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Abbreviations (L)(O)PN (laparoscopic) (open) partial nephrectomy (L)RN (laparoscopic) radical nephrectomy CKD chronic kidney disease eGFR estimated GFR MSKCC Memorial Sloan Kettering Cancer Center MDRD Modification in Diet and Renal Disease SCORED screening for occult renal disease US ultrasound/ultrasonography R.E.N.A.L. Radius of tumour, Exophytic/Endophytic, Nearness to collecting system or sinus, Anterior or posterior, and Location relative to the polar line (scoring system) ABC argon-beam coagulator EBL estimated blood loss LOS length of stay RFA radiofrequency ablation SEER Surveillance Epidemiology and End Results. INTRODUCTION Partial nephrectomy (PN) is under utilized in the USA and abroad, despite its virtues as an operation that achieves equivalent local tumour control to radical nephrectomy (RN) in T1 tumours (2.0 ng/mL) was 26% when no renal artery occlusion was used, 30% after warm ischaemia, and 41% after cold ischaemia. In this study, the cold ischaemia may have been selectively used in more challenging cases.

The authors felt a limit of 20 min of warm ischaemia could decrease the risk of severe CKD in this highly susceptible patient population. Most Laparoscopic PNs (LPNs) are performed with no attempt at cold ischaemia although there are reports of cumbersome attempts at ureteric catheter placement and collecting system cold perfusion, renal artery cold perfusion directly or using temporary balloon occlusion, and placement of ice-slush laparoscopically. Although, the precise degree of lasting renal damage caused by any form ischaemia is not known with certainty, most experts agree that working quickly in either warm or cold ischaemic states is in the patient’s best interest.

Until a more precise serum or urinary marker for ischaemic renal injury is identified, the matter of ischaemic injury to the kidney during PN will remain unresolved. A robust dialogue between minimally invasive and open surgeons concerning case selection (including patient age, solitary kidney, and preoperative eGFR) and optimum surgical approach based on the tumour location and size, and the anticipated ischaemic time required to resect the tumour, would be ideal in centres where expertise in both approaches exists as a means of maximizing both oncological and renal functional outcomes.

In my mind, sensible recommendations at this time are as follows: • • If a tumour is in an exophytic location performing the PN (OPN or LPN) without renal artery occlusion is likely to cause the least renal injury; • • If warm ischaemia is used during LPN, tumour resection should be completed in. • • Preoperative nomogram predicting 12-years metastasis-free survival based on clinical features combining data on 2517 patients from MSKCC and the Mayo Clinic (adapted from Raj et al. In the early experience with PN, surgeons would consider this operation only if the tumour was cortically based, exophytic, and without close proximity to the renal hilar vessels or encroachment upon the collecting system. However, as the virtues of PN became increasingly apparent, surgical approaches to more complicated tumours became feasible. Decisions concerning whether a PN or an RN should be performed were largely based on the comfort level of the operating surgeon for encountering and repairing these vital renal structures.

Recently, investigators from Fox Chase proposed a scoring system (R.E.N.A.L. For Radius of tumour, Exophytic/Endophytic, Nearness to collecting system or sinus, Anterior or posterior, and Location relative to the polar line) as a means for comparing of renal masses and comparing outcomes of different procedures. Examples of scoring in the RENAL system are as follows; tumours that were ≤4 cm are given 1 point, 2 points for 4–7 cm, and 3 points for >7 cm.

~best pdf~ - Download PDF/ePub eBook Bedside Clinics In Medicine By Arup Kumar Kundu Free Bedside Clinics In Medicine By Arup Kumar Kundu Free [PDF] BEDSIDE CLINICS. The clinical indications and principles of surgical technique for this procedure are discussed. The oncological. Keywords: robotic partial nephrectomy, robot-assisted partial nephrectomy, robotic surgery, minimally invasive surgical. Bedside assistant can present challenges unique to RAPN.

Tumours that are ≥50% exophytic are assigned 1 point, tumours. • • a, Standard positioning in the flank position for a mini-flank surgical approach to the kidney (adapted from Diblasio et al. B, Mini-flank surgical incision, ≈8–10 cm, with incision above the 11th rib and in the space between the 10th ribs (adapted from Diblasio et al. C, Soft tissues of the retroperitoneal space are entered above the 11th rib (supra 11th space). D, Retroperitoneal space is bluntly developed exposing peri-renal fat and gaining rapid access to the kidney.

E, The ureter is isolated from retroperitoneal soft tissues and identified with a yellow vessel loop. • • a, The renal vein and renal artery (arteries) are carefully dissected from surrounding lymphatic soft tissues and identified by red (artery) and blue (vein) vessel loops. During cold ischaemia, a ‘bulldog’ vascular clamp is applied to the renal artery. B, Reno-protective ice slush is applied to the kidney with careful time keeping to accurately record the cold ischaemia time. Now that the kidney is completely mobilized, careful palpation and inspection of its entire surface is performed to confirm the presence of the tumour and seek any satellite lesions. All preoperative imaging is available in the operating room to confirm tumour laterality before starting the operation. For patients with endophytic tumours that are not palpable or apparent on the surface of the kidney careful correlation between CT imaging and intraoperative US is required to precisely locate the tumour by measuring the CT distance from either pole in centimetres, marking the kidney surface with a marking pen, and then confirming the exact location with the intraoperative US before nephrotomy incision and tumour resection.

We also routinely use intraoperative US to confirm the presence of the tumour, seek satellite lesions, assess the proximity to intra renal veins or branched renal vein thrombus and determine if there is tumour encroachment or invasion of the renal collecting system (). For a purely exophytic tumour or in a patient with significant underlying CKD, resection of the tumour without renal artery occlusion is performed. For other patients with large, endophytic, or perihilar tumours who require renal artery occlusion, we always use reno-protective measures including mannitol infusion (12.5 g/200 mL of normal saline) and ice slush. In no cases of OPN at our centre will we use renal artery occlusion without such reno-protective measures.

• • Intraoperative US is routinely performed to locate endophytic tumours, assess kidney for satellite tumours, collecting system invasion, or branched renal vein thrombus invasion. Once the tumour is isolated with its surrounding perinephric fat, the renal cortex is scored using the electrocautery. Sharp scissor dissection is used with a careful eye to keep the plain of surgical dissection within the renal cortex (pink kidney tissue) and not get too close to the renal tumour and its pseudocapsule. If dissection is too close and renal tumour pseudocapsule is identifed, readjustment to a deeper plane of dissection is made. Once the renal sinus is entered beneath the tumour, 3–0 absorbable sutures are placed into small veins and arteries, or breaches in the collecting system to both secure these items as well as provide upward traction on the kidney, which effectively decreases venous bleeding as the kidney is now higher than the central venous pressure. A later search for venous bleeding can be accomplished by simply dropping the kidney into the wound and then raising it again.

Once the specimen is delivered, it is carefully inspected to be certain that no false planes of dissection occurred and that there is a complete covering layer of kidney and soft tissue around the specimen. The deepest surgical margin of the specimen is marked with a silk suture to orientate the specimen, which is then is delivered to the pathology department fresh and in sterile condition. Frozen section of the deep margin and specimen can provide immediate reassurance to the surgeon and the family but is not essential in each case particularly if the surgeon, using loupes sees that the specimen is completely surrounded by normal kidney or intra-renal soft tissue. With the aide of loupe magnification, defects in the collecting system and small vessels are easily identified and closed using 3–0 or 4–0 absorbable suture with special care taken to separately repair veins and arteries to decrease the risk of iatrogenic arteriovenous fistula (pseudoaneurysm) formation.

The use of bulky and deep sutures (2–0) into bleeding areas of the renal sinus should be avoided as this can promote iatrogenic arteriovenous fistula formation. Endophytic tumours may be emanating from elements of the renal cortex facing the renal sinus and completely impalpable. In this setting, the tumour is located using intraoperative US and after renal artery clamping and the institution of reno-protective ice slush cold ischaemia, access to the renal sinus is achieved by going through the cortex preferably in a relatively avascular plane (Brodel’s line). Once in the sinus, the renal tumour is palpated and identified, and carefully resected with care being taken not to get too close to the tumour or enter its pseudocapsule. Once the tumour is removed, it should be carefully inspected to ensure it is completely intact. Similar careful repair of the renal sinus vessels and collecting system described above is performed.

On occasion, the resection plane may leave an intact renal papilla without corresponding collecting system for drainage. In this case, the argon-beam coagulator (ABC) is used to destroy the papilla to avoid urinary extravasation without a means of draining the system. We also use the ABC to coagulate the renal parenchymal surface throughout the resection bed.

Once haemostasis is achieved and collecting system repairs completed, perinephric fat and haemostatic agents such as FloSeal TM (Baxter, Deerfield, IL, USA) and Surgicel TM (Johnson and Johnson, New Brunswick, NJ, USA) are then placed in the resection cavity. Size zero chromic liver sutures are then placed between pledgets of Surgicel to re-approximate the edges of renal cortex and close the resection cavity (). • • a, Kidney is split along avascular plane (Brodel’s Line) to gain access to renal sinus and endophytic tumour. B, Endophytic tumour within renal sinus is identified and resected completely.

C, Repairs are made in the collecting system and rents in renal sinus arteries and veins are repaired with absorbable sutures. D, ABC is used to control the cut surface of the renal parenchyma. E, Floseal and Surgicel are applied to the resection cavity to fill the potential space and achieve haemostasis. F, Atraumatic sutures (0-chromic liver needle) pledgeted with surgical are used to close the cut renal parechymal edges. The renal artery is unclamped and gentle pressure is applied to the kidney for 3–5 min. We ask anaesthesia staff to be certain that blood pressure is within normal range for the patient and then inspect the kidney for any arterial bleeding or venous oozing before initiating closure. A closed suction Jackson-Pratt drain (Allegiance Healthcare, McGaw Park, IL, USA) is placed through a separate stab wound in the retroperitoneal space in a dependent position posteriorly if the collecting system is entered.

Free Download Mp3 Indie Band Surabaya. For exophytic tumours excised completely without exposure to the renal sinus and collecting system elements, the drain can safely be omitted. The surgical incision is closed in two layers using no. 1 polydioxanone, and the skin incision is re-approximated using 4–0 absorbable sutures in a subcuticular fashion. In our previously published series of 167 consecutive patients undergoing OPN ( n= 133) or ORN ( n= 34) from 2000 to 2003 using the supra-11th mini-flank incision, we reported that this approach can safely provide optimum anatomical exposure without rib exposure with decreased intraoperative estimated blood loss (EBL) and length of stay (LOS) as well as a better cosmetic result compared with traditional rib resecting open techniques. In the original OPN group, the median (range) LOS was 4.5 (2–8) days and the EBL was 375 (50–2000) mL. At the median follow-up of 18 months, 3.6% of patients reported a bulge (no hernia but muscular atony) at the incision site, and one patient was diagnosed with an incisional hernia requiring surgical intervention. There were no intraoperative complications although one patient had a prolonged hospitalization due to a concomitant urinary fistula with a UTI, which also resulted in delayed removal of the drain.

In an update of 280 additional cases of OPNs (April 2003 to January 2007) using the supra-11th mini-flank approach, the median (range) LOS decreased further to 4 (2–12) days with an EBL of 300 (50–3000) mL. There was one reported major intraoperative complication (bleeding), but it did not result in loss of the kidney. At a median follow-up of 8 months for this cohort, 1.8% of patients reported a flank bulge. Today we encourage early ambulation (walking a mile around the hospital ward on postoperative day 1), which makes a 2-day hospital stay achievable in most patients. Muscle atony/bulge at the incision site without hernia can be a disconcerting finding ameliorated or improved completely by exercises that passively twist the upper torso (using an exercise bar, broom or golf club), which thereby strengthens collateral muscle groups leading to resolution of the bulge. For the rare flank hernia, open complex repair with synthetic mesh is more effective than attempted primary repair, which is much more prone to recurrence.

The appropriate management of the ipsilateral adrenal gland during PN has created some confusion. Insight into this problem and an effective management scheme was recently described by Cleveland Clinic investigators who perform ipsilateral adrenalectomy only if there is a suspicious adrenal mass on preoperative imaging or if intraoperative findings suggest a direct tumour extension from an upper pole renal mass. Ipsilateral adrenalectomy was performed only in 48 of 2065 PNs (2.3%). There was direct extension of a renal cancer in only one patient, noncontiguous metastatic disease in two patients, and other adrenal pathology in three patients. In 42 patients (87%), the adrenal gland was benign despite the abnormal preoperative imaging appearance. During long-term follow-up, 15 patients underwent subsequent adrenalectomy (0.74%) revealing metastatic disease in 11 patients, two of which were bilateral and two that were contralateral.

The authors concluded that in the absence of abnormal preoperative imaging or obvious intraoperative findings, ipsilateral adrenalectomy is not necessary during PN. MINIMALLY INVASIVE APPROACHES TO THE SMALL RENAL MASS The development of minimally invasive laparoscopic renal tumour surgery and tumour ablative techniques, such as radiofrequency ablation (RFA) and cryoablation, has been ongoing for 19 years by committed investigators in the USA and abroad. The advantages of cosmetic incisions, decreased perioperative analgesic requirements, decreased hospitalization, and more rapid return to normal activity were emphasized in early publications and short-term oncological endpoints seemed equivalent to their open surgical counterparts. However, at centres with expertise in both open and minimally invasive surgery approaches for renal cortical tumours, published experiences have shown inconsistencies in the management of small renal tumours. Open surgeons were more likely to perform PN, and laparoscopic surgeons were more likely to perform RN. These reports suggested that minimally invasive surgery learning curves were being conquered by RN applied to small renal tumours (.

• • Minimally invasive PN can be done using laparoscopic and robot-assisted approaches but renal artery occlusion with warm ischaemia is usually used. As minimally invasive urological oncologists gain more experience and instrumentation, including robotic devices, continue to improve, coupled with further refinements in case selection, it is expected that complications related to LPN will decrease and the ability to effectively resect larger and increasingly challenging hilar tumours will increase. An expert laparoscopic surgeon from the Cleveland Clinic recently analysed his LPN experience from 1999 to 2008 and noted a transition from smaller more peripheral tumours in the early years to larger more central tumours. At the same time, warm ischaemia times decreased from 31.9 min to 14.4 min. In addition, overall complications and the adverse impact on renal function also declined. This study clearly showed enhanced laparoscopic skills and improved results over time but the degree to which this is transferrable to lesser volume and lesser expert surgeons’ remains uncertain.

For expert laparoscopic surgeons the early experience with robotic assistance indicates the procedure is feasible and safe but associated with longer warm ischaemia times compared with pure laparoscopic approaches. The ultimate goal of PN to achieve local tumour control and preserve maximum renal tissue will require careful case selection and robust dialogue between open and minimally invasive surgeons. Renal tumour ablative methods, including percutaneous and laparoscopic approaches to RFA and cryoablation, are offered selectively to some patients with renal tumours that are exophytic and not encroaching upon renal hilar vessels or collecting system elements. Patients considered by many as ideal candidates for ablation are often very old or comorbidly ill individuals harbouring small renal tumours, the very patients ideally suited for active surveillance. Although the concept of non-surgical ablation is appealing, published reports have serious deficiencies including up to 40% of patients not having pre-ablation confirmation of tumour due to non-diagnostic or nonexistent biopsy, short overall follow-up, and high rates of tumour recurrence compared with PN ranging from 7.45 to 18.23-fold greater than PN for RFA and cryotherapy, respectively. Additionally, because most studies lacked pathological confirmation to confirm the completeness of the ablation, it is not known whether changes in radiological images after ablation represent complete or partial tumour destruction or simply a renal tumour, partially treated and not in active growth.

As described above, the Cleveland Clinic experience with difficult salvage operations after failed ablation leads to a high likelihood of RN as the final outcome in a patient population initially candidates for either active surveillance or PN, an outcome that now must be viewed as unfavourable from both oncological and renal functional points of view. Carefully designed ‘ablate and resect’ clinical protocols need to be done, much like those done in the 1990s for cryotherapy and localized prostate cancer, to determine the true effectiveness of these approaches. COMPLICATIONS OF PN Surgical complications related to PN historically were the major disincentive for many urologists for advocating its expanded use and relate to three major categories; bleeding, urinary fistula, and infection. Using a graded scale of complications in 15 categories describing over 163 unique complications, MSKCC investigators evaluated 361 (34%) patients undergoing PN and 688 (66%) patients undergoing RN from 1995 to 2002. Procedure-related complications included urinary leak, acute renal failure, retroperitoneal haemorrhage, pneumothorax, adjacent organ injury and small bowel obstruction. Urinary fistula was defined as persistent urine leak lasting >7 days after PN or a collection requiring a percutaneous drain placement.

Complications were graded using a five-tiered system: grade 1, oral medication or bedside care; grade 2, i.v. Therapy or thoracostomy tube; grade 3, intubation, interventional radiology, endoscopy, or re-operation; grade 4, major organ resection or chronic disability; grade 5, death. In this study, 235 complications occurred in 180 patients (17%). Overall 55% and 31% of the complications were grade 1 and 2, respectively.

There were three perioperative deaths (0.2%). PN was not associated with more complications compared with RN but PN did have more procedure-related complications (9% vs 3%) due mainly to urinary fistula with re-intervention rates of 2.5% for PN vs 0.6% for RN. All but one re-intervention involved endoscopy or interventional radiology. Neither tumour size, tumour location (central vs polar) or imperative vs elective indication was associated with complications of PN.

Multivariate analysis indicated that operative duration and solitary kidney were significantly associated with procedure-related complications of PN. Using the same five-tiered complications grading scale, Cleveland Clinic minimally invasive surgeons evaluated 200 consecutive patients undergoing LPN using either transperitoneal or retroperitoneal approaches for cases performed between 2003 and 2005.

The mean tumour size was 3 cm and a mean parenchymal depth of 1.8 cm. In all, 35 patients (17%) had a complication. Of these, 29% and 42% were grade 1 and 2, respectively. Conversion to ORN (two patients) and LRN (one patient) was an uncommon event. The median (range) warm ischaemia time was 35 (8–60) minute. Compared to their initial experience with LPN in 200 patients, the authors felt that their increased experience with laparoscopic techniques and ability to resect more complicated tumours based on size and location indicated that technical improvements in the operation were decreasing the overall complications by 44%, urological complications by 56%, and haemorrhagic complications by 53%.

Bot Programs For Eq2 Wiki more. In another analysis of their overall LPN experience from 1999 to 2006, the same group showed an increasing willingness to resect complex, large, and central renal tumours while overall, urological, and non-urological complications significantly decreased. Risk factors associated with complications after LPN were prolonged ischaemia, increased intraoperative EBL, and solitary kidney status.

As the experience with PN was increasing, particularly from centres of excellence with a strong experience in both OPN and LPN, careful case selection and preoperative surgical planning were emerging as the critical factors that affected outcome. The Cleveland Clinic group reported their experience in 169 patients with T1 (48 h. Overall, 21 patients (13.3%) had urine leakage. Factors associated with a greater likelihood of urine leak included larger tumour size, endophytic tumour location and repair of collecting system at the time of tumour resection.

Factors not associated with urine leak included number of tumours resected, EBL, ischaemia time, body mass index, age, or other surgical complications. The median duration of the leak was 20 days. Most urine leaks resolved with prolonged drainage, but 10 patients (38%) required a secondary intervention including a ureteric stent (eight patients) and percutaneous nephrostomy (two patients). No RNs or surgical re-explorations were required. In a larger study, MSKCC investigators analysed 1118 PNs defining persistent urinary leak as that lasting for >2 weeks or a patient that represents after drain removal with a urinoma requiring percutaneous drainage.

In all, 52 patients developed a postoperative urinary fistula (4.4%) with persistent leak accounting for 4% and delayed fistula presentation accounting for 0.4% of cases. Factors associated with urine leak were larger tumours (3.5 vs 2.6 cm), more EBL (400 mL vs 300 mL), and longer ischaemia time (50 min vs 39 min). Overall, 36 patients (69%) resolved the fistula without intervention while 16 patients (31%) underwent a secondary procedure including stent (eight patients) and another drain (two patients).

No patient lost their kidney or required a nephrectomy to manage the fistula. Urologists often debate in conferences whether closed suction or Penrose drainage is preferable after PN. MD Anderson surgeons evaluated 184 patients undergoing 197 PNs at their centre, with drainage type based solely on surgeon preference.

A Penrose drain was used in 74 patients (37.6%) and a closed-suction drain in 123 patients (62.4%). Clinical characteristics between the groups were similar and mean tumour size was 3.1 cm. There was no significant difference in the mean duration of drainage between those receiving a Penrose drain (7.1 days) and those receiving a closed-suction drain (7.8 days). In addition, there was no significant difference in postoperative complications between the groups. On a practical level when faced with a persistent urinary leak, I encourage patients to eat ‘three square meals a day’, rest, and exercise in hopes of speeding natural wound healing.

If urine leak continues for more than 6–8 weeks without any sign of gradual decline, a cystoscopy and retrograde pyelogram should be done to exclude the possibility of distal ureteric obstruction. A disconcerting finding on such a study could be the finding of a normal pyelocalyceal system yet persistent urinary drainage. In this case, it must be assumed that there is an excluded renal papilla without a corresponding calyx that is causing the leak.

In this circumstance, the leak may take several months to resolve until that papilla is no longer functional. • • Retrograde pyelogram showing leakage of contrast from a middle pole calyx into perinephric drain. An internal double stent was used to facilitate closure of the urinary fistula. Pseudoaneurysm or iatrogenic arteriovenous fistula forms when surgical repair of vascular rents fuses arteries and veins with the occurrence of direct communication between the two. On rare occasions, a palpable thrill can be noticed during the closing of a PN. In this case, the situation needs to be addressed immediately with either re-exploration of the PN bed and ligation of the communicating vessels or completion by RN. Delayed postoperative bleeding with perinephric haematoma can present with pain, gross haematuria, and hypotension, flank mass, or flank discoloration from dissecting blood through the healing wound.

After appropriate resuscitation, CT renal protocol is used to make the diagnosis. This will show arterial blood is pooling in a closed space with or without perinephric haematoma, a finding which should initiate an urgent request to interventional radiology for a diagnostic and therapeutic selective renal artery angiogram and coil embolization. The interventional radiologist should make every effort to occlude a tertiary and quaternary branches of the renal artery as close to pseudoaneurysmal pocket as possible to limit collateral damage to viable, healthy renal tissue (). Cohenpour et al. Reported five such pseudoaneurysms (four after OPN, one after LPN) which presented 1–21 days after PN. Selective coil embolization was successful in four of the five cases and RN was required in one case.

Careful surgical technique during OPN or LPN with avoidance of deep haemostatic ‘bites’ with large needles into the renal sinus will greatly diminish the likelihood of this complication. • • a, Renal protocol CT showing postoperative pseudoaneurysm of the left kidney with perinephric haemorrhage. B, Selective angiogram showing pseudoaneurysm (iatrogenic arteriovenous fistula) of a tertiary branch of an upper pole renal artery. C, Successful coil embolization of the feeding arterial branch with subsequent complete resolution of the pseudoaneurysm. PN IS UNDER-UTILIZED In 2009, it is estimated that >57 760 patients will develop renal cortical tumours in the USA of which ≈70% are incidentally detected at a tumour size of ≤4 cm. Over the last 10 years, despite the well-described oncological and medical arguments in the contemporary literature supporting PN as the ideal treatment for such small renal masses, the urological oncology community continued to use RN as the predominant treatment of the T1 renal mass. Investigators took a cross-sectional view of clinical practice using the Nationwide Inpatient Sample; they reported that only 7.5% of kidney tumour operations in the USA 1988–2002 were PNs.

Using the Surveillance Epidemiology and End Results (SEER) data base, investigators from the University of Michigan reported from 2001, only 20% of all renal cortical tumours of 2–4 cm were treated by PN and using the SEER database linked to Medicare claims, MSKCC investigators reported a utilization rate of only 19% for T1a tumours (≤4 cm). Interestingly and for uncertain reasons, women and elderly patients are more likely to be treated with RN. Many urologists think a ‘quick’ RN in an elderly patient would expose the patient to fewer postoperative complications than would a PN. However, MSKCC investigators evaluated age and type of procedure performed in 1712 patients with kidney tumours and found that the interactive term was not significant indicating a lack of statistical evidence that the risk of complications associated with PN increased with advancing age. Furthermore, no evidence was reported linking age to EBL or operative duration. Given the advantages of renal functional preservation, the authors concluded that elderly patients should be perfectly eligible for PN.

Although the urology literature has a great many articles written concerning the use of laparoscopy techniques to resect kidney tumours, the penetrence of LRN according to the National Inpatient Sample from 1991 to 2003 was only 4.6% with a peak incidence of 16% in 2003. This data indicates clearly that the bulk of ‘kidney wasting operations’ are still being done by the traditional open surgical approach.

In England, a similar under-utilization of PN was reported in 2002 with only 108 (4%) PNs out of 2671 nephrectomies performed. Investigators at MSKCC tracked nephrectomy use in 1533 patients between 2000 and 2007 excluding patients with bilateral tumours and tumours in a solitary kidney, and including only patients with an eGFR of >45 mL/min/1.73 m 2. Overall 854 (56%) patients underwent PN and 679 (44%) underwent RN. In the 820 patients with a renal tumour of ≤4 cm, the frequency of PN increased from 69% in 2000 to 89% in 2007.

In the 365 patients with a renal tumour of 4–7 cm, the frequency of PN increased from 20% in 2000 to 60% in 2007. Despite a commitment to kidney-sparing operations by our group during this period, multivariate analysis indicated that PN was a significantly favoured approach for males, younger patients, smaller tumours, and open surgeons.

Abouassaly et al. From the University of Toronto provided more insight into the under-utilization of PN problem by evaluating 7830 patients in the Ontario Cancer Registry from 1995 to 2004. Of these, 7042 (89.9%) underwent RN and 788 (10.1%) underwent PN. In 2003, LRN was introduced to Ontario by surgeons in this province but LPN was not available. The authors used a multinomial logistic regression model to relate the relative numbers of patients with ORN and LRN, and OPN to patient age, gender and surgery year. Using a segmented trend regression model, the authors showed a clear change in PN usage with time ( P= 0.001) such that the odds of PN increased by 18% per year before January 2003 (odds ratio 1.18, 95% CI 1.14–1.23) and subsequently decreased by 12% per year (odds ratio 0.88, 95% CI 0.75–1.02). In the multinomial regression model, age and surgery year but not gender were independently associated with PN.

This study also showed that elderly patients were more likely to undergo RN (by any technique) than PN. One can only speculate that the emerging publications describing the benefits of PN was initially appreciated by the Ontario surgeons but subsequently overwhelmed by the desire of the surgeons to integrate new surgical technology (LRN) into their practices, essentially conquering the technical learning curve on patients with small renal masses.

The extent to which effective marketing by instrument makers, hospitals, and surgeons wishing to portray the most contemporary surgical techniques played in the reversal of PN utilization is not known. CONCLUSION The emergence of PN as an effective treatment for small renal masses is based on the following fundamental facts: • I. About 20% of renal tumours are benign and 25% are indolent with limited metastatic potential; • II.

PN and RN provide equivalent oncological control for tumours of ≤7 cm; • III. RN is associated with the development of CKD and associated cardiovascular morbidity and mortality. Despite the clinical research supporting PN for the treatment of small renal masses, the procedure remains under-utilized in the USA and abroad, a situation the will be rectified only by enhanced educational and surgical training programmes. Problems unique to PN, including the best means to provide renal ischaemia during tumour resection and management of potential postoperative complications of bleeding, infection, urinary fistula remain of significant concern to urological surgeons whether the operation is performed using open or minimally invasive techniques. It is now clear that, despite the technical challenges associated with executing an effective PN, that local tumour control and preservation of renal function make it the surgical procedure of choice for the treatment of the small renal mass. CONFLICT OF INTEREST None declared.

QUESTIONS • 1Patients more susceptible to the adverse impact of ischaemia during PN include: • (a) elderly patients with a low eGFR prior to operation • (b) extensive blood loss during the operation • (c) long duration of ischemia time • (d) all of the above • Answer: d • 2True or false: A mini-flank surgical incision is associated with partial resection of the 11th rib. • Answer: False • 3True or false: In the absence of a radiological abnormality on preoperative imaging, the surgeon performing a PN does not need to remove the ipsilateral adrenal gland.

• 1 Vivek Venkatramani, Sanjaya Swain, Ramgopal Satyanarayana, Dipen J.