Nefrectomia parcial minimamente invasiva versus crioablação renal para pequenas massas renais

• Ano de defesa: 2016
• Autor(a) principal: Juncal, Samuel Ribeiro [UNIFESP]
• Tipo de documento: Tese
• Tipo de acesso: Acesso aberto
• Idioma: por
• Instituição de defesa: Universidade Federal de São Paulo (UNIFESP)
• Palavras-chave em Português: Renal cell carcinoma; Minimally invasive partial nephrectomy; Cryoablation; Carcinoma de célula renal; Nefrectomia parcial minimamente invasivo; Crioablação
• Link de acesso: https://sucupira.capes.gov.br/sucupira/public/consultas/coleta/trabalhoConclusao/viewTrabalhoConclusao.jsf?popup=true&id_trabalho=4153837; http://repositorio.unifesp.br/handle/11600/47699

Introduction and Objectives: Minimally invasive partial nephrectomy (MIPN) is the first-line option for the management of small renal masses (SMRs). Renal cryoablation (RC) is being increasingly offered to patients with SRMs due to encouraging outcomes and increasing experience with this treatment modality. We compared the perioperative, functional, and oncologic outcomes of MIPN and RC in the treatment of patients with SRMs. Methods: We retrospectively reviewed the medical records of 264 patients who underwent minimally invasive nephron-sparaing approach (percutaneous renal cryoablation, laparoscopic renal cryoablation, laparoscopic partial nephrectomy, and robotic partial nephrectomy) as a primary treatment for renal mass at our institution from January 2003 to March 2013. The tumors were divided into two groups according to the procedure performed: renal cryoablation (percutaneous and laparoscopic renal cryoablation) and minimally invasive partial nephrectomy (laparoscopic and robotic partial nephrectomy). Results: A total of 271 SRMs were identified in 264 patients (RC, n=123; MIPN, n=148). Patients undergoing MIPN were significantly younger (mean age: 60.6 years vs 65.8 years; P<0.0001). The two groups were similar in gender, body mass index, ethnicity, and American Society of Anesthesiologists score. Patients treated under RC had more baseline comorbidities, presenting a significantly higher percentage of solitary kidney and previous surgery in ipsilateral kidney (P=0.003 and P=0.013,respectively), and a trend to a higher age-adjusted Charlson comorbidity index (P=0.063). Median renal mass size (cm) was larger in the MIPN group (3.0 vs 2.4; P<0.0001). The incidence of perioperative complications had a lower trend in favor of RC (14.6% vs 23.6%;P=0.062). RC was associated with a shorter mean operative and anesthesia time (P<0.001 and P<0.0001, respectively), decreased median estimated blood loss (P<0.0001), shorter mean hospital stay (P<0.0001). Patients who underwent RC had a significantly higherimmediate and delayed treatment failure rate (8.9% vs 2.0%;P=0.01). The 3-,5-, and 10-year recurrence-free survival rate was 94.9%, 86.3% and 86.3% and 97.4%, 97.4% and 91.3% for the RC and MIPN groups, respectively (p=0.123). The 10-year disease-free survival probability was 95.5% for patients in the RC group and 98.5% for patients in the MIPN group (P=0.930). When comparing exclusively the eGFR postoperative day 1 value between both groups, the MIPN group had a significantly lower value compared to the RC group (P=0.019) and a significantly reclassification to a higher CKD stage (P=0.033). CONCLUSION : Renal cryoablation and minimally invasive partial nephrectomy remain viable treatment options in the management of SRMs. Patients undergoing RC had a lower incidence of perioperative complications and better preservation of renal function on immediate postoperative. Although MIPN had a lower local recurrence rate, there was an equivalent treatment effect when patients initially treated under RC were salvaged. A well-designed prospective comparative study with long-term follow is expected to validate our findings.