Correlation of pathology with tumor size of renal masses.

OBJECTIVE: The current standard of care for radiographically identified enhancing renal lesions is surgical removal. However, some of these lesions prove to be benign and did not truly warrant extirpation. Mass size has been traditionally described as a parameter to predict the malignant potential. We compiled our experience with surgically treated renal masses and correlated lesion size with final pathology. MATERIALS AND METHODS: We performed a retrospective analysis of extirpative renal surgery and resultant renal mass pathology from 1998- January 2006. Nephrectomies performed for non-malignant disease or transitional cell carcinomas were excluded. Renal tumors were staged by the 2002 TNM classification system. RESULTS: Three hundred ninety-four patients with 460 lesions were identified. Overall, 24% of masses were determined to be benign and 76% were malignant. Three hundred forty-three malignant lesions were renal cell carcinoma (98%). Masses were stratified by size. Two hundred thirty masses were smaller than 4 cm and 72 (31.3%) of these were benign. There were 166 lesions between 4 cm and 7 cm with an 18% benign rate. Sixty-four lesions were > 7 cm in size. Only eight of these were benign (12.5%). Chi square testing revealed the 31.3% benign rate of the < 4 cm group to be significantly different than the benign rates of the other groups. CONCLUSIONS: The preponderance of renal lesions removed for benign pathology occurs when lesion size is small, typically less than 4 cm. This information may be useful in deciding to offer expectant management of an otherwise surgical lesion in a patient who is a poor candidate to undergo an operative procedure.

Outcomes of hand-assisted laparoscopic nephrectomy in technically challenging cases.

OBJECTIVES: To evaluate the outcomes of hand-assisted laparoscopic nephrectomy in patients with significant complicating clinical factors. METHODS: We performed a retrospective review of 322 hand-assisted laparoscopic nephrectomy cases that were completed at a single institution from 1998 to 2004. Patients with a history of extensive abdominal surgery or prior procedures on the affected kidney, evidence of perirenal inflammation, renal lesions 10 cm or more in diameter, or level I renal vein thrombus were included. RESULTS: A total of 42 patients were included in this series. Of these, 16 patients had a lesion 10 cm or larger, 10 had a renal vein thrombus, and 10 had undergone prior major abdominal surgery. Many patients had more than one complicating factor. Another 6 patients had a history of prior renal procedures or chronic inflammatory processes involving the affected kidney. One Stage T4 renal tumor with paraspinous muscle invasion was successfully managed without conversion. The overall mean operative time and estimated blood loss was 235 minutes and 439 mL, respectively, with a mean hospital stay of 4 days. Four patients (9.5%) required open conversion (one renal hilar injury, two failure to progress, and one persistent bleeding from the renal fossa). Postoperative complications included pulmonary embolism in 1, ileus in 1, and chronic obstructive pulmonary disease exacerbation in 1 patient. One patient developed an incarcerated port site hernia requiring reoperation. CONCLUSIONS: Hand-assisted laparoscopic nephrectomy is an attractive minimally invasive option in the setting of significant complicating factors. This technique may facilitate the successful laparoscopic completion of these challenging cases with reasonable operative times, blood loss, and complication rates.