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DOI: http://dx.doi.org/10.20534/ESR-17-5.6-47-50
Tillyashayhova Rano Mirzagalebovna, doctor oncology, department of urological oncology City branch of the Republican Scientific and Practical Centerof Oncology and Radiology,
Republic of Uzbekistan E-mail: usmanov-83@mail.ru
THEOPPORTUNITIES OF ORGAN-SAVING SURGERY FOR EARLY DIAGNOSED KIDNEY CANCER
Abstract: The study design was a comparative study of the results of partial nephrectomy and total nephrectomy in patients with stage Tlkidney cancer: identification of indications and identify the special characteristics of resection of kidney cancer in stage Tl; comparative analysis of the immediate results of partial nephrectomy and radical nephrectomy in stage T1; explore long-term results of surgical treatment.The object of the study were 75 patients with morphologically verified diagnosis of renal cell carcinoma (RCC) T1N0-1M0 stage, treated in urological departments ofRepublic research center of oncology (RSCO) and Tashkent city oncology dispensary (TashCOD) for the years 2011-2015. For a comparative analysis of results of treatment, patients were divided into two groups: the first — 25 patients, who underwent anorgan-savingoperation — kidney resection; the second — 50 patients who underwent the traditional radical nephrectomy.
Keywords: kidney cancer, partial nephrectomy, tumor, survival rate, long-term results.
Introduction
Due to the rapid development of medical technology and the modernization of intensive care services in clinical oncology the possibility of the organ-saving surgical interventionshave appeared. Implementation of organ-saving surgery primarily aimed at improving of the quality of life of patients, which in turn should be in conformity with established oncologic principles and should guarantee, at least, identical results with radical surgery.
Despite the introduction of the modern technologies, until recently, the "golden" standard in the treatment of operable kidney cancer was nephrectomy [1; 2; 5; 7; 9]. However, patients with a solitary kidney after surgery can not be considered as completely healthy [3; 4]. Consequently, these patients constantly need medical and social rehabilitation. Therefore, performing organ-saving surgery for kidney cancer looks very promising. In literature, there are works devoted to this issue. Several authors already have some good long-term results [1; 2; 3; 4; 5; 9]. However, analysis of the literature shows that the available results were not based on sufficient clinical materials, do not provide a clear indication to form and define the distinction between partial nephrectomy and radical nephrectomy.
In general, the available views on this issue are various and multidirectional. Proceeding from the above, the actuality of this problem is the following:
a) Is early kidney cancer (EKC) the indication for organ-saving operation?
b) Can partial nephrectomy be compared with radical nephrectomy for their immediate and long-term results?
c) What is influence of organ-savingoperations on the quality of life of patients with EKC?
Objective: To study the results of organ-saving operations in treatment of early kidney cancer.
Materials and Methods:
The study design was a comparative study of the results of partial nephrectomy and total nephrectomy in patients with stage T1kidney cancer: identification of indications and identify the special characteristics of resection of kidney cancer in stage T1; comparative analysis of the immediate results of partial nephrectomy and radical nephrectomy in stage T1; explore long-term results of surgical treatment.The object of the study were 75 patients with morphologically verified diagnosis of renal cell carcinoma (RCC) T1N0-1M0 stage, treated in urological departments ofRepublic research center of oncology (RSCO)and Tashkent city oncology dispensary (TashCOD) for the years 2011-2015. For a comparative analysis of results of treatment, patients were divided into two groups: the first — 25 patients, who underwent anorgan-savingoperation — kidney resection; the second — 50 patients who underwent the traditional radical nephrectomy.
Among the patients 54 (72.0%) were performed by males, 21 (28.0%) were females. Lymph node involvement — N1 7 patients in the first group, 15 patients in the second group. The common stage T1a (tumor > 4 cm) was observed in 22 (86%) (first group) and 31 (63%) (second group). In both groups aged and older patients prevailed over the young and middle age group, accounting for 65% and 70% respectively. Consequently, the average age of patients in the first and the second group was 56,3 ± 0,3 and 59,5 ± 0,5 years. For localization of tumor in the kidneys indices were not significantly different from each other (tab.1). But there was a slight predominance of the tumor in the upper pole of the kidney (44%) over the lower pole (36%) in the first group. Bilateralrenallesion hadbeenestablishe-din 1 patient (4%) in the firstgroup.
Histologically in 61 (81.3%) patients squamous cell RCC-was verified, 7 patients (9.3%) hadchromofilic and 5 (6.6%) — chromophobe type of the tumor. Patients of the first group in 74% of cases had extrarenal growth. In the second group intrarenal growth was observed in 47% ofthe cases (diagr.1).
Tablel. - Localization of tumor in the groups, n=75
Side of lesion 1-group (n-25) 2-group (n-50)
Number % Number %
Left kidney 11 42% 25 50%
Right kidney 13 54% 25 50%
Bilateral 1 4% 0 0
Comorbidities of contralateral kidney was detected in 5 (20%) Variants of growth of tumor in groups
patients of group-1 and in 2 (4%) patients (Table. 2) ofagroup-2.
extrarenal ■ intrarenal ■ mixed ■ extrarenal ■ intrarenal ■ mixed
Diagram 1.
Table 2. - Characteristics of comorbidities in contralateral kidney, n = 75
Pathology of contralateral kidney Group-1 Group-2
# % # %
Cystic disease 1 4% 0 0
Urolithiasis 1 4% 1 2%
Pyelonephritis 2 8% 1 2%
Hypoplasia 1 4% 0 0
Total 5 20% 2 4%
Results and Discussion:
Based on the pre-operative research methods the indications for partial nephrectomy were following:
— The presence of concomitant pathology of the contralateral kidney (5 patients);
— Bilateral lesions of the kidneys (1 patient);
— Extra organ tumor growth without the involvement of the pelvi-caliceal system (19 patients);
— The absence of thrombus formations in the venous system;
— Hystologically verified RCC with no signs of invasion to the perirenal structure.
Along with this, a compulsory component of partial nephrectomy was performing lymph dissection at the level N1. So for tumors greater than 4 cm (T1b <7 cm) and pre-operative determination of the existence of increased lymph nodes preference was given to the transabdominal approach.
A special feature of the kidney resection in our survey was
short-term renal ischemia by clamping the renal artery. Time of the controlled compression ischemia ranged between 5 and 25 minutes, averaging 9,2 ± 1,4 minutes (p > 0,05). In addition, the main method of hemostasis in the final partial nephrectomy was to impose an 8-shaped atraumaticsutures and stypageof theresected area by-perirenalfat. Preference was given to the wedge resection of the renal parenchyma with distance to 0.5 cm from the tumor visual margins. For tumors less than 4 cm with mixed or intrarenal growth there were performed enucleoresection — 43%.
In the postoperative periodcomplications had developed in 3 (12%) patients of the first group (Table. 3). In one case 1 (4%) draining of the abscessing haemotomewas done. Urinary fistula had been liquidated within 3 months after the surgery. In the 2 — group complications were observed in 4 (8%) patients, where there has been a bleeding and evisceration — in 2 (4%) patients. Mortality at the second group was observed in 1 (2%) case, the cause of which was posthemorrhagic shock.
Table3. - Postoperative complications after surgery in early kidney cancer, n = 75
Type of complication Group1, n=25 Group2, n=50
1 2 3
Retroperitoneal hematoma with developing of abscesses 1 0
1 2 3
Woundinfection 1 2
Urinary Fistula 1 0
Eventration 0 1
Hemorrhage 0 1
Total 3 (12%) 4 (8%)
The study of long-term results (Diagram 2), directly related to the conduct of operations has shown that1 (4%) patient of the first group experienced recurrence of the disease and in 2 (8%) patients there were observed a progressive nephrosclerosisof resected kidney. In contrast, in secondgroup patients locoregional metastasis
development was noted in 2 (4%) and distant organ metastases 4 (8%) cases. The frequency of recurrence of the tumor in the kidney removal was identical as in the first group — 1 patient. Long-term results of surgical treatment of EKC, n=75.
Diagram 2.
During the a year of follow up three patients have died in the investigated groups: 1 — group — 1 (4%) in group-2 2 (4%).
A comparative study of survival rates (diagr. 3) shows that in 3 years of monitoring of the patient survival there are significant differences between the study groups. 5 year survival after organ-saving partial nephrectomy was 84% versus 68% after radical nephrectomy.
Analysis of the quality of life of patients with early kidney cancer after surgery also showed variation in the data, depending on the type of the operation. So, after resection methods of surgical treatment of EKC an average quality of life for the Karnofsky scale was 73, 5 ± 0,7% (p > 0,05) vs. 61 ± 0,3% (p < 0,05) after radical nephrectomy.
Comparable survival rates of patients with EKC, n = 75
Diagram 3.
Thus, the analysis shows the benefits of organ-saving methods of surgical treatment of early kidney cancer, which contributes to a better medical and social rehabilitation of patients.
Conclusions:
1. Performing of organ-saving surgery in T1N0-1M0 stage of kidney cancer patients indicated for middle and older age groups, as well as in presence of concomitant diseases of the urinary system.
2. Partial nephrectomy in early kidney cancer is not accompanied by an increase in the incidence of postoperative complications, which may be considered as treatment of choice.
3. Partial nephrectomy at early kidney cancer contributes to the early rehabilitation of the patients, which is reflected in the increase in the 5 — year survival rate and quality of life.
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