Words of wisdom. Re: enucleation of renal cell carcinoma with ablation of the tumour base.

Experts’ summary: The authors evaluated the oncologic results of open tumor enucleation (TE) using either the argon-beam or the Nd-YAG laser for ablation of the tumor base in 97 patients with single sporadic pT1a-pT1b renal cell carcinoma (RCC). TE was performed by blunt dissection with the butt end of the scalpel handle and a metal-tipped sucker. Isolation and clamping of hilar renal vessels was avoided in all cases. After a mean follow-up of 25 mo(median: 21mo; range: 0–120 mo), only one patient had local recurrence. No metastatic progressions were observed. Experts’ summary: In very recent years, urologic opinion has changed from skepticism of TE to a wider level of acceptance based on larger retrospective series with longer follow- up [1–4]. Indeed, we and others have recently shown TE to have oncologic results similar to those of standard nerve-sparing surgery (NSS) [1–6]. This paper confirms the safety and efficacy of open blunt TE for the treatment of RCC up to 7 cm in greatest dimension, albeit in a series with a mean follow-up of 25 mo (range: 0–120 mo). Moreover, this study allows us to discuss some technical aspects of this technique. In their series, Kutikov and coworkers clearly show that blunt TE can be performed without clamping the hilar vessels. In our patients, we usually clamp the hilar vessels before starting the procedure, and we avoid renal ischemia only for small, exophytic, polar lesions [1,2]. Warm ischemia brings the advantages of operating in a bloodless surgical field and of clearly defining the correct enucleation plane between healthy renal parenchyma and tumor pseudocapsule. Once the correct surgical plane has been found, the procedure is easily and quickly carried out by blunt dissection. In our recent papers, mean ischemia times of 16.3 min (range: 8–21 min) and 15.7 min (range: 8–21 min) for pT1a and pT1b tumors, respectively, were reported [2,3]. Nevertheless, the possibility of obviating the need for renal ischemia can represent a further advantage of TE, especially for patients without normally functioning kidneys [4–6]. Another interesting technical and oncologic issue related to TE is whether or not to coagulate the enucleation bed using an energy source such as diathermy or argon-beam or Nd-YAG laser. In the present series, Kutikov and coworkers ablated the tumor bed with either the argon-beam or Nd- YAG laser to free kidney parenchyma from any tumor cells that extend beyond the pseudocapsule and, therefore, to improve cancer control. We used either argon-beam laser or diathermy spray coagulation until October 2004 [1–3], andthen we modified our technique, avoiding coagulation of the enucleation bed;we did not observe an increase in local recurrence rate in comparison with our previously published data [1–3]. The oncologic safety of in vivo pure blunt TE without the need to coagulate the surgical bedwas further confirmed by our recent prospective study that investigated the pseudocapsule and surgical margins status to define the real need to take a rim of healthy parenchyma around the tumor to avoid the risk of positive surgical margins [7]. Our study of 90 consecutive TEs for RCC showed that tumor pseudocapsule can be infiltrated with or without invasion beyond it on the parenchymal side (26.6%), but the presence of a thin layer of parenchymal tissue invariably allows for negative surgical margins. Additionally, if no efforts are made to leave a rim of healthy kidney tissue around the neoplasm (TE technique), thus concluding that if the surgeon follows the natural cleavage plane between tumor pseudocapsule and kidney parenchyma, there is no risk of positive surgical margins and therefore the use of any energy source to extirpate cancer cells left on the surgical bed is not needed [7].