORT to similar or shorter open ORT. This study aims to identify ORT when a minimally invasive procedure becomes inferior to its open counterpart. Minimally invasive and open total and partial nephrectomies, and nephroureterectomies were identified in the National Surgical Quality Improvement Program (NSQIP) from 2005-2012. Procedures were split into open and MIS and stratified into 4 ORT groups: 0-90 minutes, 91 minutes-3 hours, 3-6 hours, and ≥6 hours. 30-day mortality and morbidity were analyzed. Univariate analysis was performed using chi-square and Fishers Exact tests. Significant univariate results were tested using stepwise logistic regression, controlling for demographics, comorbidities, and preoperative treatments. 14,813 patients were identified. Both partial and total minimally invasive kidney procedures had significantly improved outcomes compared to open counterparts of similar ORT. In the total group, MIS had a lower rate of SSI’s, sepsis, pneumonia, return to OR and length of stay when compared to open procedures of the same duration. Length of hospital stay decreased in MIS regardless of operative time, except when comparing minimally invasive cases longer than 6 hours to open cases less than 90 minutes. Transfusion rates also significantly decreased in minimally invasive total nephrectomies. In the partial group, similar outcomes were seen with length of stay and infectious outcomes. Interestingly, transfusion was decreased in the open partial nephrectomy group when comparing cases less than 90 minutes to minimally invasive partials lasting 3-6 hours; otherwise there was no significant correlation with transfusion. Minimally invasive operations are less morbid than open operations of similar ORT. Longer and likely more complex laparoscopic procedures continue to provide a benefit when compared to shorter and possibly less complex open procedures. These data should be considered during a surgeon’s pre-operative and operative decision-making.

Concepts: Kidney, Nephrectomy, Minimally-invasive, Invasive, Open surgery, Minimally invasive, Invasiveness of surgical procedures, Surgery

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Primary mucinous adenocarcinoma of the renal pelvis is easily misdiagnosed and it was rarely reported in the literature. We describe in this study a case of 40-year-old male patient presented with right lumbar pain of one year duration and elevated level of carcinoembryonic antigen (CEA). After a series of imaging examinations, the initial impression was a cystic renal cell carcinoma. Right radical nephrectomy was performed on the patient. The postoperative pathological examination indicated a primary mucinous adenocarcinoma of enteric type of the renal pelvis. After surgical removal of the tumor, an immunotherapy was administrated to prevent recurrence. The patient survives upon this report. A review of pertinent literature is also presented.

Concepts: Carcinoembryonic antigen, Hospital, Examination, Anatomical pathology, Cancer, Nephrectomy, Kidney, Renal cell carcinoma

24

In adult tuberous sclerosis complex (TSC) patients, renal complications are the leading cause of death. Beginning in childhood, up to 80 % of patients develop renal angiomyolipoma characterized by a size-dependent risk of life-threatening bleeding. After discovery of the two causative genes, TSC1 and TSC2, and the role of mammalian target of rapamycin (mTOR) regulation in the pathogenesis of TSC, an increasing number of clinical studies evaluating mTOR inhibition in TSC patients have shown impressive results in many organ manifestations, such as brain, lung, and kidney. For renal angiomyolipoma, mTOR inhibitor treatment fundamentally changed the approach from preventive embolization or even partial nephrectomy to everolimus treatment in order to preserve kidney function.

Concepts: Hamartoma, Nephrectomy, Function, TSC2, Angiomyolipoma, TSC1, Kidney, Tuberous sclerosis

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To assess the risk factors of positive surgical margins (PSM) and the influence of margin status on recurrence in pT1 clear cell renal cell carcinoma (RCC) following partial nephrectomy (PN).

Concepts: Squamous cell carcinoma, Surgical oncology, Kidney, Nephrectomy, Renal cell carcinoma

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Contrast-enhanced CT is necessary before donor nephrectomy and is usually combined with a Tc-99m-mercapto-acetyltriglycine (MAG3) scan to check split renal function (SRF). However, all transplant programs do not use MAG3 because of its high cost and exposure to radiation. We examined whether CT volumetry of the kidney can be a new tool for evaluating SRF.

Concepts: Nephrectomy, Renal failure, Renal physiology, Renal cortex, Nephrology, Parenchyma, Kidney

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The incidence of kidney cancer has increased in the majority of countries worldwide, and this disease has relatively high lethality. For many years, the Slovak Republic has been among the countries with the highest kidney cancer incidence, in particular in 2012 (according to global estimated values) in both genders, although mainly in females. In the last few years, the Czech Republic has had the highest incidence of kidney cancer worldwide. The use of imaging techniques such as ultrasound and computerized tomography has increased the detection of asymptomatic renal cell cancer. Etiological factors include lifestyle factors such as smoking, obesity, and hypertension. Nephrectomy and partial nephrectomy are the standard treatments. Locally confined tumors in stage T1 should be treated with kidney-preserving surgery. Minimally invasive surgery is often possible as long as the surgeon has the requisite experience. For patients with metastases, overall and progression-free survival can be prolonged by pharmacotherapy with VEGF and mTOR inhibitors. The resection or irradiation of metastases can be a useful palliative treatment for patients with brain or osseal metastases that are painful or increase the risk of fracture. Minimally invasive surgery and new systemic drugs have expanded the therapeutic options for patients with renal cell carcinoma. The search for new predictive and prognostic markers is now in progress.Key words: kidney cancer - epidemiology - risk factors - pathology - diagnosis - therapy The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers.Submitted: 2. 12. 2016Accepted: 3. 1. 2017.

Concepts: Kidney, Renin, Czechoslovakia, Surgery, Oncology, Nephrectomy, Cancer, Renal cell carcinoma