Surgical strategy of bilateral synchronous sporadic renal cell carcinoma—experience of a Chinese university hospital
© The Author(s). 2017
Received: 9 March 2016
Accepted: 15 December 2016
Published: 28 February 2017
The objective of this study is to investigate the optimal therapeutic protocol for BSSRCC.
A total of 32 BSSRCC patients, including 28 males and 4 females, were enrolled the study from January 2004 to May 2016. The diagnoses were defined by the measurements of CT, ultrasound, and MRI. Patients with hereditary syndrome were excluded. The management of surgical manner, operation staging, and sequence were scheduled in accordance with the tumor’s location and size (based on Zhongshan score, ZS score), as well as the performance status of the patients. Among them, 8 cases were conducted with bilateral surgical procedure simultaneously and 24 cases were implemented with staged operations. NSS on the one side with contralateral RN, and NSS on both sides were performed in 17 and 15 patients separately.
Thirty cases were conducted 56 operations in total. The average operation time was 260 ± 52 min in simultaneous operations and 162 ± 40 min in staged operations. The length of hospital stay in average was 11.5 ± 1.8 and 7.5 ± 1.4 days, respectively. Twenty-eight cases were followed up by 6–138 months. The level of creatinine was elevated in 5 cases without hemodialysis conducted.
The location and size of the carcinomas, and the performance status of patients should be considered in determination of an appropriate surgical approach. Both renal function preservation and tumor eradication were similarly critical, whereas the latter is of more importance. ZS score may be helpful in the dilemma. Longer follow-up period and more patient enrolment are required.
KeywordsKidney neoplasm Nephron-sparing surgery Radical nephrectomy Synchronous ZS score
Bilateral synchronous sporadic renal cell carcinoma (BSSRCC) is an uncommon disease accounting for 3~4.2% renal carcinomas [1, 2]. It is a difficult surgical dilemma for the urologist to formulate the therapeutic strategy for individual patient. Previous study disclosed patients with this type of tumor usually demonstrated a poor prognosis . As usual, bilateral radical nephrectomy (RN) followed by renal replacement was the major management to these patients, which can obtain a 71% 5-year survival in patients undergoing hemodialysis and 86% 5-year survival in patients receiving kidney transplantation . However, increasing evidences in a variety of studies [5–7] suggested the favorable outcomes of the disease recently. Surgical resection may provide the longer beneficial effect of cancer control for patients treated by bilateral RCC, with similar survival between synchronous and metachronous cancers. Meanwhile, the prognosis between the patients with N0M0 synchronous bilateral RCC and the patients with N0M0 unilateral RCC are comparable. Singer et al.  reported that the overall survival (OS) was 88% in the patients with synchronous sporadic carcinomas in a median 16-year follow-up period, which indicated the nephron-sparing surgery (NSS) was an essential procedure to bilateral renal tumors. They emphasized that all efforts should be made during operation, so as to protect the renal function. In the present study, we summarize the experience in the treatment of the BSSRCC and suggest the selection criteria of the surgical manner.
A total of 32 BSSRCC patients, including 28 males and 4 females at Zhongshan Hospital, Fudan University, were enrolled in the study between January 2004 and May 2016. The study was a prospective design, and the data were collected into an institutional review board-approved database. The patients with bilateral metachronous renal tumors, cystic renal masses, familial renal cell carcinoma syndromes, urothelial cell carcinomas, and defined hereditary syndromes were excluded in accordance with the diagnosis criteria . ECOG PS of all the patients were 0~2.
Baseline demographic and clinical characteristics of the BSSRCC patients
Number(percentage), N = 32
Right side, N = 32
Left side, N = 32
N = 32
N = 32
N = 32
N = 32
N = 24
N = 23
All tumors were stratified into three complexity levels according to Zhongshan score (ZS score) . Low-risk tumors were scored between 3~4, whereas moderate tumors were scored between 5~7, and high-risk tumors were scored ≥8.
The preoperative work-up consists of medical history, physical examinations, and routine laboratory tests. Concentrations of serum creatinine were recorded before and after operation consecutively at an interval of 3–6 months. Estimated Glomerular filtration rate (GFR) was calculated using the modification of diet in renal disease (MDRD) formula. Postoperative assessments during follow-up period included abdominal ultrasonography and chest x-ray examinations at the interval of each 3 months in the first 2 years and at each 6 months afterward.
One-stage bilateral surgery was performed in eight patients, of which six cases were carried out bilateral NSS and two cases were taken RN for one side first and NSS for the opposite side thereafter. Two-stage operations were performed in other 24 cases, of which 5 cases were adopted NSS first and RN for the opposite side 4–8 weeks later; 10 cases were performed RN first and then NSS for the opposite side 4–8 weeks later; 9 cases were conducted NSS in both sides within 4–8 weeks. For one patient with tumor embolus in vena cava, an intravenous stent was placed and a filter was positioned at inferior vena cava before operation to prevent the embolus occlusion, followed by ipsilateral RN and contralateral NSS 7 weeks later. The characteristics of tumor size and the therapeutic options are summarized in Table 1. Complications were evaluated using the Clavien scale .
Surgical strategy for BSSRCC
Selection of surgical stage
One-stage bilateral surgery (OBS): OBS is considered when physical status of the patient is fitted (ECOG PS = 0) while being without any comorbidity.
Two stages surgery (TSS): TSS is selected for the patient with large size tumor or other complications, such as cancer embolus in the vena cava. Patients with ECOG PS > 0 are also enrolled in this group.
Surgical sequence of the BSSRCC based on ZS score
Higher risk side
Lower risk side
NSS (low-moderate risk)
NSS (high risk)
The same criteria should be met in one-stage bilateral surgery in management of surgical schedule.
A total of 56 operations were productively completed in all 32 patients (average age 54.7 years, range 31 to 77). Surgical patterns of retroperitoneal open partial nephrectomy (OPN) and transperitoneal open/laparoscopic radical nephrectomy were selectively applied. Mean operation time of OBS and TSS were 263 ± 50 min (range 200–320) and 154 ± 42 min (range105–180), mean hospitalization time of OBS and TSS were 11.4 ± 1.9 days (range 8–15) and 7.4 ± 1.3 days (range 6–9), respectively. The warm ischemia time in NSS was 26 ± 7 min (range 16–45). Pathological examination of 64 neoplasms samples revealed that 57 samples were clear cell carcinoma, 5 were papillary carcinoma, and 2 were chromophobe carcinoma.
Results of following up of the BSSRCC patients
Lost in follow-up
Although BSSRCC is an uncommon disease with lower incidence , the management is much more difficult and complicated than that of metachronous RCC. Accordingly, the selection of surgical approach and the schedule of operation sequence require careful evaluation of the disease and the general condition of patients.
Selection of operation pattern in our study
- 1).Bilateral NSS: The location and size of the tumor in both sides meet the indication for NSS (Fig. 6). In present series, 15 patients were implemented bilateral NSS.
- 2).Lateral NSS on the one side and RN on the contralateral side. In general, it was applied for patients with small tumor on the one side which meet the indication for NSS and with relatively larger tumor on the other side which required RN. Seventeen patients in the cohort received surgery in this manner (Fig. 7). Four patients showed the elevation of creatinine levels after operation because of inadequate preservation of renal parenchyma. It indicated the renal parenchyma should be conserved as much as possible in NSS to avoid postoperative dialysis.
Bilateral RN. It is applied in patients with bilateral large tumors which are unsuitable for NSS. Due to the complete loss of renal function after surgery, kidney replacements are necessary to maintain the life of patients. Therefore, the selection of this surgical manner should be particularly cautious. None of our patient has taken this surgical manner.
The individual therapeutic protocol for each patient should be created only through appropriately weighing the advantages and disadvantages of different surgical sequences, then make the selection of either one-stage or two-stage surgery manner and which side is the first for surgery. The essential principle is which manner can provide the optimal effects of thoroughly eliminating the tumor cells as early as possible. One-stage bilateral surgery may be the effective therapeutic method for BSSRCC based on the criteria in case of physical status of the patient allowed. However, the elderly patients or those with vital organ dysfunction owing to complicated status of operation either in one or two sides is better to take staged surgery after 1–2 months of the first-stage surgery done. The initial operation on one side is a pivotal procedure in staged surgery. We should focus on the high risk tumor of BSSRCC following the above criteria. But it is not always the case. Maximal preservation of renal function should be taken into account at the same time, especially in the case of NSS with contralateral RN. Consequently, we describe the therapeutic methods in combination of renal function preservation and tumor removal in making our surgical criteria.
In summary, both preservation of the renal parenchyma and tumor eradication should be considered simultaneously in management of BSSRCC. Before formulating an individual therapeutic regime, the patient’s performance status, tumor size, and location should be evaluated carefully  according to the ZS score. The renal parenchyma should be preserved as much as possible during the operation to prevent hemodialysis postoperatively, but complete tumor removal is the most important target for the treatment of patient.
We established our promising surgical criteria for BSSRCC based on the ZS score.
Both preservation of renal parenchyma and tumor eradication should be considered in BSSRCC. Before formulating a therapeutic regime, the patient’s performance status, tumor size, and location should be evaluated. Renal parenchyma should be preserved as much as possible during the operation, but complete tumor removal is more important.
Longer follow-up and more patients enrolment are required.
Bilateral synchronous sporadic renal cell carcinoma
Chronic renal insufficiency
- ECOG PS:
Eastern cooperative oncology group, performance status
Glomerular filtration rate
One-stage bilateral surgery
Open partial nephrectomy
Two stages surgery
- ZS score:
The authors thank Ms. Shicui Liu of China Oncology Medical Affairs of Pfizer Investment Company Ltd. for the english check and sentence polishing.
Availability of data and materials
Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.
XYH and LX carried out the main studies and drafted the manuscript. JMG and HW participated in the research design and coordination while HW performed all the operations. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Consent for publication
We have obtained consent to publish from all the patients to report their individual data in this article.
Ethics approval and consent to participate
This study has been approved by the ethics committee of Fudan University and has therefore been performed in accordance with the ethical standards laid down in the Declaration of Helsinki 1964 and its later amendment.
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