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Ninth European InternationalKidney Cancer SymposiumDublin – 25-26 April 2014
Laparoscopic Nephrectomy for Locally Advanced RCC – Anecdote or
the FutureDavid Nicol
Consultant Urologist and Chief of SurgeryRoyal Marsden Hospital
London, UK
Ninth European InternationalKidney Cancer SymposiumDublin – 25-26 April 2014
Lap Nx for Locally Advanced RCCDefinitionspT3 a. Perirenal/renal sinus fat
b. Renal veinI. Renal veinII. < 2cm from renal veinIII. IntrahepaticIV. Supradiaphragmatic
pT4
N+
Ninth European InternationalKidney Cancer SymposiumDublin – 25-26 April 2014
Lap Nx for Locally Advanced RCCDefinitionspT3 a. Perirenal/renal sinus fat
b. Renal veinI. Renal veinII. < 2cm from renal veinIII. IntrahepaticIV. Supradiaphragmatic
pT4
N+
Ninth European InternationalKidney Cancer SymposiumDublin – 25-26 April 2014
Lap Nx for Locally Advanced RCCDefinitionspT3 a. Perirenal/renal sinus fat
b. Renal veinI. Renal veinII. < 2cm from renal veinIII. IntrahepaticIV. Supradiaphragmatic
pT4
N+
Ninth European InternationalKidney Cancer SymposiumDublin – 25-26 April 2014
Lap Nx for Locally Advanced RCCPurpose
1. Curative
2. Cytoreductive
Ninth European InternationalKidney Cancer SymposiumDublin – 25-26 April 2014
Lap Nx for Locally Advanced RCCWhat is reported
Ninth European InternationalKidney Cancer SymposiumDublin – 25-26 April 2014
Lap Nx for Locally Advanced RCCLiterature
1. Anecdotal/case series 2. Selection/reporting bias
Small median tumour size in seriesPathological staging >> clinical staging (ie cT1/2 → pT3)
Ninth European InternationalKidney Cancer SymposiumDublin – 25-26 April 2014
Lap Nx for Locally Advanced RCCLiterature1. Technically feasible in ‘selected cases’ 2. Equivalent oncological outcomes*#
1. Local recurrence rates2. Time to recurrence3. Survival
*Stewart et al BJUI 2012#Laird et al World J Urol 2014
Ninth European InternationalKidney Cancer SymposiumDublin – 25-26 April 2014
Lap Nx for Locally Advanced RCCWhat is not in the LiteratureDenominator in surgical seriesCatastrophes
Vascular disaster (lymph nodes++, use of clips, SMA division)
Duodenal/visceral injuryProtracted surgery
Ninth European InternationalKidney Cancer SymposiumDublin – 25-26 April 2014
Lap Nx for Locally Advanced RCCT3b1. Pure lap only feasible with Level 12. Some staple line +ve margins reported*3. Level 2/3 – hand assist/open completion4. Largest series – only 30% ‘feasible’ #
*Guzzo et al J Endourol Jan 2009#Xu et al J Endourol Feb 2014
Ninth European InternationalKidney Cancer SymposiumDublin – 25-26 April 2014
Lap Nx for Locally Advanced RCCTechnical Issues – limiting factorsLarge tumour(specimen) size Marked lymphadenopathyVenous congestion (haematuria + non-functioning kidney)Multivisceral resection (except distal pancreas/spleen)
Right sidePerinephric neovascularisation
Ninth European InternationalKidney Cancer SymposiumDublin – 25-26 April 2014
Lap Nx for Locally Advanced RCCCytoreductive
1. Margins less of an issue2. Recovery/morbidity – earlier
introduction/reintroduction of systemic therapy
Ninth European InternationalKidney Cancer SymposiumDublin – 25-26 April 2014
Lap Nx for Locally Advanced RCCCytoreductive
1. Pre-operative medical therapy does not increase prospects of laparoscopic approach
2. Pazopanib/Axitinib preferred if initial medical therapy
Ninth European InternationalKidney Cancer SymposiumDublin – 25-26 April 2014
Lap Nx for Locally Advanced RCCConclusions
1. Clinical reality – pathological upstaging2. Selected cases with cT3 disease3. Careful selection – safety/margins4. Advantageous when feasible in cytoreductive
setting
