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Câncer de rim
tratamento minimamente
invasivo
Álvaro Sarkis
Professor Livre Docente Universidade de São Paulo
Urologista do Hospital do Servidor Público de São Paulo
Outline
• Nefrectomia minimamente invasiva vs
aberta para tumores 4cm a 7cm
• Crioablação laparoscópica vs PN para
tumores renais pequenos: revisão
sistemática
• Evolução funcional e oncológica de NSS
para tumores renais >7 cm
Nefrectomia minimamente
invasiva vs aberta para
tumores 4cm a 7cm
MSKCC
N=280 de 2290
Seguimento livre de recidivas e metástases
Mediana de follow-up para OPN 29 meses e MIPN 13 mo,
Seguimento curtoi!!
EUROPEAN UROLOGY 61 (2012) 593–599
Nefrectomia parcial para
Tumores > 4 cm
EUROPEAN UROLOGY 61 (2012) 593–599
9()% das nefrectomias não são parciais
EUROPEAN UROLOGY 61 (2012) 593–599
Conclusão
• LPN pode ser feita com segurança em
tumores > 4 a 7cm, com aumento de
morbidade (fistula 7% laparoscopia vs 5%
aberta)
Crioablação laparoscópica vs
PN para tumores renais
pequenos
revisão sistemática
EUROPEAN UROLOGY 60 (2011) 435–443
EUROPEAN UROLOGY 60 (2011) 435–443
Crioablação laparoscópica vs PN
para tumores renais pequenos
EUROPEAN UROLOGY 60 (2011) 435–443
Crioablação laparoscópica vs PN
para tumores renais pequenos
EUROPEAN UROLOGY 60 (2011) 435–443
Conclusões
• LCA e PN são opções viáveis para o
tratamento de SRMs
• LCA tem maior risco de progressão local
• PN é "gold standard"
Evolução funcional e oncológica de
NSS para tumores renais >7 cm
Platinum Priority – Kidney Cancer
Editorial by Craig G. Rogers on pp. 938–939 of this issue
Short-Term Functional and Oncologic Outcomes of
Nephron-Sparing Surgery for Renal Tumours I 7 cm
Frank Becker a,b,1, Frederik C. Roosc,1,*, Martin Janssen a, Walburgis Brenner c,
Christian Hampel c, Stefan Siemer a, Joachim W. Thu¨roff c, Michael Sto¨cklea
a
Department of Urology, University of Saarland, Kirrbergerstrasse, Homburg/Saar, Germany
b
Boxberg Center, Department of Urology and Group Practice Derouet/Poenicke/Becker, Boxbergweg 3, Neunkirchen/Saar, Germany
c
Department of Urology, Medical Centre, Johannes Gutenberg University, Langenbeckstr, Mainz, Germany
Article info
Abstract
Article history:
Accepted February 3, 2011
Published online ahead of
pr int on Febr uar y 11, 2011
Background: Nephron-sparing surgery (NSS) for renal tumourspreserves renal function
and has become the standard approach for small renal tumours. Little is known about
perioperative and oncologic outcomes of patients following NSSin renal tumours 7 cm
in the presence of a healthy contralateral kidney.
Objective: To analyse oncologic outcomes and perioperative morbidity in patients
treated by NSSfor renal tumours 7 cm.
Design, setting, and participants: In total, 5767 patients were treated for renal tumours
at two institutions from 1984 to 2009. In 91 patients, elective NSSwas performed for
renal tumours 7 cm.
Measurements: Complication rates were assessed in detail and stratified using the
Clavien-Dindo score (CDS). Oncologic outcomes for overall survival (OS), cancer-specific
survival (CSS),and progression-freesurvival (PFS) wereestimated usingtheKaplan-Meier
method.Logisticregression analysiswasused to identify clinical risk factorsfor complications and prognosticators that have an oncologic impact on OS.
Results and limitations: The median follow-up was 28 mo (range: 1–247 mo). Twentyseven patients (29.6%) had perioperative complications and, of these, 89.1%had CDS
grade 1 and 2.
Twenty-seven percent of the 91 patients had benign lesions. Seven patients (10.6%)
died from cancer-related causes. The 5- and 10-yr rates for OS, CSS, and PFSwere 88%
and 64%, 97%and 83%, and 91%and 78%, respectively. None of the analysed parameters
had an impact on morbidity or OSin the univariate analysis. Limitations of this study
were its retrospective nature and the relatively short follow-up period for oncologic
outcome.
Conclusions: NSSfor renal tumours 7 cm can be performed with acceptable complication rates and with oncologic outcomes comparable to radical nephrectomy studies.
Our findings support NSS whenever technically feasible to reduce the loss of renal
function.
# 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved.
Keywords:
Renal cell carcinoma
Surgical treatment
NSS
Oncologic outcome
Complications
Please visit
www.eu-acme.org/
europeanurology to read and
answer questions on-line.
The EU-ACME credits will
then be attributed
automatically.
1
Equal contribution.
* Correspondi ng author. Department of Urology and Paediatric Urology, Medical Centre, Johannes
Gutenberg University, Langenbeckstrasse 1, 55101 Mainz, Germany. Tel. +49 6131 177183;
5767 patients were treated for renal tumours
at two institutions from 1984 to 2009.
In 91 patients, elective NSS was performed
for renal tumours > 7 cm.
The median follow-up was 28 mo (range:
1–247 mo). Twenty- seven patients
(29.6%)
Comparavel
à cirurgia
aberta
Conclusão
• NSS para tumores renais > 7cm é viavel
e pode ser sempre feita desde que
tecnicamente factível*
*proposta dos autores
Conclusões gerais
• LPN pode ser feita com segurança em tumores
> 4 a 7cm, com aumento de morbidade (fistula
7% lap. vs 5% aberta)
• LCA e PN são opções viáveis para o tratamento
de SRMs
• LCA tem maior risco de progressão local
• PN é "gold standard”
• NSS para tumores renais > 7cm é viavel e pode
ser sempre feita desde que tecnicamente
factível
n addition to a comparable oncological
outcome be- tween NSS and RN for renal
tumors larger than 4 cm, we have shown that
increasing age, ASA score 3􏰄4, preoperative eGFR, and RN are associated with
the develop- ment of CKD in a balanced
cohort for patients treated by NSS or RN for
renal tumors 􏰄4 cm. NSS maintains renal
function with comparable perioperative
morbidity to RN. It is therefore reasonable to
postulate that NSS should be performed,
whenever technically feasible.