The Management of Small Renal Masses Diagnosis and

Management

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Contents

1 Renal Anatomy and Physiology����������������������������������������������������    1

Nicolòmaria Buffi, Pasquale Cardone,
and Giovanni Lughezzani
2 Introduction to T1 Renal Tumours and Prognostic
Indicators����������������������������������������������������������������������������������������    7
Vincenzo Ficarra, Marta Rossanese, Alessandro Crestani,
Gioacchino De Giorgi, Guido Martignoni,
and Gianluca Giannarini
3 Diagnostic Modalities��������������������������������������������������������������������   21
Elstob Alison, Uday Patel, and Michael Gonsalves
4 The Role of Renal Biopsy��������������������������������������������������������������   37
Patrick O. Richard, Jaimin R. Bhatt, Antonio Finelli,
and Michael A.S. Jewett
5 The Role of Active Surveillance for Small Renal Masses����������   49
Alessandro Volpe
6 Image-Guided Radiofrequency Ablation for Small
Renal Masses����������������������������������������������������������������������������������   61
Emily F. Kelly and Raymond J. Leveillee
7 Laparoscopic and Percutaneous Cryoablation
of Small Renal Masses ������������������������������������������������������������������   75
M. Pilar Laguna, Patricia J. Zondervan,
and Jean J.M.C.H. de la Rosette
8 Open Partial Nephrectomy ����������������������������������������������������������   87
M. Hammad Ather
9 Laparoscopic Partial Nephrectomy����������������������������������������������   95
Philip T. Zhao, David A. Leavitt, Lee Richstone,
and Louis R. Kavoussi
10 Robot-Assisted Partial Nephrectomy ������������������������������������������ 107
Giacomo Novara, Vincenzo Ficarra, Sabrina La Falce,
Filiberto Zattoni, and Alexander Mottrie

vii
viii Contents

11 Other Minimally Invasive Approaches

(LESS and NOTES) ���������������������������������������������������������������������� 119
Koon Ho Rha and Dae Keun Kim
12 Training and Simulation in the Management
of Small Renal Masses ������������������������������������������������������������������ 131
Abdullatif Aydin, Oliver Brunckhorst, and Kamran Ahmed
13 The Future of Robotic-Assisted Partial Nephrectomy �������������� 143
Theo Malthouse, Nicholas Raison, Veeru Kasivisvanathan,
Wayne Lam, and Ben Challacombe
14 Challenging Situations in Robotic Partial Nephrectomy ���������� 153
Nicholas Raison, Norbert Doeuk, Theo Malthouse,
Veeru Kasivisvanathan, Wayne Lam, and Ben Challacombe
15 Complications and Their Management �������������������������������������� 163
Peter A. Caputo and Jihad Kaouk
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
 Renal Anatomy and Physiology
1
Nicolòmaria Buffi, Pasquale Cardone,
and Giovanni Lughezzani

Key Messages 1.1 Macroscopic

1. The kidney is divided into the cortex and Microscopic Anatomy
and medulla. The medullary areas are of the Kidney
pyramidal, more centrally located, and
separated by sections of cortex. These Grossly, the kidneys are bilaterally paired
segments of cortex are called the col- reddish-­brown organs. Typically each kidney
umns of Bertin. weighs 150 g in the male and 135 g in the female.
2. Gerota’s fascia can be considered as an The kidneys generally measure 10–12 cm verti-
anatomic barrier to the spread of malig- cally, 5–7 cm transversely, and 3 cm in the antero-
nancy and a means of containing peri- posterior dimension (Fig. 1.1). Because of
nephric fluid collections. compression by the liver, the right kidney tends
3. From anterior to posterior, the renal to be somewhat shorter and wider. In children,
hilar structures are the renal vein, renal the kidneys are relatively larger and possess more
artery, and collecting system.
4. The progression of arterial supply to the
kidney is as follows: renal artery → seg-
mental artery → interlobar artery →
arcuate artery → interlobular artery →
afferent artery.
5. Each renal pyramid terminates centrally
in a papilla. Each papilla is cupped by a
minor calyx. A group of minor calyces
join to form a major calyx. The major
calyces combine to form the renal pelvis.

N. Buffi (*) • P. Cardone • G. Lughezzani

Humanitas Clinical and Research Centre,
Rozzano, Milan, Italy Fig. 1.1 Relative position of the left and right kidney and
e-mail: [email protected] renal vessels

© Springer International Publishing AG 2018 1

K. Ahmed et al. (eds.), The Management of Small Renal Masses,
https://doi.org/10.1007/978-3-319-65657-1_1
2 N. Buffi et al.

prominent foetal lobulations. These lobulations Instead, the medulla is composed of multiple,
are present at birth and generally disappear by the distinct, conically shaped areas noticeably darker
first year of life, although occasionally they per- in colour than the cortex. These same structures
sist into adulthood. An additional common fea- are also commonly called renal pyramids, mak-
ture of the gross renal anatomy is a focal renal ing the terms renal medulla and renal pyramid
parenchymal bulge along the kidney’s lateral synonymous. The apex of the pyramid is the
contour, known as a dromedary hump. This is a renal papilla, and each papilla is cupped by an
normal variation without pathologic significance. individual minor calyx. The renal cortex is lighter
It is more common on the left than the right and in colour than the medulla and not only covers
is believed to be caused by downward pressure the renal pyramids peripherally but also extends
from the spleen or liver. As one proceeds cen- between the pyramids themselves. The exten-
trally from the peripherally located reddish-­ sions of cortex between the renal pyramids are
brown parenchyma of the kidney, the renal sinus given a specific name: the columns of Bertin.
is encountered. Here the vascular structures and These columns are particularly important during
collecting system coalesce before exiting the kid- surgical procedures because it is through these
ney medially. These structures are surrounded by columns that renal vessels traverse from the renal
yellow sinus fat, which provides an easily recog- sinus to the peripheral cortex, decreasing in
nized landmark during renal procedures such as diameter as the columns move peripherally. It is
partial nephrectomy. At its medial border, the because of this anatomy that percutaneous access
renal sinus narrows to form the renal hilum. It is to the collecting system is made through a renal
through the hilum that the renal artery, renal vein, pyramid into a calyx, thus avoiding the columns
and renal pelvis exit the kidney and proceed to of Bertin and the larger vessels found within
their respective destinations. Both grossly and them (Fig. 1.2).
microscopically, there are two distinct compo- The position of the kidney within the retroperi-
nents within the renal parenchyma: the inner toneum varies greatly by side, degree of inspira-
medulla and outer cortex. Unlike the adrenal tion, body position, and presence of anatomical
gland, the renal medulla is not a contiguous layer. anomalies. The right kidney sits 1–2 cm lower

Cortical
blood vessels Arcuate
blood vessels
Interlobar
blood vessels Minor calyx

Renal vein Major calyx

Renal pelvis
Renal
nerve
Pyramid
Renal artery
Papilla
Medulla
Renal column
Ureter
Cortex
Capsule

Fig. 1.2 Gross internal

anatomy of the kidney
1 Renal Anatomy and Physiology 3

than the left in most individuals owing to displace- adrenal gland is encountered. On the medial
ment by the liver. Generally, the right kidney aspect, the descending duodenum is intimately
resides in the space between the top of the first related to the medial aspect of the kidney and hilar
lumbar vertebra to the bottom of the third lumbar structures. Finally, on the anterior aspect of the
vertebra. The left kidney occupies a more superior lower pole lies the hepatic flexure of the colon.
space from the body of the twelfth thoracic verte- The left kidney is bordered superiorly by the tail
bral body to the third lumbar vertebra. Of surgi- of the pancreas with the splenic vessels adjacent
cal importance are the structures surrounding the to the hilum and upper pole of the left kidney. The
kidney. Interposed between the kidney and its left adrenal gland is also found cranial to the
surrounding structures is the perirenal or Gerota’s upper pole and further, superolaterally, the spleen.
fascia. This fascial layer encompasses the perire- The splenorenal ligament attaches the left kidney
nal fat and kidney and encloses the kidney on three to the spleen. This attachment can lead to splenic
sides: superiorly, medially, and laterally. Superiorly capsular tears if excessive downward pressure is
and laterally, Gerota’s fascia is closed, but medi- applied to the left kidney. Superior to the pancre-
ally it extends across the midline to fuse with the atic tail, the posterior gastric wall can overlie the
contralateral side. Inferiorly, Gerota’s fascia is not kidney. Caudally, the kidney is covered by the
closed and remains an open potential space. splenic flexure of the colon.
Gerota’s fascia can be considered as an anatomic The renal excretory system consists of papillae,
barrier to the spread of malignancy and a means of calyces, and the renal pelvis. The renal papillae are
containing perinephric fluid collections. Hence, the tip of a medullary pyramid and constitute the
perinephric fluid collections can track inferiorly first gross structure of the collecting system.
into the pelvis without violating Gerota’s fascia. Typically, there are seven to nine papillae per kid-
Both kidneys have similar muscular surroundings. ney, but this number is variable, ranging from 4 to
Posteriorly, the diaphragm covers the upper third 18. The papillae are aligned in two longitudinal
of each kidney, with the 12th rib crossing at the rows situated approximately 90° from one another.
lower extent of the diaphragm. Important to note There is an anterior row that, owing to the orienta-
for percutaneous renal procedures and flank inci- tion of the kidney, faces in a lateral direction and a
sions is that the pleura extends to the level of the posterior row that extends directly posterior. Each
12th rib posteriorly. Medially the lower two thirds of these papillae is cupped by a minor calyx. In the
of the kidney lie against the psoas muscle, and lat- upper and lower poles, compound calyces are
erally the quadratus lumborum and aponeurosis of often encountered. These compound calyces are
the transversus abdominis muscle are encountered. the result of renal pyramid fusion and because of
First, the lower pole of the kidney lies laterally and their anatomy are more likely to allow reflux into
anteriorly relative to the upper pole. Second, the the renal parenchyma. Clinically this can result in
medial aspect of each kidney is rotated anteriorly more severe scarring of the parenchyma overlying
at an angle of approximately 30°. An understand- compound calyces. After cupping an individual
ing of this renal orientation is again of particular papilla, each minor calyx narrows to an infundibu-
interest for percutaneous renal procedures in lum. Just as there is frequent variation in the num-
which kidney orientation influences access site ber of calyces, the diameter and length of the
selection. Anteriorly, the right kidney is bordered infundibula vary greatly. Infundibula combine to
by a number of structures. Cranially, the upper form two or three major calyceal branches. These
pole lies against the liver and is separated from are frequently termed the upper, middle, and lower
the liver by the peritoneum except for the liver’s pole calyces, and the calyces in turn combine to
posterior bare spot. The hepatorenal ligament form the renal pelvis. The renal pelvis itself can
further attaches the right kidney to the liver vary greatly in size, ranging from a small intrare-
because this extension of parietal peritoneum nal pelvis to a large predominantly extrarenal pel-
bridges the upper pole of the right kidney to the vis. Eventually the pelvis narrows to form the
posterior liver. Also at the upper pole, the right ureteropelvic junction, marking the beginning of
4 N. Buffi et al.

the ureter. On close examination, it is clear that aorta and inferior vena cava just below the supe-
there is significant variation in the anatomy of the rior mesenteric artery at the level of the second
renal collecting system with the number of caly- lumbar vertebra. The vein is anterior to the artery.
ces, diameter of the infundibula, and size of the The renal pelvis and ureter are located posteri-
renal pelvis all varying significantly amongst nor- orly to these vascular structures. The right renal
mal individuals. Even in the same individual, the artery leaves the aorta and progresses with a cau-
renal collecting systems may be similar but are dal slope under the inferior cava vein toward the
rarely identical. Microscopically, the renal collect- right kidney. The left renal artery courses hori-
ing system originates in the renal cortex at the zontally, directly to the left kidney. Given the
glomerulus where filtrate enters the Bowman’s rotational axis of the kidney, both renal arteries
capsule. Together the glomerular capillary net- move posteriorly as they enter the kidney. Both
work and Bowman’s capsule form the renal arteries also have branches supplying their
­corpuscle (Malpighian corpuscle). The glomerular respective adrenal gland, renal pelvis, and ureter.
capillary network is covered by specialized epithe- Approaching the kidney, the renal artery divides
lial cells called podocytes that, along with the cap- into four or more branches (most commonly
illary epithelium, form a selective barrier across five). These are the renal segmental arteries. Each
which the urinary filtrate must pass. The filtrate is segmental artery supplies a distinct portion of the
initially collected in Bowman’s capsule and then kidney with no collateral circulation between
moves to the proximal convoluted tubule. The them. Thus, occlusion or injury to a segmental
proximal tubule is composed of a thick cuboidal branch will cause segmental renal infarction.
epithelium covered by dense microvilli. These Generally, the first and most constant branch is
microvilli greatly increase the surface area of the the posterior segmental branch, which separates
proximal tubule, allowing a large portion of the from the renal artery before it enters the renal
urinary filtrate to be reabsorbed in this section of hilum. Typically, there are four anterior branches,
the nephron. The proximal tubule continues deeper which from superior to inferior are apical, upper,
into the cortical tissue where it becomes the loop middle, and lower. The relationship of these seg-
of Henle. The loop of Henle extends variable dis- mental arteries is important because the posterior
tances into the renal medulla. Within the renal segmental branch passes posterior to the renal
medulla, the loop of Henle reverses course and pelvis, while the others pass anterior to the renal
moves back toward the periphery of the kidney. As pelvis. Ureteropelvic junction obstruction caused
it ascends out of the medulla, the loop thickens and by a crossing vessel can occur when the posterior
becomes the distal convoluted tubule. This tubule segmental branch passes anterior to the ureter
eventually returns to a position adjacent to the causing occlusion. This division between the
originating glomerulus and proximal convoluted posterior and anterior segmental arteries has an
tubule. Here the distal convoluted tubule turns additional surgical importance since between
once again for the interior of the kidney and these two circulations is an avascular plane. This
becomes a collecting tubule. Collecting tubules longitudinal plane lies just posterior to the lateral
from multiple nephrons combine into a collecting aspect of the kidney. Incision within this plane
duct that extends inward through the renal medulla results in significantly less blood loss than out-
and eventually empties into the apex of the medul- side it. However, there is significant variation in
lary pyramid, the renal papilla. the location of this plane, requiring careful delin-
eation before incision. This can be done with
either preoperative angiography or intraoperative
1.2 Renal Vasculature segmental arterial injection with a dye such as
methylene blue. Once in the renal sinus, the seg-
The renal pedicle classically consists of a single mental arteries branch into lobar arteries, which
artery and a single vein that enter the kidney via further subdivide within the renal parenchyma to
the renal hilum. These structures branch from the form interlobar arteries. These interlobar arteries
1 Renal Anatomy and Physiology 5

progress peripherally within the cortical col- vein. The left renal vein is typically 6–10 cm in
umns of Bertin, thus avoiding the renal pyramids length and enters the left lateral aspect of the
but maintaining a close association with the inferior cava vein after passing posterior to the
minor calyceal infundibula. At the base (periph- superior mesenteric artery and anterior to the
eral edge) of the renal pyramids, the interlobar aorta. Compared with the right renal vein, the left
arteries branch into arcuate arteries. Instead of renal vein enters the inferior cava vein at a
moving peripherally, the arcuate arteries run par- slightly more cranial level and a more anterolat-
allel with the edge of the corticomedullary junc- eral location. Additionally, the left renal vein
tion. Interlobular arteries branch off the arcuate receives the left adrenal vein superiorly, lumbar
arteries and move radially, where they eventually vein posteriorly, and left gonadal vein inferiorly.
divide to form the afferent arteries to the The right renal vein typically does not receive
glomeruli. any branches.
The two million glomeruli within each kidney
represent the core of the renal filtration process.
Each glomerulus is fed by an afferent arteriole. 1.3 Renal Lymphatics
As blood flows through the glomerular capillar- and Nervous Innervation
ies, the urinary filtrate leaves the arterial system
and is collected in the glomerular (Bowman’s) The renal lymphatics largely follow blood ves-
capsule. Blood flow leaves the glomerular capil- sels through the columns of Bertin and then form
lary via the efferent arteriole and continues to one several large lymphatic trunks within the renal
of two locations: secondary capillary networks sinus. As these lymphatics exit the hilum,
around the urinary tubules in the cortex or branches from the renal capsule, perinephric tis-
descending into the renal medulla as the vasa sues, renal pelvis, and upper ureter drain into
recta. The renal venous drainage correlates these lymphatic vessels. They then empty into
closely with the arterial supply. The interlobular lymph nodes associated with the renal vein near
veins drain the postglomerular capillaries. These the renal hilum. From here, the lymphatic drain-
veins also communicate freely via a subcapsular age between the two kidneys varies.
venous plexus of stellate veins with veins in the On the left, primary lymphatic drainage is into
perinephric fat. After the interlobular veins, the the left lateral para-aortic lymph nodes including
venous drainage progresses through the arcuate, nodes anterior and posterior to the aorta between
interlobar, lobar, and segmental branches, with the inferior mesenteric artery and the diaphragm.
the course of each of these branches mirroring Occasionally, there will be additional drainage
the corresponding artery. After the segmental from the left kidney into the retrocrural nodes or
branches, the venous drainage coalesces into directly into the thoracic duct above the dia-
three to five venous trunks that eventually com- phragm. On the right, drainage is into the right
bine to form the renal vein. Unlike the arterial inter-aortocaval and right paracaval lymph nodes
supply, the renal veins communicate freely, form- including nodes located anterior and posterior to
ing venous collars around the infundibula. This the vena cava, extending from the common iliac
creates an extensive collateral circulation in the vessels to the diaphragm. Occasionally, there will
venous drainage of the kidney. Surgically, this is be additional drainage from the right kidney into
important because unlike the arterial supply, the retrocrural nodes or the left lateral para-aortic
occlusion of a segmental venous branch has little lymph nodes.
effect on venous outflow. The renal vein is located Innervation of the sympathetic preganglionic
directly anterior to the renal artery, although this nerves originates from the eighth thoracic
position can vary up to 1–2 cm cranially or cau- through to the first lumbar spinal segments and
dally relative to the artery. The right renal vein is then travels to the coeliac and aorticorenal gan-
generally 2–4 cm in length and enters the right glia. From here, postganglionic fibres travel to
lateral to posterolateral edge of the inferior cava the kidney via the autonomic plexus surrounding
6 N. Buffi et al.

the renal artery. Parasympathetic fibres origi- tion and the parasympathetics causing vasodila-
nate from the vagus nerve and travel with the tion. Despite this innervation, it is important to
sympathetic fibres to the autonomic plexus realize that the kidney functions well even
along the renal artery. The primary function of without this ­neurologic control, as evidenced
the renal autonomic innervation is vasomotor, by the successful function of transplanted
with the sympathetics inducing vasoconstric- kidneys.
 Introduction to T1 Renal Tumours
and Prognostic Indicators 2
Vincenzo Ficarra, Marta Rossanese,
Alessandro Crestani, Gioacchino De Giorgi,
Guido Martignoni, and Gianluca Giannarini

Abbreviations Key Messages

1. Kidney cancers represent the 14th most
ARCD Acquired renal cystic disease common malignancies with more than
CSS Cancer-specific survival 300,000 new cases diagnosed in 2012.
ESRD End-stage renal disease 2. In 2012, kidney cancers accounted for
NSS Nephron-sparing surgery 143,000 deaths with a crude rate value
OS Overall survival of 2% of all cancer deaths.
PN Partial nephrectomy 3. Cigarette smoking, overweight and obe-
RCC Renal cell carcinoma sity and arterial hypertension are the
UCS Urinary collecting system most prevalent modifiable risk factors
VHL von Hippel-Lindau for RCC in both genders.
4. Preoperative variables influencing the
decision-making process for T1 renal
tumours can be classified as patient-­
related (age, co-morbidities and perfor-
mance status) and tumour-related (mode
of presentation, clinical tumour size and
anatomical/topographic characteristics)
V. Ficarra (*) factors.
Department of Experimental and Clinic Medical 5. The use of nephrometry systems
Sciences, Urology Unit, University of Udine,
Udine, Italy
(RENAL or PADUA) to define the ana-
tomical and topographic characteristics
Academic Medical Centre Hospital “Santa Maria
della Misericordia”, Udine, Piazzale Santa Maria
of small renal masses should be consid-
della Misericordia 15, 33100, Italy ered the standard of care for the preop-
e-mail: [email protected] erative evaluation of patients suitable to
M. Rossanese • A. Crestani • G. De Giorgi nephron-sparing surgery.
G. Giannarini 6. Treatment of cT1N0M0 parenchymal
Academic Medical Centre Hospital “Santa Maria renal tumours should be based on
della Misericordia”, Udine, Piazzale Santa Maria
della Misericordia 15, 33100, Italy
patient-related factors, tumour-related
characteristics and surgeon experience.
G. Martignoni
Department of Pathology, University of Verona,
Verona, Italy

© Springer International Publishing AG 2018 7

K. Ahmed et al. (eds.), The Management of Small Renal Masses,
https://doi.org/10.1007/978-3-319-65657-1_2
8 V. Ficarra et al.

Like incidence trends, overall mortality rates

7. Beyond tumour characterization accord- were highest in North America, Australia/New
ing to histological subtype, the most Zealand and Europe and lowest in Africa and
important traditional pathological fac- Asia [2]. After several years of increasing trends
tors dictating the prognosis of patients in RCC mortality, it seems that rates are stabiliz-
with RCCs are the pathological size and ing or even declining in many Western countries.
extent of the primary tumour, nuclear In Europe, a decrease in mortality was observed
grading, coagulative necrosis, micro- in Scandinavian countries, France, Germany,
vascular invasion and sarcomatoid Italy, Austria and the Netherlands, while
dedifferentiation. increased mortality rates are still reported in
8. Prognosis can be estimated combining Ireland and Slovenia [2].
clinical and pathological factors in the Cigarette smoking, being overweight and
context of mathematical models. This obese and arterial hypertension are the most
information can be used to improve the prevalent modifiable risk factors for RCC in both
counselling process and to guide the genders. Thus, recommended strategies to pre-
follow-up. vent kidney cancers should entail programmes
for smoking cessation, reducing excess body
weight and treatment of uncontrolled arterial
blood pressure. Notably, patients with end-stage
2.1 Epidemiology and Aetiology renal disease (ESRD) or on long-term haemodi-
alysis developing an acquired renal cystic disease
Kidney cancers represent the 14th most common (ARCD) present a significant risk to develop
malignancies with more than 300,000 new cases RCC. Therefore, these patients should be regu-
diagnosed in 2012. Renal cell carcinoma (RCC) larly screened. On the other hand, it is unclear
accounts for approximately 90% of all kidney whether renal transplantation in these patients
cancers. According to the gender, around 200,000 can reduce the risk to develop RCC [3].
new cases were observed in men and 100,000 in Numerous studies have tested the potential
women. Moreover, there were around 198,000 role of nutrition and diet as risk factors for
new cases in more developed regions and RCC. Conflicting or inconclusive data have been
130,000 in less developed regions [1]. Indeed, reported for proteins and fats, vitamins, fruits and
renal tumours are more frequently detected in vegetables, meat and fish, alcohol, coffee and
Europe, North America and Australia than in other beverages. Currently no dietary recommen-
India, Japan, Africa and China. The Czech dations can be given. Moreover, epidemiological
Republic, Lithuania, Latvia, Estonia and Iceland studies have demonstrated that kidney cancer
have the highest incidence in Europe. should not be considered to be a typical
Interestingly, the incidence of kidney cancers is occupation-­related tumour. Nevertheless, current
declining in some European countries, namely, guidelines recommend decreasing or preventing
Sweden, Poland, Finland and the Netherlands exposure to occupational carcinogens like asbes-
[2]. Furthermore, incidence rates in Europe and tos, polycyclic aromatic hydrocarbons, dry-­
the USA increase consistently with age. This cleaning solvents and cadmium [2].
trend can be strongly correlated with the parallel Genetic factors are implicated in the develop-
use of non-invasive diagnostic testing, such as ment of the 2–3% of familial RCC syndromes,
abdominal ultrasound, for symptoms that are not such as von Hippel-Lindau syndrome, hereditary
strictly related to the suspicion of kidney cancer. papillary RCC syndrome, familial leiomyomato-
In 2012, kidney cancers accounted for 143,000 sis and RCC syndrome and Birt-Hogg-Dubè syn-
deaths with a crude rate value of 2% of all cancer drome. All these syndromes are transmitted in an
deaths. 91,000 deaths were in men (crude rate autosomal-dominant manner. Germline muta-
2.6%) and 52,000 in women (crude rate 1.5%) [1]. tions in the von Hippel-Lindau (VHL) gene are
2 Introduction to T1 Renal Tumours and Prognostic Indicators 9

the most common alterations, and active screen- Few data are available about the potential
ing in these patients might be considered to detectimpact of age on renal tumour characteristics and
RCC at an early enough stage to permit nephron-­ prognosis. A multi-institutional study showed that
sparing surgery (NSS). patients aged ≤40 years were more likely to have
Despite advances in imaging techniques and papillary or chromophobe RCC and less likely to
the increase in incidentally detected renal tumourshave clear cell RCC. Interestingly, the authors
with abdominal ultrasound performed for unre- have observed that age was an independent pre-
lated complaints, about 20–30% of all patients are dictor of cancer-specific survival (CSS), with
still diagnosed with metastatic disease. Moreover, older patients having significantly worse survival
20–30% of patients undergoing surgical treat- [5]. Notably, Sun et al. recently published a SEER
ments for organ-confined disease will have a local database analysis showing that in patients aged
relapse or develop distant metastases [2]. This ≥75 years, 2- and 5-year overall survival (OS) is
chapter focuses on non-metastatic RCC confined comparable after radical nephrectomy or partial
to the parenchyma and ≤7 cm in largest size, i.e. nephrectomy (PN). According to this study, the
clinically T1N0M0. The 2009 TNM staging sys- indication for elective PN in patients aged
tem classifies organ-confined renal tumours ≥75 years should be carefully discussed during
according to the 7-cm size cut-off. Specifically, pretreatment counselling [7]. Similar consider-
masses ≤7 cm are classified as T1 and larger ations can be made considering the co-morbidity
tumours as T2. Moreover, the latest version of profile of patients with T1 tumours suitable for
TNM classification confirms the classical stratifi-NSS. Indeed, in the SEER registry analysis,
cation of T1 tumours in two different subgroups patients with >2 baseline co-­morbidities showed a
(T1a and T1b) according to the 4-cm size cut-off. comparable 2- and 5-year OS after PN or radical
Notably, the system introduces a further stratifica-
nephrectomy [7]. Therefore, patient co-morbidi-
tion of T2 tumours in two categories (T2a and ties must be taken into account as a selection cri-
T2b), according to the 10-cm size cut-­off [4]. terion for NSS. Performance status was an
Several clinical factors play a relevant role in
independent predictor of CSS [7], but its prognos-
the decision-making process for surgical treat- tic role seems to be more relevant in patients with
ment planning of T1N0M0 RCC. Similarly, cer- locally advanced or metastatic tumours [8].
tain pathological features warrant tailored Considering preoperative tumour-related vari-
post-operative management plan and, in the ables, mode of presentation was extensively eval-
future, will determine selection for targeted adju-uated, and its independent predictive role was
vant therapy. Moreover, both clinical and patho- demonstrated in multi-institutional series [8].
logical factors are key to predicting the prognosisAccording to the Patard classification, tumours
of patients who are candidates for surgical treat- diagnosed during abdominal imaging for signs
ment. To improve their accuracy, prognostic vari- and symptoms unrelated to RCC are classified as
ables have been combined to generate incidental (S1). Conversely, flank pain, haematu-
mathematical models, such as algorithms and ria and flank mass are considered as local symp-
nomograms [4]. toms (S2). Systemic symptoms suggesting
advanced stage disease (weight loss, fever and
para-neoplastic syndromes) are defined as S3
2.2 Clinical Factors cases [9]. Notably, asymptomatic patients have
more favourable CSS rates in comparison with
Preoperative variables influencing the decision-­ patients with local symptoms. Therefore, this
making process for T1 renal tumours can be clas- parameter might be considered a further criterion
sified in patient-related (age, co-morbidities and in the decision-making process for management
performance status) and tumour-related (mode of of T1 tumours. Haematuria is considered by some
presentation, clinical tumour size and anatomi- authors as a relative contraindication for PN
cal/topographic characteristics) factors. because this sign may indicate upper collecting
10 V. Ficarra et al.

system involvement. Notably, urinary collecting Neither nephrometry systems consider the sta-
system (UCS) involvement is still not included in tus of perirenal fat tissue as a further potential
the current TNM staging system. However, factor influencing the complexity of a PN. The
Verhoest et al. in 2009 demonstrated in a large presence of adherent perinephric fat is known to
series of patients the independent role of UCS make tumour exposure and excision more diffi-
invasion to predict the cancer-specific survival of cult, requiring subcapsular renal dissection and
both patients with pT1 and pT2 tumours [10]. hence increasing the risk of complications. In
Clinical tumour size is traditionally recog- 2014, an additional scoring system, called the
nized as an important prognostic factor, and it has Mayo Adhesive Probability, has been proposed
been used as the main criterion to select patients by Davidiuk et al. [14]. Based on a series of 100
suitable for NSS. Considering T1 tumours, inter- patients undergoing robot-assisted PN, the
national guidelines recommend NSS as standard authors built a scoring algorithm predicting the
of care for T1a tumours and strongly support presence of adherent perinephric fat. The risk
expanding indications also for T1b tumours score was created using two image-derived vari-
whenever technically feasible. ables, i.e. posterior perinephric fat thickness and
However, rather than size alone, it is the ana- stranding, which were most highly predictive at
tomical and topographic characteristics of T1 renal multivariable analysis. This system requires
tumours as well as surgeon experience that repre- external validation on a large-scale basis before
sent the main factors influencing the technical fea- entering clinical practice. Similarly, Zheng et al.
sibility of NSS. In 2009, two nephrometry systems, tested the role of perinephric fat density mea-
the RENAL nephrometry and PADUA classifica- sured during preoperative CT scan to predict
tion, were proposed to classify parenchymal renal intraoperative fat dissection difficulty. They
tumours according to their anatomical and topo- reported that this parameter is a strong indicator
graphic characteristics with the aim to predict the of so-called sticky fat and can anticipate more
surgical complexity, thereby refining selection cri- difficult PN cases [15].
teria for, and improving the main outcomes of, PN Several studies demonstrated that RENAL and
[11, 12]. Figure 2.1 shows the variables included in PADUA systems are able to predict perioperative
PADUA classification and the different scores outcomes such as ischaemia time, blood loss and
applied for each anatomical situation. intra- and post-operative complications regardless
Table 2.1 describes the parameters included in of the approach used to perform NSS [16].
the RENAL and PADUA classifications. Besides Therefore, both systems are widely used in clinical
a different criterion used to define longitudinal practice. However, few studies compared the
polar location (Fig. 2.2), the PADUA system PADUA and RENAL systems. In 2011, Hew et al.
includes rim location and considers involvement tested the PADUA and RENAL systems in a series
of urinary collecting system and of renal sinus of 134 patients undergoing PN. Both systems pre-
separately (Table 2.1). In 2010, Simmons et al. dicted complications at univariable analysis. At
described the centrality index (c-index) system, multivariable analyses, PADUA score ≥ 10 (OR
which gives a single score based entirely on 3.98, p = 0.01), RENAL score ≥ 9 (OR 4.21,
tumour size and tumour depth variables. This p = 0.02), tumour size (OR 1.35, p = 0.02) and age
system does not communicate data on geographic (OR 1.04, p = 0.04) were independent predictors
location, but provides information about the of complications. Moreover, both scores resulted
proximity of the tumour to the kidney centre [13]. able to predict ischaemia time. Interestingly, both
Probably, the complexity to calculate this score systems showed a substantial reproducibility with
was responsible of a more limited application of an interclass correlation coefficient of 0.73 for
this system compared to PADUA and RENAL PADUA and 0.70 for RENAL score [16]. In 2012,
nephrometry scores. Bylund et al. evaluated the association of tumour
2 Introduction to T1 Renal Tumours and Prognostic Indicators 11

1 3 1

2 2
1

1 1

Polar location Exophytic rate Rim location

1
2

1
3
1

Renal sinus involvement UCS involvement Tumour size

Fig. 2.1 Features included in the PADUA classification and scores applied for each anatomical situation

Table 2.1 Differences and parameters included in RENAL nephrometry and PADUA classification
Variables RENAL PADUA Differences
Tumour size ≤4; 4–7; >7 cm ≤4; 4–7; >7 cm No
Exophytic (%) ≥50%; <50%; endophytic ≥50%; <50%; endophytic No
Polar location Renal hilar as landmark Sinus line as landmark Yes
Rim location Not evaluated Lateral, medial Yes
Renal sinus ≤4; 4–7; >7 mm Not involved, involved Yes
involvement
UCS involvement Not involved, involved Yes
Face Anterior/posterior Anterior/posteriora No/Yes
Excluded from the score according to univariable analysis
a