Radikale Nephrektomie und Nierenteilentfernung

Zusammenfassung

Das Nierenzellkarzinom ist der zweithäufigste bzw. dritthäufigste urologische maligne Tumor der Frau bzw. des Mannes mit einem Erkrankungsgipfel in der 7. Lebensdekade. Früh erkannt ist es gut heilbar, sofern der Tumor nicht metastasiert ist. Im Gegensatz zu früher ist bei lokal begrenzten Nierenzellkarzinomen die lokale Therapie (Teil-Entfernung/topische Energieapplikation wie Radio-Frequenz-Ablation oder Kryoablation) die leitliniengerechte operative Therapie, wobei je nach Expertise des Operateurs die minimalinvasive (laparoskopisch/roboterassistiert) oder offene Operation ihre Berechtigung haben. Die verschiedenen Leitlinien setzen hier unterschiedliche Akzente. Bei der individuellen Therapieentscheidung müssen aber insbesondere Alter und Komorbiditäten in die Überlegung einbezogen werden. Dies kann dazu führen, dass auch bei lokal begrenzten Tumoren aufgrund der geringen perioperativen Morbidität eine (minimalinvasive) radikale Nephrektomie an Stelle einer Teil-Nephrektomie zu empfehlen ist oder aber eine aktive Überwachungsstrategie die richtige Behandlungsoption darstellt, ohne die Lebenserwartung des Karzinomträgers zu kompromittieren. Höhergradige Tumoren hingegen sollen – vorausgesetzt es sind keine Metastasen nachweisbar – Indikation zur Nephrektomie sein, auch wenn z. B. Tumorthromben bis in den Vorhof reichen. Mögliche Komplikationen eines operativen Eingriffs sind in aller Regel selten und gut beherrschbar.

Abstract

Renal cell carcinoma is the 2nd most frequent urological malignancy in women and the third most frequent in men, with an age peak in the seventh decade of life. If detected early in a local non-metastatic stage, options for complete recovery are excellent. While two decades ago, even locally limited cancers of the kidney were cured by radical nephrectomy, treatment today mostly consists of local treatment for locally confined cancers. Guidelines today recommend local surgical excision (open or minimally-invasive) or – in selected cases – topical energy application (radio-frequency ablation, cryoablation). The surgeon’s expertise is most important in the selection of the appropriate kind of surgery and different guidelines have slightly different recommendations.

Treatment decisions should be made on an individual basis in due consideration of an individual’s age and co-morbidities. This may lead to the recommendation that, due to low perioperative morbidity, even localised carcinomas should be treated by (minimally-invasive) radical nephrectomy instead of nephron-sparing surgery and, in other cases, a non-interventional, active surveillance strategy may be pursued without compromising the patient’s life expectancy. For higher-grade renal cell carcinomas, there is usually an indication for radical nephrectomy, as long as no metastases are detected. This also applies to carcinomas with venous thrombi extending into the atrium of the heart. Complications in the treatment of renal carcinomas are usually rare and easily treatable in most cases.

Schlüsselwörter

Nierenkarzinom - Nephrektomie - Teilnephrektomie - Enukleation

Keywords

renal cancer - nephrectomy - partial nephrectomy - enucleation

Publication History

Article published online:
28 July 2020

• Literatur

• 1 https://www.krebsdaten.de/Krebs/DE/Content/Publikationen/Krebs_in_Deutschland/kid_2019/krebs_in_deutschland_2019.pdf?__blob=publicationFile
• 2 Leitlinienprogramm Onkologie, S3-Leitlinie Nierenzellkarzinom, Version 1.2. 2017 https://www.leitlinienprogramm-onkologie.de/fileadmin/user_upload/Downloads/Leitlinien/Nierenzellkarzinom/LL_Nierenzell_Langversion_1.2.pdf
• 3 European Association of Urology (EAU). Aktuelle Leitlinien zum Nierenzellkarzinom. https://uroweb.org/guideline/renal-cell-carcinoma/
• 4 American Association of Urology (AUA). Leitlinie. https://www.auanet.org/guidelines/renal-cancer-renal-mass-and-localized-renal-cancer-guideline
• 5 Paner GP, Stadler WM, Hansel DE. et al. Updates in the Eighth Edition of the Tumor-Node-Metastasis Staging Classification for Urologic Cancers. Eur Urol 2018; 73: 560-569 DOI: 10.1016/j.eururo.2017.12.018.
• 6 International Agency for Research on Cancer. WHO classification of tumours of the urinary system and male genital organs (IARC WHO classification of tumours) 4. Lyon: WHO/IARC Press; 2016
• 7 Ahn T, Roberts MJ, Ab Duljabar A. et al. A Review of Prostate-Specific Membrane Antigen (PSMA) Positron Emission Tomography (PET) in Renal Cell Carcinoma (RCC). Mol Imaging Biol 2019; 21: 799-807
• 8 Sanz E, Hevia V, Gómez V. et al. Renal Complex Cystic Masses: Usefulness of Contrast-Enhanced Ultrasound (CEUS) in Their Assessment and Its Agreement with Computed Tomography. Curr Urol Rep 2016; 17: 89
• 9 Graumann O, Osther SS, Karstoft J. et al. Bosniak classification system: a prospective comparison of CT, contrast-enhanced US, and MR for categorizing complex renal cystic masses. Acta Radiol 2016; 57: 1409-1417 DOI: 10.1177/0284185115588124.
• 10 Capitanio U, Montorsi F. Renal cancer. Lancet 2016; 387: 894-906 DOI: 10.1016/S0140-6736(15)00046-X.
• 11 Huang WC, Elkin EB, Levey AS. Partial nephrectomy versus radical nephrectomy in patients with small renal tumors: is there a difference in mortality and cardiovascular outcome?. J Urol 2009; 181: 55-62
• 12 Krebs RK, Andreoni C, Ortiz V. et al. Impact of radical and partial nephrectomy on renal function in patients with renal cancer. Urol Int 2014; 92: 449-454
• 13 Chong JT, Paulucci D, Lubin M. Comparison of overall survival and unplanned hospital readmissions between partial and radical nephrectomy for cT1a and cT1b renal masses. Ther Adv Urol 2018; 10: 383-391 DOI: 10.1177/1756287218810313.
• 14 Ficarra V, Novara G, Secco S. et al. Preoperative aspects and dimensions used for an anatomical (PADUA) classification of renal tumours in patients who are candidates for nephron-sparing surgery. European Urolog 2009; 56: 786-793 DOI: 10.1016/j.eururo.2009.07.040.
• 15 Kutikov A, Uzzo R. The R.E.N.A.L. nephrometry score: a comprehensive standardized system for quantitating renal tumor size, location and depth. J Urol 2009; 182: 844-853 DOI: 10.1016/j.juro.2009.05.035.
• 16 Desantis D, Lavallée LT, Witiuk K. et al. The association between renal tumour scoring system components and complications of partial nephrectomy. Can Urol Assoc J 2015; 9: 39-45 DOI: 10.5489/cuaj.2303.
• 17 Gupta R, Tori M, Babitz SK. et al. Comparison of RENAL, PADUA, CSA, and PAVP Nephrometry Scores in Predicting Functional Outcomes After Partial Nephrectomy. Urology 2019; 124: 160-167 DOI: 10.1016/j.urology.2018.03.055.
• 18 Kambara T, Tanimoto R, Araki M. et al. Renal Function after Nephrectomy Influences the Risk of Cardiovascular Events. Acta Med Okayama 2018; 72: 241-247 DOI: 10.18926/AMO/56069.
• 19 An JY, Ball MW, Gorin MA. et al. Partial vs Radical Nephrectomy for T1-T2 Renal Masses in the Elderly: Comparison of Complications, Renal Function, and Oncologic Outcomes. Urology 2017; 100: 151-157 DOI: 10.1016/j.urology.2016.10.047.
• 20 Zeuschner P, Siemer S. Neue Aspekte zur Therapie des lokal begrenzten Nierenzellkarzinoms. Urologe A 2020; 59: 142-148 DOI: 10.1007/s00120-019-01105-8.
• 21 Andrews JR, Atwell T, Schmit G. et al. Oncologic Outcomes Following Partial Nephrectomy and Percutaneous Ablation for cT1 Renal Masses. Eur Urol 2019; 76: 244-251 DOI: 10.1016/j.eururo.2019.04.026.
• 22 Prins FM, Kerkmeijer LGW, Pronk AA. Renal Cell Carcinoma: Alternative Nephron-Sparing Treatment Options for Small Renal Masses, a Systematic Review. J Endourol 2017; 31: 963-975 DOI: 10.1089/end.2017.0382.
• 23 Pierorazio PM, Johnson MH, Ball MW. et al. Five-year analysis of a multi-institutional prospective clinical trial of delayed intervention and surveillance for small renal masses: the DISSRM registry. Eur Urol 2015; 68: 408-415 DOI: 10.1016/j.eururo.2015.02.001.
• 24 Herrera-Caceres JO, Jewett MAS. Roles for active surveillance in renal cancer. Curr Opin Urol 2018; 28: 375-382 DOI: 10.1097/MOU.0000000000000506.
• 25 Bravi CA, Larcher A, Capitanio U. et al. Perioperative Outcomes of Open, Laparoscopic, and Robotic Partial Nephrectomy: A Prospective Multicenter Observational Study (The RECORd 2 Project) [Epub ahead of print]. Eur Urol Focus 2019; DOI: 10.1016/j.euf.2019.10.013.
• 26 Liu F, Yuan H, Li X. et al. Application of Hypothermic Perfusion via a Renal Artery Balloon Catheter During Robot-assisted Partial Nephrectomy and Effect on Renal Function. Acad Radiol 2019; 26: e196-e201 DOI: 10.1016/j.acra.2018.09.024.
• 27 Dagenais J, Bertolo R, Garisto J. et al. "At-risk" kidney: How surgical factors influence renal functional preservation after partial nephrectomy. Int J Urol 2019; 26: 565-570 DOI: 10.1111/iju.13930.
• 28 Dong W, Wu J, Suk-Ouichai C. et al. Ischemia and Functional Recovery from Partial Nephrectomy: Refined Perspectives. Eur Urol Focus 2018; 4: 572-578 DOI: 10.1016/j.euf.2017.02.001.
• 29 Aykan S, Temiz MZ, Ulus I. et al. The Use of Three Different Hemostatic Agents during Laparoscopic Partial Nephrectomy: A Comparison of Surgical and Early Renal Functional Outcomes. Eurasian J Med 2019; 51: 160-164 DOI: 10.5152/eurasianjmed.2018.18293.
• 30 Minervini A, Campi R, Sessa F. et al. Positive surgical margins and local recurrence after simple enucleation and standard partial nephrectomy for malignant renal tumors: systematic review of the literature and meta-analysis of prevalence. Minerva Urol Nefrol 2017; 69: 523-538 DOI: 10.23736/S0393-2249.17.02864-8.
• 31 Weight CJ, Mulders PF, Pantuck AJ. et al. The Role of Adrenalectomy in Renal Cancer. Eur Urol Focus 2016; 1: 251-257 DOI: 10.1016/j.euf.2015.09.005.
• 32 Gu L, Li H, Wang Z. et al. A systematic review and meta-analysis of clinicopathologic factors linked to oncologic outcomes for renal cell carcinoma with tumor thrombus treated by radical nephrectomy with thrombectomy. Cancer Treat Rev 2018; 69: 112-120 DOI: 10.1016/j.ctrv.2018.06.014.
• 33 Sosa-Barrios HR, Burguera V, Rodriguez-Mendiola N. et al. Arteriovenous fistulae after renal biopsy: diagnosis and outcomes using Doppler ultrasound assessment. BMC Nephrol 2017; 18: 365-371 DOI: 10.1186/s12882-017-0786-0.
• 34 Chung DY, Lee JS, Ahmad A. et al. Lessons learned from clinical outcome and tumor features of patients underwent selective artery embolization due to postoperative bleeding following 2076 partial nephrectomies: propensity scoring matched study [Epub ahead of print]. World J Urol 2019; DOI: 10.1007/s00345-019-02883-8.
• 35 Erlich T, Abu-Ghanem Y, Ramon J. et al. Postoperative Urinary Leakage Following Partial Nephrectomy for Renal Mass: Risk Factors and a Proposed Algorithm for the Diagnosis and Management. Scand J Surg 2017; 106: 139-144 DOI: 10.1177/1457496916659225.
• 36 Nouri YM, Chu HH, Shin JH. et al. PercutaneousObliteration of Urinary Leakage after Partial Nephrectomy Using N-Butyl-Cyanoacrylate Obliteration of the Urinoma with or without Coil Embolization of the Fistula Tract. J Vasc Interv Radiol 2019; 30: 2002-2008 DOI: 10.1016/j.jvir.2019.05.019.
• 37 Kowalewski KF, Hendrie JD, Nickel F. et al. Prophylactic abdominal or retroperitoneal drain placement in major uro-oncological surgery: a systematic review and meta-analysis of comparative studies on radical prostatectomy, cystectomy and partial nephrectomy [Epub ahead of print]. World J Urol 2019; DOI: 10.1007/s00345-019-02978-2.
• 38 Majdalany BS, El-Haddad G. et al. Contemporary lymphatic interventions for post-operative lymphatic leaks. Transl Androl Urol 2020; 9: S104-S113 DOI: 10.21037/tau.2019.08.15.
• 39 Zinssius D, Jünemann K, Geiger F. et al. Evaluation von Padua- und R.E.N.A.L.-Score hinsichtlich ihrer Aussagekraft und Implikationen auf das perioperative Management bei der partiellen Nephrektomie. Aktuelle Urologie (efirst) 2020; DOI: 10.1055/a-0888–7234.