|Year : 2021 | Volume
| Issue : 1 | Page : 9-11
Minimal invasive treatment of locally advanced renal cancer
Periklis Giannakis, Panagiotis Prodromos Papadopoulos, Panagiotis Mourmouris, Ioannis Varkarakis, Charalambos Deliveliotis
2nd Department of Urology, National Kapodistrian University of Athens, Sismanoglio General Hospital, Athens, Greece
|Date of Submission||30-Aug-2021|
|Date of Decision||20-Sep-2021|
|Date of Acceptance||09-Oct-2021|
|Date of Web Publication||15-Feb-2022|
2nd Department of Urology, National and Kapodistrian University of Athens, 1 Sismanogleiou Str Marousi, Athens
Source of Support: None, Conflict of Interest: None
Despite the progress in diagnosis and treatment, renal cancer still represents one of the deadliest malignancies of the urogenital tract. Surgically wise, one could certainly make the case that locally advanced renal cancer, especially with vena cava involvement, is the most challenging operable tumor. Conventionally, these patients have been operated with open approach. Nowadays, the contribution of advanced technology (both laparoscopy and robotics) as well as the increasing experience of the surgeons has led to the usage of minimal invasive (MI) techniques in increasingly complex cases. The purpose of this review is to highlight the most important data in the literature as far as usage of MI techniques in the treatment of locally advanced RC is concerned.
Keywords: Laparoscopy, locally advanced renal cancer, robotics
|How to cite this article:|
Giannakis P, Papadopoulos PP, Mourmouris P, Varkarakis I, Deliveliotis C. Minimal invasive treatment of locally advanced renal cancer. Hellenic Urology 2021;33:9-11
| Introduction|| |
Renal carcinoma (RC) is still one of the deadliest urogenital tumors in the modern era of diagnostics and treatment. Interestingly enough, the most challenging tumors to resect are without a doubt the locally advanced ones, including the ones who infiltrate the renal vein (renal vein) or with vena cava (VC) involvement. In the past, locally advanced RC as well as tumors with size >7 cm were considered as strong contraindications for the use of minimal invasive (MI) techniques. However, the unneglectable advantages of MI (i.e., three-dimensional [3D] vision and flexible tools) and the undisputed rise of surgical expertise have led to the incorporation of these techniques in increasingly advanced cases. This is not just an assumption, as the literature on laparoscopic partial nephrectomy for T3a tumors and robotic nephrectomy with additional excision of inferior vena cava (IVC) thrombus above the diaphragm is constantly enriched. In conclusion, MI techniques are already a part of locally advanced RC excision and it seems like its use will follow an ascending trajectory.
| Material and Methods|| |
We conducted a thorough search in PubMed for articles written only in English and from inception to 2021. We reviewed only studies with at least one abstract. We used the terms “T3a renal tumors”, “IVC thrombus”, “laparoscopic nephrectomy”, “robotic nephrectomy”, “locally advanced renal tumors”.
Renal vein or branch infiltration (T3a)
Even from the very first studies, laparoscopic excision of T3a tumors provided very encouraging results. More than a decade ago, a large study was conducted at John Hopkins with 37 patients diagnosed with RC and thrombosis of the RV. Despite the large mean size (7.5 cm), transfusions were only needed in 16% of cases, the mean postoperative hospital stay was 3 days, and complications occurred in 19% of the cases. It is noteworthy that only one case was converted to open surgery. In a more recent study, survival rates of patients who were treated with laparoscopic radical nephrectomy (LRN) were compared and contrasted to those of the ones treated with an open approach. In a sample of more than 1000 patients, neither single nor multivariable statistical analysis showed worse prognosis in the laparoscopic approach. Confirmatory results for the efficacy of LRN for locally advanced RC were provided by a smaller but prospective study of 25 patients, in which there were no conversions to open approach, and no statistically significant differences in complications (P < 0.52) as well as better results in blood loss (P < 0.001) and hospitalization (P < 0.001) were reported.
Furthermore, the scientific leaps in robotics quickly changed the landscape in the treatment of locally advanced RC, offering robotic partial nephrectomy (RPN) as another MI alternative. One of the largest studies in the literature includes 157 patients who underwent RPN for T3 tumors, of which 34 involved the RV or a branch. During the operation, tumor excision (mean size 7 cm) as well as thrombectomy were performed. The trifecta was achieved, with 95% negative surgical margins, 76% warm ischemia time, and 85% no postoperative complications.
The aforementioned promising results of RPN could only lead to its comparison to another MIS modality, and robotic radical nephrectomy (RRN) as far as T3 tumors are concerned. In a 140 patient study, Andrade et al. showed that RPN achieved the same oncological results without a burden on survival, and in contrast with RRN, renal function was better preserved. It is worth mentioning, however, that studies indicate optimal preoperative staging as a prerequisite for success in robotic excision of locally advanced RC. A large meta-analysis shows worse outcomes on patients that underwent robotic nephrectomy and were staged as pT1 and cT3 relative to patients with the same clinical and pathology staging.
Inferior vena cava thrombus
It is only logical to assume that MI IVC thrombectomy was first tested below the diaphragm, with classic laparoscopy. In 2002, Sundaram et al. first reported their experience from a patient with a 12 cm RC and a level 2 IVC thrombus. Not only were the results promising, with EBL 500 mL and a 3-day postoperative hospital stay but also other researchers managed to report increasingly encouraging results in the following years as well.,, Increasing experience and confidence led to larger patient samples, with Martin et al. reporting a study of 14 patients, 4 of which had an IVC thrombus. All tumors and thrombi were excised on negative margins, with only one complication (PE that was treated with anticoagulants) and no recurrence in the 4 years of follow-up. The most recent study regarding laparoscopy was published in 2015 and includes patients with more advanced level 4 IVC thrombi; mean operation time was 275 min, mean EBL was 850 mL with no patient having a complication Clavien >3.
The emergence of robotic systems has vastly renovated the field of angioplasty procedures by bringing tools for fast suturing and 3D vision. Robotics were used pretty early in simple renal procedures, so there should be no surprise that they are now being used in much more complex scenarios. The first report of robotic nephrectomy with concurrent IVC thrombectomy was published by Abaza et al., who for the first time performed side-clamping and thrombectomy simultaneously, thus sparing IVC flow. The same technique was used in the first multicenter study concerning 32 patients, 2 of which had level 3 IVC thrombi; mean thrombus size was 4.2 cm (2–11 cm), mean operational time was 292 min (largely shorter than laparoscopic approach), and no operation was converted to open approach. In the following years, more studies on robotic thrombectomy were published, with increases in both the complexity of cases and the number of patients. Short hospital stays (1–5 days) were achieved, with no conversions to open surgery and complication rates that did not exceed 25%.,,,
Level 4 IVC thrombectomies are without a doubt the most technically demanding procedure as far as locally advanced RC is concerned and traditionally require an open approach. However, Wang et al. very recently presented their attempt to deal with such thrombi (right side) using robotic surgery. In cooperation with cardiac surgeons, cardiopulmonary bypass was initiated, the proximal IVC was then clamped, and RA thrombectomy was performed. Moving on, the IVC was clamped below the diaphragm along with the LRV and the hepatic vein, allowing IVC thrombectomy above the diaphragm. On the upside, despite a mean EBL of 2800 mL and a mean duration of 510 min, 60% of the patients did not show major complications, which makes this technique a success considering the complexity of the case. On the downside, the aforementioned technique requires highly experienced robotic surgeons and frequent repositioning of trocars and robotic arms, which significantly increase the operational time and skill requirement.
Comparison of open and minimal invasive approaches
Inevitably, advancements in MIS led to its comparison with the open approach, which is still the first-line treatment for T3 RC. The first multivariable analysis between open and MI approaches for level 1 and 2 thrombi proved that surgical technique is not influential in the overall survival rates. That being said, robotics showed favorable results in terms of hospitalization time, intraoperative blood loss, operational time, and overall complications. However, due to the low number of patients, these results present some limitations, which were put to rest by an 872 patient study, in which open approach was associated with greater blood loss, longer hospital stays, and no advantage in postoperative complications.
At this point, it is worth mentioning that surgeons who managed to perform such demanding operations, such as robotic IVC thrombectomy, have a much greater experience than the normal learning curve (over 1000 operations). This review demonstrates perhaps the most basic benefits of MI as a treatment modality for locally advanced RC. Although the series are relatively small, the smaller blood losses and the reduction in hospitalization time are evident., At the same time, the reduced or even zero need for sedatives leads to faster recovery as well as faster initiation of adjuvant therapy, when indicated.
Despite the encouraging results, it is important to recognize the significant limitations of the studies that offer them. Most of the studies are retrospective and therefore characterized by significant selection bias. In addition, prospective randomized trials are almost impossible to carry in such a clinical entity. Furthermore, these operations require extremely experienced robotic surgeons, and therefore, they cannot be easily widespread, but even so, the latter should have experience in open surgeries, in case a conversion is required.
| Conclusions|| |
The treatment of locally advanced RC with MIS techniques proves feasible and safe and offers corresponding oncological results with the classic open approach in combination with more favorable peri- and postoperative results. However, the use of these techniques requires extensive surgical experience and given the low level of evidence from the existing literature, larger and better organized studies are needed to determine the patients who will benefit from the use of these methods.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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