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Nephron sparing surgery per
masse sino a 7cm: una realtà?
L. Cindolo
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98.4%/97.5%98.4%/97.5%48/4148/41Barbalias GA et al. Barbalias GA et al.
J Surg Oncol 1999J Surg Oncol 1999
96%/96%96%/96%21/1921/19D’Armiento M et al. Br J Urol 1997D’Armiento M et al. Br J Urol 1997
91.2%/98%91.2%/98%125/108125/108Belldegrun A et al. Belldegrun A et al.
J Clin Oncol 1999J Clin Oncol 1999
97.8%/95.5%97.8%/95.5%
95%/95%95%/95%
97%/100%97%/100%
89%/89%89%/89%
Soprav Tumore Soprav Tumore Specif. a 5 aaSpecif. a 5 aa
183/79183/79Lee CT et al. J Urol 2000Lee CT et al. J Urol 2000
216/369216/369Becker F et al Eur Urol 2006Becker F et al Eur Urol 2006
42/4642/46Butler BP et al. Urology 1995Butler BP et al. Urology 1995
209/185209/185Lerner SE et al. J Urol 1996Lerner SE et al. J Urol 1996
Paz Nefrect/NSS Paz Nefrect/NSS AutoriAutori
Nefrectomia radicale vs Nefrectomia radicale vs NSSNSS
844/844/847847 89-98.4% 89-98.4%
vs vs 89-100%89-100%
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Trattamento forme localizzate NSS
Van Poppel H, et al. Eur Urol. 2007;51(6):1606-15. 10 centri, 541 procedure, randomizzato centrale
EORTC, indicazioni strette ed omogenee NSS o RN in <=5 cm, T1-T2N0 M0,
rene controlaterale normale Risultati sovrapponibili,
NSS maggiore sanguinamentoPrima dimostrazione effettiva che la
nefrectomia parziale è una procedura sicura e fattibile.
Risultati oncologici a lunga distanza attesi.
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4
3 centri, 1800 procedure NSS non randomizzate, open vs lap
OPN resta il gold standard per le masse più complesse
LAP ottima alternativa, in masse piccole minore sanguinamento, centri con esperienza
Risultati oncologici e funzionali identici*Risultati oncologici e funzionali identici*
Gill IS, et al. J Urol. 2007;178(1):41-6.*Gill IS, et al. J Urol. 2007 AUA abstr #496
*Huang WC, et al. J Urol. 2007 AUA abstr #493*Ficarra V. Eur Urol 2007;51;593-595
Trattamento forme localizzate NSS
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Qualche domanda..... vi ricordate?
• Urology. 1999 Dec;54(6):988-93.
• Nephron-sparing surgery for renal cell carcinoma-is tumor size a suitable parameter for indication?
• Miller J et al.
• Only tumors smaller than 2.5 cm should be considered suitable for nephron-sparing surgery in patients eligible for elective surgery. In patients in whom nephron-sparing surgery is imperative, even tumors between 2.5 and 4 cm appear to be suitable. In patients requiring extensive resection, however, the risk of local recurrence seems to be higher because of the higher incidence of multifocality.
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Qualche domanda..... vi ricordate?
• Eur Urol 49 (2006) 952–954
• Expanding the Indications for Elective Partial Nephrectomy: Is this Advisable?
• Campbell SC, Novick AC
• Taking all of these considerations into account, particularly the small but real risk of local recurrence and the potential functional advantages of partial nephrectomy, our current perspective is that partial nephrectomy can be considered for some patients with T1b tumour and a normal contralateral kidney, presuming careful and sensible patient selection.
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5.1.2.2 RaccomandazioniLa NSS può essere proposta ed eseguita anche per RCC tra 4 e 7 cm di dimensioni massime in
centri di riferimento e su pazienti adeguatamente selezionati
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Eur Urol 2008, 53; 691-693
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Terapia chirurgica per RCC
2010
2007
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Le raccomandazioni EAU 2010
2007 2010
T1a Open NSS Open NSS
T1b-T2 VLP RN VLP RN
T3-4 Open RN Open RN
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Terapia chirurgica per RCC
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Trend tumor size
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BJU Int 2008. Joniiau et al.
Outcome of nephron-sparing surgery for T1b renal cell carcinoma 67 OPN (39% necessità)50% ischemia, mean WIT 14min, mean tum size 4.5
4 marg positivi: nessuna recidiva localeTasso di complicanze complessivo: circa 16%Ematoma postoperatorio 6%; Difetto cicatrizzazione 3%Perdita di urina dal drenaggio 0%;Polmonite 3;FA 3%;Colecistite <1%;Ileo <1%.
.... Ultime notizie.....
5-year PFS, CSS and OS 88%, 99% 72%
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J Urol 2009. Peycelon et al.
Long-term outcomes after nephron sparing surgery for renal cell carcinoma larger than 4 cm.
61 Pazienti T1b OPN
WIT 26 (range 10–50 min)Tasso di complicanze complessivo: circa 36%Margini positivi circa 7%
.... Ultime notizie.....
5- and 10-year CSS81% and 78%
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Thompson et al. J Urol 2009
1159 pts con 4–7 cm RCC, unilaterale, singolo, corticale
873 RN vs 286 OPN
no differenze in OS fra gruppi (p 0.8)
RN hazard ratio 2.16 morte per RCC vs PN
Pahernik et al. J Urol 2008
372 T1a vs 102 T1b elective OPN
5 years Estimated CSS 97.9 and 95.8% (P<0.58) 5 years Local recurrence-rate-free 98.5 and 98.3% (P<0.28)
.... Ultime notizie.....
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Qualche domanda..... avete letto?La chirurgia renale conservativa eseguita per via laparoscopica è da considerare una tecnica fattibile ma complessa per la difficolà di mantenere il T di ischemia calda inferiore a 30 min dovuta alla
difficoltà nell’eseguire una emostasi adeguata e suture intracorporee.
Se caratteristiche di Se caratteristiche di imagingimaging
--Diametro max < 4 cmDiametro max < 4 cm
- tipo di crescita espansivatipo di crescita espansiva
- sede centrale, periilaresede centrale, periilare
- Sviluppo endorenale > Sviluppo endorenale > 50%50%
NSS OPENNSS OPEN
Se caratteristiche di Se caratteristiche di imagingimaging
-D max della lesione < 4 cmD max della lesione < 4 cm
- tipo di crescita espansivatipo di crescita espansiva
- sede perifericasede periferica
- Sviluppo esofitico ≥ 50%Sviluppo esofitico ≥ 50%
NSS VLPNSS VLP
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Urology 2008, 73; 481
Spesso casi aneddotici
Nefrectomie di necessità
Serie limitate
Nessun confronto prospettico
Altissima esperienza VLP
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>4cm vs <4 cm
Tasso di complicanze: 33.3% vs 11.6% p = 0.006
T ospedalizzazione: 4.5 vs 3.2 gg p=0 .055
Elective laparoscopic partial nephrectomy in patients with tumors
>4 cm.Rais-Bahrami S, et al.
Urology 2008;72(3):580-3
Complicanze NSS Lap in RCC 4-7 cmComplicanze NSS Lap in RCC 4-7 cm
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RCC con diametro > 4 cm si comportano in modo piu’ aggressivo dei pT1a e sono associati a
prognosi probabilmente peggiore ma la sopravvivenza tumore specifica non e’ in
relazione al tipo di chirurgia adottata (NSS vs RN)
Frequenza di recidive locali stabile nel tempo e nelle serie indipendente dalla strategia
chirurgica adottata
Considerazioni NSS verso Considerazioni NSS verso l'aumento delle indicazionil'aumento delle indicazioni
! ma assenza di studi prospettici
! ma assenza di gruppi omogenei (spesso diametri medi 4,.... cm)
! spesso follow-up intorno ai 4-5 anni
! complicanze aumentate se >4cm
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Confronti• Patard et al J Urol 2004• 7 centres EU+ USA• PN (379) and RN (1075)
PNLoc Dist
RNLoc Dist
T1a 0.8% 2.4% 0.6% 4.6%
T1b 3.6% 7.1% 2.3% 15.6%
p = 0.6
p = 0.5
CSS between PN and RN not significantly different ( p = 0.8)
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Margini chirurgiciEAU … a minimal tumor-free surgical margin of healthy renal
parenchyma surrounding the resected tumor, without specifying the exact minimum thickness of the healthy parenchyma to be taken
Quale ruolo prognostico dei PSM?
Bensalah et al. solo tumor location (centrale vs periferica) e indicazione (imperativa vs elettiva) predittori di local recurrence.
Bernhard et al PSM , diam >4cm e bilateralità predittore indipendente di recidiva ipsilaterale dopo NSS
Carini et al. proposta semplice enucleazione più di enucleoresezione
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Margini chirurgici
Patients with PSMs are candidates for a careful watchful waiting program, thus avoiding RN.
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Margini chirurgiciIn summary, ….
1)… a 1-cm margin of healthy parenchymatous rim throughout the specimen is not always possible
2)… a wide margin is not needed3)…often be limited to an enucleation
Karim Touijer et al. Eur Urol 2009;2:214-222
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VLP
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Robot
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oltre
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oltre
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oltre
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Expanding indications