Ponad 7000 publikacji medycznych!
Statystyki za 2021 rok:
odsłony: 8 805 378
Artykuły w Czytelni Medycznej o SARS-CoV-2/Covid-19

Poniżej zamieściliśmy fragment artykułu. Informacja nt. dostępu do pełnej treści artykułu
© Borgis - Postępy Nauk Medycznych 4/2012, s. 356-361
*Sebastian Piotrowicz, Jakub Dobruch, Piotr L. Chłosta, Tomasz Szopiński, Andrzej Borówka
Leczenie chirurgiczne chorych na raka nerki
Surgical treatment of renal cell carcinoma
Department of Urology, European Health Centre Otwock, Medical Centre of Postgraduate Education Warsaw
Head of the Dept.: Prof. Andrzej Borówka, MD, PhD
Rak nerkowokomórkowy (RCC – renal cell carcinoma) powstaje zwykle z komórek nabłonka proksymalnych kanalików krętych nefronu. RCCs stanowią nie mniej niż 3% wszystkich nowotworów złośliwych, a zapadalność na ten nowotwór zwiększa się w Europie o 2% rocznie. Od czasu rozpowszechnienia ultrasonografii i tomografii komputerowej zwiększyła się liczba chorych, u których guzy nerki rozpoznaje się przypadkowo u osób, u których wspomniane badania wykonywane są z innych powodów niż „urologiczne”. Guzy rozpoznane przypadkowo (IRT – incidental renal tumors), zwane także „guzami radiologicznymi”, są zwykle mniejsze od guzów „objawowych”. Jedyną metodą pierwotnego leczenia RCCs jest leczenie chirurgiczne, przy czym zakres i rodzaj operacji zależą głównie od stopnia zaawansowania raka. Zasady leczenia operacyjnego chorych na RCC uległy w ostatnich latach istotnym zmianom. Z jednej strony polegają one na ograniczeniu inwazyjności i zakresu operacji u chorych, u których rozpoznaje się guz ograniczony do nerki, aczkolwiek bez zmniejszenia jej skuteczności onkologicznej, z drugiej natomiast na możliwie jak najbardziej agresywnym leczeniu operacyjnym tych chorych, u których nowotwór jest zaawansowany miejscowo. Dynamiczne leczenie operacyjne ma także zastosowanie u chorych, u których stwierdza się współistnienie przerzutów odległych, jeśli stan chorych pozwala na poddanie ich operacji, a także u chorych, u których po częściowym wycięciu nerki wraz z guzem lub po nefrektomii radykalnej dochodzi do wznowy miejscowej nowotworu lub do przerzutów odległych, które można wyciąć.
Renal Cell Carcinoma (RCC) derives from various parts of the nephron. The incidence of RCC increases by an average of 2% per year and accounts for 2% to 3% of all adult malignant neoplasms. The implementation of ultrasonography and computed tomography increased the number of fortuitous diagnoses of RCCs which are called Incidental Renal Tumours (IRT). Such tumours are usually smaller than symptomatic ones. Surgical treatment is the best option for the primary tumour. The type of surgical treatment depends of the stage of the tumour. However, the technique of surgical treatment has changed recently. The trend is to decrease the extent and invasiveness of surgery without affecting the oncological safety in patients with localized RCC. On the other hand there is indication for aggressive treatment in patients with locally advanced disease. Tumour nephrectomy is also recommended for metastatic RCC patients with good performance status when combined with IFN – alpha. Complete removal of metastatic lesions or isolated local recurrences after partial nephrectomy or radical nephrectomy contribute to an improvement of clinical prognosis.

In 2009, the incidence of malignant tumours arising from the renal parenchyma in Poland is estimated to have been 14.8/100 000 in men and 9.5/100 000 in women, while the associated death rates were 8.4/100 000 and 5.0/100 000, respectively (1). Among renal tumours, the dominating renal cell carcinoma (RCC) arises from the proximal canaliculi of the nephron. RCCs comprise at least 3% of all malignant neoplasms (2), while their incidence in Europe grows annually by 2% (3). RCC occurs 1.5-2 times more frequently in men compared to women (4), and the incidence rises in the sixth and seventh decades of life (5). The main risk factors of RCC are tobacco smoking, obesity and arterial hypertension (6, 7). In the majority of patients, RCC is a sporadic tumour, with only 2-3% occurring in a familial background (7).
“Renal cell carcinoma” is a broad term. It encompasses several histologically dissimilar tumours. The one with the highest incidence is clear cell carcinoma (CCC), which makes up 70-80% of all RCCs. The remaining types are papillary cancer (10-15%), chromophobic cancer (3-5%) and an exceptionally malignant cancer arising from the collecting duct epithelium (collecting duct carcinoma), also known as Bellini’s tumour (< 1 %) (8).
The signs and symptoms associated with solid renal tumours are not characteristic. The main ones include pain, haematuria, and a palpable mass in the kidney region, collectively known as Israel’s triad. Tumours found when diagnostic workup was induced by symptoms are usually advanced. Ever since ultrasound and computed tomography imaging became widely available, there is a growing number of cases identified accidentally by studies performed for “non-urological” indications. Incidental renal tumours (IRT), also called “imaging tumours”, are usually smaller than “symptomatic” tumours. The proportion of fortuitously diagnosed tumours in the total number of diagnosed renal tumours is currently approx. 60% (9,10).
The only method of primary treatment of RCC is surgery, while the type and scope of the operation depend chiefly on the disease stage. The grading of the cancer based on a four-grade Fuhrman scale (11) can be determined after tumour excision, since percutaneous lesion biopsy is not deemed to be a part of standard preoperative management. The latter is only applied when the tumour is to be removed by a minimally invasive method executed through thermal ablation.
Less advanced stages and smaller sizes of RCCs at the time of diagnosis as well as a better understanding of the biology of these tumours has encouraged the search for surgical methods that would be less invasive and more limited in scope compared to the classic radical nephrectomy (RN), which has been the mainstay of treatment. Currently, in cases with a favourable anatomical location of the tumour, which measures no more than 7 cm in its largest diameter, nephron-sparing surgery is advocated (NSS).
Partial nephrectomy
The pioneer of partial nephrectomy (PN), also known as kidney resection, is Vincent Czerny, who performed a renal parenchyma-sparing operation in 1887. However, this method was not broadly adopted due to numerous complications. Currently, PN is recommended for tumours measuring up to 4 cm in diameter (cT1a) and is a method of choice for tumours measuring between 4 and 7 cm, which are limited to the kidney (cT1b), provided that it is technically feasible (12-24). The occurrence of major complications, which were reported earlier, has been greatly reduced by the advent of new techniques, devices and materials, however, the risk of their emergence should not be ignored. They can include secondary bleeding from the resected kidney, and urinary or arterio-venous fistulas, which may lead to serious haematuria. The fundamental advantage of PN is the preservation of the unaffected part of the kidney. This markedly reduces the risk of chronic renal failure, which may emerge with varied delay following total nephrectomy, especially in patients with diabetes, atherosclerosis or arterial hypertension (25). According to some authors, the quality of life of patients subjected to PN is superior to that of patients treated by radical nephrectomy (26, 27). Moreover, the execution of surgery with a short period of renal ischaemia usually does not impair renal function (28).
Until recently, the indications for PN were limited to the so-called absolute kind and included tumours developing in an anatomically or functionally single kidney (i.e. absence of the contralateral kidney or failure or complete lack of function of the contralateral kidney), as well as a bilateral RCC. Currently, these have been broadened to include relative indications, which regard patients with a risk of future failure of the contralateral kidney; or with a genetic defect, which increases the risk of renal tumours developing in the future, as in syndromes like von Hippel-Lindau, hereditary papillary RCC, familial leiomyomatosis, Birt-Hogg-Dubé (29, 30); as well as elective indications, such as the technical feasibility and safety of PN in patients, whose contralateral kidney is intact (12).
Partial nephrectomy can involve the resection of the inferior, superior, or even central fragment of the kidney, which contains the tumour, together with a margin of macroscopically unaltered renal parenchyma (a margin of 1 mm is sufficient). It is performed retroperitoneally via lumbotomy (open surgery) or, with increasing frequency, by laparoscopy or retroperitoneoscopy (endoscopic surgery without opening of the peritoneal cavity). Surgery is performed in conditions of ischaemia achieved after clamping the major vessels of the renal pedicle, or preferably, if possible, the selective clamping of vessels supplying the resected fragment of the kidney. The duration of ischaemia is critically important for the later function of the resected kidney. In the case of so-called “warm ischaemia”, its duration should not exceed 20 minutes (31). On the other hand, if “cold ischaemia” is applied by packing the kidney with sterile crushed ice, its duration can be safely extended up to 60 minutes (32). PN reduces the risk of renal failure. McKiernan et al. performed a 10-year prospective study, which enrolled 290 patients with RCC measuring up to 4 cm, in whom the contralateral kidney was normal. The study compared 173 patients treated by radical nephrectomy (RN) with a group of 117 patients treated by PN. The former group had a higher risk of developing chronic renal failure, compared to the latter group (33). Dash et al. performed a prospective study, which followed 196 subjects with RCC measuring 4-7 cm, in whom either RN or PN was performed. They found that 3 months post-op, creatinine levels were significantly lower in patients treated with PN (20). Nevertheless, the most important goal regarding PN is to achieve long-term oncological outcomes that match classic radical nephrectomy. Lee et al. compared PN and RN outcomes in patients with RCC tumours measuring < 4 cm finding that 5-year survival without local recurrence is comparable for both types of treatment (34). Many other papers have reported similar outcomes of PN and RN in patients operated for tumours measuring < 7 cm (13, 17, 18, 20, 22, 24).

Powyżej zamieściliśmy fragment artykułu, do którego możesz uzyskać pełny dostęp.
Mam kod dostępu
  • Aby uzyskać płatny dostęp do pełnej treści powyższego artykułu albo wszystkich artykułów (w zależności od wybranej opcji), należy wprowadzić kod.
  • Wprowadzając kod, akceptują Państwo treść Regulaminu oraz potwierdzają zapoznanie się z nim.
  • Aby kupić kod proszę skorzystać z jednej z poniższych opcji.

Opcja #1


  • dostęp do tego artykułu
  • dostęp na 7 dni

uzyskany kod musi być wprowadzony na stronie artykułu, do którego został wykupiony

Opcja #2


  • dostęp do tego i pozostałych ponad 7000 artykułów
  • dostęp na 30 dni
  • najpopularniejsza opcja

Opcja #3


  • dostęp do tego i pozostałych ponad 7000 artykułów
  • dostęp na 90 dni
  • oszczędzasz 28 zł
1. www.onkologia.org.pl
2. Dobruch J, Borówka A, Szostek P et al.: Małoinwazyjne metody leczenia chirurgicznego guzów nerki – część I. Urol Pol (PJU) 2008; 62:125-129.
3. Dobruch J, Borówka A, Szostek P et al.: Małoinwazyjne metody leczenia chirurgicznego guzów nerki – część II. Urol Pol (PJU) 2008; 62: 130-135.
4. Carrizosa DR, Godley PA: Epidemiology and screening of renal cell carcinoma. [In:] Rini BI, Campbell SC, editors. Renal cell carcinoma, Shelton (CT): People’s Medical Publishing House; 2009:15-24.
5. Wallen EM, Pruthi RS, Joyce GF et al.: Kidney cancer. J Urol 2007; 177: 2006-2019.
6. McLaughlin JK, Lipworth L: Epidemiologic aspects of renal cell cancer. Semin Oncol 2000; 27: 115-123.
7. Lipworth L, Tarone RE, McLaughlin JK: The epidemiology of renal cell carcinoma. J Urol 2006; 176: 2353-2358.
8. Zhou M: Pathology of renal cell carcinomas. [In:] Rini BI, Campbell SC, ed. Renal cell carcinoma, Shelton (CT): People’s Medical Publishing House 2009; 1-14.
9. Dobruch J, Borówka A, Dzik T et al: Charakterystyka onkologiczna guzów nerki rozpoznanych przypadkowo. Urol Pol 2005; 4: 266-269.
10. Minimally Invasive Nephron-Sparing Surgery (MINSS) for Renal Tumors Part 1: Laparoscopic Partial Nephrectomy. European Urology 2007; 51: 337-347.
11. Fuhrman SA, Lasky LC, Limas C: Prognostic significance of morphologic parameters in renal cell carcinoma. Am J Surg Pathol 1982; 6: 655-663.
12. Ljungberg B, Cowan N, Hanbury DC et al.: 2010 Guidelines on Renal Cell Carcinoma 2011; European Guidelines of Urology 2011 Edition. p. 5-42.
13. Patard JJ, Shvarts O, Lam JS et al.: Safety and efficacy of partial nephrectomy for all T1 tumors based on an international multicenter experience. J Urol 2004;171: 2181-2185.
14. Nguyen CT, Campbell SC, Novick AC: Choice of operation for clinically localized renal tumor. Urol Clin North Am 2008; 35: 645-655.
15. Russo P: Open partial nephrectomy: an essential operation with an expanding role. Curr Opin Urol 2007; 17: 309-315.
16. Russo P, Huang W: The medical and oncological rationale for partial nephrectomy for the treatment of T1 renal cortical tumors. Urol Clin North Am 2008; 35: 635-643.
17. Joniau S, Vander Eeckt K, Srirangam SJ et al.: Outcome of nephron-sparing surgery for T1b renal cell carcinoma. BJU Int 2009; 103: 1344-1348.
18. Leibovich BC, Blute ML, Cheville JC et al.: Nephron sparing surgery for appropriately selected renal cell carcinoma between 4 and 7 cm results in outcome similar to radical nephrectomy. J Urol 2004; 171: 1066-1070.
19. Patard JJ, Pantuck AJ, Crepel M et al.: Morbidity and clinical outcome of nephron-sparing surgery in relation to tumour size and indication. Eur Urol 2007; 52: 148-154.
20. Dash A, Vickers AJ, Schachter LR et al.: Comparison of outcomes in elective partial vs radical nephrectomy for clear cell renal cell carcinoma of 4-7 cm. BJU Int 2006; 97: 939-945.
21. Becker F, Siemer S, Hack M et al.: Excellent long-term cancer control with elective nephron-sparing surgery for selected renal cell carcinomas measuring more than 4 cm. Eur Urol 2006; 49: 1058-1063.
22. Antonelli A, Cozzoli A, Nicolai M et al.: Nephron-sparing surgery versus radical nephrectomy in the treatment of intracapsular renal cell carcinoma up to 7 cm. Eur Urol 2008; 53: 803-809.
23. Peycelon M, Hupertan V, Comperat E et al.: Long-term outcomes after nephron sparing surgery for renal cell carcinoma larger than 4 cm. J Urol 2009; 181: 35-41.
24. Thompson RH, Siddiqui S, Lohse CM et al.: Partial versus radical nephrectomy for 4 to 7 cm renal cortical tumors. J Urol 2009; 182: 2601-2606.
25. Thompson RH, Boorjian SA, Lohse CM et al.: Radical nephrectomy for pTa renal masses may be associated with decreased overall survival compared with partial nephrectomy. J Urol 2008; 179: 468-471.
26. Clark PE, Schover LR, Uzzo RG et al.: Quality of life and psychological adaptation after surgical treatment for localized renal cell carcinoma: impact of the amount of remaining renal tissue. Urology 2001; 57: 252-256.
27. Lesage K, Joniau S, Fransis K et al.: Comparison between open partial and radical nephrectomy for renal tumours: perioperative outcome and health-related quality of life. Eur Urol 2007; 51: 614-620.
28. La Rochelle J, Shuch B, Riggs S et al.: Functional and oncological outcomes of partial nephrectomy of solitary kidneys. J Urol 2009; 181: 2037-2042.
29. Birt AR, Hogg GR, Dubé WJ: Hereditary multiple fibrofolliculomas with trichodiscomas and acrochordons. Arch Derm 1977; 113: 1674-1677.
30. Ljungberg B, Hanbury DC, Kuczyk MA et al.: Guidelines on renal cell carcinoma. http://wwwuroweborg/fileadmin/tx_eauguidelines/2009/Full/RCCpdf
31. Novick AC: Open surgery of the kidney. [In:] Campbell MF, Wein AJ, Kavoussi LR, editors. Campbell-Walsh Urology. Philadelphia: WB Saunders 2007; p. 1686-1758.
32. Thompson RH, Frank I, Lohse CM et al.: The impact of ischemia time during open nephron sparing surgery on solitary kidneys: a multiinstitutional study. J Urol 2007; 177: 471-476.
33. McKiernan J, Simmons R, Katz J et al.: Natural history of chronic renal insufficiency after partial and radical nephrectomy. Urology 2002; 59: 816-820.
34. Lee CT, Katz J, Shi W et al.: Surgical management of renal tumors 4 cm. or less in a contemporary cohort. J Urol 2000; 16: 730-736.
35. Ng CS, Gill IS, Ramani AP et al.: Transperitoneal versus retroperitoneal laparoscopic partial nephrectomy: patient selection and perioperative outcomes. J Urol 2005; 174: 846-849.
36. Lane BR, Gill IS: 5-Year outcomes of laparoscopic partial nephrectomy. J Urol 2007; 177: 70-74.
37. Gill I, Kamoi K, Aron M, Desai MM: 800 laparoscopic partial nephrectomies: a single-surgeon series. J Urol 2010; 183: 34-41.
38. Gill IS, Kavoussi LR, Lane BR et al.: Comparison of 1,800 laparoscopic and open partial nephrectomies for single renal tumors. J Urol 2007; 178: 41-46.
39. Turna B, Aron M, Gill IS: Expanding indications for laparoscopic partial nephrectomy. Urology 2008; 72: 481-487.
40. Kirkali and P. Mulders – Kidney Cancer Edition 2011 1st EAU-ICUD International Consultation on Kidney Cancer Barcelona 2010; Van Poppel H, Becker F, Caddedu J et al.: Treatment of localised renal cell carcinoma 2011; p. 122-127.
41. Van Poppel H, Da Pozzo L, Albrecht W et al.: Prospective, randomised EORTC Intergroup phase 3 study comparing the oncologic outcome of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma. Eur Urol 2011; 59: 543-552.
42. Robson CJ, Churchill BM, Anderson W: The results of radical nephrectomy for renal cell carcinoma. J Urol 1969; 101: 297-301.
43. Van Poppel H, Deroo F, Joniau S: Open surgical treatment of localized renal cell cancer. AUA Update series 2003; 1: 220-225.
44. Van Poppel H, Da Pozzo L, Albrecht W et al.: A prospective randomized EORTC intergroup phase 3 study comparing the complications of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma. Eur Urol 2007; 51: 1606-1615.
45. Mattar K, Finelli A: Expanding the indications for laparoscopic radical nephrectomy. Curr Opin Urol 2007; 17: 88-92.
46. Nambirajan T, Jeschke S, Al-Zahrani H et al.: Prospective, randomized controlled study: transperitoneal laparoscopic versus retroperitoneoscopic radical nephrectomy. Urology 2004; 64: 919-924.
47. Desai MM, Strzempkowski B, Matin SF et al.: Prospective randomized comparison of transperitoneal versus retroperitoneal laparoscopic radical nephrectomy. J Urol 2005; 173: 38-41.
48. Portis AJ, Yan Y, Landman J et al.: Long-term followup after laparoscopic radical nephrectomy. J Urol 2002; 167: 1257-1262.
49. Burgess NA, Koo BC, Calvert RC et al.: Randomized trial of laparoscopic v open nephrectomy. J Endourol 2007; 21: 610-613.
50. Chung SD, Huang KH, Lai MK et al.: Long-term follow-up of hand-assisted laparoscopic radical nephrectomy for organ-confined renal cell carcinoma. Urology 2007; 69: 652-655.
51. Martin SF, Dhanani N, Acosta M et al.: Conventional and hand-assisted laparoscopic radical nephrectomy: Comparative analysis of 271 cases. J. Endourol 2006; 20: 891-894.
52. Hemal AK, Kumar A: A prospective comparison of laparoscopic and robotic radical nephrectomy for T1-114 2N0M0 renal cell carcinoma. World J Urol 2009; 27: 89-94.
53. Leibovich BC, Blute ML: Surgical management of renal cell carcinoma. Seminars in oncology 2006; 33: 552-562.
54. Marshall VF, Middleton RG, Holswade GR et al.: Surgery for renal cell carcinoma in the vena cava. J Urol 1970; 103: 414-420.
55. Oto A, Herts BR, Remer EM et al.: Inferior vena cava tumor thrombus in renal cell carcinoma: staging by MR imaging and impact on surgical treatment. Am J Roentgenol 1998; 171: 1619-1624.
56. Haferkamp A, Bastian PJ, Jakobi H et al.: Renal cell carcinoma with tumor thrombus extension into the vena cava: prospective long-term followup. J Urol 2007; 177: 1703-1708.
57. Blute ML, Leibovich BC, Lohse CM et al.: The Mayo Clinic experience with surgical management, complications and outcome for patients with renal cell carcinoma and venous tumour thrombus. BJU Int 2004; 94: 33-41.
58. Pantuck AJ, Zisman A, Dorey F et al.: Renal cell carcinoma with retroperitoneal lymph nodes: role of lymph node dissection. J Urol 2003; 169: 2076-2083.
59. Margulis V, Sanchez-Ortiz RF, Tamboli P et al.: Renal cell carcinoma clinically involving adjacent organs: experience with aggressive surgical management. Cancer 2007; 109: 2025-30.
60. Karellas ME, Jang TL, Kagiwada MA et al.: Advanced-stage renal cell carcinoma treated by radical nephrectomy and adjacent organ or structure resection. BJU Int 2009; 103: 160-4.
61. Capitanio U, Perrotte P, Zini L et al.: Nephrectomy improves survival in patients with invasion of adjacent viscera and absence of nodal metastases (stage T4N0 renal cell carcinoma). BJU Int 2009; 104: 795-9.
otrzymano: 2012-01-25
zaakceptowano do druku: 2012-02-29

Adres do korespondencji:
*Sebastian Piotrowicz
Department of Urology, European Health Centre Otwock, Medical Centre of Postgraduate Education Warsaw
Borowa Str. 14/18 05-400, Otwock
tel.: +48 515-103-409
e-mail: spiotrowicz@wp.pl

Postępy Nauk Medycznych 4/2012
Strona internetowa czasopisma Postępy Nauk Medycznych