Introduction. The aim of this study is to examine the feasibility of reducing postoperative hospital stay following open partial nephrectomy through the implementation of a goal directed clinical management pathway. Materials and Methods. A fast track clinical pathway for open partial nephrectomy was introduced in July 2006 at our institution. The pathway has daily goals and targets discharge for all patients on the 3rd postoperative day (POD). Defined goals are (1) ambulation and liquid diet on the evening of the operative day; (2) out of bed (OOB) at least 4 times on POD 1; (3) removal of Foley catheter on the morning of POD 2; (4) removal of Jackson Pratt drain on the afternoon of POD 2; (4) discharge to home on POD 3. Patients and family are instructed in the fast track protocol preoperatively. Demographic data, tumor size, length of stay, and complications were captured in a prospective database, and compared to a control group managed consecutively immediately preceding the institution of the fast track clinical pathway. Results. Data on 33 consecutive patients managed on the fast track clinical pathway was compared to that of 25 control patients. Twenty two (61%) out of 36 fast track patients and 4 (16%) out of 25 control patients achieved discharge on POD 3. Overall, fast track patients had a shorter hospital stay than controls (median, 3 versus 4 days; <mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML"><mml:mi>P</mml:mi></mml:math> = .012). Age (median, 55 versus 57 years), tumor size (median, 2.5 versus 2.5&#x02009;cm), readmission within 30 days (5.5% versus 5.1%), and complications (10.2% versus 13.8%) were similar in the fast track patients and control, respectively. Conclusions. In the present series, a fast track clinical pathway after open partial nephrectomy reduced the postoperative length of hospital stay and did not appear to increase the postoperative complication rate.

Bilal Chughtai

Christa Abraham

Daniel Finn

Stuart Rosenberg

Bharat Yarlagadda

Michael Perrotti

Fast Track Open Partial Nephrectomy: Reduced Postoperative Length of Stay with a Goal-Directed Pathway Does Not Compromise Outcome

Objectives. To review the natural history and biological potential of small renal masses in order to evaluate surveillance as a treatment option. Methods. Literature search of Medline and additional references from non-Medline-indexed publications concerning surveillance of small renal masses. Results. The natural history and biological potential of small renal masses can still not be unambiguously predicted at present. There seems to be no clear correlation between tumour size and presence of benign histology. The majority of small renal masses grow and the majority are cancer, but one cannot safely assume that a lack of growth on serial CT scans is the confirmation of absence of malignancy. Needle core biopsies could be used to help in decision making. They show a high accuracy for histopathological tumour type but are less accurate in evaluating Fuhrman grade. Conclusions. At present, surveillance of small renal masses should only be considered in elderly and/or infirm patients with competing health risks, in those with a limited life expectancy, and in those for whom minimal invasive treatment or surgery is not an option. In all other patients, active surveillance should only be considered in the context of a study protocol. Long-term, prospective studies are needed to provide a more accurate assessment of the natural history and metastastic potential of small renal masses.

S. Klaver

S. Joniau

H. Van Poppel

Surveillance as an Option for the Treatment of Small Renal Masses

Introduction. Partial nephrectomy (PN) is playing an increasingly important role in localized renal cell carcinoma (RCC) as a true alternative to radical nephrectomy. With the greater experience and expertise of surgical teams, it has become an alternative to radical nephrectomy in young patients when the tumor diameter is 4 cm or less in almost all hospitals since cancer-specific survival outcomes are similar to those obtained with radical nephrectomy. 
Materials and Methods. The authors comment on their own experience and review the literature, reporting current indications and outcomes including complications. The surgical technique of open partial nephrectomy is outlined. 
Conclusions. Nowadays, open PN is the gold standard technique to treat small renal masses, and all nonablative techniques must pass the test of time to be compared to PN. It is not ethical for patients to undergo radical surgery just because the urologists involved do not have adequate experience with PN. Patients should be involved in the final treatment decision and, when appropriate, referred to specialized centers with experience in open or laparoscopic partial nephrectomies.

J. M. Cozar

M. Tallada

Open Partial Nephrectomy in Renal Cancer: A Feasible Gold Standard Technique in All Hospitals

Surveillance is a new management option for small renal masses (SRMs) in aged and 
                  infirm  patients with 
                   short-life expectancy. The current literature on surveillance of SRM contains mostly small, retrospective studies with limited data. Imaging alone is inadequate for suggesting the aggressive potential of SRM for both diagnosis and followup. Current data suggest that a computed tomography (CT) or magnetic resonance imaging (MRI) every 3 months in the 1st year, every 6 months in the next 2 years, and every year thereafter, is appropriate for observation. The authors rather believe in active surveillance with mandatory initial and followup renal tumor biopsies than classical observation. Since not all SRMs are harmless, selection criteria for active surveillance need to be improved. In addition, there is need for larger studies in order to better outline oncological outcome and followup protocols.

Mehmet Ozsoy

Tobias Klatte

Matthias Waldert

Mesut Remzi

Surveillance for the Management of Small Renal Masses

During the past two decades, several new hereditary renal cancers have been discovered but are not yet widely known. Hereditary renal cancer syndromes can lead to multiple bilateral kidney tumors that occur at a younger age than that at which the nonhereditary renal cancers occur. 
The aim of our work is to review the features of hereditary renal cancers, the basic principles of genetic relevant to these syndromes, and the various histopathologic features of renal cancer. In addition, we will describe the known familial syndromes associated with small renal masses.

Jorge Hidalgo

Gilberto Ch&#233;chile

Familial Syndromes Coupling with Small Renal Masses

A significant increase in the incidental detection of small renal tumors has been observed with the routine use of cross-sectional abdominal imaging.  However, the proportion of small renal tumors associated with multifocal RCC has yet to be established. Here then, we report our experience with the treatment of multifocal RCC in which the primary tumor was ≤4 cm. In our series of 1113 RCC patients, 5.4% (60/1113) had multifocal disease at the time of nephrectomy. Discordant histology was present in 17% (10/60) of patients with multifocal RCC. Nephron sparing surgery was utilized more frequently in patients with solitary tumors. Overall, cancer-specific, and distant metastasis-free survival appeared to be similar between multifocal and solitary tumors.  These findings are consistent with previous series which evaluated multifocal RCC with tumors &gt;4 cm. With the known incidence of multifocality RCC, careful inspection of the entire renal unit should be performed when performing nephron sparing surgery.

Paul L. Crispen

Christine M. Lohse

Michael L. Blute

Multifocal Renal Cell Carcinoma: Clinicopathologic Features and Outcomes for Tumors <svg style="vertical-align:-0.546pt" height="10.15" version="1.1" viewBox="0 0 14.825 10.15" width="14.825" xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg"><g transform="matrix(.017,-0,0,-.017,.062,9.413)"><path id="x2264" d="M531 71l-474 214v50l474 215v-56l-416 -184l416 -183v-56zM531 -40h-474v50h474v-50z"/></g></svg> 4cm

Advances in imaging techniques (CT and MRI) and widespread use of imaging especially ultrasound scanning have resulted in a dramatic increase in the detection of small renal masses. While open partial nephrectomy is still the reference standard for the management of these small renal masses, its associated morbidity has encouraged clinicians to exploit the advancements in minimally invasive ablative techniques. The last decade has seen the rapid development of laparoscopic partial nephrectomy and novel ablative techniques such as, radiofrequency ablation (RFA), high-intensity focused ultrasound (HIFU), and cryoablation (CA). In particular, CA for small renal masses has gained popularity as it combines nephron-sparing surgery with a minimally invasive approach. Studies with up to 5-year followup have shown an overall and cancer-specific 5-year survival of 82&#37; and 100&#37;, respectively. This manuscript will focus on the principles and clinical applications of cryoablation of small renal masses, with detailed review of relevant literature.

J. L. Dominguez-Escrig

K. Sahadevan

P. Johnson

Cryoablation for Small Renal Masses

Introduction. The objective is to determine the clinical and experimental evidences of the renal responses to warm and cold ischemia, kidney tolerability, and available practical techniques of protecting the kidney during nephron-sparing surgery. Materials and methods. Review of the English and non-English literature using MEDLINE, MD Consult, and urology textbooks. Results and discussion. There are three main mechanisms of ischemic renal injury, including persistent vasoconstriction with an abnormal endothelial cell compensatory response, tubular obstruction with backflow of urine, and reperfusion injury. Controversy persists on the maximal kidney tolerability to warm ischemia (WI), which can be influenced by surgical technique, patient age, presence of collateral vascularization, indemnity of the arterial bed, and so forth. Conclusions. When WI time is expected to exceed from 20 to 30 minutes, especially in patients whose baseline medical characteristics put them at potentially higher, though unproven, risks of ischemic damage, local renal hypothermia should be used.

Fernando P. Secin

Importance and Limits of Ischemia in Renal Partial Surgery: Experimental and Clinical Research

Introduction. Most of the kidney masses are being detected incidentally with smaller size due to widespread use of imaging modalities leading to increased RCC incidence worldwide with an earlier stage. This article reviews the role of open partial nephrectomy (PN) in the management of small renal masses. Material and Methods. Review of the English literature using MEDLINE has been performed between 1963–2008 on small renal masses, partial nephrectomy, kidney cancer, nephron sparing surgery (NSS), radical nephrectomy, laparoscopy, and surgical management. Special emphasis was given on the indications of NSS, oncological outcomes and comparison with open and laparoscopic PN. Results. Overall 68 articles including 31 review papers, 35 human clinical papers, 1 book chapter, and 1 animal research study were selected for the purpose of this article and were reviewed by the authors. Conclusions. Currently, open NSS still remains as the gold standard surgical treatment modality in patients with small renal masses.

Ziya Kirkali

A. Erdem Canda

Open Partial Nephrectomy in the Management of Small Renal Masses

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