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Nephron sparing surgery for
multifocal RCC
Gennady Bratslavsky, M.D.
Professor and Chairman
Department of Urology
Upstate Medical University
Syracuse, NY
Disclosures
No relevant financial disclosures
The Urologic Oncology Branch at the
National Cancer Institute
Upstate Department of Urology 2011
Upstate Department of Urology 2012
Upstate Department of Urology 2013
Upstate Department of Urology 2014
Upstate Department of Urology 2015
Upstate Department of Urology 2016
Upstate Department of Urology 2017
Outline
1. Prevalence of multifocal RCC
2. Surgical and functional outcomes
3. Oncologic outcomes
Bratslavsky and Linehan.
Nature Rev Urol. 2010
How Multifocal is Multifocal?
VHL: up to 600 tumors/ kidney (Walther, J Urol 1995)
HPRC: up to 3400 tumors/ kidney (Ornstein, J Urol 2000)
BHD: tens of tumors/ kidney (Pavlovich, Am J Surg Path 2002)
Unknown genes: tens of tumors resected
Renal tumors in VHL patients
Multifocal disease
What should we do?
Bilateral renal cell carcinoma in von
Hippel-Lindau syndrome:
treatment with staged bilateral
nephrectomy and hemodialysis
` Fetner CD, Barilla DE, Scott T, Ballard J, Peters P
1977
J Urol. 1977 Apr;117(4):534-6
Survival free of local tumor
recurrence following NSS
Steinbach et al, JU 1995
If you wait long enough… Recurrence
Novick et al, J Urol 1992
Steinbach et al, J Urol 1995
Walther et al, J Urol 1995
Belldegrun et al, JCO 1999
Hafez et al, J Urol 1999
Ansari et al, Int J Nephrol 2003
Johnson et al, J Urol 2008
Bratslavsky et al, J Urol 2008
Long-term management of recurrences
NEPHRECTOMY OR
REPEAT INTERVENTION?
Why save these kidneys?
1. Renal insufficiency is bad (Go et al, NEJM 2004)
2. Dialysis is not benign (Rocco et al, Ann Intern Med 2006)
3. Transplant (5 year graft survival is 75-80%)
(Lin et al, Clin Transplant 2006)
Go et al, NEJM 2004
Rocco et al, Ann Intern Med 2006
Lin et al, Clin Transplant 2006
Repeat Partial Nephrectomy
Salvage Partial Nephrectomy
Comparison of NCI Partial Nephrectomy Series
Kowalczyk et al, J Urol 2009
Renal functional outcome
Oncologic Outcomes Procedure Median F/U
(months)
Metastasis-Free
Survival (%)
Overall
Survival (%)
Initial partial
nephrectomy
30
100% 100%
Partial for resection of
20 or more tumors
50 92% 92%
Repeat partial
nephrectomy
56 94% 98%
Repeat partial on a
solitary unit
69 95% 90%
Salvage partial
nephrectomy
25 100% 100%
• 128 patients with median follow up 16 years (10-40)
• RCC specific survival 97%, Overall survival 88%,
• 95% avoided dialysis
• Median time to re-intervention 6.7 years
0
20000
40000
60000
80000
100000
120000
140000
160000
180000
0 0.5 1 1.5 2 2.5 3 3.5 4 4.5
Co
st (
tho
usa
nd
s)
Time (years)
Costs vs time
Reoperative Renal Surgery
Dialysis
Conclusions
Recurrence is not always a surgeon’s failure
Reoperative renal surgery may become more common as
urologic surgeons embark on more renal preservation
Save kidneys even in the setting of mutifocality
Fasten your seat belt for these operations