Partial Nephrectomy Workup
- Author: Reza Ghavamian, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS more...
Routine preoperative laboratory studies, including complete blood cell count, electrolyte assessment, blood urea nitrogen, and creatinine assessment, are obtained. Note the following:
Although no set level of serum creatinine precludes nephron-sparing surgery (NSS), the patient's baseline renal function is important. Not all patients with chronic renal insufficiency (CRI) require renal replacement therapy in the short term, and many can be treated medically for long periods.
Radical nephrectomy can place the patient in need of immediate renal replacement therapy. If anatomically feasible, NSS can delay the onset of dialysis without compromising cancer care in the properly selected patient with CRI.
The patient's blood should be typed and cross-matched.
Other blood tests may include liver function tests and serum ferritin assessment, although tests to detect metastases are not always necessary in the small, incidentally detected mass that is amenable to partial nephrectomy.
With the advent of modern imaging modalities, most renal cell carcinoma (RCC) is detected incidentally during CT scan performed with and without intravenous contrast or abdominal ultrasonography. Intravenous urography may not clearly define a small renal mass; therefore, other forms of confirmatory imaging are frequently required.
The size, location, and characteristics of the renal mass (cystic vs solid) are assessed adequately with ultrasonography, CT scanning, and magnetic resonance imaging (MRI) of the abdomen. Note the following:
CT scanning and MRI of the abdomen can be beneficial to rule out metastatic or locally extensive disease.
MRI also has a role in evaluating the inferior vena cava for the presence of tumor thrombus and its proximal and distal extent. Magnetic resonance angiography (MRA) also allows for excellent definition of the vascular anatomy and the segmental vascular anatomy for optimal surgical planning.
Some surgeons have used intraoperative ultrasonography for evaluation of multifocality in select cases when preoperative imaging studies are equivocal or intraparenchymal nonpalpable tumors are suggested. Intraoperative ultrasonography can be a valuable adjunct in this setting. Its use is associated with a learning curve; however, this can be overcome with the aid of a radiologist or frequent use of the modality.
Inferior and superior venacavography are not generally needed in the era of modern imaging. Furthermore, preoperative imaging modalities must delineate the relationship of the tumor to the normal surrounding parenchyma to allow for safe and adequate tumor excision while preserving maximal normal renal parenchyma.
Although not essential in small peripherally located tumors, preoperative evaluation of the vasculature of the kidney and the tumor can aid in tumor excision. This is especially true of larger lesions and those that occupy a more central position close to the renal hilum, especially in a solitary kidney. In the past, renal angiography was used routinely to delineate vasculature. In the modern era, less invasive modalities, such as MRA, can be used to define anatomic relationships preoperatively.
In addition, the use of 3-dimensional helical CT scan has provided important anatomical information concerning the renal vasculature and excretory function of the affected kidney. This technique better defines the relationship of the tumor with the collecting system and renal vasculature for preoperative surgical planning. In addition, it helps to anticipate tumor extension further so that operative complications can be minimized while obtaining the maximum surgical outcome. Small cuts through the tumor can be generated and the 3-dimensional reconstruction can aid in the surgical planning.
In the unusual case in which the above studies fail to provide adequate imaging, conventional renal angiography can be of considerable value. Oblique views of the kidney may further delineate the segmental arteries. An important component of renal angiography is the venous phase of the study. Complete delineation of the renal arterial and venous vasculature is essential in the setting of a centrally located tumor in a solitary kidney.
Chest radiography is indicated as a routine preoperative test.
The role of PET scanning in RCC is not well established, although its role has been studied to a limited extent. The extent to which it can help in the identification of limited nodal disease is not well known. However, it has been used for monitoring the response to therapy (to interleukin-2) of the original tumor and metastatic sites. It may allow for the identification of appropriate marker lesions for further monitoring of therapy and can be yet another way to characterize tumors in patients with a complete response.
A dilemma exists with respect to the nature of the solid lesion prior to planned surgery. In a recent prospective study, 103 patients diagnosed with a solid renal mass on CT scan and scheduled for surgery were evaluated. Note the following:
At the time of surgery, a biopsy sample of the surgical specimen was obtained under direct vision. Frozen section biopsy samples were compared to whole tissue specimens and reviewed by 2 pathologists.
These experienced pathologists were able to diagnose only 3 out of 4 cases based on frozen section findings.
Although the positive predictive value was excellent (94%), a large degree of inaccuracy existed for benign lesions, and many biopsy samples (approximately 22%) were nondiagnostic.
The authors do not recommend routine use of intraoperative frozen section needle biopsy to guide surgical decision making. Percutaneous image-guided biopsies still have a role, especially to help rule out metastatic lesions. The information presented is clear evidence that, even under ideal biopsy circumstances, needle biopsy is insufficiently accurate (75%) in defining the nature of small renal lesions. For this reason, NSS with complete excision plays an important role for the small incidentally detected tumor because biopsy findings frequently do not change the surgical management.
Ghavamian R, Cheville JC, Lohse CM, Weaver AL, Zincke H, Blute ML. Renal cell carcinoma in the solitary kidney: an analysis of complications and outcome after nephron sparing surgery. J Urol. 2002 Aug. 168(2):454-9. [Medline].
Dechet CB, Sebo T, Farrow G, Blute ML, Engen DE, Zincke H. Prospective analysis of intraoperative frozen needle biopsy of solid renal masses in adults. J Urol. 1999 Oct. 162(4):1282-4; discussion 1284-5. [Medline].
Belldegrun A, Tsui KH, deKernion JB, Smith RB. Efficacy of nephron-sparing surgery for renal cell carcinoma: analysis based on the new 1997 tumor-node-metastasis staging system. J Clin Oncol. 1999 Sep. 17(9):2868-75. [Medline].
Richstone L, Montag S, Ost MC, et al. Predictors of hemorrhage after laparoscopic partial nephrectomy. Urology. 2011 Jan. 77(1):88-91. [Medline].
Potretzke AM, Knight BA, Zargar H, Kaouk JH, Barod R, Rogers CG, et al. Urinary fistula after robot-assisted partial nephrectomy: a multicentre analysis of 1 791 patients. BJU Int. 2016 Jan. 117 (1):131-7. [Medline].
Fergany AF, Hafez KS, Novick AC. Long-term results of nephron sparing surgery for localized renal cell carcinoma: 10-year followup. J Urol. 2000 Feb. 163(2):442-5. [Medline].
Huang WC, Levey AS, Serio AM, et al. Chronic kidney disease after nephrectomy in patients with renal cortical tumours: a retrospective cohort study. Lancet Oncol. 2006 Sep. 7(9):735-40. [Medline].
Licht MR, Novick AC, Goormastic M. Nephron sparing surgery in incidental versus suspected renal cell carcinoma. J Urol. 1994 Jul. 152(1):39-42. [Medline].
Kletscher BA, Qian J, Bostwick DG, Andrews PE, Zincke H. Prospective analysis of multifocality in renal cell carcinoma: influence of histological pattern, grade, number, size, volume and deoxyribonucleic acid ploidy. J Urol. 1995 Mar. 153(3 Pt 2):904-6. [Medline].
Van Poppel H, Bamelis B, Oyen R, Baert L. Partial nephrectomy for renal cell carcinoma can achieve long-term tumor control. J Urol. 1998 Sep. 160(3 Pt 1):674-8. [Medline].
Lau WK, Blute ML, Weaver AL, Torres VE, Zincke H. Matched comparison of radical nephrectomy vs nephron-sparing surgery in patients with unilateral renal cell carcinoma and a normal contralateral kidney. Mayo Clin Proc. 2000 Dec. 75(12):1236-42. [Medline].
Tsui KH, Shvarts O, Smith RB, Figlin R, de Kernion JB, Belldegrun A. Renal cell carcinoma: prognostic significance of incidentally detected tumors. J Urol. 2000 Feb. 163(2):426-30. [Medline].
Dechet CB, Blute ML, Zincke H. Nephron sparing surgery for unilateral renal cell carcinoma: which variables contribute to contralateral recurrence?. J Urol. 1998. 159:169 A.
Krejci KG, Blute ML, Cheville JC, Sebo TJ, Lohse CM, Zincke H. Nephron-sparing surgery for renal cell carcinoma: clinicopathologic features predictive of patient outcome. Urology. 2003 Oct. 62(4):641-6. [Medline].
Gill IS, Matin SF, Desai MM, et al. Comparative analysis of laparoscopic versus open partial nephrectomy for renal tumors in 200 patients. J Urol. 2003 Jul. 170(1):64-8. [Medline].
Rogers CG, Singh A, Blatt AM, Linehan WM, Pinto PA. Robotic partial nephrectomy for complex renal tumors: surgical technique. Eur Urol. 2008 Mar. 53(3):514-23. [Medline].
Gettman MT, Blute ML, Chow GK, Neururer R, Bartsch G, Peschel R. Robotic-assisted laparoscopic partial nephrectomy: technique and initial clinical experience with DaVinci robotic system. Urology. 2004 Nov. 64(5):914-8. [Medline].
Ficarra V, Bhayani S, Porter J, et al. Predictors of warm ischemia time and perioperative complications in a multicenter, international series of robot-assisted partial nephrectomy. Eur Urol. 2012 Feb. 61(2):395-402. [Medline].
Mir SA, Cadeddu JA, Sleeper JP, Lotan Y. Cost comparison of robotic, laparoscopic, and open partial nephrectomy. J Endourol. 2011 Mar. 25(3):447-53. [Medline].
Gill IS, Novick AC, Meraney AM, et al. Laparoscopic renal cryoablation in 32 patients. Urology. 2000 Nov 1. 56(5):748-53. [Medline].
Bosniak MA. The use of the Bosniak classification system for renal cysts and cystic tumors. J Urol. 1997 May. 157(5):1852-3. [Medline].
Butler BP, Novick AC, Miller DP, Campbell SA, Licht MR. Management of small unilateral renal cell carcinomas: radical versus nephron-sparing surgery. Urology. 1995 Jan. 45(1):34-40; discussion 40-1. [Medline].
Campbell SC, Novick AC, Streem SB, Klein E, Licht M. Complications of nephron sparing surgery for renal tumors. J Urol. 1994 May. 151(5):1177-80. [Medline].
Duffey BG, Choyke PL, Glenn G, et al. The relationship between renal tumor size and metastases in patients with von Hippel-Lindau disease. J Urol. 2004 Jul. 172(1):63-5. [Medline].
Gill IS, Hsu TH, Fox RL, et al. Laparoscopic and percutaneous radiofrequency ablation of the kidney: acute and chronic porcine study. Urology. 2000 Aug 1. 56(2):197-200. [Medline].
Hafez KS, Novick AC, Butler BP. Management of small solitary unilateral renal cell carcinomas: impact of central versus peripheral tumor location. J Urol. 1998 Apr. 159(4):1156-60. [Medline].
Hoh CK, Seltzer MA, Franklin J, deKernion JB, Phelps ME, Belldegrun A. Positron emission tomography in urological oncology. J Urol. 1998 Feb. 159(2):347-56. [Medline].
Lang EK. Comparison of dynamic and conventional computed tomography, angiography, and ultrasonography in the staging of renal cell carcinoma. Cancer. 1984 Nov 15. 54(10):2205-14. [Medline].
Lerner SE, Hawkins CA, Blute ML, et al. Disease outcome in patients with low stage renal cell carcinoma treated with nephron sparing or radical surgery. J Urol. 1996 Jun. 155(6):1868-73. [Medline].
Morgan WR, Zincke H. Progression and survival after renal-conserving surgery for renal cell carcinoma: experience in 104 patients and extended followup. J Urol. 1990 Oct. 144(4):852-7; discussion 857-8. [Medline].
Ornstein DK, Lubensky IA, Venzon D, Zbar B, Linehan WM, Walther MM. Prevalence of microscopic tumors in normal appearing renal parenchyma of patients with hereditary papillary renal cancer. J Urol. 2000 Feb. 163(2):431-3. [Medline].
Russo P. Open partial nephrectomy: an essential contemporary operation. Nat Clin Pract Urol. 2006 Jan. 3(1):2-3. [Medline].
Steinbach F, Novick AC, Zincke H, et al. Treatment of renal cell carcinoma in von Hippel-Lindau disease: a multicenter study. J Urol. 1995 Jun. 153(6):1812-6. [Medline].
Uzzo RG, Novick AC. Nephron sparing surgery for renal tumors: indications, techniques and outcomes. J Urol. 2001 Jul. 166(1):6-18. [Medline].
Walther MM, Lubensky IA, Venzon D, Zbar B, Linehan WM. Prevalence of microscopic lesions in grossly normal renal parenchyma from patients with von Hippel-Lindau disease, sporadic renal cell carcinoma and no renal disease: clinical implications. J Urol. 1995 Dec. 154(6):2010-4; discussion 2014-5. [Medline].
Zincke H, Ghavamian R. Partial nephrectomy for renal cell cancer is here to stay--more data on this issue. J Urol. 1998 Apr. 159(4):1161-2. [Medline].