1. Management of T1 Kidney Cancer Laparoscopic Surgery
Karim Touijer, MD

2. Kidney Cancer is a Misnomer!!!
Kidney cancer = is not a single disease
Kidney cancer = Compendium of a number of
different cancers that originate
in the Kidney
Each have a distinct:
- Clinical course
- Prognosis
- Genetic background

3. Clear cell type or Conventional
Most common (75%) +++
Aggressive ++
Accounts for most metastatic cases
Mutation in VHL gene

4. Papillary Type 1 15% of kidney cancers Multifocal Bilateral
Relatively low risk of Metastases
Mutation of c-Met proto –oncogene on Chrs 7

5. Papillary Type 2 Aggressive +++ Metastatic potential
Mutation of the Fumarate Hydratase gene

6. Chromophobe 5% of kidney cancers Less aggressive than conventional
Could be associated to the Birt-Hogg-Dube

7. Oncocytoma
Benign
Metastases are rare

8. Management of T1 RCC - Ideal Scenario -
Diagnosis
Identify the histologic subtype
Treatment
Treat accordingly

9. Management of T1 RCC - Current Status -
Diagnosis (-)
Renal Tumor
Imaging
Needle Biopsy
G250 scan
Vascular density on US
Treatment
Renal Tumor
Surgery
Pathology (+++)
Specific Histotype
H&E
Immunohistochemistry
Genetic probes
Tyrosine Kinase inhibitors for metastatic Clear Cell RCC

10. Surgical Treatment of T1 RCC
Partial vs. radical Nephrectomy
Laparoscopic vs. Open approach
Investigative therapy

11. Partial vs. Radical Nephrectomy
Whenever possible Partial Nephrectomy should be the preferred treatment.
Comparable long-term cancer control
Lesser risks of Chronic renal insufficiency and proteinuria

12. Partial vs Radical Nephrectomy ~ Cancer Control ~

13. Partial vs Radical Nephrectomy ~ Cancer Control ~

14. Chronic Kidney Disease

15. Chronic Kidney Disease

16. Results New Onset of GFR < 60
Median Time to GFR < 60
RN: 18 months
PN: Was not reached
Solid: Partial Nephrectomy
Dashed: Radica1 Nephrectomy

17. Laparoscopic vs Open No Randomized Trial !?
Cancer control
Morbidity and Convalescence

18. Oncologic Outcomes for T1 and T2 Disease
LAP
5 year cancer-specific survival for T1: 95% - 98%
5 year cancer-specific survival for T2: %
Portis et al. J Urol. 167:1257, 2002
Ono et al. J Urol. 169: 77, 2003
Local recurrence rate up to 4.1%
Open
5 year cancer-specific survival for T1: 90%-95%
5 year cancer-specific survival for T2: 74%-88%
Tsui et al. J Urol. 163: 1090, 2000
Javidan et al. J urol. 162: 730, 1999
Local recurrence for T1 and T2 is ~ 4%.
Lee et al. J Urol. 163: 730, 2000
Gogus et al. Urology 61: 926, 200

19. Morbidity of Partial Nephrectomy Lap vs. open
Review of the recent MSKCC experience

20. Patient Characteristics
Open
Laparoscopic
p-value
n (%)
337
(90) 36
(10)
Age, years, mean (SD) 61
(13) 60
(11)
0.537
Gender
Males (%)
204
(60) 27
(75)
Females (%)
133
(40) 9
(25)
Laterality
Left
168
(50) 21 58
0.383
Right
169 15 42
0.289
Incidentally Detected (%)
278
(82)
1.0
Size, cm, mean (SD)
3.0
(1.5)
2.4
(1.0)
0.05
Location (%)
Peripheral
161
(48) 18
0.118
Central
128
(38) 17
(47)
Missing 48
(14) 1
(3)
ASA Score>2 (%)
122
(36) 11
(31)
0.584

21. Operative/Postop Data
Open
Laparoscopic
p-value
n (%)
337
(90) 36
(10)
Clamp (%)
291
(89) 34
(94)
0.559
Clamp Time, min, mean (SD) 38
(18) 37
0.760
OR Time, min, mean (SD)
162
(49)
249*
(83)
<0.001
EBL, cc, mean (SD)
403
(378)
343
(398)
0.367
Conversion to Radical nephrectomy (%)
31/390
(8)
3/41
(7)
1.00
Positive Margins (%) 13
(4) 2
(5)
0.138
Length of Stay, days mean (SD)
4.8
(2.4)
3.1
(1.9)
*Includes time for cystoscopy and stent placement

22. Complications Laparoscopic group Open group
10 complications in 8 patients
22% complication rate
Open group
80 complications in 69 patients
20% complications rate

23. Complication MSKCC Grading System
Grade I: Oral medication or bedrest
Grade II: IV therapy or thoracostomy tube
Grade III: Intubation, interventional radiology, endoscopy or reoperation
Grade IV: Major organ resection or chronic disability
Grade V: Death

24. Complications by Grade
Open
Laparoscopic 1 47
13.0% 5
13.9% 2 15
4.2%
2.8% 3 10
5.6% 4
0.6%
0.0%

25. Priorities in the management of T1 renal
Conclusions
Priorities in the management of T1 renal
cell carcinoma are:
Identifying the histotype at the time of Diagnosis +++
Using a partial nephrectomy as much as possible ++
Lap vs. Open: depending on the available skills