In addition, the benefits of the transperitoneal approach were highlighted when considering minimally invasive surgery anatomic relationships and it facilitates surgical movements by working in a larger cavity.
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The use of kidney cancer predictive tools and other kidney function normograms was also encouraged. Current treatment trends have changed the paradigm in the treatment of renal masses and renal biopsy should be done when clinically indicated. The learning curve for this approach was assessed by a study that compared RAPN with laparoscopy where the threshold for acceptable perioperative outcomes was 30 cases.
This learning curve is reasonable when considering how technically demanding it can be when teaching complex laparoscopy cases to trainees. The remaining group of patients underwent nephrectomy.
Results : NSS was performed more frequently among patients with lesions in the lower pole of the kidney and there was no infiltration to the calyx and renal pelvis. Radical nephrectomy RN was pursued in cases with lesions in the central or upper pole. Lesion diameter in patients qualified for NSS was smaller than in patients qualified for radical nephrectomy.
Conclusions : Determining the relationship between tumour and adjacent structures is not a simple matter. Tumour diameter determined in CT examination is larger than in ultrasound and histopathological measurements while US scanning tends to underestimate tumour size in relation to histopathological assessment. Mean age of the grafted kidney at the time of diagnosis was All tumors were asymptomatic except one discovered on an US performed for a decreased renal function.
The mean time between diagnosis and surgery was All tumors were analyzed and classified by histological type, Fuhrman grade and pTNM stage. Nineteen tumors had biopsies prior to surgery Biopsy results and postsurgical histology were discordant in two cases benign on biopsies and RCC on definitive histology. One 2.
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Ten RCC According to our modified pTNM classification, 39 tumors were pT1a All surgical margins were negative. Preoperative mean creatinine was The increase in the creatinine level was not significant. No recipients returned to dialysis after surgery. None of them had dialysis after surgery. Two had ureteral strictures, one secondary to entrapment in the aponeurosis running suture Clavien IIIb , the other secondary to a postseptic ischemia Clavien IIIb.
All immunosuppressive regimen modifications were done after surgery and definitive histologic results. The immunosuppressive regimens used are described in Table 3. Among the 43 cases of NSS, six patients were taken off calcineurin inhibitor three cyclosporine and three tacrolimus. Data were missing for seven cases. One patient had a nonfunctional grafted kidney, requiring dialysis after chronic allograft rejection.
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One patient died All patients were cured from their cancer without any local or distant recurrence. No statistical differences were found between the renal clear cell carcinoma group and the papillary carcinoma group for all the variables described in Table 2.
The incidence of RCC among kidney transplanted patients is between 0. This incidence will probably increase progressively because renal transplant recipients and donors are older. The review of literature remains poor about the treatment of kidney graft tumors using NSS.
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Indeed there are fewer than 30 case reports in the literature 5 , 10 - 15 with acceptable outcomes for surgery. No multicenter study has been established yet. No consensus is established about diagnosis and treatment of these tumors. Most de novo renal graft tumors were asymptomatic and discovered on systematic annual screenings as previously described 6 , Two percutaneous renal mass biopsies However, systematic biopsies for tumors of grafted kidneys should be performed.
Indeed, biopsies may reveal benign lesions in The complications of percutaneous renal mass biopsies are minor and biopsy may prevent surgery for benign lesions In these cases, watchful waiting is indicated. In our cohort, two patients had oncocytomas on the final pathologic microscopic analysis of the tumor. We believe that surgery could be elected by a systematic application of percutaneous biopsies of tumors. In our experience, papillary carcinomas were more frequent Papillary carcinoma was commonly accepted as an indication of transplantectomy because of its multifocal characteristics.
On the contrary, they are less aggressive with a better prognosis than clear cell carcinomas Even if local recurrence occurs, Johnson et al 22 demonstrated the feasibility of repeated NSS on the same kidney for small tumors and argued that transplantectomy remains possible in case of recurrence.
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Some tumors such as renal lymphoma could mimic renal RCC. Posttransplant lymphoma disorder could thus be another diagnosis for a renal graft mass, especially when associated with regional adenopathy. Its reported incidence in the literature is very low 0. All margins were negative after surgery. Thickness of margins is not important and only positivity of margins constitutes a negative prognostic factor.
This allowed preserving a functional nephron capital as much as possible without a guaranteed return to dialysis as in transplantectomy.
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Feasibility of large NSS in a renal transplant was demonstrated recently by Kaouk et al A few cases are described in the transplanted population 27 , This was confirmed in single kidney populations with RF 30 and CA A few series comparing RF ablation to CA did not show significant differences in oncological and functional outcomes 36 , De novo kidney graft tumors were less aggressive than in the general population.
According to our results, mean time between diagnosis and treatment was 8.
This long time lapse can be explained by the lack of guidelines for the treatment of these tumors, their small size and slow growth rate leading to a period of watchful waiting before treatment. Some teams decided upon a watchful waiting management with regular CT scan or US screenings for small renal masses. This alternative is currently discussed in the literature for native renal carcinomas However, could such management be proposed in immunosuppressed patients?