Nephron sparing surgery for

multifocal RCC

Gennady Bratslavsky, M.D.

Professor and Chairman

Department of Urology

Upstate Medical University

Syracuse, NY

Disclosures

No relevant financial disclosures

The Urologic Oncology Branch at the

National Cancer Institute

Upstate Department of Urology 2011

Upstate Department of Urology 2012

Upstate Department of Urology 2013

Upstate Department of Urology 2014

Upstate Department of Urology 2015

Upstate Department of Urology 2016

Upstate Department of Urology 2017

Outline

1. Prevalence of multifocal RCC

2. Surgical and functional outcomes

3. Oncologic outcomes

Bratslavsky and Linehan.

Nature Rev Urol. 2010

How Multifocal is Multifocal?

VHL: up to 600 tumors/ kidney (Walther, J Urol 1995)

HPRC: up to 3400 tumors/ kidney (Ornstein, J Urol 2000)

BHD: tens of tumors/ kidney (Pavlovich, Am J Surg Path 2002)

Unknown genes: tens of tumors resected

Renal tumors in VHL patients

Multifocal disease

What should we do?

Bilateral renal cell carcinoma in von

Hippel-Lindau syndrome:

treatment with staged bilateral

nephrectomy and hemodialysis

` Fetner CD, Barilla DE, Scott T, Ballard J, Peters P

1977

J Urol. 1977 Apr;117(4):534-6

Survival free of local tumor

recurrence following NSS

Steinbach et al, JU 1995

If you wait long enough… Recurrence

Novick et al, J Urol 1992

Steinbach et al, J Urol 1995

Walther et al, J Urol 1995

Belldegrun et al, JCO 1999

Hafez et al, J Urol 1999

Ansari et al, Int J Nephrol 2003

Johnson et al, J Urol 2008

Bratslavsky et al, J Urol 2008

Long-term management of recurrences

NEPHRECTOMY OR

REPEAT INTERVENTION?

Why save these kidneys?

1. Renal insufficiency is bad (Go et al, NEJM 2004)

2. Dialysis is not benign (Rocco et al, Ann Intern Med 2006)

3. Transplant (5 year graft survival is 75-80%)

(Lin et al, Clin Transplant 2006)

Go et al, NEJM 2004

Rocco et al, Ann Intern Med 2006

Lin et al, Clin Transplant 2006

Repeat Partial Nephrectomy

Salvage Partial Nephrectomy

Comparison of NCI Partial Nephrectomy Series

Kowalczyk et al, J Urol 2009

Renal functional outcome

Oncologic Outcomes Procedure Median F/U

(months)

Metastasis-Free

Survival (%)

Overall

Survival (%)

Initial partial

nephrectomy

30

100% 100%

Partial for resection of

20 or more tumors

50 92% 92%

Repeat partial

nephrectomy

56 94% 98%

Repeat partial on a

solitary unit

69 95% 90%

Salvage partial

nephrectomy

25 100% 100%

• 128 patients with median follow up 16 years (10-40)

• RCC specific survival 97%, Overall survival 88%,

• 95% avoided dialysis

• Median time to re-intervention 6.7 years

0

20000

40000

60000

80000

100000

120000

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180000

0 0.5 1 1.5 2 2.5 3 3.5 4 4.5

Co

st (

tho

usa

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Time (years)

Costs vs time

Reoperative Renal Surgery

Dialysis

Conclusions

Recurrence is not always a surgeon’s failure

Reoperative renal surgery may become more common as

urologic surgeons embark on more renal preservation

Save kidneys even in the setting of mutifocality

Fasten your seat belt for these operations