Partial nephrectomy and autotransplantation with pyelovesicostomy for renal urothelial carcinoma in solitary kidneys: a clinical update

Authors


Joachim Steffens, Department of Urology and Paediatric Urology, St. Antonius Hospital, 52249 Eschweiler, Germany.
e-mail: joachim.steffens@sah-eschweiler.de

Abstract

OBJECTIVE

To evaluate the indications and outcomes after partial nephrectomy and renal autotransplantation for urothelial cancer in solitary kidneys, with special attention to the ease of endoscopic tumour control after pyelovesicostomy.

PATIENTS AND METHODS

In all, 978 records of three institutions were reviewed for patients undergoing partial nephrectomy between January 1990 and December 2000. Ex vivo organ-preserving surgery was used in selected patients with a solitary kidney and localized pelvic or calyceal tumour. Autotransplantation was established using a pyelovesicostomy. The follow-up included ultrasonography, pelvi-cystoscopy, urine cytology, computed tomography, renal functional evaluation and video-urodynamics. The study included four patients aged 52–56 years, with a follow-up of 6–14 years.

RESULTS

The histopathological status was pT1G2R0 in two and pT1G1R0 in the other two patients. One of them had an additional papilloma in the upper ureter. All patients entered a protocol of mitomycin/bacille Calmette-Guérin instillation therapy after surgery. The patients are currently alive with no recurrences. There is stable kidney function despite vesico-renal reflux, and normal bladder function with no subvesical obstruction.

CONCLUSIONS

Partial nephrectomy and renal autotransplantation for renal urothelial cancer in solitary kidneys is feasible, but should only be used in the rarest cases, and for the most selective indications. Dialysis and renal replacement can be avoided. Pyelovesicostomy allows effective chemotherapy instillation therapy, and easy and secure urothelial cancer control of the upper urinary tract.

Abbreviations
RUC

renal urothelial cancer.

INTRODUCTION

Elective nephron-sparing surgery has become the standard treatment for small unilateral RCCs [1–4]. Imperative partial nephrectomy for parenchymal renal malignancy in patients with a solitary kidney, synchronous bilateral tumours, or renal failure in the opposite kidney is also an accepted alternative to radical nephrectomy, followed by haemodialysis or transplantation [5–7]. However, for the rare and oncologically different clinical situation of renal urothelial cancer (RUC) in solitary kidneys, partial nephrectomy is neither a routine procedure nor much debated. Recently, the Cleveland group was the first to describe the behaviour of this subgroup in detail [8].

The standard treatment options for RUCs include radical nephroureterectomy [9] and endourological surgery [10–12]. Percutaneous management is justified for grade 1 and 2, stage Ta and T1 tumours, with long-term functional salvage in 60% of patients [12]. We present our experience with partial nephrectomy and renal autotransplantation for RUCs in solitary kidneys, reporting rare indications and the outcome, with special attention to the pyelovesical anastomosis, allowing a chemoprophylaxis and good cancer control of the remnant renal collecting system.

PATIENTS AND METHODS

In all, 978 records of three institutions were reviewed for patients undergoing partial nephrectomy from January 1990 to December 2000. Organ-preserving operations for RUCs were reserved for patients with a normal functioning solitary kidney and locally confined tumours. Endoscopic management in these cases was not feasible because of tumour location, tumour size or stage/grade uncertainty.

The evaluation before surgery included IVU, CT, cystoscopy, retrograde pyelography, and urinary cytology. A flank incision nephroureterectomy, with preservation of the vessels and immediate perfusion of the kidney with a cold storage solution, was used as ‘bench’ surgery. Under bloodless conditions, a ureterectomy, wide pyelotomy and endoscopic examination of the pelvicalyceal system were used to exactly define tumour size and location. Depending on these findings, partial resection and reconstruction of the urine-collecting system and renal parenchyma was established, followed by a contralateral autotransplantation with pyelovesicostomy through a supra-inguinal incision. For pyelovesicostomy the bladder was mobilized, followed by a ≈2 cm broad side-to-side anastomosis between the renal pelvis and lateral bladder. An adjuvant chemo/immunotherapy instillation treatment was offered after surgery in all patients. Follow-up data were recorded from clinic visits or the tumour registry. Follow-up assessments included cystoscopy, pyeloscopy, reflux cystogram, CT, urine cytology, nuclear renography and video-urodynamic studies.

RESULTS

In all, four patients (three men, one woman, age 52–56 years) had partial nephrectomy, ureterectomy and renal autotransplantation; the follow-up was 6–14 years. The left kidney was involved in three patients and the right in one. Two had a solitary kidney that was congenital and in the others it was acquired by contralateral tumour nephrectomy 2–5 years previously. All patients presented with haematuria, and one with additional stone disease. Two tumours were in the upper and the others in the lower pole. ‘Bench’ surgery (partial nephrectomy with complete removal of the polar calyceal system, complete ureterectomy and additional stone extraction in the first case) was performed under cold ischaemia using Euro-Collins solution. Surgical margins were confirmed by frozen-section analysis. The mean (range) cold ischaemia time was 2.7 (2.5–3) h and the warm ischaemia time (time for the vascular anastomosis) was 25–35 min. For autotransplantation we used an end-to-end anastomosis with the right intern iliac artery and an anastomosis between the renal pelvis and bladder (Fig. 1). The histopathological status was T1G2 in two and pT1G1 in the other two patients; a ureteric papilloma was also identified in the first patient. All had negative surgical margins. After surgery in one patient, 2 units of blood transfusion were given; in the others the recovery was normal, with no unusual morbidity. There were no urological or surgical complications, and no patient required dialysis.

Figure 1.

Surgical view after tumour resection of the renal pelvis (left) and autotransplantation with pyelovesicostomy (right). Flexible cystoscopy allows easy control of the remnant urothelial system.

Before surgery the creatinine levels were 1.0–1.4 mg/dL; in all patients there was a transient increase in creatinine level after surgery, to 4.8 mg/dL (Table 1). However renal function recovered within 8 and 12 weeks after surgery, resulting in creatinine levels of 1.0–1.9 mg/dL. There was long-term preservation of renal function, despite vesico-renal reflux (Fig. 2) in all patients. Video-urodynamics showed a normal bladder capacity and compliance, and no subvesical obstruction.

Table 1. 
Renal function changes in the four patients
Creatinine, mg/dLPatient
1234
Before surgery1.01.41.21.1
Peak after surgery3.74.84.44.7
12 weeks after surgery1.01.91.51.3
Figure 2.

Postoperative cystogram of the first patient: right vesicorenal reflux into the autotransplanted kidney.

Adjuvant intravesical immunotherapy was used in the first and fourth patients; they received BCG six times at weekly intervals. In the second and third patients mitomycin C (20 mg) was used six times at weekly intervals and then once monthly over 2 years.

Regular cystoscopy allowed not only an inspection of the bladder, but also an excellent assessment of the renal pelvis and the remnant calyceal system. Neither endoscopy nor cytology showed signs of tumour recurrence. CT showed no local or distant metastases after 2 years. The patients are currently alive with no tumour recurrence after a follow-up of 6–14 years.

DISCUSSION

Partial nephrectomy is an established procedure for renal cell cancer, even in the presence of a solitary kidney [7,13,14]. However, the role of nephron-sparing surgery for RUCs remains unclear, although its use has been reported [8,15–17]; recently, the Cleveland Clinic published the largest series and concluded that it should be considered in a selected population [8]. Open partial nephrectomy was suggested for endoscopically difficult RUCs, uncertain pathological state and advanced tumour in a solitary kidney. Therefore, open surgery is an alternative when endoscopic management is not feasible [8].

The present results confirm the published data, and show that patients with low-stage and -grade urothelial tumours and negative surgical margins have a good outcome [8,16,18,19]. By contrast, the presence of residual tumour, high stage and grade and multifocality correlate with an increased relapse rate and a poor outcome. The Cleveland group reported a recurrence rate of 42% and a progression rate of 50% in their patients [8]. The risk of recurrence and progression was proportional to tumour stage and grade.

Extracorporeal partial nephrectomy, renal reconstruction and autotransplantation represent an additional treatment option in selected cases for low- to medium-grade and stage RUCs in a solitary kidney. In the absence of effective endoscopic options it enables surgeons to avoid ablative operations, especially in patients with solitary or functionally solitary kidneys, where preserving renal parenchyma is most desirable and the patient is close to requiring haemodialysis [20]. A few reported cases confirmed that low-grade, low-stage RUCs were controlled just as effectively in the long term by organ-preserving procedures as they were by radical nephroureterectomy [21–25]. Most of these patients were treated by ex situ partial nephrectomy. For larger pelvic tumours or multiple tumours in one calyceal region the ex vivo operation of the kidney under cold perfusion has advantages. It allows major reconstruction of the kidney under cold ischaemia in the preservative perfused solution, a bloodless organ, and avoids spreading of tumour cells [20]. Furthermore, surgical margins can be safely cleared of tumour, as confirmed by the analysis of frozen sections. Also, in all studies and in the present patients, as much urothelium as possible was removed to minimize the risk of recurrence. Incidentally, a ureteric papilloma could even be identified in the first case.

Considering the extent of resection, Fergany et al.[13] reported on the functional long-term results after partial resection of a solitary kidney. After a mean follow-up of 3.6 years, about a fifth of the patients (21%) had no change in serum creatinine, while 41% had an insignificant change and 38% had a significant increase. Those authors estimated that an increase in serum creatinine of half or more would be significant. They concluded that patients with small kidney remnants and usually accompanying renal insufficiency should be screened for proteinuria [13]. Patients with progressive proteinuria should be treated with angiotensin-converting enzyme inhibitors and protein restriction [19]. Nevertheless, even the chance of developing renal failure at a slower rate might be considered a major benefit for these patients and their quality of life. Interestingly, renal function remained stable over many years in the present patients, despite the vesicorenal anastomoses made by pyelovesicostomy. These findings reconfirm the experience of Pettersson et al.[26] and show clearly that vesicorenal reflux in the elderly does not compromise renal function under conditions of good bladder capacity, stable bladder function and absent infravesical obstruction.

Complications were expected to occur at an equal or even lower rate in autografted kidneys than in allografts, because there were no immunological problems [18]. There were no urological complications in the present four patients. Flatmark et al.[27] reported a mortality rate of 4% of 274 autotransplanted patients and 3.6% of the kidneys were lost. In these cases the indications for operation were renovascular diseases in 56% and nephrolithiasis in 35%. Complications were more common after autotransplantations for renal malignancies [20,28].

In the present study, we also examined the results of the special method of urothelial anastomosis. Direct pyelovesicostomy has two advantages. First, it allows an adjuvant chemo/immunotherapy to reach the remnant upper urinary tract and thus minimize the recurrence rate. Second, it makes possible endoscopic assessment after surgery, and even transurethral fulguration of small recurrences in the pelvicalyceal system [26].

Our good oncological results were achieved with adjuvant BCG/mitomycin C instillations into the upper urinary tract, but there are only two case reports on BCG treatment of patients with autotransplanted kidneys. One patient with a pyelovesicostomy received two courses of BCG but developed additional recurrences [23]. The other had a pyelo-ileostomy and developed life-threatening sepsis after the first instillation, followed by a complete response for 1 year [29].

The decision to use autotransplantation remains the surgeon’s, and mostly depends on the complexity of the lesion and the question of whether endoscopic management is feasible. Before surgery the patient should be examined extensively, as noted above. Care should be taken to exclude severe iliac atherosclerosis or chronic inflammation of the kidney [20]. Other key factors in the decision include personal experience and interdisciplinary communication.

In conclusion, open partial nephrectomy and renal autotransplantation for RUCs in solitary kidneys should only be used in the rarest cases and for the most selective indications, where endoscopic management is not feasible. Dialysis and renal replacement can be delayed or avoided. Direct pyelovesicostomy allows an adjuvant chemo/immunotherapy and safe endoscopic cancer control of the remnant urothelial tract. It does not compromise renal function if there is normal function of the lower urinary tract.

CONFLICT OF INTEREST

None declared.

Ancillary