**2. Technique of nephron-sparing surgery**

All patients were operated through extraperitoneal, extrapleural incision above the 12th rib in 38 cases and above the 11th rib in 19 cases. The kidney was completely mobilized to ex‐ clude the presence of satellite tumors. Peritumoral fat was left in situ. Sharp incision of the

renal capsule was performed 2 to 3 mm away from the tumor margin. The renal pedicle was isolated completely and the renal artery was clamped just before beginning the incision on the renal capsule. The venous clamping was not used in any case. For diminishing the out‐ comes of renal ischemia vigorous hydration, infusion of Mannitol before the arterial clamp‐ ing, and renal hypothermia was adopted in all cases. Tumors were enucleated without a layer of normal parenchyma in 17 cases and enucleoresection was performed in 40 cases. Tumor bed was inspected very carefully on the presense of residual tissue. Intraoperative frozen section of tumor bed was routinely performed. The results of frozen section were negative in all cases. The data of the patients who underwent nephrectomy due to positive margins on the frozen section were not included in the study. The visible bleeding vessels and opened calices were closed using running sutures. Finally, tumor bed was coagulated carefully for haemostatic and partly for oncological reasons. The coagulation was performed by means of diathermy. The parenchymal defect was closed using absorbable interrupted sutures. In case of large capsular defect it was covered with free peritoneal graft.

without extension into the renal sinus. At the diagnosis 53 (92.9 %) tumors were detected incidentally and 4 (7.1%) were associated with microscopic haematuria. The NSS was per‐ formed for absolute indications in 5 (8.7%) and for relative indications in 11 (19.9%) cases. 41

Nephron-Sparing Surgery for the Treatment of Renal Cell Carcinoma 4 to 7 cm in Size

http://dx.doi.org/10.5772/53830

89

(71.9%) patients underwent NSS for elective indications.

**Gender**

**Tumor location**

**Clinical presentation**

**Stage**

**Fuhrman grade**

**Histological subtype (%)**

**Surgical complications**

Disease Recurrence

**Age at surgery (years)** 53.1 (37-68)

Male 35 (61.4 %) Female 22 (38.6 %)

Left 34 (59.6%) Right 23 (40.4 %) Upper pole 21 (36.8 %) Mid kidney 7 (12.2 %) Lower pole 29 (51%) Central 11 (19.3%) Peripheral 46 (80.7%)

Incidental 53 (93%) Presented by haematuria, pain etc. 4 (7%) **Tumor size (mm.)** 48.1 (41-70)

pT1b 53 (93%) pT3a 4 (7%)

G1 22 (38.6 %) G2 27 (47.4 %) G3 8 (14 %)

Clear cell 49 (85.9 %) Pappilary 5 (8.7 %) Chromophobe 2 (3.7 %) Cystic RCC 1 (1.75 %)

Bleeding 1(1.75 %) Urinary leakage 4 (7%)

Local recurrence 2 (3.5 %) Distant metastases 4 (7%)

**Table 1.** Clinico-pathological characteristics of 57 patients operated with NSS.

The stained slides from all tumor specimens were reviewed by urological pathologist. Short‐ ly, the resected kidneys were evaluated macroscopically. The maximal tumor size was meas‐ ured and 1.5 x 2cm tissue samples were taken for further assessment. Specimens were fixed, stained and evaluated by the same pathologist according to conventional technique. Patho‐ logical tumor staging was performed according to the 2002 TNM staging system [11] and nuclear grade was assigned according to the Furhman's grading system [12]. The removed tumor specimen was always inspected by pathologists and the surgical margins were inked.

Patients were followed with renal functional tests, chest X-ray, abdominal ultrasound or CT every 3 months during the first year, once in 6 months for the next two years and annually thereafter. In terms of statistical analysis the probability of cumulative and cancer-specific survival was estimated by the Kaplan-Meier method using the whole number of events.
