Tratamiento quirúrgico del carcinoma de células renales en personas de edad avanzada / Surgical treatment of renal-cell carcinoma in elderly people

Objetivo: Describir las características oncológicas y evolución de los pacientes con 65 años o más que son sometidos a cirugía por cáncer de células renales (CCR). Métodos: Revisamos en nuestra base de datos a todos los pacientes con CCR tratados quirúrgicamente. Aquellos mayores de 65 años fueron seleccionados. Se analizaron las características clínicas y patológicas, así como los desenlaces oncológicos y funcionales. La supervivencia global (SG) fue estimada con el método de Kaplan-Meier. El análisis multivariado fue hecho con el modelo de Cox para determinar los predictores de SG. Resultados: Se incluyeron un total de 156 pacientes ancianos con una edad media de 72,0 ± 5,5 años (rango 65-92) y una mediana de seguimiento de 33 meses. El abordaje quirúrgico fue nefrectomía radical abierta en 114 (73,5%) pacientes, nefrectomía radical laparoscópica en 13 (8,4%), nefrectomía parcial abierta en 23 (14,2%) y nefrectomía parcial laparoscópica en 6 (3,9%). El estadio patológico fue: estadio i 71 (45,5%), estadio ii 27 (17,3%), estadio iii 48 (30,8%) y estadio iv 10 (6,4%). Finalmente, 51 (32,6%) pacientes murieron, 22 (43,1%) por cáncer. La SG a 5 años de acuerdo al estadio patológico fue 77,6%, 71,9%, 45,1% y 11,7% para los estadios i, ii, iii y iv, respectivamente (p < 0,001). En el análisis multivariado el estadio patológico fue un factor independiente para predecir la SG (HR: 1,96, IC 95% [1,36-2,84], p = 0,0003). Conclusiones: El tratamiento quirúrgico del CCR parece seguro en pacientes mayores de 65 años debidamente seleccionados. El estadio patológico predice la supervivencia en esta población

Objective: To describe the oncological characteristics and evolution of patients 65 years or older who underwent surgery for renal-cell carcinoma (RCC). Methods: We reviewed our prospectively maintained database of patients with RCC treated surgically. Those ≥ 65 years old were selected. We analyzed clinical and pathological characteristics as well as oncological and functional outcomes. Overall survival (OS) was estimated with the Kaplan-Meier method. Multivariate Cox-proportional hazards model was used to determine predictors of OS. Results: A total of 156 elderly patients with mean age 72.0 ± 5.5 years (range 65-92) and median follow-up of 33 months were included. Surgical approach was open radical nephrectomy in 114 (73.5%), laparoscopic radical nephrectomy in 13 (8.4%), open partial nephrectomy in 23 (14.2%) and laparoscopic partial nephrectomy in 6 (3.9%). Pathological stage was: Stage I, 71 (45.5%); Stage II, 27 (17.3%); Stage III, 48 (30.8%); and Stage IV, 10 (6.4%). Lastly, 51 (32.6%) patients died, 22 (43.1%) from cancer. The 5-year OS according to pathological stage was 77.6%, 71.9%, 45.1% and 11.7% for stage I, II, III and IV, respectively (P < .001). On multivariate analysis, pathological stage independently predicted OS (HR 1.96, 95% CI [1.36-2.84], P = .0003). Conclusions: The surgical management of RCC appears to be safe in properly selected patients 65 years or older. Pathological stage predicts survival in this population

Surgical treatment of renal-cell carcinoma in elderly people. / Tratamiento quirúrgico del carcinoma de células renales en personas de edad avanzada.

OBJECTIVE: To describe the oncological characteristics and evolution of patients 65 years or older who underwent surgery for renal-cell carcinoma (RCC). METHODS: We reviewed our prospectively maintained database of patients with RCC treated surgically. Those ≥ 65 years old were selected. We analyzed clinical and pathological characteristics as well as oncological and functional outcomes. Overall survival (OS) was estimated with the Kaplan-Meier method. Multivariate Cox-proportional hazards model was used to determine predictors of OS. RESULTS: A total of 156 elderly patients with mean age 72.0±5.5 years (range 65-92) and median follow-up of 33 months were included. Surgical approach was open radical nephrectomy in 114 (73.5%), laparoscopic radical nephrectomy in 13 (8.4%), open partial nephrectomy in 23 (14.2%) and laparoscopic partial nephrectomy in 6 (3.9%). Pathological stage was: Stage I, 71 (45.5%); Stage II, 27 (17.3%); Stage III, 48 (30.8%); and Stage IV, 10 (6.4%). Lastly, 51 (32.6%) patients died, 22 (43.1%) from cancer. The 5-year OS according to pathological stage was 77.6%, 71.9%, 45.1% and 11.7% for stage I, II, III and IV, respectively (P<.001). On multivariate analysis, pathological stage independently predicted OS (HR 1.96, 95% CI [1.36-2.84], P=.0003). CONCLUSIONS: The surgical management of RCC appears to be safe in properly selected patients 65 years or older. Pathological stage predicts survival in this population.

Hand-assisted laparoscopic versus open donor nephrectomy: a retrospective comparison of perioperative and functional results in a tertiary care center in Mexico.

BACKGROUND: Laparoscopic nephrectomy for living donors is the current procedure of choice. Hand-assisted laparoscopic donor nephrectomy (HALDN) is the variation of this technique currently used in our institution. Though the advantages and disadvantages have been described for this procedure, the graft function compared with open surgery has been shown to be equal. We compared the outcomes of patients undergoing the former standard open donor nephrectomy (ODN) versus the current HALDN technique. METHODS: In this retrospective, comparative, and analytic study we reviewed our institutional database of renal transplantation procedures from January 2005 to April 2011 for perioperative variables and 1-year follow-up data. Donor renal function was evaluated with serum creatinine concentrations and estimated glomerular filtration rates with the Chronic Kidney Disease-Epidemiology formula. Complications were reported with the Clavien-Dindo classification. RESULTS: The 190 consecutive donors included 99 ODN and 91 HALDN, who did not show baseline differences. ODN had a shorter mean operative time (217 ± 57.5 vs 270 ± 60.1 minutes) and shorter warm ischemia time (2.12 ± 1.4 vs 4.62 ± 2.7 minutes). HALDN had less operative blood loss (274.4 ± 198.1 vs 202.99 ± 157.1 mL) and shorter in-hospital stay (5.58 ± 2.2 vs 4.23 ± 1.8 days). There were no significant differences in 30-day surgical complications or transfusion requirements. No graft loss was reported. No difference in renal function was observed between the groups at days 1-2 or months 1, 6, or 12 after nephrectomy. CONCLUSIONS: Laparoscopic surgery has replaced conventional open surgery for living renal donors. HALDN is a safe and successful procedure compared with ODN. It is now the procedure of choice in our institution.

Ablación por radiofrecuencia de lesiones renales: experiencia inicial en un centro de referencia en la ciudad de México (INNSZ) / Radiofrequency ablation of renal lesions: initial experience in a center of reference in Mexico city (INNSZ)

Introducción y objetivos: La incidencia de los tumores renales ha aumentado, debido con mucho, a los avances de la tecnología, pero el estadio al momento del diagnóstico ha disminuido. En pacientes seleccionados puede realizarse nefrectomía parcial (o ahorradora de nefronas). Hay pacientes que tienen comorbilidades importantes que no son candidatos a tratamiento quirúrgico; para ellos hay modalidades nuevas de mínima invasión que utilizan diferentes tipos de energía para realizar ablación del tejido neoplásico, una de éstas es la ablación por radiofrecuencia. Este artículo reporta la experiencia inicial con esta modalidad terapéutica en un centro de referencia de la ciudad de México. Métodos: Cuatro pacientes con 5 lesiones renales menores a 3 cm, con comorbilidades importantes que los excluían de posibilidad quirúrgica, se sometieron a ablación por radiofrecuencia bajo guía fluoroscópica. Resultados: cinco lesiones renales en cuatro pacientes sometidos a ablación por radiofrecuencia en un periodo de 18 meses. No se presentaron complicaciones importantes durante el procedimiento, el seguimiento promedio de 12 meses y mantienen buen control oncológico. Conclusiones: La ablación por radiofrecuencia es una opción terapéutica segura y reproducible para pacientes con lesiones renales incidentales menores a 3 cm. Se requiere de más tiempo para comparar el control oncológico con el estándar de oro, la cirugía (AU)

Introduction and objectives: With the advances of technology, the incidence of renal cancer has increased, but the stage at the time of diagnosis has decreased. In selected patients nephron sparing surgery can be made but there are patients who have important comorbidities and therefore they are not candidates to surgical management. For them, there are new minimally invasive procedures that use different types of energy to perform ablation of the neoplastic tissue; one of which is radiofrequency ablation. This article reports the initial experience with this therapeutic modality in a reference center of Mexico City. Methods: Four patients with 5 renal masses of 3 cm or less, and with insignificant comorbidities that exclude the possibility of surgery, underwent radiofrequency ablation under fluoroscopic guidance. Results: Five renal tumors in four patients were treated with radiofrequency ablation in a period of 18 months. No major complication during the procedure was reported, mean follow- up was of 12 months and they keep a good oncologic control. Conclusions: Radiofrequency ablation is a safe and reproducible therapeutic option for patients with incidental renal masses below 3 cm. We need more follow up to compare oncologic control with the gold standard, surgery (AU)

[Radiofrequency ablation of renal lesions: initial experience in a center of reference in Mexico City (INNSZ)]. / Ablación por radiofrecuencia de lesiones renales: experiencia inicial en un centro de referencia en la ciudad de México (INNSZ).

INTRODUCTION AND OBJECTIVES: With the advances of technology, the incidence of renal cancer has increased, but the stage at the time of diagnosis has decreased. In selected patients nephron sparing surgery can be made but there are patients who have important comorbidities and therefore they are not candidates to surgical management. For them, there are new minimally invasive procedures that use different types of energy to perform ablation of the neoplastic tissue; one of which is radiofrequency ablation. This article reports the initial experience with this therapeutic modality in a reference center of Mexico City. METHODS: Four patients with 5 renal masses of 3 cm or less, and with significant comorbidities that exclude the possibility of surgery, underwent radiofrequency ablation under fluoroscopic guidance. RESULTS: Five renal tumors in four patients were treated with radiofrequency ablation in a period of 18 months. No major complication during the procedure was reported, mean follow- up was of 12 months and they keep a good oncologic control. CONCLUSIONS: Radiofrequency ablation is a safe and reproducible therapeutic option for patients with incidental renal masses below 3 cm. We need more follow up to compare oncologic control with the gold standard, surgery.

[Use of a virtual immersion computer simulator as a model for basic training in laparoscopic urology]. / Simulador computarizado de inmersión virtual como modelo de inicio de entrenamiento de laparoscopia urológica.

BACKGROUND: to date, it has not been defined the best method for teaching urologic laparoscopy, however it is well recognized that it involves a steep learning curve. METHODS: A course of Laparoscopic Urology was done in our Institute. The program included skill practices in a virtual immersion simulator which evaluated, the score and time to complete each activity. This was done in a group of residents with previous experience with this virtual simulator (group 1) and another group of residents with no experience (group 2). Four different basic tasks were performed in the virtual simulator, which included: coordination, cutting, clip application and performing a simple suture. RESULTS: When we compared the scores between both groups the mean scores for each task were superior in group 1 compared to the group 2, with no statistically significant difference, however when we compared the time to complete each task, it was shorter in group 1 compared to group 2 with a statistically significant difference. CONCLUSIONS: The performance of residents without experience in a virtual simulator was similar to that of previously trained residents, however it takes less time to complete each task as the resident gains experience in these simulators. The use of virtual simulators for laparoscopy training are useful when learning basic techniques allowing the surgeon to improve hand dexterity and coordination in laparoscopic surgery.

Simulador computarizado de inmersión virtual como modelo de inicio de entrenamiento de laparoscopia urológica / Use of a virtual inmersion computer simulator as a model for basic training in laparoscopic urology

Antecedentes: En la actualidad aún no está definido el mejor método de enseñanza para laparoscopia aplicada en urología, sin embargo se sabe que implica una larga curva de aprendizaje. Métodos: Se llevó a cabo en nuestro Instituto un Curso de Laparoscopia Urológica que incluyó prácticas en un simulador computarizado de inmersión virtual en el que se evaluó las aptitudes de residentes que utilizaron rutinariamente el simulador como el grupo con experiencia (grupo 1) contra otro grupo sin experiencia (grupo 2). Se utilizaron diferentes modalidades en el simulador calificando la destreza y el tiempo para completar 4 tareas: coordinación, corte, colocación de clips y suturas endoscópicas. Resultados: Las calificaciones promedio en las cuatro tareas fueron superiores en el grupo 1 comparado con el grupo 2, sin embargo nunca existió una diferencia estadísticamente significativa. Por otra parte en lo que corresponde al tiempo para realizar las prácticas fue menor en el grupo 1 comparado con el grupo 2, con diferencia estadísticamente significativa. Conclusiones: El desempeño de los alumnos sin experiencia en el uso de simuladores fue similar al de los alumnos habituados a este tipo de entrenamiento, sin embargo, se observó una mayor velocidad en la realización de las tareas conforme se aumenta el tiempo del uso de estos simuladores. El uso de simuladores permite el aprendizaje de técnicas básicas permitiendo mejorar la destreza y coordinación para la práctica de laparoscopia

Background: to date, it has not been defined the best method for teaching urologic laparoscopy, however it is well recognized that it involves a steep learning curve. Methods: A course of Laparoscopic Urology was done in our Institute. The program included skill practices in a virtual immersion simulator which evaluated, the score and time to complete each activity. This was done in a group of residents with previous experience with this virtual simulator (group 1) and another group of residents with no experience (group 2). Four different basic tasks were performed in the virtual simulator, which included: coordination, cutting, clip application and performing a simple suture. Results: When we compared the scores between both groups the mean scores for each task were superior in group 1 compared to the group 2, with no statistically significant difference, however when we compared the time to complete each task, it was shorter in group 1 compared to group 2 with a statistically significant difference. Conclusions: The performance of residents without experience in a virtual simulator was similar to that of previously trained residents, however it takes less time to complete each task as the resident gains experience in these simulators. The use of virtual simulators for laparoscopy training are useful when learning basic techniques allowing the surgeon to improve hand dexterity and coordination in laparoscopic surgery