Lokalize Böbrek Kanserinde Cerrahi Tedaviler
Özet
Lokalize renal hücreli kanserlerde (RCC) küratif tedavi için cerrahi yöntemler ön plandadır. Geçmişte radikal nefrektomi (RN) standart kabul edilirken, günümüzde nefron koruyucu cerrahinin önem kazanmasıyla parsiyel nefrektomi (PN) sıklığı artmıştır. Tedavi seçiminde klinik T evresi kritik rol oynar; T1 tümörlerde PN, T2 tümörlerde ise soliter böbrek veya kronik böbrek hastalığı (KBH) gibi özel durumlar dışında genellikle RN önerilir. Cerrahi yaklaşımlar açık, laparoskopik ve robot yardımlı laparoskopik olarak üçe ayrılır. Laparoskopik RN, açık cerrahiye kıyasla daha kısa hastanede kalış süresi, daha az kan kaybı ve daha düşük morbidite gibi perioperatif avantajlar sunar. Robot yardımlı RN ise benzer onkolojik sonuçlara sahip olmakla birlikte, laparoskopik yaklaşıma göre daha uzun ameliyat süresi ve yüksek maliyetle ilişkilidir. PN cerrahisinde temel amaç negatif cerrahi sınır elde ederken sağlıklı parankim dokusunu maksimum düzeyde korumaktır. Açık, laparoskopik ve robotik PN yöntemleri arasında uzun dönem onkolojik sonuçlar, lokal nüks ve sağkalım oranları açısından anlamlı bir fark bulunmamaktadır. Robot yardımlı PN, daha kısa sıcak iskemi süresi ve açık cerrahiye geçiş oranının düşüklüğü ile öne çıkar. Sonuç olarak, minimal invaziv cerrahiler perioperatif parametrelerde farklılık gösterse de uzun dönem onkolojik güvenilirlikleri benzerdir ve teknik seçim cerrahın tecrübesine göre yapılmalıdır.
Surgical treatments are paramount for curative intent in localized renal cell carcinoma (RCC). Although radical nephrectomy (RN) was historically accepted as the standard treatment, the frequency of partial nephrectomy (PN) has increased with the recognized importance of nephron-sparing surgery. Clinical T staging plays a critical role in treatment selection; PN is recommended for T1 tumors, while RN is generally preferred for T2 tumors unless specific conditions like a solitary kidney or chronic kidney disease (CKD) exist. Surgical approaches are categorized into open, laparoscopic, and robot-assisted laparoscopic techniques. Laparoscopic RN offers perioperative advantages over open surgery, such as shorter hospital stays, less blood loss, and lower morbidity. Robot-assisted RN provides similar oncological outcomes but is associated with longer operative times and higher hospital costs compared to laparoscopy. The primary goal in PN surgery is to maximize the preservation of healthy parenchymal tissue while achieving a negative surgical margin. No significant differences exist among open, laparoscopic, and robotic PN methods regarding long-term oncological outcomes, local recurrence, and survival rates. Robot-assisted PN stands out due to a shorter warm ischemia time and a lower rate of conversion to open surgery. In conclusion, while minimally invasive surgeries differ in perioperative parameters, their long-term oncological safety remains similar, and the technical approach should be tailored to the surgeon's experience.
Referanslar
Lane BR, Tiong H-Y, Campbell SC, et al. Management of the adrenal gland during partial nephrectomy. The Journal of urology. 2009;181(6):2430-2437.
Fero K, Hamilton ZA, Bindayi A, et al. Utilization and quality outcomes of cT 1a, cT 1b and cT 2a partial nephrectomy: analysis of the national cancer database. BJU international. 2018;121(4):565-574.
Banegas MP, Harlan LC, Mann B, et al., editors. Toward greater adoption of minimally invasive and nephron-sparing surgical techniques for renal cell cancer in the United States. Urologic Oncology: Seminars and Original Investigations; 2016: Elsevier.
Gunn AJ, Parikh NS, Bhatia S. Society of interventional radiology quality improvement standards on percutaneous ablation in renal cell carcinoma. Journal of vascular and interventional radiology. 2020;31(2):195-201. e193.
Uzosike AC, Patel HD, Alam R, et al. Growth kinetics of small renal masses on active surveillance: variability and results from the DISSRM registry. The Journal of urology. 2018;199(3):641-648.
Ljungberg B, Albiges L, Bensalah K, et al. EAU guidelines on renal cell carcinoma. European Association of Urology. 2017.
Mir MC, Derweesh I, Porpiglia F, et al. Partial nephrectomy versus radical nephrectomy for clinical T1b and T2 renal tumors: a systematic review and meta-analysis of comparative studies. European urology. 2017;71(4):606-617.
Gershman B, Thompson RH, Boorjian SA, et al. Radical nephrectomy with or without lymph node dissection for high risk nonmetastatic renal cell carcinoma: a multi-institutional analysis. The Journal of Urology. 2018;199(5):1143-1148.
Peng B. Retroperitoneal laparoscopic nephrectomy and open nephrectomy for radical treatment of renal cell carcinoma: A comparison of clinical outcomes. Academic Journal of Second Military Medical University. 2006:1167-1169.
Steinberg AP, Finelli A, Desai MM, et al. Laparoscopic radical nephrectomy for large (greater than 7 cm, T2) renal tumors. The Journal of urology. 2004;172(6):2172-2176.
Gratzke C, Seitz M, Bayrle F, et al. Quality of life and perioperative outcomes after retroperitoneoscopic radical nephrectomy (RN), open RN and nephron‐sparing surgery in patients with renal cell carcinoma. BJU international. 2009;104(4):470-475.
Hemal A, Kumar A, Kumar R, et al. Laparoscopic versus open radical nephrectomy for large renal tumors: a long-term prospective comparison. The Journal of urology. 2007;177(3):862-866.
Li J, Peng L, Cao D, et al. Comparison of perioperative outcomes of robot-assisted vs. laparoscopic radical nephrectomy: a systematic review and meta-analysis. Frontiers in Oncology. 2020;10:551052.
Asimakopoulos AD, Miano R, Annino F, et al. Robotic radical nephrectomy for renal cell carcinoma: a systematic review. BMC urology. 2014;14(1):1-6.
Choi JE, You JH, Kim DK, et al. Comparison of perioperative outcomes between robotic and laparoscopic partial nephrectomy: a systematic review and meta-analysis. European urology. 2015;67(5):891-901.
Steinestel J, Steffens S, Steinestel K, et al. Positive surgical margins in nephron-sparing surgery: risk factors and therapeutic consequences. World journal of surgical oncology. 2014;12(1):1-6.
Van Poppel H, Da Pozzo L, Albrecht W, et al. A 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. European urology. 2011;59(4):543-552.
Scosyrev E, Messing EM, Sylvester R, et al. Renal function after nephron-sparing surgery versus radical nephrectomy: results from EORTC randomized trial 30904. European urology. 2014;65(2):372-377.
Sun M, Bianchi M, Trinh QD, et al. Comparison of partial vs radical nephrectomy with regard to other‐cause mortality in T1 renal cell carcinoma among patients aged≥ 75 years with multiple comorbidities. BJU international. 2013;111(1):67-73.
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. European urology. 2007;51(6):1606-1615.
Marszalek M, Meixl H, Polajnar M, et al. Laparoscopic and open partial nephrectomy: a matched-pair comparison of 200 patients. European urology. 2009;55(5):1171-1178.
Patel P, Nayak JG, Liu Z, et al. A multicentered, propensity matched analysis comparing laparoscopic and open surgery for pT3a renal cell carcinoma. Journal of Endourology. 2017;31(7):645-650.
Gill IS, Kavoussi LR, Lane BR, et al. Comparison of 1,800 laparoscopic and open partial nephrectomies for single renal tumors. The Journal of urology. 2007;178(1):41-46.
Tugcu V, Bitkin A, Sonmezay E, et al. Transperitoneal versus retroperitoneal laparoscopic partial nephrectomy: initial experience. Arch Ital Urol Androl. 2011;83(4):175-180.
Minervini A, Ficarra V, Rocco F, et al. Simple enucleation is equivalent to traditional partial nephrectomy for renal cell carcinoma: results of a nonrandomized, retrospective, comparative study. The Journal of urology. 2011;185(5):1604-1610.
Gong EM, Orvieto MA, Zorn KC, et al. Comparison of laparoscopic and open partial nephrectomy in clinical T1a renal tumors. Journal of endourology. 2008;22(5):953-958.
Masson-Lecomte A, Yates DR, Hupertan V, et al., editors. A prospective comparison of the pathologic and surgical outcomes obtained after elective treatment of renal cell carcinoma by open or robot-assisted partial nephrectomy. Urologic Oncology: Seminars and Original Investigations; 2013: Elsevier.
Alimi Q, Peyronnet B, Sebe P, et al. Comparison of short-term functional, oncological, and perioperative outcomes between laparoscopic and robotic partial nephrectomy beyond the learning curve. Journal of Laparoendoscopic & Advanced Surgical Techniques. 2018;28(9):1047-1052.
