CC BY
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II. ХИРУРГИЯ
RECURRENT RENAL CELL CARCINOMA OF SOLITARY KIDNEY: RENAL SPARING SURGERY. CLINICAL CASE
Ibragimov R.P., Madadov I.K., Syrymov Zh.M., Belgibaev E.B., Baiguissova D.Z., Syrymova A.K.
National Scientific Center of Surgery named after A.N. Syzganov, Almaty, Kazakhstan.
Abstract
57 years old female was admitted to the hospital absolutely asymptomatic. Previously on ultrasound investigation 3 renal neoplasms were detected. Five years ago patient underwent nephrectomy on the left for renal cell carcinoma. Preoperatively laboratory tests were in reference range.
Patient underwent renal sparing surgery - all neoplasms were fully excised. After each excision arterial circulation was temporarily restored for up to 10 min. We call this -"start-break" technique. Also after excision it was better to assess hemostasis. Total warm ischemic time was 18 min. Total blood loss was 200ml. Patient's condition was relatively stable and did not necessitate hemodialysis. She was discharged on 11th postop day.
Renal cell carcinoma of the solitary kidney presents a great challenge either for the surgeons or patients, because it depends on what is the main purpose of treatment, because organ sparing surgery and radical surgery have mostly different outcomes in long-term period. The decision is made according to the clinical data, patient's preference, safety and good quality of life for patient. But organ sparing surgery bears the risk of recurrence more than the radical surgery. So these aspects must be considered before the informed consent is taken.
МРНТИ 76.29.43
ABOUT THEАUTHORS
R.P. Ibragimov - urologist, transplant-surgeon, head of kidney transplantation, urology and nephrology department, scientific manager. (rava747@mail.ru 87017472070)
I.K. Madadov - urologist, kidney transplantation, urology and nephrology department (dominic89@mail.ru 87478397H0)
Zh.M. Syrymov - urologist, kidney transplantation, urology and nephrology department (syrymov89@mail.ru 87072727002)
E.B.Belgibaev - urologist, kidney transplantation, urology and nephrology department (dr_beb@mail.ru 87759776773)
D. Z. Baiguissova - radiologist, radiology department (dina_gallyamova@mail.ru. 87017719371).
A.K. Syrymova - resident, radiology department (aidana.syrymova@mail.ru, 87072727001).
Keywords
renal cell carcinoma, solitary kidney, excision, ischemic time.
Жалрыз калган оц бYЙректщ рецидивт бYЙрек-жасушалык карциномасы: орган сактау отасы
Ибрагимов Р.П., Мададов И.К., Сырымов Ж.М., Белгибаев Е.Б., Байгуисова Д.З., Сырымова А.К.
А.Н. Сызганов атывда?ы Улттык, Рылыми Хирургия, Алматы, Казахстан
Ацдатпа
57 жасар наукас aypyxaHafa тускен кезде оц буйрепнде ультрадыбыстык зерттеу бойынша 3 iciK табыл€ан жэне наукаста еш кандай клиникалык симптом болмаган. AHaMHe3i бойынша наукаска 5 жыл бурын сол буйректн буйрек-жасушалык кßтерлi idri себебнен нефрэктомия отасы жасалын€ан. Келп тускен кезнде лабораториялык кврсетюштер дурыс болтн.
Наукаска орган сактау отасы жасалынды - iсiктердiн барль^ы толь^ымен кесп алынды. Эр резекциядан кейн артериальд кан айналымы уакытша 10 минутке дейн калпына келтiрiлдi. Бул техниканы «старт-пауза» техникасы деп атадык,. Осымен гемостаздын бакылауы жаксы болды. Жылу ишемиясыныц жалпы уакыты 18 минут болды. Жалпы кан кетуi 200 мл болды. Наукастыц жаFдайы бiр калыпты болды жэне гемодиализ кажет болмады. Наукас отадан кейЫ 11 тэулiкте уйге шырарылды.
Жалтыз кал€ан буйректщ буйрек-жасушалык карциномасыныц емi дэрiгерге де наукаска да вте киын тандау бо-лып саналады, вйткен барлы^ы койыл€ан басты максатка байланысты - орган сактау отасы немесе радикальд ота жасау, ею жаедайда да узак мерзiмде эртYрлi нэтижелерi болады.
АВТОРЛАР ТУРАЛЫ
Р. П. Ибрагимов - уролог-транспланто-логдэрiгерi, буйрек трансплантациясы, урология жэне нефрология бвлiмшесiнiц мецгерушс, гылыми жетекшi (rava747@ mail.ru 87017472070)
И.К. Мададов - уролог дэрiгерi, буйрек трансплантациясы, урология жэне нефрология бвлiмшесi, кИ гылыми кызметкер (dominic89@mail.ru 87478397110)
Ж.М. Сырымов - уролог дэргер, буйрек трансплантациясы, урология жэне нефрология бвлiмшесi (syrymov89@mail.ru 87072727002)
Е.Б. Белгибаев - уролог дэргер, буйрек трансплантациясы, урология жэне нефрология бвлiмшесi (dr_beb@mail.ru 87759776773)
Д. З. Байгуисова - сэулелiдиагностика дэрiгерi, сэулелiдиагностика бвлiмшесiнiц мецгеруша (dina_gallyamova@mail.ru. 87017719371).
А.К. Сырымова - резидент-дэрiгерi, сэулелi диагностика бвлiмшесi (aidana. syrymova@mail.ru, 87072727001).
Туйш свздер
бYЙpeк-жacyшaлык кapциномa, жaлFыз Kantae ôypeк, peзeкция, ишeмия yaкыты.
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Рецидивная почечно-клеточная карцинома единственной оставшейся правой почки: органосохраняющая операция. Клинический случай
ОБ АВТОРАХ
Р. П. Ибрагимов - уролог-трансплантолог, заведующий отделением трансплантации почек, урологии и нефрологии, руководитель исследования (гауа747@ mail.ru 87017472070)
Д.А. Исаев - уролог, отделение трансплантации почек, урологии и нефрологии (dzhanibek@issayev.com 87477218977)
И.К. Мададов - уролог, отделение трансплантации почек, урологии и нефрологии, младший научный сотрудник ^оттС89@ mail.ru 87478397110)
Ж.М. Сырымов - уролог, отделение трансплантации почек, урологии и нефрологии, (syrymov89@mail.ru 87072727002)
E.Б. Белгибаев - уролог, отделение трансплантации почек, урологии и нефрологии (dr_beb@mail.ru 87759776773)
Д. З. Байгуисова - врач лучевой диагностики, заведующий отделением лучевой диагностики ^та_да11уатоуа@ mail.ru. 87017719371).
А.К.Сырымова - врач-резидент, отделение лучевой диагностики (aidana. syrymova@mail.ru, 87072727001).
Ключевые слова
почечно-клеточная карцинома, единственная почка, резекция, время ишемии.
Ибрагимов Р.П., Мададов И.К., Сырымов Ж.М., Белгибаев Е.Б., Байгуисова Д.З., Сырымова А.К.
Национальный Научный центр хирургии им. А.Н. Сызганова, Алматы, Казахстан
Аннотация
Пациентка 57 лет поступила в наше учреждение с признаками 3-х образований единственной правой почки по ультразвуковому исследованию, без клинических проявлений. Из анамнеза: 5 лет тому назад пациентке была выполнена левосторонняя нефрэктомия по поводу почечно-клеточного рака. На этапе предоперационного обследования лабораторные показатели были в пределах нормы.
Пациентке была выполнена органосохраняющая операция - все образования были полностью иссечены. После каждой резекции артериальный кровоток был временно восстановлен до 10 мин. Мы назвали эту технику - техника «старт-пауза». Это улучшило контроль гемостаза. Общее время тепловой ишемии составило 18 мин. Общая кровопотеря составила 200 мл. Состояние пациентки было стабильным, гемодиализ не потребовался. Пациентка была выписана на 11 сутки после операции.
Почечно-клеточная карцинома единственной почки является вызовом как для специалиста, так и для пациента, ведь все зависит от того, какова основная цель лечения, так как, органосохраняющая операция и радикальная операция имеют разные результаты в отдаленном периоде. Таким образом, эти аспекты должны быть учтены при получении согласия на операцию.
Introduction
Renal cell carcinoma is the most common type of kidney cancer in adults. [1] It accounts for approximately 3% of adult malignancies and 90-95% of neoplasms arising from the kidney.
Initial treatment is most commonly either partial or complete removal of the affected kidney(s) [2]. Where the cancer has not any metastasis (spread to other organs) or burrowed deeper into the tissues of the kidney, the five-year survival rate is 65-90%,
[3] but this is lowered considerably when the cancer has spread.
Small renal tumors (< 4 cm) are treated increasingly by partial nephrectomy when possible.
[4] Most of these small renal masses manifest indolent biological behavior with excellent prog-
Figure 1.
Computed tomography
nosis.[5] Nephron-sparing partial nephrectomy is used when the tumor is small (less than 4 cm in diameter) or when the patient has other medical concerns such as diabetes or hypertension. [6] The partial nephrectomy involves the removal of the affected tissue only, sparing the rest of the kidney, Gerota's fascia and the regional lymph nodes. This allows for more renal preservation as compared to the radical nephrectomy, and this can have positive long term health benefits.[7] Larger and more complex tumors can also be treated with partial nephrectomy by surgeons with a lot of kidney surgery experience.
Case presentation
57- year old female with the previous history of nephrectomy of the left kidney with renal cell carcinoma was admitted to our department completely asymptomatic with no classic clinical signs such as pain, gross hematuria or palpable mass. Preoperatively, on renal computed tomography with contrast enhancement 3 (three) neoplasms were detected on the right kidney: 2.5 cm tumor on posterior surface centrally, 3.0 cm - laterally on the lower pole and 3.0 cm - anteriorly on the upper pole. (Fig.1). Creatinine was 1.02 mg/dl and BUN was 5.2 mmol/l. During the preoperative evaluation there were not detected any sites of metastasis.
According to the patient's history in 2013 she underwent open surgery - radical nephrectomy on the left for renal cell carcinoma. She was on follow up annually to date. Considering the previous history, the neoplasms were regarded as recurrent
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ВЕСТНИК ХИРУРГИИ КАЗАХСТАНА № 2-2019
renal cell carcinoma. Taking into account normal function of the kidney, the refusal of patient to go on hemodialysis furtherly and the desire to maintain good quality of
life we decided to perform renal sparing surgery.
All neoplasms were fully excised and total warm ischemic time was 18 min (Fig.2). We used "start - break" technique, that refers to the temporary revascularization of kidney after each excision for up to 10 min. This technique has two advantages: firstly, it minimizes the warm ischemic time and, the second, is the opportunity to better control blood loss precisely after each excision. Postoperatively patient was hemodynamically stable, but the levels of creatinine and BUN increased on 2 postop day up to 4.1 mg/dl and 15.6 mmol/l, respectively. Potassium level was constant. Urine output was decreased until 800 ml. Patient's condition was relatively stable and did not necessitate hemodialysis. On the 10th postop day creatinine was 1.78 mg/dl and BUN was 6.5mmol/l. Urine output also greatly increased up to 2.5 l/day. Patient was discharged on 11th postoperative day in stable state condition. Histologically neoplasms were regarded as clear cell renal cell carcinoma grade 2. After 4 weeks of follow up creatinine and BUN are 1.3 mg/dl and 7.0 mmol/l, respectively. 6 month after the surgery patient has arrived for check - up. On computed tomography of kidney were no signs of recurrence and biochemistry assays were normal (Fig. 3). Creatinine was 1.2 mg/dl.
Conclusion
According to previous reports at 5 and 10 years the overall survival rate in such kind of patients after renal sparing surgery was 74.7% and 45.8%, the cancer specific survival rate was 80.7% and 63.7%, the local recurrence-free survival rate was 89.2% and 80.3%, and the metastasis-free survival rate was 69% and 50.4%, respectively [8].
Such cases are very rare but if it is encountered we suppose that "start - break" can be safely used for excision two or more neoplasms in a solitary
Figure 2.
Excision of neoplasms. End view
Figure 3.
Computed tomography 6 months after surgery
kidney in order minimize the ischemic injury and preserve the function.
References
1. Jemal A, Murray T, Ward E, et al. Cancer statistics, 2005. CA Cancer J Clin. 2005;55:10-30.
2. Janzen NK, Kim HL, Figlin RA, Belldegrun AS. Surveillance after radical or partial nephrectomy for localized renal cell carcinoma and management of recurrent disease. Urol Clin North Am. 2003;30:843-852.
3. McNichols DW, Segura JW, DeWeerd JH. Renal cell carcinoma: long-term survival and late recurrence. J Urol. 1981;126:17-23.
4. Ljungberg B, Alamdari FI, Rasmuson T, Roos G. Follow-up guidelines for nonmetastatic renal cell carcinoma based on the occurrence of metastases after radical nephrectomy. BJU Int. 1999;84:405-411.
5. Levy DA, Slaton JW, Swanson DA, Dinney CP. Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol. 1998;159:1163-1167.
6. Lam JS, Leppert JT, Figlin RA, Belldegrun AS. Surveillance following radical or partial nephrectomy for renal cell carcinoma. Curr Urol Rep. 2005;6:7-18.
7. Lam JS, Leppert JT, Figlin RA, Belldegrun AS. Surveillance following radical or partial nephrectomy for renal cell carcinoma. Curr Urol Rep. 2005;6:7-18.
8. Bani-Hani AH, Leibovich BC, Lohse CM, et al. Association with contralateral recurrence following nephrectomy for renal cell carcinoma using a cohort of 2352 patients. J Urol. 2005;173:391-4.
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